ethiopian-national-health-care-quality-strategy.pdf

ETHIOPIAN NATIONAL

HEALTH CARE QUALITY

STRATEGY

Transforming the Quality of Health Care in Ethiopia

2016 – 2020

ETHIOPIAN NATIONAL HEALTH CARE QUALITY STRATEGY l 2016 – 2020 i

Contents

Foreword: The Call to Action iv Acknowledgements vi Executive Summary vii

1. Background 1

1.1. Context of Quality Initiatives 1

1.2. Why Now? 2

2. Approach 3

3. Current State Analysis 5

3.1. Health of the Population: Priority Health Areas 5

3.2. Leadership and Functionality 6

3.3. Data Systems 10

4. Introducing the Ethiopian National Health Care

Quality Strategy: Quality in Ethiopia 11

4.1. Why do we have a national strategy for

improving quality in health care? 12

4.2. Defining Quality 12

4.3. Defining Quality in Ethiopia 13

4.4. Three Core Elements of Quality 13

4.4.1. Quality Planning 13

ETHIOPIAN NATIONAL HEALTH CARE QUALITY STRATEGY l 2016 – 2020ii

4.4.2. Quality Improvement 13

4.4.3. Quality Control 14

4.5. Ideal State of Quality in the Ethiopian Health

Care System 15

5. The Response 17

5.1. The Aim 17

5.2. Strategic Focus Areas 18

6. Making This Happen 30

6.1. The Commitments 30

6.2. Roadmap 34

7. Measuring Improvement 35

7.1. Introducing the Quality Indicator Framework 35

7.2. Populating the Quality Indicator Framework 37

7.3. Detailed Quality Indicator Framework 38

7.4. Testing and Improving Quality Indicators 45

7.5. Aspirational Indicators 46

8. Conclusion 47

ETHIOPIAN NATIONAL HEALTH CARE QUALITY STRATEGY l 2016 – 2020 iii

9. Appendices 48 Appendix A: List of Acronyms 48 Appendix B: Glossary of Terms 49 Appendix C: Collaborators and Stakeholder Interviews 52 Appendix D: Leadership and Functionality Detail 58 Appendix E: Data Systems Detail Analysis 75 Appendix F: Quality Improvement: Kaizen and the Science of Improvement 79 Appendix G: Indicator Data Sources 82 Appendix H: Alternative Quality Indicator Frameworks 83

Table of Figures Figure 1: Roadmap to Achieving Improved

National Quality 3 Figure 2: Ideal State of Quality in the

Ethiopian Health Care System 15 Figure 3: Strategic Focus Areas 18 Figure 4: Indicator Framework and how it maps to the Balanced Scorecard Framework 36

ETHIOPIAN NATIONAL HEALTH CARE QUALITY STRATEGY l 2016 – 2020iv

Foreword: The Call to Action

As policymakers, as healthcare professionals, and most importantly, as clients of the Ethiopian health care system ourselves, many of us are aware of the challenges in delivering reliable high quality healthcare to improve patient safety, effectiveness, and patient-centeredness in Ethiopia.

Despite significant improvements in health care services in recent years, inconsistent and unreliable quality of care is very rampant.

Ethiopia has achieved significant improvements in priority areas such as maternal and child health, malnutrition, communicable and chronic diseases, as well as in quality of emergency and surgical services. But this progress must accelerate in order to achieve the goals laid out in the Health Sector Transformation Plan (HSTP) of significantly improving the health outcomes in the next five years and meeting the expectations of the Ethiopian people.

A dramatic shift in the status quo requires a view to the entire system, to the issues facing health system leaders, practitioners, outreach workers, community members, and patients alike. This

Ethiopian National Healthcare Quality Strategy builds on the plan laid out in HSTP to further align key stakeholders across prioritized interventions that will drive large-scale improvement in quality of care delivery over the next five years. This will ultimately move Ethiopia towards our long-term goals of achieving the health outcomes of a lower-middle-income country by 2025 and of a middle-income country by 2035.1

Dramatic improvement in quality of health care services is within reach. This strategy provides a roadmap for addressing key quality challenges and for accelerating the improvement of health care quality nationwide. The ultimate aim is to consistently improve the outcomes of clinical care, patient safety, and patient-centeredness, while increasing access and equity for all segments of the Ethiopian population, by 2020. This is done by ensuring reliable, excellent clinical care, protecting patients, staff, and attendants from harm, and improving the efficiency of the delivery of care, while increasing access, equity and dignity of care for all segments of the Ethiopian population.

More specifically, this document spells out specific next steps to reach this aim, centred on four priority strategic areas, namely:

1. Health Sector Transformation Plan

ETHIOPIAN NATIONAL HEALTH CARE QUALITY STRATEGY l 2016 – 2020 v

1. Develop an integrated approach to planning, improving, and controlling quality

2. Activate key constituencies to advance quality

3. Drive improvements in quality by explicitly linking

Universal Health Coverage (UHC) strategy with quality

4. Support strong data systems and feedback loops as

“backbone” of all improvement actions The development of this strategic plan which is also informed by WHO guideline2 is the call to action, the opportunity to each make a difference in improving quality and equity for all Ethiopians.

Kesete-birhan Admasu Birhande (Dr.)

