Introduction

The main purpose of knowledge dissemination is to convert knowledge into practice. The inability to convert Continuous Quality Improvement (CQI) evidence-based knowledge and research into practice is known as a “translation gap.” When this gap exists in healthcare, it leads to needless deaths, suffering, and inequality [1]. Derman and Jaerger highlighted that “when research is designed to improve health, dissemination is critical to the development of evidence-based healthcare and the adoption of evidence-supported interventions and improved practice patterns” (2, p.121). A lack of dissemination devalues research, wastes resources, and minimizes the opportunity to improve the health of patients and their families. Adopting and implementing health research findings has been slow in low-and middle-income countries [2]. Poor dissemination is one component that accounts for the “translation gap.”

A recent review summarized many of the lessons learned about the lack of dissemination and the “translation gap.” Passive approaches to uptake are often ineffective. Alternatively, there are demonstrated lessons that support more active and effective dissemination, including: stakeholder involvement in research and evaluation enhances dissemination; dissemination of information to non-scientists is improved by creating interest and emotion; dissemination approaches should be time efficient, consistent with organizational climate, culture, resources; and align with the skills of staff members; and a major objective of evidence-based research dissemination should be to achieve academic and clinical impact [1].

Applying continuous quality improvement (CQI) in global health systems is primarily about catalyzing change. Publishing about CQI principles and their application is only the first step to using CQI to create safer, more effective, efficient, and patientcentered health systems in LMIC. (1) This article identifies CQI global leaders and disseminators of CQI knowledge and practice, examines global health CQI definition, reviews the reasons for using CQI in LMICs, recognizes what happens in the absence of CQI efforts, notes challenges to implementing CQI, appraises lessons learned from past CQI efforts in LMICs, and investigates options for new models for better outcomes and impact. The concluding section amalgamates the presented content through the experiences of one non-governmental organization’s (NGO) model and its African projects.

Defining CQI

There is no universally accepted definition of CQI. A general understanding of CQI can be achieved with two questions, “how are we doing?” and “can we do better?” [3]. The definition of quality assurance has broadened over the years from overseeing how healthcare practitioners deliver their services to reviewing management, processes, systems, outcomes, and patient experience - a total quality approach. A simple definition of CQI is “all actions taken to establish, protect, promote, and improve the quality of health care” [4].

Why promote CQI in LMICs?

In 2015, all the countries in the United Nations adopted the 2030 Agenda for Sustainable Development. The agenda sets out 17 Goals, which included 169 targets. Goal 3 is to ensure healthy lives and promote wellbeing for all at all ages. CQI is pivotal in reaching the WHO’s Sustainable Development Goals for health care [5].

Breakdowns in evidence-based care can affect systematic patient assessment, accurate diagnosis, appropriate treatment, and patient education; and have significant impact on CQI outcomes. While there are quality assurance issues throughout LMICs’ health systems, there are a myriad of difficulties at the provider-patient level that can affect delivery of such quality care: misdiagnoses, inappropriate treatments, slow implementation of treatment plans, underuse of effective treatments, overuse of ineffective treatments, patient dissatisfaction with treatments, lack of patient education about processes, patient disrespect, and sometimes, patient abuse [6-8]. In 2018, to help address these concerns, major international organizations such as the World Health Organization (WHO); Organization for Economic Co-operation and Development (OECD); World Bank (WB); the National Academies of Sciences, Engineering, and Medicine; and the Lancet Global Health Commission produced reports highlighting the deficits in health delivery on a global scale. 

The Lancet Global Health Commission noted there is a cumulative effect of poor healthcare delivery in LMICs to the point that quality of care is a bigger problem than access to care [9]. Inadequate care accounts for about 60% of treatable deaths per year in LMICs; in addition, there are high mortality rates for treatable conditions such as injuries, surgical conditions, maternal and newborn conditions, and cardiovascular disease, which occur at high frequencies. Health providers often are doing less than half of the recommended evidence-based care actions [9].

The WHO, OECD, and WB highlighted concerns on quality, noting: 1) unwarranted variations in health care provision and delivery persist, and a considerable proportion of patients do not receive appropriate, evidence-based care; 2) nearly 40% of LMIC facilities lack clean water, and nearly 20% lack sanitation; and 3) concern about child and infant mortality, in addition to the high number of adults not being diagnosed or treated for common conditions such high blood pressure, is as much as 50% in some countries [10].

The National Academies of Science and World Health Organization estimated that low-quality healthcare accounts for about 15% of the 56 million annual deaths in LMICs [11]. The Academies wrote that healthcare workers and healthcare recipients worldwide are not well-served by their health systems. They identified various health systems’ shortcomings that directly affect healthcare worker experience and satisfaction, such as fragmentation, mal-aligned payments, unclear goals, poor training, unreliable supply chains, burdensome rules, inadequate information flows, lack of useful data, corruption, and fear. There are significant costs to this lost productivity to society, at about $1.4 to $1.6 trillion annually [12]. The report stated that annually, approximately $455 billion of the $7.35 trillion spent globally on healthcare is lost to fraud and corruption [11].

Given the available evidence-based data, there is a need for CQI in low- and middle-income countries. CQI can help fulfill the WHO’s goal for global health systems in “improving health and health equity, in ways that are responsive, financially fair, and make the best, or most efficient, use of available resources” (12, p. 2). African healthcare opinion leaders have pointed out that doing more of what has been done in the past at the same rate impedes African health systems from achieving their goals. They suggest a comprehensive approach and system-wide changes to produce patient-centered and collaborative health systems in sub-Saharan Africa [13].

