Improving health system quality in low- and middle-income countries that are expanding health coverage: a framework for insurance.

PURPOSE: Low- and middle-income countries are increasingly pursuing health financing reforms aimed at achieving universal health coverage. As these countries rapidly expand access to care, overburdened health systems may fail to deliver high-quality care, resulting in poor health outcomes. Public insurers responsible for financing coverage expansions have the financial leverage to influence the quality of care and can benefit from guidance to execute a cohesive health-care quality strategy. DATA SOURCES: and selection Following a literature review, we used a cascading expert consultation and validation process to develop a conceptual framework for insurance-driven quality improvements in health care. RESULTS OF DATA SYNTHESIS: The framework presents the strategies available to insurers to influence the quality of care within three domains: ensuring a basic standard of quality, motivating providers and professionals to improve, and activating patient and public demand for quality. By being sensitive to the local context, building will among key stakeholders and selecting context-appropriate ideas for improvement, insurers can influence the quality through four possible mechanisms: selective contracting; provider payment systems; benefit package design and investments in systems, patients and providers. CONCLUSION: This framework is a resource for public insurers that are responsible for rapidly expanding access to care, as it places the mechanisms that insurers directly control within the context of broader strategies of improving health-care quality. The framework bridges the existing gap in the literature between broad frameworks for strategy design for system improvement and narrower discussions of the technical methods by which payers directly influence the quality.

Piloting the development of a cost-effective evidence-informed clinical pathway: managing hypertension in Jordanian primary care.

OBJECTIVES: The UK's National Institute for Health and Clinical Excellence (NICE) and the Jordan office of the Medicines Transparency Alliance embarked on a pilot project to design an evidence-based guideline for cost-effective pharmacological treatment of essential hypertension in Jordan. The project's objectives were to directly address a major health problem for Jordan by producing a guideline; and to delineate the strengths and weaknesses of Jordan's healthcare process to allow similar future efforts to be planned more efficiently. METHODS: The pilot spanned a period of approximately 8 months. Activities were overseen by local technical and guideline development teams, as well as experts from NICE. NICE's hypertension guidelines and economic model were used as a starting point. Parameters in the economic model were adjusted according to input and feedback from local experts with regards to Jordanian physician and patient practices, resource costs, and quality of life estimates. The results of the economic model were integrated with the updated available clinical trial literature. RESULTS: The outputs of the economic model were used to inform recommendations, in the form of a clinical algorithm. A report of the process and the strengths and weaknesses observed was developed, and recommendations for improvements were made. CONCLUSIONS: The pilot represented the start of what is intended to be a healthcare process change for the country of Jordan. Issues emerged which can inform strategies to ensure a more cohesive and comprehensive approach to the cost-effective use of appropriate drugs in managing chronic disease in Jordan and countries operating in a similarly resource-constrained environment. Furthermore, our pilot highlights how richer countries with relevant experience in evidence-informed healthcare policy making can assist others in strengthening their decision-making methods and processes.

Quality of Health Care in Ghana: Mapping of Interventions and the Way Forward.

BACKGROUND: Ghana has made major strides in improving access to health services. Despite these improvements, Ghana did not meet the Millennium Development Goals 4 and 5. Quality of care is a major factor that could explain this shortfall. OBJECTIVE: To understand current practice and to identify needs in the area of quality of care in Ghana for improving health outcomes and to guide the National Institute for Health and Care Excellence (NICE) in supporting the care quality improvement efforts in Ghana. METHODS: The directory of existing standards, guidelines and protocols of the Ghana Health Service was reviewed and sixteen in-depth interviews were conducted to identify interventions that addressed quality of care. Additional information was obtained during a NICE scoping visit to Accra followed by a study tour of Ghanaian stakeholders to NICE and to the National Health Service. RESULTS: Since 1988, 489 policy interventions have been identified that address quality of care. Among them, the development of health protocols and guidelines were the most frequent interventions (n=150), followed by health policies and strategies (n=106); interventions related to health information (n=77); development of training manuals and staff training (n=69); development of regulations (n=38) and interventions related to organisation of services (n=15). CONCLUSIONS: Ghana has made significant efforts in developing guidelines, policies and conducting in-service training. Supervision, monitoring and evaluation have also received attention. However, less effort has been made in developing processes and systems and involving communities and service users. Some recommendations were made to guide the future work on quality of care. FUNDING: Rockefeller Foundation.