Minister

2. Quality of care: a process for making strategic choices in health systems. World Health Organization 2006

ETHIOPIAN NATIONAL HEALTH CARE QUALITY STRATEGY l 2016 – 2020vi

Acknowledgements

Stakeholders at all levels of the Ethiopian Health Care System contributed to this Quality Strategy. We gratefully recognize the providers, patients, community members, professional associations, regulatory agencies, Woreda Health Offices, and Zonal and Regional Health Bureaus who shared their insights into the state of quality of the health system. We also acknowledge the Bill and Melinda Gates Foundation which funded the development of this strategy and the Institute for Healthcare Improvement for their technical assistance in the development of the strategy. A full list of collaborators can be found in Appendix C.

For a list of acronyms and a glossary of terms used in this document, see Appendices A and B

ETHIOPIAN NATIONAL HEALTH CARE QUALITY STRATEGY l 2016 – 2020 vii

Executive Summary

Clarifying the Vision: The ultimate aim of the National Health Care Quality Strategy is to consistently ensure and improve the outcomes of clinical care, patient safety and patient-centeredness while increasing access and equity for all segments of the Ethiopian population.

This will result in safe, more effective, more accessible and more equitable care for every Ethiopian, all the time. All patients – regardless of age, geography, or income – will have equal access to reliable, excellent clinical care, which protects them from harm and treats them with dignity and respect.

Since the launch of the Health Sector Development Program (HSDP) in the 1990s, there have been significant achievements in improving health outcomes for the Ethiopian population, such as the reduction of child deaths by more than two-thirds over the past twenty years to meet Millennium Development Goal Four.

However, more work remains to be done. The National Health Care Quality Strategy will focus on improving quality across the spectrum of the health care system from prevention to palliative care, with special emphasis on the following five priority public health areas:

• Maternal Neonatal and child health, specifically reducing maternal and neonatal mortality

• Malnutrition, especially the prevention and management of severe acute malnutrition

• Communicable diseases, particularly malaria, HIV, and TB

• Non communicable diseases prevention and management, particularly diabetes, cancer, cardiovascular diseases, mental health, and chronic respiratory diseases

• Clinical and surgical services, particularly regarding timeliness of care

Achieving this Vision: In order to significantly improve the outcomes of these particular health areas, the National Health Care Quality Strategy prioritizes the following four key strategic focus areas:

• Develop an integrated approach to planning, improving, and controlling quality

• Activate key constituencies to advance quality

• Drive improvement in quality by explicitly linking UHC strategy with quality

• Support strong data systems and feedback loops as

“backbone” of all improvement actions

Executing this Vision: To successfully implement the National Health Care Quality Strategy, there are a number of key next steps. In particular, the National Health Care Quality Strategy

ETHIOPIAN NATIONAL HEALTH CARE QUALITY STRATEGY l 2016 – 2020viii

Executive Summary commits to three key infrastructural changes to improve the quality of our healthcare system:

1. Create a formal Quality Unit within the Ministry of Health to oversee the development of quality agenda through coordinated quality planning, QI and quality control, as well as related structures at all levels to support quality teams and expertise including making the HDAs QI teams., and be ultimately accountable for Quality in Ethiopia.

2. Build the quality expertise of dedicated personnel to drive this quality agenda within each FMoH Directorate, FMHACA, professional associations, Ethiopia Health Insurance Agency, Pharmaceutical Fund and Supply Agency (PFSA), and Core Processes of Regional Health Bureaus.

3. Develop quality structures and learning systems within every level of the system that are capable of delivering, improving and maintaining high levels of quality. These include the development of a Quality Team within each of the health facilities in both the private and public sectors, as well as within the community structure itself.

Roadmap Ahead: This National Health Care Quality Strategy reflects Ethiopia’s commitment to safer, more effective, more accessible, and more equitable care for every Ethiopian by 2020.

The document begins with an overview of previous quality initiatives in this country, an explanation of why a National Health Care Quality Strategy is needed now, and an outline of how the Strategy was developed. After examining the current state of quality, key strategic areas to reach our aim (including estimated resources) are outlined, as well as a roadmap and plan for execution that links strategy to action, and a proposed set of indicators to measure improvement.

The time is now for better, more equitable health care for all.

This is the National Health Care Quality Strategy’s commitment to every patient and every provider across each region in Ethiopia.

Let’s do this together.

ETHIOPIAN NATIONAL HEALTH CARE QUALITY STRATEGY l 2016 – 2020 1

1. Background

In order to achieve the health improvement goals stated in the Health Sector Transformation Plan, this Strategy builds on a number of quality initiatives and tools that have been developed and implemented over the last 20 years – all of which have been aimed at improving the quality of health care delivery and services. These quality improvement initiatives have not always been well coordinated and generally have lacked strategic guidance and uniformity across the sector and across the regions.

1.1. Context of Quality Initiatives

The Federal Ministry of Health (FMoH) has increasingly focused on improving the quality of care over the past 20 years. This is evident in the Health Sector Development Plan (HSDP) IV, which discusses various elements of quality including accelerating speed of delivery, improving service integration, avoiding missed opportunities, increasing effectiveness, enhancing patient safety, and ensuring the availability of resources together with program designs for prioritized diseases and conditions for better outcomes. Following cross-sectoral government initiatives such as Business Process Reengineering (BPR) and Balanced Scorecard, implementation of the reformed HMIS, the FMoH now promotes Kaizen, a quality improvement methodology adopted across multiple sectors in the country, as a means of achieving better health care and health outcomes.

