Ethiopian_National_Healthcare_Quality_and_Safety_Strategy_Final_draft-July122021 (2) (2).pdf

NATIONAL HEALTHCARE QUALITY AND SAFETY STRATEGY (NQSS)

2021-2025

(2013-2017 EFY)

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TABLE OF CONTENTS

FOREWORD ........................................................................................................................... iii

1 ACKNOWLEDGMENTS ................................................................................................ vii

2 EXECUTIVE SUMMARY ............................................................................................ viii

3 INTRODUCTION

3.1 Background

3.2 Rationale

3.3 Approach

3.4 Framework, Elements, Definition, and Dimensions of High-Quality Healthcare

3.5 Core Elements of Quality Management

3.5.1 Quality Planning

3.5.2 Quality Improvement

3.5.3 Quality Control

3.6 Definition and Dimensions of Quality

3.6.1 Healthcare quality

3.6.2 Healthcare safety:

3.6.3 Dimensions of Quality

4 CURRENT STATE ANALYSIS

4.1 Healthcare outcomes

4.2 Experience of care:

4.3 Effective/evidence-based care

4.4 Safe and timely care

4.4.1 People-centered care

4.4.2 Foundations of high-quality health systems

4.4.3 Continuous learning, improvement, and knowledge management

4.5 SWOT Analysis

4.6 Stakeholder Analysis

5 STRATEGIC OBJECTIVES, KEY RESULTS AREA, AND STRATEGIC

INITIATIVES

5.1 Vision, Mission, and Guiding principles

5.1.1 Vision:

5.1.2 Mission:

5.1.3 Guiding principles

5.2 Goal, Objectives, Strategic Interventions, and Major Activities ii

5.2.1 Goal:

5.2.2 Strategic Objectives

5.2.3 Strategic Objective 1: Improve evidence-based healthcare provision

5.2.4 Strategic Objective 2: Improve people-centeredness of care

5.2.5 Strategic Objective 3: Reduce preventable harm arising from care delivery

5.2.6 Strategic Objective 4: Improve the efficiency of healthcare delivery

5.2.7 Strategic Objective 5: Create a culture of quality through continuous learning and improvement

5.3 Targets

6 IMPLEMENTATION ARRANGEMENT

6.1 Governance and Organization Arrangement

7 MONITORING AND EVALUATION

7.1 Monitoring and evaluation framework plan

7.2 Quality Indicators and Core Measures

7.3 Performance monitoring

7.3.1 Data quality and reporting

7.3.2 Performance review

7.3.3 Quality and safety dashboard

7.4 The State of Healthcare Quality and Safety Assessment Report

7.5 Evaluation of the NHQSS

8 INTEGRATING THE NHQSS WITH TECHNICAL PROGRAMS

9 COSTING THE STRATEGY PLAN

10 REFERENCES

11 ANNEXURES

11.1 Annex 1 : Indicators and Targets

11.2 Annex 2: Linkage Between HSTP-II Strategic Directions and Healthcare Quality . 68

11.3 Annex 3: Future State of Healthcare Quality and Safety in Ethiopia

11.4 Annex 4: List of Contributors, Reviewers, and Workshop Participants iii

FOREWORD

For the first time, Ethiopia developed and executed the National Health Quality Strategy

(NQS) during the first period of the Health

Sector Transformation Plan (HSTP-I) from

2015-16 to 2019-20. During this time, significant achievements were registered in improving the quality management system at all levels of the health system. The capacity building of healthcare professionals in quality improvement sciences and improvement initiatives and projects has resulted in significant improvement in patients’ outcomes and experiences. National learning platforms and inter-facility learning, and collaborative endeavors have been established and promising results were noted.

Despite these gains, much work is still needed to institute a robust quality management system that guarantees continuous improvement. Upon the final year evaluation, it has been noted that inadequate collaborative implementation and insufficient integration of the interventions into the existing programs and projects were the major weaknesses in the execution of NQS. This new strategy, however, is designed building on the previous one and in such a way that it redresses the flaws. Besides, it is among other strategies that aim to operationalize the Health

Sector’s transformation plan (HSTP-II) Transformation agenda- Quality and Equity.

This strategy is co-designed by different stakeholders to establish a fertile ground for its collaborative implementation and integration with different programs. At every phase of the development, key stakeholders have been engaged, and their opinions and recommendations have been given serious attention. Evidence and guidance from the global quality and safety arena were tailored into the country context. World Health Organization’s Guidance development for quality policy and strategy was followed.

The emergence of the Covid-19 pandemic has uncovered significant gaps in healthcare safety and put the care receivers, health workforce, and careers at an increased safety risk. Moreover, the magnitude and severity of healthcare-acquired infections and antimicrobial resistance call for a systematic response. As a result, this strategy puts in place certain interventions to strengthen evidence-based practice towards healthcare safety. Furthermore, The safety dimension of quality has gained global attention, for a great deal of evidence shows that it is much needed to address high-risk clinical conditions and the causes of harm. Hence this strategy is going to be known as the Ethiopian National Healthcare Quality and Safety Strategy

(NHQSS).

The execution of this strategic plan demands a collaborative approach with high political commitment, active participation of the health workforce, and the contribution of all stakeholders. Extending my sincere appreciation to all who contributed to the development of

H.E. Dr. Lia Tadesse

Minister of Health, Federal Democratic Republic of Ethiopia iv this strategy, it is with great hope that I would like to call upon all stakeholders, to continue all efforts that we have initiated previously and transform the quality and safety of our healthcare and achieve the ambitious targets set in the plan.

