1. ‘‘QUALITY IMPROVEMENT IN HEALTH CARE IN DEVELOPING COUNTRIES’’
A Term paper submitted to fulfill the partial requirement of BPH Third semester
[TPP 8.1 HEALTH SYSTEM DEVELOPMENT]
SUBMITTED TO:
DEPARTMENT OF PUBLIC HEALTH,
LA GRANDEE INTERNATIONAL COLLEGE,
SIMALCHAUR-8, POKHARA
2012
SUBMITTED BY:
RAJESH KUMAR YADAV
PURNIMA TIMILSINA
KALPANA GURUNG
SAGUN PAUDEL
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2. 1. Acknowledgement
The students of Bachelor of Public Health 3rd semester of 2nd year like to express our humbly
thanks to all those who have supported and helped us in accomplishing this term paper in the
topic ‘‘QUALITY IMPROVEMENT IN HEALTH CARE IN DEVELOPING
COUNTRIES’’.
We would like to convey our heartfelt thanks to all those who were directly or indirectly
concerned with this and to all our well-wishers.
First of all we would like to thank our respected subject teacher Mr. Hari kafle for giving us
opportunity to prepare this term paper. We are fully indebted to our coordinator Mr. Dilip kumar
Yadav for expert guidance, regular supervision, untiring encouragement, inspiration and valuable
suggestion and full support during preparation of term paper.
This term paper is written in simple language, with every bit of necessary information related to
the topic so that studying independently also would not find any difficulties. We think that this
effort will help every individual to understand about the information of the related topic.
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3. 2. Table of content
1. Acknowledgement ........................................................................................................................... 2
2. Table of content .............................................................................................................................. 3
3. Introduction .................................................................................................................................... 4
3.1 Definition of Quality: ......................................................................................................................... 4
3.2 Quality of service: .......................................................................................................................... 4
4. Objective: ........................................................................................................................................ 6
4.1 General Objectives:........................................................................................................................ 6
5. METHODOLOGY ............................................................................................................................... 7
6. Finding and discussion: .................................................................................................................... 8
6.1 Elements of Quality:....................................................................................................................... 8
6.2 QUALITY OF CARE FRAMEWORK .................................................................................................... 9
6.3 QUALITY OF CARE IN DEVELOPING COUNTRIES: ............................................................................. 9
6.4 Quality of care in Nepal:............................................................................................................... 10
7. Conclusion ..................................................................................................................................... 11
8. References:.................................................................................................................................... 11
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4. 3. Introduction
3.1 Definition of Quality:
Quality is a degree of excellence. In health care, quality is defined in the light of the provider’s
technical standards and patient’s expectations. Quality is doing right thing in right way. It is a
comprehensive and multifaceted concept.
3.2 Quality of service:
Quality of services refers to what is actually provided at the service delivery point. Quality of
services is determined by how policy makers and programme managers convert their resources
(staff, suppliers and physical locations) into services. The quality of services should be measured
objectively.
William R. finger
‘The degree to which health services for individuals and populations increase the likelihood of
desired health outcomes and are consistent with current professional knowledge’
(Institute of Medicine, 2001)
Institute of Medicine, 2001: Crossing the Quality Chasm, Washington, DC: National Academy
Press
Quality of health care should always fulfill three points which are;
 It should fulfill clients or patient’s need and wants.
 It should give positive impact on health status.
 It should follow scientifically approved methods and techniques.
Quality of care is views in 3 perspective;
Client/community perspective
Service provider’s perspective
Manager/supervisor’s perspective.
Client perspective:
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5. Quality of care includes effectiveness, Accessibility, Interpersonal relation, continuity and
amenities.
Service provider’s perspective:
It implies the skills, resources and other conditions necessary to improve health status.
Health care manager/ supervisor’s perspective:
Involves addressing needs of clients/ service providers through resource allocation, mobilization
etc.
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6. 4. Objective:
4.1 General Objectives:
o To Study Quality Improvement in Health Care In Developing Countries.
4.2 Specific Objectives:
o To study the elements of quality of health care
o To study a framework for quality of care
o To study the Policy interventions to improve quality
o To study how to Measurement of quality
o Analyze the Economic benefits and costs of quality
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7. 5. METHODOLOGY
Secondary data
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8. 6. Finding and discussion:
6.1 Elements of Quality:
Quality comprises three elements:
• Structure
Structure refers to stable, material characteristics (infrastructure, tools, technology) and the
resources of the organizations that provide care and the financing of care (levels of funding,
staffing, payment schemes, and incentives).
• Process
Process is the interaction between caregivers and patients during which structural inputs from
the health care system are transformed into health outcomes.