The Ethiopian Hospitals Management Initiative, which started in 2006, is a pioneering initiative to introduce a standardized based quality approach. This subsequently progressed to Ethiopian Hospitals Reform Implementation Guidelines (EHRIG) incorporating the concepts of blue print for hospitals, the health care financing strategy and the Business Process Reengineering BPR. The hospital reform was supplemented by the introduction of Key Performance Indicators for hospitals through the hospital performance monitoring and improvement guideline in 2011.

The Ethiopian Hospitals Alliance for Quality (EHAQ) and Clean and Safe Hospitals initiative (CASH) are based on experiences in implementing Ethiopian Hospital Reform Implementation Guidelines (EHRIG).

The establishment of the Food, Medicine, Health Care Administration and Control Authority (FMHACA) enabled the development of various regulatory standards for the different levels of care at both private and public health facilities.

These initiatives have paved the way for the Health Sector Transformation Plan (HSTP), which has given due emphasis to quality through appropriate design for quality planning, quality control and quality improvement at all levels.

This National Health Care Quality Strategy builds on existing quality initiatives within our Ministry and across Regional

ETHIOPIAN NATIONAL HEALTH CARE QUALITY STRATEGY l 2016 – 20202

1. Background

Health Bureaus, Woredas, and development partners occurring across the country. To achieve coherence, the Strategy also creates a comprehensive framework that integrates all quality related initiatives under one “roof” for better coordination of efforts throughout the country and functions as a backbone for addressing “Quality and Equity” – the cornerstones of HSTP.

1.2. Why Now?

Given the tremendous work and interest in quality in Ethiopia, there is momentum around the role that quality can play in helping to achieve our national health goals. Through the HSDP, Ethiopia made great strides toward access to health care for its entire population. With that advance comes the increasing responsibility to plan, improve, and control the quality of the care being delivered and ensure that is being provided equitably.

Ethiopia stands at a crossroads in its ability to dramatically improve health outcomes – strengthened by the increasing push towards universal health coverage for primary care, the continued strength of the Health Development Army and the role it can play in the structure of quality improvement, and increasing public awareness of safety and quality problems in health care delivery.

Strategies for improving quality will help the existing health workforce and new health care professionals to better perform towards better health outcomes and will maximize use of available resources through better coordination of quality related initiatives. Given the concurrent launch of the Health Sector Transformation Plan which gives emphasis to Quality and Equity, this National Health Care Quality Strategy presents a timely and vital opportunity to accelerate the achievement of Ethiopia’s health goals.

ETHIOPIAN NATIONAL HEALTH CARE QUALITY STRATEGY l 2016 – 2020 3

2. Approach

Following the approach recommended by the World Health Organization, the strategy development process has been a collaborative effort led by the Medical Services Directorate (MSD) at the FMoH with the technical support of the Institute for Healthcare Improvement (IHI) and involvement of partners working on quality and other key stakeholders.3 Beginning with a Landscape Report conducted by FMoH and IHI in 2014 to better understand the landscape of quality improvement in Ethiopia, the six broad steps of the roadmap to achieving improved national quality are outlined below:

A core quality task force to this effect has been established under the Medical Services Directorate. Beginning with a document review of existing National Quality Strategies outside Ethiopia, as well as detailed quality documents within Ethiopia, the team conducted a series of interviews with stakeholders at the national, regional, and Woreda levels, utilizing a semi-structured interview guide around key areas of quality. These interviews were held to better understand the leadership and functionality system of quality in Ethiopia, the use of data systems and quality indicators, and existing quality initiatives.

Understand Catalyst and

Context

Understand Current State and Identify Priorities for Improvement

Define Scope

Identify Mechanisms to

Influence Quality System-Wide

Select Interventions/

Technical Methods

Implementation and Evaluation

Figure 1: Roadmap to Achieving Improved National Quality

3. World Health Organization, “Quality of Care: A Process for Making Strategic Choices in Health Systems”.

ETHIOPIAN NATIONAL HEALTH CARE QUALITY STRATEGY l 2016 – 20204

2. Approach

Site visits were conducted in multiple regions (including Addis Ababa, Oromia, Amhara, and SNNP) to better understand how quality translates at the facility and community levels, and how patients experience quality on a day-to-day basis.

In addition to individual interviews, one group interview and one stakeholder workshop were held with multiple Directorates within the FMoH to collaborate and co-create our aim and generate key drivers to impact this aim and improve quality.

This group interview and stakeholder workshop sought to better understand the main levers that various actors within the health care system have to influence and improve quality across all levels of the system.

In parallel, as indicated above, a task force on quality was developed within the FMoH, consisting of the Medical Services and Maternal and Child Health directorates of the FMoH, as well as key quality partners, including the Institute for Healthcare Improvement, Clinton Health Access Initiative, Jhpiego, and Abt Associates. This group met to discuss approach and content of the quality strategy. Throughout the process, the team consulted global experts in the field of national quality strategies, many of whom have helped other countries develop their own quality strategies.