Barriers to Implementing CQI

There are numerous barriers to the adoption of CQI. Many of these barriers are summarized by Kostal and Shah in a comprehensive, evidence-based review through a fishbone diagram. (14, figure 1) These factors can serve as a basis for problem solving before and after initiating CQI interventions.

Figure 1: Fish bone diagram of barriers to CQI Figure 1. Reprinted with permission. Fish bone diagram of barriers to CQI [14].

Implementing CQI can be time-consuming and costly. Failing to implement CQI processes can affect an organization or system at many levels. As a health facility becomes inefficient, quality drops, leading to more patient and family complaints. As a result, health professionals can feel more isolated and unhappy with their work. Their unhappiness can be demotivating and cause them to resist change. Partners can become disengaged as goals are not met and services deteriorate. Worse patient outcomes and higher adverse events can result from substandard care. The organization’s culture can deteriorate [15].

CQI lessons learned in LMICs

Unfortunately, decades of initiatives have not achieved the level of success that is needed to provide high quality healthcare in LMICs [9, 13]. Various types of interventions to improve quality have been tried in LMIC.

Two broad categories of interventions have been used for CQI in LMICs: point of care interventions and system-level initiatives. Each has had shortcomings. Point of care practice and behavior are difficult to change with training alone. Healthcare workers revert to past practices if the system around them does not promote suggested changes. Combining incentives with accountability and continuous evaluation systems using institutions and regulatory bodies to assist may produce better outcomes [11].

Further, system level initiatives may have deficits such as operating in silos doing what funders, other countries, and agencies feel are best, which may or may not fit a country’s priorities. Examples of this include projects focused on inputs such as providing medications, equipment, or staff gap-filling, rather than addressing process issues; projects that are shortterm and unsustainable; project delivery that lacks staff expertise, reliability and adequate measurement of outcomes; projects that promise more than they can achieve; projects that cannot achieve goals because they do not include the context of their situation; projects that do not make use of local resources; and projects that do not look towards collective solutions with their implementation environment [9, 13]. Both point of care and systems approaches have their unique shortcomings, but the identified deficits can be addressed with new approaches, combining point of care CQI with health system changes may help garner greater success versus siloed approaches.

One of the most comprehensive CQI reviews came from Rowe and colleagues who completed a systematic review of the effectiveness and cost of strategies to improve healthcare personnel performance in LMICs, the Health Care Provider Performance Review (HCPPR) [16].  They reviewed 499 LMIC studies using 161 intervention strategies from 79 countries. Table 1 summarizes the component categories that were examined.

Table 1: Ten evaluated categories in Health Care Provider Performance Review (HCPPR).

Adapted from Rowe SY, Peters DH, Holloway KA, Chalker J, Ross-Degnan D, et al. A systematic review of the effectiveness of strategies to improve health care provider performance in lowand middle-income countries: Methods and descriptive results [16].

Rowe and colleagues found that training, supervision, and patient and community support were the most common CQI strategies used in LMICs. Most strategies involved patients and health care providers (HCPs), including health workers in hospitals, clinics, pharmacies, and communities [16]. The review concluded that evaluating the effectiveness of CQI interventions in LMICs has been problematic because of methodological problems. Study problems included bias; missing data elements (e.g., sample sizes); and incomplete descriptions of the strategy, methods, and setting. Study heterogeneity such as using data from different countries, varied outcome measures, and differing study time periods hinder the interpretation and generalizability of study findings.

Without a gold standard or well-established scientific proof of techniques to use, there remains uncertainty about the effectiveness of previously tried CQI interventions in Africa and LMIC countries. In other words, after many years of implementing numerous CQI interventions, much of the published data does not support any specific type of CQI intervention, and no intervention stands out above others as being consistently successful [16]. Rowe et al.’s data suggested we need to be better at study designs and find new ways to implement CQI projects.

Moving forward with CQI changes to build high-quality health systems in LMICs

It is important to determine how global health CQI efforts can change to achieve greater success and improve health systems in LMICs and African countries. The path to longer and healthier lives for all Africans by 2030 by Agyepong and others gives direction as to where action can be taken [13]. African leaders want to see future CQI efforts in eight interconnected key areas, as shown in Table 2.

Table 2: Areas for action - African opinion leaders’ perspective [13].

Additionally, Kruk et al., disseminated a how-to-implement framework in High-quality health systems in the Sustainable Development Goals era: Time for a revolution, which suggests three components for intervention to improve health systems: care processes, quality impacts, and foundations. Foundational factors include the population, governance, platforms, workforce, and tools [9]. Figure 2 illustrates their model.

Figure 2: Lancet Commission: Framework for building a high-quality health system.

Reprinted with permission [9].

The Lancet Global Health Commission suggested four universal actions to raise the quality of health systems while recognizing that solutions should be individualized to the context of each LMIC [9]. First, health system leaders should govern for quality, endorsing shared visions and strategies within and outside government. Second, country health systems should emphasize outcomes rather than access to care. Third, health systems should promote competency-based clinical education and introduce ethics training and respectful care to encourage its workforce’s highest level of service. Fourth, governments should promote a culture of accountability and expectation of high-quality care among citizens and institutions.

Dissemination

There is immense value in sharing data whether an intervention to improve healthcare delivery is successful or not. Disseminating CQI study results helps build a database for future studies. A stronger database can prevent a repetition of ineffective CQI interventions and promote learning and novel initiatives. Information sharing can empower patients and communities to help themselves and promote system changes. Data sharing can provide governments and institutions with facts to make evidence-based decisions to achieve best practices [9].