• Outcomes
Outcome can be measured in terms of health status, deaths, or disability-adjusted life years—a
measure that encompasses the morbidity and mortality of patients or groups of patients.
Outcomes also include patient satisfaction or patient responsiveness to the health care system
(WHO 2000).
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9. 6.2 QUALITY OF CARE FRAMEWORK
6.3 QUALITY OF CARE IN DEVELOPING COUNTRIES:
In the fifteen years since the Alma Ata Declaration, in which the international community committed itself to
providing primary health care (PHC) for all, major efforts have been made in nearly all developing countries to
expand PHC services. This has been achieved through increased resources allocated by both national and
international sources, expanded health worker training, and major health system reorganization. Dramatic
increases in outreach and health coverage have been reported by most countries, many of which have posted
modest declines in infant and child mortality and some reductions in selected morbidity. However, the reported
improvements have not always been commensurate with the resources expended. Furthermore, not enough has
been done to assess service quality or to ensure that resources are having an optimal impact. Quality assurance
(QA) methods can help health program managers to define clinical guidelines and standard operating
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10. procedures, to assess performance compared with selected performance standards, and to take tangible steps
toward improving program performance and effectiveness.
The process of providing care in developing countries is often poor and varies widely. A large body of
evidence from industrial countries consistently shows variations in process, and these findings have
transformed how quality of care is perceived (McGlynn and others 2003). A 2002 study found that physicians
complied with evidence-based guidelines for at least 80 percent of patients in only 8 of 306 U.S. hospital
regions (Wennberg, Fisher, and Skinner 2002). It is important to note that these variations appear to be
independent of access to care or cost of care: Neither greater supply nor higher spending resulted in better care
or better survival. Studies from developing countries show similar results. For example, care in tertiary and
teaching hospitals and care provided by specialists may be better than care for the same cases in primary care
facilities and by generalists (Walker, Ashley, and Hayes 1988).
One explanation for variation and low-quality care in the developing world is lack of resources. Limited data
indicate, however, that high-quality care can be provided even in environments with severely constrained
resources. A study in Jamaica, which used a cross-sectional analysis of government-run primary care clinics,
showed that better process alone was linked to significantly greater birthweight (Peabody, Gertler, and
Liebowitz 1998). A study in Indonesia attributed 60 percent of all perinatal deaths to poor process and only 37
percent to economic constraints (Supratikto and others 2002).
Cross-system or cross-national comparisons provide the best examples of the great variation in clinical practice
in developing countries. In one seven-country study, researchers directly observing clinical practice found that
75 percent of cases were not adequately diagnosed, treated, or monitored and that inappropriate treatment with
antibiotics, fluids, feeding, or oxygen occurred in 61 percent of cases (Nolan and others 2001). Another study
compared providers’ knowledge and practice in California and FYR Macedonia, using vignettes to adjust for
case-mix severity. Although the quality of the overall or aggregate process was lower in FYR Macedonia, a
poor country, the top 5 percent of Macedonian doctors performed as well as or better than the average
Californian doctor (Peabody, Tozija, and others 2004).
In a study commissioned for this chapter, an international team measured quality in five developing countries
(China,
El Salvador, India, Mexico, and the Philippines), using the same clinical vignettes at each site. The team
evaluated the process for common diseases according to international, evidence-based criteria. Quality varied
only slightly among countries. The within-country range of quality of doctors was 10 times as great as the
between-country range. Such wide variation strongly suggests that efforts to improve health status must
involve policies that change the quality of clinical care.
6.4 Quality of care in Nepal:
In Nepal, there is lack of well trained, qualified, midlevel health care workers (MLHCW) in rural areas. The
lack of poor performance of providers at these health posts results in inadequate preventive and curative health
services to the poor and geographically isolated population of all ethnic groups. The lack of quality providers
is a primary reason for a continued high maternal and neonatal mortality rates as well as general reduction in
the quality of life due to the burden of diseases of the rural population.
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11. 7. Conclusion
In industrialized countries, quality of care is widely debated in the context of health sector
reform. A wealth of literature reflects the progress made in developing tools to monitor and
improve the quality of health care. Poor quality health services can violate basic human rights,
lead to negative therapeutic outcomes and prevent people from enjoying the highest standard of
physical and mental health. However, poor quality of care can be substantially redressed through
concerted and systematic quality improvement strategies.
8. References:
 The Quality of Care in Developing Countries, John W. Peabody, Mario M. Taguiwalo,
David A. Robalino, and Julio Frenk
 Quality Assurance of Health CareIn Developing Countries, Lori DiPreteBrown,Lynne
Miller Franco,NadwaRafeh,TheresaHatzell
THANKYOU
Prepared by: sagun paudel
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