The objective of this process has been to develop a comprehensive National Health Care Quality Strategy based on an understanding of the population health needs and the measured gaps in the health system in addressing the needs as well as working with leadership on the will to improve. The quality strategy strives to articulate a vision and aim for quality;

develop a plan to improve; and develop corresponding policies that lead to changes in health system performance, using quality planning, quality improvement, and quality control methods. The model balances the planning efforts needed to ensure strong systems, the control efforts that must be in place to ensure accountability and safety, and the bold improvement efforts needed to rapidly shift and transform performance at scale.

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3. Current State Analysis

This section provides an assessment of the health of the population and of the health system. Specifically, we examine the leadership and functionality elements that can be leveraged for a National Health Care Quality Strategy across all levels of the health system, as well as data systems that will serve as the backbone to any future quality improvement activities.

3.1. Health of the Population: Priority Health Areas

Ethiopia has made great strides in improvement of health outcomes for our population over the past 20 years. Notably, under-five mortality decreased from 204 per 1,000 live births in 1990 to 68 per 1,000 live births in 2013, thus achieving Ethiopia’s Millennium Development Goal Four. But challenges remain, in the maternal and child health (MCH) realm and beyond. We have identified five priority public health areas where the need is great and improvements in health care service quality have the potential to make a great impact on health outcomes. They are:

1. Maternal and Child Health: While under-five mortality overall has reduced significantly, the proportion of deaths that occur during the neonatal period are reducing at a slow rate.

Meanwhile, data on trends in maternal mortality show varied results, highlighting the need for improved data quality and increased attention. Thus, priority issues within MCH are the reduction of neonatal mortality though improving the prevention and management of top causes of mortality (e.g.

asphyxia and neonatal sepsis), and the reduction of maternal mortality through improving the prevention and management of top causes of death (e.g. postpartum hemorrhage).

Furthermore, there are great strides to be made with regard to dignity and respect in maternity care. To improve quality in this realm, it is essential that we focus on the patient- and family- centeredness of care.

2. Nutrition: Ethiopia has the highest rate of malnutrition in Sub- Saharan Africa, affecting 40% of the country’s children.4 Our priority area is the reduction of child mortality through the prevention and management of severe acute malnutrition.

3. Communicable Diseases: Priority areas within communicable disease are HIV/AIDS, malaria, and tuberculosis (TB), with a focus on reducing the incidence of these diseases. Remarkable progress has been made to reduce prevalence and incidence of HIV/AIDS, however 750,000 people still live with the disease in Ethiopia. After years of overall decline, multi-drug resistant TB rates showed an alarming increase between 2005 and 2014.

And while no major malaria epidemics have been reported in the country since 2003/2004, about 70% of the population continues to be at risk. Reduction in the incidence among targeted groups (MARPS and Youth) and expansion of option

4. Mini DHS 2014

ETHIOPIAN NATIONAL HEALTH CARE QUALITY STRATEGY l 2016 – 20206

B+ for elimination of mother to child transmission of HIV are focus areas for the strategy.

4. Chronic Diseases: Non-communicable chronic diseases account for 30% of deaths in Ethiopia in 2014. Our priority within chronic diseases is prevention and treatment of acquiring disease, as well as prevention of associated morbidity, through addressing risk factors such as physical inactivity, unhealthy diet, alcohol consumption and cigarette smoking. Specific target illnesses are diabetes, cancer, cardio-vascular disease, mental health, and chronic respiratory disease.

5. Clinical and Surgical Services: Improvements in emergency services at hospitals and health centers, particularly for clinical and surgical services, are a priority to ensure that the population of Ethiopia has confidence in its health system to provide high quality care.

3.2. Leadership and Functionality

In the current state assessment of the role of Leadership and Functionality in driving quality, stakeholders at the national, regional, zonal and Woreda levels, as well as within facilities and the community, were analyzed with respect to quality improvement. By analyzing the strengths and challenges at each level, mechanisms were identified that can be utilized in Quality Planning, Quality Control and Quality Improvement. Through this process, an ideal state of the Ethiopian health system has been developed, outlined in the table on the following pages.

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Level of Health System

Current State Mechanisms to Influence Quality Future State

National • Existence of policies, guidelines and some tools to assess quality

• Existence of regulatory bodies (FMHACA) developing minimum standards and guidelines (e.g. EHRIG, standards, key performance indicators)

• No common understanding or vision of quality among leadership

• Inadequate mechanisms to ensure timeliness and availability of supplies and procurement and maintenance of equipment

• Disconnect between standards and ability to achieve them

• Integrated Supportive Supervision (ISS) is provided to facilities who do not meet Lots Quality Assurance Sampling (LQAS) assessment criteria

• Private sector and public sector are not always held to the same criteria or standards

• Defined protocols exist, but enforcement of standards is inconsistent and punitive measures have not been defined

• Government, rather than partners, is main driver of quality initiatives, leading to unified understanding of needs and goals

• Provision of partner expertise and resources

Quality Planning

• Policy development

• Planning process for programmatic implementation

Quality Control

• Standards and regulations development and enforcement

• Qualification, licensing, trainingb and accreditation of laboratories, professionals, facilities

Quality Improvement

• Strategize with NGOs to drive nationwide

QI initiatives

• Harmonized standards (e.g. hospital) with institutionalized quality control mechanisms to ensure minimum standards are met

• Standards and action plans or punitive measures enforced consistently for underperforming facilities

• Leadership within the health system has a common definition and vision for quality and is knowledgeable in quality assurance and improvement approaches

• Quality structures will be instituted and strengthened at all levels of the health care system

• Necessary and appropriate equipment, medicines and reagents are readily available with systems in place to mitigate stock-outs of supplies and breakdown of equipment

• Successful quality improvement programs scaled to cover facilities beyond hospitals nationwide(e.g.

