Clinical governance

In all reviewed countries, the German development cooperation has worked on improving the countries’ capacity for clinical governance (table 1. Examples of interventions are displayed in online supplementary file 2). In many countries (Bangladesh, Cambodia, Kenya, Malawi, Nepal, Yemen and Tanzania), technical expertise has also been provided to help the creation or the strengthening of national regulating or coordinating bodies focusing on quality of care, such as national steering committees. In many countries as well, technical and financial support to national midwives’ associations has also been provided to strengthen their legal basis for regulation, as well as their competencies in human resource management and fundraising.

Accreditation

Moreover, country teams have established national quality accreditation systems in 6 out of 14 countries. The process includes the setting of official quality standards towards which the health facilities strive for. After a self-assessment or an external evaluation, an accrediting organisation certifies that the health facility has met the standards and has implemented measures for sustainable improvement. Additionally, capacity development was provided to national accreditation agencies, to peer assessors/surveyors and to participating health facilities.

Training and supervision of workforce

Capacity-building and supportive supervision are two types of interventions aiming to improve the system’s environment widely implemented in GIZ-supported programmes.

Healthcare workers’ pre-service and in-service education, coaching, mentoring and supervision are other QI strategies widely supported by GIZ as a continuum of human resource capacity-building process. In particular, in recent years there have been tremendous efforts to develop the midwifery workforce, both at pre-service and in-service levels in 9 of the 14 countries reviewed (table 1). In-servicetraining of obstetricians, anaesthesiologists and intensive care medical doctors has been a key approach used in Kyrgyzstan and Tajikistan to improve EmONC through a regional approach involving other neighbouring countries as well. In-service training has been provided to health workers in several countries also about SRHR issues and services.

Coaching and mentoring were extensively implemented to improve staff performance and confidence (table 1). Both coaching and mentoring are flexible training methods that can be learnt on the job, although with different objectives. When coaching, the coach, a responsible clinician, enables her students to achieve specific short-term goals by instructing them, while still assuming responsibility for patient care.21 Mentoring implies a longer relationship between a mentor and a mentee, based on mutual trust and respect, and true partnership, only possible once confidence is built between them.21 Mentoring aims to develop the full potential of the mentee, with benefits to all partners: mentor, mentee and the organisation.22 Some programmes have promoted clinical mentoring and the mentoring of the health facility management team to improve the work environment.

Supportive supervision is the last element of this capacity-building continuum implemented in 10 of the 14 countries reviewed (table 1). Supportive supervision is a form of traditional supervision of health staff, where the emphasis is on improving staff performance through encouragement, guidance and follow-up.21 It is an interactive and iterative process providing further training opportunities.

Clinical standards

Technical support was provided to national health institutions for the preparation of policy documents guiding health practices, such as guidelines or standard operation procedures on EmONC in 3 of 14 countries, on referral procedures in 4 countries, and on newborn care and kangaroo mother care in 3 countries.

Collaborative and team-based improvement cycles

In several programmes, complex systemic processes were promoted to improve the quality of care provided at health facilities.

The 5S-Kaizen-Total Quality Management (TQM) approach has been pioneered by the Japanese cooperation since the 1990s,23 and later implemented through GIZ-supported programmes in Bangladesh, Kenya, Tanzania and Malawi. 5S stands for the starting point of the method: a sequence of activities (Sort, Set, Shine, Standardise and Sustain) to improve the work environment. The ‘Kaizen’ step mobilises group-solving and cocreation techniques in repetition cycles, involving both clinicians and health facility management teams, to identify the weakest points of the quality management, and to find and implement local solutions. The TQM aspect looks at the management of medicines and equipment, and at other elements which may increase patients’ and providers’ satisfaction.24

The Standards-Based Management and Recognition (SBM-R) approach used in Nepal’s EmONC mentoring programme aimed at improving the performance of medical, nursing and midwifery staff. Based on the Deming cycle of Plan-Do-Check-Act,25 the concept has been initially developed by Jhpiego in USA-supported programmes.26 In GIZ programmes, it was implemented in repeated cycles of four steps: (1) set healthcare performance standards for high quality of care; (2) put these standards into practice through capacity-building techniques; (3) measure performance before, during and after the programme; and (4) recognise and reward achievements.

