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.

What gets published: the characteristics of quality improvement research articles from low- and middle-income countries.

OBJECTIVES: Reports of quality improvement (QI) research from low- and middle-income countries (LMICs) remain sparse in the scientific literature. The authors reviewed the published literature to describe the characteristics of such reports. METHODS: The authors conducted a systematic search for QI research articles from LMICs catalogued in the PubMed databases prior to December 2011, complemented by recommendations from experts in the field. Articles were categorised based on bibliometric and research characteristics. Twenty papers were randomly selected for narrative analysis regarding strategies used to present the methods and results of interventions. RESULTS: Seventy-six articles met the inclusion criteria. Publication rate accelerated over time, particularly among observational studies. Most studies did not use a concurrent control group; pre-/post-study designs were most common overall. Four papers were published in top-tier journals, 17 in journals at the top of their specialty and 20 in quality-specific journals. Among the papers selected for narrative analysis, four distinct components were observed in most: a description of the problem state, a description of the improvement processes and tools, a separate description of the interventions tested and a description of the evaluation methods. DISCUSSION: The small number of articles identified by this review suggests that publication of QI research from LMICs remains challenging. However, recent increases in publication rates, especially among observational studies, may attest to greater interest in the topic among scientific audiences. Though the authors are not able to compare this sample with unpublished papers, the four components observed by them in the narrative analysis seem to strengthen QI research reports.