EHAQ, initiatives for priority conditions and diseases)

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Health System

Current State Mechanisms to Influence Quality Future State

Regional, Zonal and Woreda

• Recognition of well-performing facilities, leading to sharing of best practices at regional (and national) forums

• Supportive supervision provided to facilities

• Difficulty in driving initiatives in settings with minimal management support or commitment; need for strong champions and quality mentoring

Quality Planning

• Regional priority setting

• Resource distribution

• Ensure system for providing capacity and capability to drive quality

Quality Control

• Clinical audits and inspections of health facilities

• Licensing for private hospitals

• Data and reporting standards and requirements development

Quality Improvement

• Supportive supervision as a QI mentoring and learning system

• Focused improvement efforts around high priority topics using QI methods and learning systems

• Strengthened leadership across regional, zonal and woreda levels of the health system, trained in quality improvement methods

• Insurance claims data is used to identify quality challenges

• Leverage two-way data feedback loop to develop focused quality improvement activities

• Financial and technical assistance may be provided for public and private facilities to implement quality improvements

Facility Based Care

• Some facilities and centers successfully implemented EHRIG standards and established quality structures

• Hospitals performing well based on KPIs and clinical audits chosen as LEAD hospitals and provide mentorship to EHAQ member hospitals

• Inadequately staffed facilities due to staff attrition / turnover, absenteeism, lack of motivation or incentives

Quality Control

• External Quality Assurance

• Collecting, analyzing and reporting data

Quality Improvement

• Best practice sharing

• Conducting QI peer-learning sessions

• Workforce motivation and training

• Designing activities based on community involvement and feedback

• Sharing best practices with EHAQ member hospitals lead to sustained increased performance and quality in the selected focus areas

• Motivation and alignment of incentives for providers and professionals (individuals and teams) to improve;

accountable to quality assessment data

• Facilities have low turnover and more satisfied employees

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Health System

Current State Mechanisms to Influence Quality Future State

Facility Based Care (continued)

• Provider basic skill gaps limit ability to provide quality patient care; capacity of hospitals for practicums is low, limiting hands-on experience

• Quality improvement concepts are not covered in medical school/pre-service training or CME

• Healthcare professionals may not be “fit to practice” but are not reviewed once accredited/licensed

• Facilities may continue to provide services even though they are unable to meet minimum standards

• Limited physician engagement in quality

• Strong clinical and QI skills are developed through pre-service and continuing medical education for all health care providers

• Career path for Health Extension Workers

• All facilities have uniform mechanisms to capture and act on patient feedback

• Empanelment of facilities is linked to quality, leveraging health insurance coverage expansion

• More emphasis given to clinical quality beyond administration

Community and Patients

• Increased community awareness is leading to demand for quality services

• Health Development Army (HDA) members within the community are key links between patients and the Health Extension Workers

• Lack of trust due to inconsistency in provider / patient service interaction; fear and lack of education of health worker treatments leading to low uptake in healthcare utilization

• Patients do not have access to rankings/ grades of facilities they plan to visit, based on quality

Quality Control

• Patient Feedback

Quality Improvement

• Leveraging HDA as quality improvement teams

• Leveraging HDA to educate patients and community around quality care

• HDA act as QI teams

• Continuous Quality Improvement is institutionalized through public forums facilitated by the HDA

• Active patient rights charter

• All patients and communities have access to quality health care, information (e.g. service availability) and clear communication with providers and facilities

• Community Endorsement Groups, comprised of citizens that assess areas that impact quality, linked with the HDAs

Additional detail on the assessment of Leadership and Functionality, mechanisms to influence quality, and implications to the National Health Care Quality Strategy, can be found in Appendix C.

ETHIOPIAN NATIONAL HEALTH CARE QUALITY STRATEGY l 2016 – 202010

3.3. Data Systems

Accurate, reliable data are crucial to improving health outcomes.

A functioning data system will help to inform program planning, policy initiatives and support ideal health outcomes thereby making the data actionable. The effort continues to strengthen Ethiopia’s health information system at all levels of the health care network. A comprehensive review of the health management information system (HMIS) was conducted to improve data accuracy, timeliness of reporting and data completeness. The community health information system (CHIS) that is used by health extension workers (HEW) to capture granular level data at the user level that is the community, household and individual was also reviewed.

Although there has been a revision of the HMIS indicators to support greater usability and to enhance comprehensiveness and standardization, high quality data remains a challenge.

