How to Improve Health in Low and Middle Income Economies

A Call to Action
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Health care interventions that are known to work and save lives are not being implemented for every patient every time. Despite improvements that have been made in health care, many resource-constrained lower- and middle-income countries are far from being on track to attain their Millennium Development Goals (MDGs). For example, currently, only 23 countries are estimated to be on track for achieving the 75% maternal mortality reduction goal by 2015. We must address this gap between knowing and doing.

Quality improvement methods enable us to re-organize care delivery and public health to enhance survival and well-being for this and future generations. Through identifying opportunities to implement best evidence, streamline and change processes of health care delivery, quality improvement (QI) approaches strengthen systems to yield better results. QI methods emphasize changes in the systems of delivering health care, rather than the provision of additional resources.

We, the participants at the Salzburg Global Seminar on “Making Health Care Better in Low and Middle Income Countries” (April 22-27, 2012), came together from 33 countries to address the critical gap between our knowledge of interventions that improve population health and the care actually provided to patients and to drive the quality improvement and patient safety agenda forward.

We urge international, regional and national stakeholders (governments, health policy leaders, communities, development partners, non-governmental organizations, health care workers and patients) to promote improvement in the quality of health for the world’s populations and to assure their health, survival, and wellbeing now and for future generations. We hereby propose and commit to the following recommendations:

We call on governments to be accountable for the improvement of health care through legislation, policies and necessary resources.

We call on governments to:

• Develop a strategic plan for the improvement of health care which includes coordination and collaboration across ministries with support for innovation.
• Develop a legislative framework for continuous improvement of evidence-based programming.
• Provide financial, human and material resources for health care improvement.
• Add quality and safety improvement methodology to medical, nursing and allied health education curricula.
• Use appropriate mechanisms to coordinate the structure, finances and communication policy for working with international donors.
• Establish dedicated advocacy and accountability mechanisms and transparent data reporting systems for quality in health care for the population.
• Develop a common terminology, implementation design and reporting format for quality improvement, in cooperation with non-governmental organizations, those providing technical assistance and development partners.

We call on health policy leaders to adopt and promote quality improvement as a cornerstone of better health for all.

We call on health policy leaders to:

• Provide leadership and direction for all countries to incorporate quality improvement initiatives as an essential part of health delivery systems to promote survival and well-being.
• Promote interventions that incorporate the of use quality improvement approaches to implement evidence-based, high impact, cost-effective, and client-centered approaches to close the gap between what we know and what we do.
• Encourage global and national leaders to take specific steps to promote quality improvement approaches for countries that are struggling to meet the MDGs.
• Encourage all countries to commit to adopt the culture and science of improvement for all new and existing health programming around the world.

We call on communities to actively advocate for quality health care as part of their rights and responsibilities.

We call on communities to:

• Get involved in improving health care at all levels, and actively participate in analyzing information, planning, implementing and evaluating higher quality health care services.
• Be aware of and promote national and international laws to make health care quality better.
• Hold governments accountable for compliance with national and international laws and policies to improve health care quality.
• Advocate actively for the leverage of resources to improve health care, as well as broader quality improvement initiatives.
• Take increased responsibility for the health of families in their communities through health promotion, prevention, seeking health care when appropriate and healthy lifestyles.

We call on development partners to invest in approaches that drive sustainable context-specific improvements in global health.

We call on development partners to:

• Harmonize development partner approaches in quality improvement from concept to evaluation, based on quality improvement principles.
• Develop a common terminology, implementation design and reporting format for quality improvement, in cooperation with on non-governmental organizations and those providing technical assistance and governments.
• Use these common approaches according to specific needs, locally, regionally and globally.
• Ensure these common approaches meet the needs and expectations of the community.
• Promote sustainability as the cornerstone of programming and execution, specifically:
  • Build leadership at all levels.
  • Use quality improvement approaches to address both effectiveness and efficiency of health care interventions.
  • Engage civil society and community in improvement activities.
  • Start with evidence based approaches and continue to refine these approaches based on results.
  • Provide all workers within the system with appropriate training, tools and incentives to improve health care quality.

We call on non-governmental organizations and those providing technical assistance in global health to incorporate evidence-based improvement methods in their work.

We call on those that provide technical assistance to:

• Support country-owned strategies for improvement.
• Develop a common terminology, implementation design and reporting format for quality improvement, in cooperation with development partners and governments.
• Share designs, tools and results freely among all stakeholders for mutual learning.
• Provide designs with the following features: sustainability, country ownership, strong national data systems, scalability, and high impact.
• Ensure that quality improvement interventions are well evaluated.
• Build the capacity of countries to engage in quality improvement approaches through pre- and in-service training.
• Produce evidence for the effectiveness of quality improvement and its adaptability to different countries’ needs.
• Align quality improvement designs with country needs for equity.

We call on health care workers to continuously improve the delivery of expert and compassionate care to patients, their families and communities.

We call on health professionals, managers, allied health care workers and educators to:

• Be actively engaged in improving the quality of the care they deliver.
• Work towards better health outcomes by meeting evidence-based standards and applying improvement methods to make care more patient- and family-centered as well as culturally appropriate.
• Document local improvement efforts to generate and share new knowledge.
• Incorporate quality improvement into the education and training of all health care workers, at all levels.
• Train and mentor leaders of the future to make improvement part of the culture of health care.