The ‘Quality Competition’ implemented in Burundi, Guinea, Cameroon and Pakistan was a voluntary and positive competition between health facilities.27 Volunteering health facilities were trained on quality of care concepts, processes and tools. In each participating health facility, an initial situation assessment was conducted by the health facility teams. The teams planned and implemented corrective measures using available means. A final self-assessment was completed, with findings reviewed by an external evaluation team (health authorities and teams from other health facilities). Health facilities were then ranked according to their achievements. Finally, participating health facilities with improved performance were rewarded (figure 2).

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Figure 2

Conceptual framework for the quality competition (QC) in Burundi, adapted from an external mid-term evaluation report. The QC underlying the theory of change is the following: participating in the QC will positively impact both the quality of care provided and the fulfilment of the population health needs by two mechanisms: (1) the quality of care will improve, which will positively affect users’ satisfaction and increase the health service use, leading to the fulfilment of the population’s needs; and (2) participation in QC will improve healthcare providers’ self-esteem, recognition and valorisation, which will increase their satisfaction and participation in the development of a quality culture.

Morbidity and mortality reviews

Finally, support has also been provided to set up or strengthen maternal and perinatal death surveillance or audit programmes in 5 of 14 countries. These programmes aim to improve the reporting of statistics on maternal and perinatal deaths to guide policy-makers’, public health managers’ and clinicians’ responses to avoid future deaths.28

Tackling the right issues in the right way?

Our review highlights that GIZ’s strategy has been to combine complementary approaches. Technical expertise was provided to ministries of health and other national institutions to develop the national quality management agenda, regulations and programmes, to promote the use of internationally recognised guidance, while at the same time support was given to improve the performance of health workers and the management of health services. This multilevel and integrated approach is supported by recent research that has shown that single interventions are unlikely to achieve important reductions in maternal, newborn and child mortality.29 Combining interventions is more effective in improving healthcare practices than implementing them individually.

Moreover, GIZ support is always provided in coordination with other external development partners, and of course with the ministries of health (MOHs), following a sector-wide approach (SWAp). The aim of the SWAp is to improve aid effectiveness by ‘bringing together governments, donors and other stakeholders’ in contexts where several health partners are present and play a significant role.30

GIZ programmes are usually defined after a project appraisal mission based on government negotiations about health priorities, which combines (1) health data review; (2) consideration of national, international evidence and WHO recommendations; and (3) discussions with the MOH at various levels, other health partners and target groups. Based on this appraisal, a proposal is developed including interventions based on national priorities and policies, and of course which are chosen to complement other health partners and government activities. The proposal would be again discussed with MOH and other partners before being submitted to the German development funding body.

The review showed that these QI programmes have focused on many factors that critically influence the quality of care. These factors are well described in the scientific literature.31–34 They mostly relate to human resources development and to weak referral mechanisms. Health facilities’ equipment, logistics, organisation and management are also known to impede the quality of care. Poor health financing (budget allocation and financial barriers for users) is another issue impacting various components of the quality of care. We believe this approach focusing on critical factors is relevant to maximise the impact of QI interventions. We have also observed that the most recent QI programmes aiming to improve EmONC services focus on healthcare providers’ performance and on the availability and readiness of services. We recommend this approach since research has shown that most stillbirths and maternal and neonatal deaths are due to complications that could be avoided if high-quality EmONC services were universally available and accessible.4 29 35

We have also shown that in several countries, GIZ supports programmes that aim to strengthen the midwifery workforce. Indeed, midwives have a pivotal part to play in MCH care. As demonstrated by strong research evidence, investment in midwives’ education, regulation, management and work environment could avert 80% of maternal and newborn deaths, including stillbirths.36 37 The current orientation towards midwifery seems therefore appropriate and should be sustained. The WHO has recently recognised that optimising the health workforce is critical to accelerate progress towards the SDGs.38

Can we measure the success of these quality improvement approaches?