Much of this stems from poor capacity building of users of the data system at all levels of the health system, a lack of feedback loops of information that could support improvement and poor documentation leading to poor reporting performance.

Although HMIS is the main source of hospital and clinical data for the health sector, additional data sources exist, which have been considered in this National Health Care Quality Strategy.

This also includes data sources that can be found outside of the health sector, but still have a major impact on health such as education, infrastructure, water and sanitation. Data to measure the effectiveness of the Ethiopian health system comes primarily from the following sources:

Data Source Frequency of Data Collected

Health Management Information System (HMIS) Monthly

Key Performance Indicators (KPIs) Monthly

Ethiopia Demographic and Health Survey (EDHS) Every five years

Community Health Information System (CHIS) Monthly

Surveys Provisional Assessment (SPA) Every two years

Additional detail on the assessment of Data Systems, as well as implications to the National Health Care Quality Strategy, can be found in Appendix D.

Based on this current state analysis on the health status of the population, leadership and functionality, and data systems, it is clear that opportunity exists for a national quality strategy to integrate policies and actions, while leveraging key strengths that already exist in the system.

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Quality Planning Sporadic Spike

Quality Control

Chronic Loss

Lessons Learned

New Zone of Quality Control

Design

Q ua lit y

Im pr ov em en t

4. Introducing the Ethiopian Nati onal Health Care Quality Strategy: Quality in Ethiopia

ETHIOPIAN NATIONAL HEALTH CARE QUALITY STRATEGY l 2016 – 202012

4. Introducing the Ethiopian National Health Care Quality Strategy: Quality in Ethiopia

4.1. Why do we have a national strategy for improving

quality in health care?

The role of a strengthened health quality framework and strategy is to ensure that national policies, guidelines, and protocols around quality are reliably implemented, building off the extensive resources and infrastructure that the government has already put in place, thereby accelerating Ethiopia’s efforts to close remaining gaps in health outcomes and ensure equity for our diverse population.

The national health care quality strategy is directly aligned with the HSTP. Far from a standalone strategy, this Ethiopian National Health Care Quality Strategy builds on existing quality initiatives and policies, recognizing the role of multiple actors already engaged in the quality mission including the FMOH, RHBs, Woreda Health Offices, health facilities, communities and development partners and the specific quality initiatives that have been undertaken by multiple actors including MSD, FMHACA, and multiple NGOs.

4.2. Defining Quality

To date, there is no universally accepted definition of “quality.”

Within the global health care community, the definition from the US Institute of Medicine (IOM) is generally used: “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”5 Within a similar framework, Dlugacz, Restifo, and Greenwood (2004) define quality more specifically to be “care that is measurably safe, of the highest standard, evidence-based, uniformly delivered, with the appropriate utilization of resources and services.”

There are six generally accepted dimensions, or aims, of quality, as laid out by the IOM6:

Safe: avoiding injuries to patients from the care that is intended to help them; the WHO defines “patient safety” as the prevention of errors and adverse effects to patients associated with health care

Effective: providing services based on scientific knowledge to all who could benefit, and refraining from providing services to those not likely to benefit

Patient-centered: providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions

Timely: reducing waits and sometimes harmful delays for both those who receive and those who give care

5. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC, USA: National Academies Press; 2001.

6. Ibid.

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Efficient: avoiding waste, including waste of equipment, supplies, ideas, and energy

Equitable: providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status7

4.3. Defining Quality in Ethiopia

In Ethiopia, as highlighted in the HSTP, quality and equity are defined together, believing that the two must go hand-in-hand.

Through various consultative processes, the domains that have been prioritized in this Strategy are: safe, effective, patient-centered, efficient, accessible, comprehensive, affordable, and timely. With these prioritized domains, quality in Ethiopia is defined to be:

“Comprehensive care that is measurably safe, effective, patient-centered, and uniformly delivered in a timely way that is affordable to the Ethiopian population and appropriately utilizes resources and services efficiently.”

4.4. Three Core Elements of Quality

In drilling deeper into quality, it is helpful to spell out the three core elements of quality, namely quality planning, quality improvement, and quality control. Leveraging all three pillars in a holistic way is one of the key foundations of this National Health Care Quality Strategy.

4.4.1. Quality Planning

Quality planning brings systems thinking to the highest levels of leadership and governance. It responds to the measured gap between what the population needs, and what is currently being delivered in the health system. It then establishes the goals, policies and strategy to close this gap, and ensures that the resources are allocated to do this effectively. Quality planning involves designing a structure that delivers the right care to patients at the right time, every time.