We call on patients to be empowered and at the forefront of promoting a shared vision for better health for all.

We call on patients and patient groups to:

• Be involved in the decision-making process of health care delivery, including during their visit to health care facilities.
• Develop a better understanding of their rights and responsibilities to receive better health care, and a respect for the rights of other patients and health care professionals.
• Utilize the health care services to their best advantage and feel ownership of the health care system and infrastructure.
• Be fully informed about their condition and to feel empowered to inform providers of any potential risks that arise whilst receiving care.
• Develop knowledge and skills to manage their own health problems appropriately, practise healthy behaviour and maintain safe living conditions.

Salzburg Global Seminar: Making Health Care Better in Low and Middle Income Economies: What are the next steps and how do we get there?, 
April 22-27, 2012 (Session 489)

Further details: http://www.SalzburgGlobal.org/go/salzburgstatement-info

The views expressed in this Statement are those of session participants individually and should not be taken to represent those of any organizations to which they are affiliated

PARTICIPANTS:

Bruce Agins (USA), NYAIDS Institute/ HealthQual | Ahmed Ahmed (Kenya), Department of Children’s Services | Mirwais Amiri (Afghanistan), USAID Health Care Improvement Project | Dorcas Amolo (Kenya), University Research Co. LLC | J. Koku Awoonor-Williams (Ghana), Ghana Health Service | Charles Nde Awasom (Cameroon), Director Bamenda Regional Hospital, Ministry of Public Health | Cynthia Bannerman (Ghana), Department of Health | Pierre M. Barker (USA), Institute for Healthcare Improvement | Viktor Boguslavsky (Ukraine), University Research Co. LLC, Representative Office | Maina Amsagana Boucar (Niger), USAID-HCIURC | Sarah Byakika (Uganda), Ministry of Health | Tracey Cooper (United Kingdom), Health Information and Quality Authority | Nils Daulaire (USA), U.S. Department of Health and Human Services | Josephine Diabate Conombo (Ivory Coast), Ministry of Health and AIDS Control | Sir Liam Donaldson (United Kingdom), WHO Envoy for Patient Safety | Ezequiel Garcia-Elorrio (Argentina), International Journal for Quality in Healthcare | Justice Gweshe (Namibia), Ministry of Health and Social Services | James Heiby (USA), USAID | Jorge Hermida (Ecuador), URC/CHS Health Care Improvement Project | S. Hussain Jafri (Pakistan), Alzheimer’s Pakistan | Robinah Kaitiritimba (Uganda), Uganda National Health Users (UNHCO) | Aigul Kalieva (Kyrgyzstan), Ministry of Health | Shirin Kazimov (Azerbaijan), USAID/Azerbaijan | Edward Kelley (USA), World Health Organisation | Anna Korotkova (Russian Federation), Federal Research Institute for Health Care Organisation | Natalia Largaespada Beer (Belize), Ministry of Health | Sheila Leatherman (USA), University of North Carolina at Chapel Hill | John Lotherington (United Kingdom), Salzburg Global Seminar | Saidou Mallam Ekoye (Niger), Ministry of Public Health | M. Rashad Massoud (USA), University Research Co. LLC | Kedar Mate (USA), Institute for Healthcare Improvement | Humphrey Megere (Uganda), University Research Co. LLC | Nana Mensah-Abrampah (USA), University Research Co., LLC | Baile Moagi (Botswana), Ministry of Health | Nanthalile Mugala (Zambia), ABT Assoc/Zambia Integrated Systems Strengthening Program | Antonio Mujovo (Mozambique), MOH Mozambique | Saleh Nagi (Yemen Arab Republic), GIZ, Yemen | Babacar Ndoye (Senegal), Pronalin | Jean Nguessan (Ivory Coast), University Research Co. LLC | Khoa Nguyen (Vietnam), Medical Services Administration | Duangta Onsuwan (Thailand), Bureau of Health Administration | Tatiana Paduraru (Moldova), Ministry of Health of the Republic of Moldova | Amit Paliwal (India), Initiatives Inc. | Rob Palkovitz (USA), University of Delaware | Carlo Irwin Panelo (Philippines), University of the Philippines | Leonardo Pinzón (Philippines), Inter-American Development Bank | Januario Reis (Mozambique), USAID Mozambique | Nigel Rollins (United Kingdom), World Health Organisation | Andrei Romancenco (Moldova), Ministry of Healthcare of the Republic of Moldova | Enrique Ruelas (Mexico), Institute for Health Care Improvement | Ayman Sabae (Egyptian), The Family Clinic | Bernarda Salas Moreira (Ecuador), Metropolitan Health Secretary, Quito Municipality | Sylvia Sax (Canada), University of Heidelberg | Anuwat Supachutikul (Thailand), The Healthcare Accreditation Institute | Mary Taylor (USA), The Bill and Melinda Gates Foundation | Michelle Vanzie (Belize), Ministry of Health | Vireak Voeurng (Cambodia), Ministry of Health | Mekhriniso Yuldasheva (Tajikistan), Ministry of Health

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Making Health Care Better in Low and Middle Income Economies: What are the next steps and how do we get there? - April 2012

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