In line with the global trends, the maternal, neonatal and child mortality rates have dropped between 2000 and 2015 in all countries where these QI programmes have been implemented.2 39 In 2015, Vietnam had already achieved the maternal, neonatal and child mortality SDGs, while Tajikistan and Kyrgyzstan had respectively achieved the maternal and child mortality SDGs (table 2). However, it is not possible to assess what portion of this progress could be directly attributed to the programmes implemented by GIZ,40 although these programmes are regularly evaluated, including assessments performed to the standards of the Organisation for Economic Co-operation and Development. These evaluations have limitations, despite continuous efforts to improve their quality. Programmes’ impacts are mostly measured by comparing data collected before and after the interventions, where data were collected by the programme teams ‘who know that it is in their benefit to minimize their failures and promote their successes’.19 Moreover, it is difficult to articulate the causal pathway between QI interventions, outcomes and impact on targeted populations’ health. More independent scientific research, embedded in bilateral cooperation programmes, is needed to measure the effectiveness of the selected QI approaches in terms of impact.41

Interestingly, USAID, which reviewed the QI methods used in their programmes in 2015, also concluded that there is a need for more research to assess the effectiveness of QI programmes.18 USAID has identified the six QI methods that account for about 80% of their total spending on quality of care.18 Four of these are widely used in GIZ-supported programmes—accreditation, SBM-R, supervision and clinical inservice training. The two other approaches (the Client-Oriented, Provider-Efficient Services (COPE) approach and Collaborative improvement) could fall into what we defined as systemic QI programmes. Rowe et al, who directed the most comprehensive and recent study on QI effectiveness,19 stated that ‘because of insufficient information about COPE^®, SBM-R, and accreditation, it was not possible to compare the effectiveness of the six target strategies [promoted by USAID]’.18 According to Rowe and colleagues, the success of a method or another depends more on its ‘suitability to a particular environment than to its technical merits’.19

Why and how to strengthen the programmes’ documentation?

The GIZ country teams have to report on their programme progresses, challenges and achievements to both their respective partner country and to the funding ministry, the BMZ. This documentation is shared at various levels of the health sector. In particular, it is shared during the joint health sector annual reviews, which involve the MOH and the external development partners. The GIZ documentation then serves to inform the health sector for its annual planning and budgeting exercises.

Robust, transparent and comprehensive reporting is therefore vital to understand the programmes’ impact, and effectively draw, interpret and build on the lessons learnt during their course. WHO and its research partners have developed a comprehensive tool to guide the reporting of sexual, reproductive, maternal, neonatal child and adolescent health programmes, taking into account the complex conditions in which they are implemented.42 During this review, we found that this tool was easy to use and effective in facilitating the reflection of our strategies.20 To illustrate the WHO tool’s effectiveness and the type of lessons learnt that can be drawn from case studies using this WHO standards, we report in box 1 the main lessons learnt in 2018 from the QI programme implemented in Tanzania. The full case studies of Nepal and Cambodia are in online supplementary files 3 and 4 to provide additional examples. We recommend the use of this WHO tool to organisations that need to better understand their underlying implementation challenges, identify their best practices, and opportunities for scaling up or replication in other contexts.

How sustainable are these quality improvement interventions?

GIZ works on health system strengthening, in the view of achieving the Universal Health Coverage, which requires long-term engagement. GIZ has long-standing relationships with partner countries and has acquired both technical and political know-how as well as a deep knowledge of its partner countries. Its programmes are built within national policies and therefore are in line with national goals and objectives. Technical expertise and capacity development are provided, often together with the provision of specific supplies. Moreover, before bilateral support ceases, GIZ develops with its counterparts adapted exit strategies.

Another factor of sustainability is that rather than focusing on single components of health systems, or on the health sector as a silo, GIZ implements programmes which account for the interactions between system components and also address the impact of other sectors, such as education or climate, on the performance of health systems.

Finally, GIZ believes that its multilevel approach, combined with good partner coordination, facilitates the institutionalisation of the implemented QI activities.