4.4.2. Quality Improvement

Quality improvement (QI) is a continuous process whereby organizations iteratively test and measure changes in work routines, set and achieve ambitious aims, shift whole system performance, and spread best practices for rapid uptake at a larger scale to address a specific issue or suite of issues they have determined to improve. One useful way to define quality improvement is: “…the combined and unceasing efforts of everyone—health care professionals, patients and their families, researchers, payers, planners, and educators—to make the changes that will lead to better patient outcomes (health), better system performance (care), and better professional

7. Ibid.

ETHIOPIAN NATIONAL HEALTH CARE QUALITY STRATEGY l 2016 – 202014

4. Introducing the Ethiopian National Health Care Quality Strategy: Quality in Ethiopia development (learning).”8 Quality improvement begins with an identification of a clear aim statement or charter, to answer the question: “What are we trying to accomplish?” Several overlapping and complementary QI models exist, which all stem from the “Science of Improvement” that starts with an aim and develops tests towards improvement. These include Lean, Six Sigma, Kaizen, and the Model for Improvement. In Ethiopia, Kaizen is thought of as the engine driving improvement, while the Model for Improvement can be seen as the “vehicle” that provides structure for improvement. Specifically, Kaizen focuses on improving efficiency and lowering cost, through a methodology that can be integrated with other complementary quality improvement tools and approaches, such as the Model for Improvement. At the heart of both methodologies are small rapid tests of change that lead to sustained improvement (more details on Kaizen and the Model for Improvement can be found in the Appendix E).

4.4.3. Quality Control

Quality control (QC), is a normative process that includes quality assurance, where a system seeks to ensure that quality is maintained or improved, and errors are reduced or eliminated. QC programs evaluate current health care quality, identify problem areas, create a method to overcome issues, and monitor the method taken to improve quality.9 Processes consist of both internal quality assurance and external quality assurance. For instance, these monitoring and improvement activities may be internally motivated (problems are identified and addressed from within a health care facility by a facility based QI team) or externally required (standards are set, and problems are identified through inspection by government agencies (woreda, zone, region, federal).10

8. Batalden PB, Davidoff F. What is “Quality Improvement” and how can it transform healthcare? Quality and Safety in Health Care. 2007;16(1):2-3. doi:10.1136/qshc.2006.022046.

National Center for Biotechnology Information. Quality Assurance, Health Care. National Center for Biotechnology Information. http://www.ncbi.nlm.nih.gov/mesh/?term=healthcare+quality+assurance.

9. Accessed January 14, 2014.

10. Donabedian A. An Introduction to Quality Assurance in Health Care. New York, NY: Oxford University Press, Inc.; 2003.

ETHIOPIAN NATIONAL HEALTH CARE QUALITY STRATEGY l 2016 – 2020 15

4.5. Ideal State of Quality in the Ethiopian Health Care System By eff ecti vely leveraging all three elements of Quality Planning, Quality Improvement, and Quality Control, the following elements are identi fi ed as the “ideal” state of quality in the Ethiopian health care system:

Shared vision for quality Integrati on of quality throughout system and key program Data used for improvement

• Leadership within the health system has a common understanding and vision for quality, and is knowledgeable in QA and QI approaches

• All stakeholders work together to develop policies and harmonized standards and guidelines; insti tuti onalized quality control mechanisms to ensure minimum standards are met

• Quality teams exist at all levels of the health system

• Necessary and appropriate equipment, medicines and reagents are readily available with systems in place to miti gate stock outs of supplies and breakdown of equipment

• Standardize enforcement of acti on plans for private and public faciliti es, if minimum standards are not met

• Successful QI programs scaled to cover faciliti es beyond hospitals nati onwide (e.g. EHAQ, initi ati ves for priority conditi ons and diseases)

• Principles of QI and data use are incorporated within each priority programmati c area

• Key quality indicators identi fi ed across existi ng reporti ng (e.g. HMIS, DHS, etc) to assess quality across system

• Core set of indicators reported publicly

• Strong leadership and communicati on across nati onal, regional, zonal and woreda levels

• Financial and technical assistance provided for public and private faciliti es to implement quality improvements

• Insurance claims data is used to identi fy quality challenges

• Two-way data feedback loop is leveraged to develop focused quality improvement acti viti es

• HDA act as QI teams

• Conti nuous Quality Improvement is insti tuti onalized through public forums facilitated by the HDA

• Acti vate pati ent rights charter

• All pati ents and communiti es have access to quality health care, informati on (e.g. service availability) and clear communicati on with providers and faciliti es

• Community Endorsement Groups that assess areas that impact quality

• Sharing best practi ce with EHAQ member hospitals lead to increased performance and quality in the selected focus areas

• Strong clinical and QI skills are developed through pre-service and conti nuing medical educati on for all health care providers

• Faciliti es have low turnover and more sati sfi ed employees

• Career path for Health Extension Workers

• Health Insurance coverage scheme expansion is leveraged by linking empanelment of faciliti es to quality

• Health care faciliti es are capable of identi fying and prioriti zing local level data

• All faciliti es have uniform mechanisms to capture and act on pati ent feedback

• Individuals moti vated and incenti vized around quality; accountable to quality assessment data

• Moti vati on and alignment of incenti ves for providers and professionals (individuals and teams) to improve

Leadership Data used for improvement

Informati on sharing Educati on and development Leveraging insurance expansion Data / incenti ves used to drive improvement

Leverage HDA Acti vate pati ents and community

Nati onal

Regional Zonal and Woreda

Facility Based

Community and

Pati ents

Figure 2: Ideal State of Quality in the Ethiopian Health Care System

ETHIOPIAN NATIONAL HEALTH CARE QUALITY STRATEGY l 2016 – 202016

To reach this ideal state of quality across Quality Planning, Quality Improvement, and Quality Control, this Nati onal Health Care Quality Strategy prioriti zes four strategic focus areas to reach the collecti ve aim, namely:

Develop an integrated approach to planning, improving, and controlling quality

Drive improvement in quality by explicitly linking Universal Health Coverage (UHC) strategy with quality

Acti vate key consti tuencies, parti cularly to moti vate workforce, build leadership across all levels, and acti vate pati ent and community demand for quality

Support strong data systems and feedback loops as “backbone” of all improvement acti ons.

4. Introducing the Ethiopian Nati onal Health Care Quality Strategy: Quality in Ethiopia

ETHIOPIAN NATIONAL HEALTH CARE QUALITY STRATEGY l 2016 – 2020 17

5.1. The Aim

The aim of this Nati onal Health Care Quality Strategy is to consistently improve the outcomes of clinical care, pati ent safety, and pati ent-centeredness, while increasing access and equity for all segments of the Ethiopian populati on, by 2020.

The approach to do this rests on the following four key strategic focus areas, represented in the dark blue boxes below. Within each focus area, the ideal state is described, along with prioriti zed interventi ons, proposed owners, ti meline, success indicators, and a resource esti mate. The proposed indicators measure success of this parti cular key strategic focus area.

5. The Response

Develop Acti vate Drive SupportActi vate Drive

ETHIOPIAN NATIONAL HEALTH CARE QUALITY STRATEGY l 2016 – 202018

Acti vate key consti tuencies to advance quality

• Develop, strengthen, and moti vate workforce towards conti nual achievement of safe and equitable care

• Build leadership across all levels of the health system who see quality as priority

• Acti vate pati ent and community demand for accessible and equitable quality services, while providing pati ent-centered care

Figure 3: Strategic Focus Areas

Drive improvement in quality by explicitly linking

UHC strategy with quality

• While expanding health insurance scheme coverage across all regions, ti e empanelment of faciliti es to quality

• Develop performance agreements with faciliti es and Health Insurance Agency that include quality and improvement

• Introduce a mix of incenti ves and disincenti ves to promote improved quality outcomes

• Refi ne and insti tuti onalize quality control mechanisms to ensure minimum standards of safety and quality are met

• Launch nati onwide results-focused quality improvement initi ati ves focused on system transformati on

• Strengthen quality planning throughout system to ensure adequate inputs for quality

Develop an integrated approach to planning, improving, and controlling quality approach to planning, improving, in quality by explicitly linking

Support strong data systems and feedback loops as “backbone” of all improvement acti ons

• Develop a reliable and transparent reporti ng system for key indicators that conti nuously inform planners, providers, and the public about the quality of the Ethiopian health system

• Uti lize data to inform quality improvement opportuniti es as health insurance coverage and access increase

5.2. Strategic Focus Areas

ETHIOPIAN NATIONAL HEALTH CARE QUALITY STRATEGY l 2016 – 2020 19

1. Strategic Focus Area #1:

Develop an integrated approach to planning, improving, and controlling quality.

Ideal State:

Quality planning, quality improvement and quality control are integral parts of the routi ne system at both health administrati ve and health facility structures across the health sector. This includes the enforcement of all set standards, development and executi on of clinical standards for each type of service, and a culture of conti nuous quality improvement across all actors of the health sector which is guided by planning for quality during strategic and operati onal planning processes.

Prioriti zed Interventi ons:

1.1. Refi ne and insti tuti onalize quality control mechanisms to ensure minimum standards of safety and quality are met

1.1.1. Provide support for public and private faciliti es to improve quality

a. Conduct analysis of gaps identi fi ed through assessment of regulatory standards and prepare acti on plan at nati onal, regional, and facility levels and act accordingly

b. Provide support to help faciliti es who fail accreditati on/empanelment to improve quality

c. Enforce standards and protocols when faciliti es (public and private) do not meet minimum guidelines and standards

d. Moti vate and provide incenti ves for faciliti es to adhere to regulatory standards and improve

e. Build system of governance and accountability around meeti ng regulati on standards

1.1.2. Harmonize hospital standards between FMoH/MSD and FMHACA standards

a. Introduce clinical protocols and treatment guidelines and ensure adherence by introducing clinical governance

1.2. Launch nati onwide results-focused quality improvement initi ati ves focused on system transformati on

1.2.1. Build on EHAQ initi ati ve to cover health faciliti es beyond hospitals, focused on peer-based quality improvement

a. Provide assistance to support improvement in the form of “lead faciliti es” and peer learning

b. Provide quality improvement training to raise levels of capability among clinicians, pharmacists, and lab technicians at all levels of care

Develop

ETHIOPIAN NATIONAL HEALTH CARE QUALITY STRATEGY l 2016 – 202020

Prioriti zed Interventi ons:

c. Develop performance management systems to build the management skills of healthcare leaders

d. Build on EHAQ to include networks of laboratory and pharmacy, as well as private faciliti es and health centers towards the goal of shared learning and the pursuit of shared aims, linked to clear improvements in quality care

1.2.2. Implement quality improvement initi ati ves for priority health conditi ons and diseases like maternal and child health;

malnutriti on; communicable diseases; chronic/non-communicable diseases; and clinical and surgical services.

a. Uti lize collaborati ve model to address priority issues nati onwide, comprised of a group of peer faciliti es that use QI approach for improvement and peer learning

b. Develop…