Looking forward to working with you all toward the successful implementation of the strategy.

Lia Tadesse, MD, MHA

Minister of Health

Federal Democratic Republic of Ethiopia v

List of acronyms

ALTS Auditable Laboratory Transactions And Services

ANC Antenatal Care

APTS Auditable Pharmaceutical Transactions And Services

ART Antiretroviral Therapy

CPD Continuing Professional Development.

CRC Compassionate And Respectful Care

CSC Community Score Card

CSD Clinical Service Directorate

CSOs Civil Society Organizations

DM Diabetes Mellitus

DHIS2 District Health Information System 2

DPCD Disease Prevention And Control Directorate

ECCD Emergency and Critical Care Directorate

EFMHACA Ethiopian Food Medicine And Healthcare Regulation and Control Authority

EHAQ Ethiopian Health Care Alliance For Quality

EHCRIG Ethiopian Health Center Reform Implementation Guideline

EHSTG Ethiopian Hospital Services Transformation Guideline

EPAQ Ethiopian Primary Healthcare Alliance For Quality

EPHI Ethiopian Public Health Institute

EPSA Ethiopian Pharmaceutical Supply Agency

HEP Health Extension Program

HEPHCD Health Extension and Primary Health Care Directorate

HF Health Facilities

HHRD Health and Health-Related Regulation Directorate

HIS Health Information System

HITD Health Information And Technology Directorate

HMIS Health Management Information System

HP Health Post

HRDD Human Resource Development Directorate

HRH Human Resource For Health

HRIS Human Resource Information System

HSTP Health Sector Transformation Plan

HSTQ Health Sector Transformation In Quality

IMCI Integrated Management Of Childhood Illness

IPC Infection Prevention And Control

LD Legal Directorate

LQAS Lots Quality Assurance System

MNCAH-N Maternal, Newborn, Child, And Adolescent Health and Nutrition Directorate

M & E Monitoring and Evaluation

MNH Maternal and Newborn Health

NHIA National Health Insurance Agency

NHQSS National Healthcare Quality and Safety Strategy vi

NQS National Quality Strategy

PMED Policy Plan Monitoring and Evaluation Directorate

QHSD Quality Health Service Directorate

RD Reform Directorate

RDQA Routine Data Quality Assessment

RHB Regional Health Bureau

SARA Services Availability and Readiness Assessment

TOT Training Of Trainers

UHC Universal Health Coverage

WoHO Woreda Health Office

WHA World Health Assembly

WHO World Health Organization

QI Quality Improvement

ZHD Zonal Health Department vii

1 ACKNOWLEDGMENTS

Stakeholders at all levels of the healthcare system contributed to this National Healthcare

Quality and Safety Strategy through various engagement modalities. The Ministry of Health is grateful for the writing team, national quality and safety technical working group members, and consultative workshop participants for their inputs and contributions. The Ministry also acknowledges the Institute for Healthcare Improvement (IHI) for its financial and technical support in the development of the strategy. A full list of collaborators can be found in annex 4.

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2 EXECUTIVE SUMMARY

The National Healthcare Quality and Safety Strategy (2021-2025) is a continuation of the previous National Quality Strategy (2016-2020). The approach for preparing this strategy document was informed by the previous quality strategy implementation. Based on the lesson gathered from the previous National Quality Strategy evaluation, the current National

Healthcare Quality and Safety Strategy document has established a transparent and participatory process of development involving the diffract directorates in the ministry of health and agencies, patient and professional associations, partners, and health facilities. The development process had three teams. The Writing Team, primarily responsible for the overall drafting of the strategic document; the Technical Team which consists of the three technical working groups; National quality working group, national healthcare safety working group, and Maternal and neonatal Health quality of care working group that provided technical inputs through consultative workshops and regular meetings; and the National Quality Steering

Committee for guidance and approval in the overall preparation of the strategy.

Based on extensive consultations of both national and global documents on quality and safety, The Ethiopian high quality and safe care framework was formulated. Based on the framework, current state analysis (The state of quality and safety in Ethiopia, SWOT analysis, Stakeholder analysis) was done.

The goal of the strategy is to continually improve health outcomes and confidence in the system through the realization of the following five Objectives: improve evidence-based essential health care provision; improved People-Centered Care; reduce harm arising from the care delivery; improve efficiency in the health care delivery; and create a Quality culture through continuous learning and improvement. For all objectives, major activities and targets were prepared. A total of 60 major activities and 21 targets were included.

Implementation arrangement and detailed monitoring and evaluation plan—with simplified M and E framework—were prepared. In addition, a detailed operational plan was prepared which disclosed when who, and how the major activities could be tracked and measured. Budget for each strategic objective and major activities were prepared; a total of 4,243,263,848.4 ETB

(92,211,084.7 USD) is needed to execute the strategic plan.

Finally, integration of this strategic plan with other technical programs was suggested to facilitate the successful implementation and the national health care quality and safety strategy

(2021-2025) was suggested.

3 INTRODUCTION

3.1 Background

Globally, for the very first time, healthcare quality and safety received attention at the 55th

World Health Assembly in 2002. Since then, several initiatives to improve quality and safety have been launched. Following the WHA resolution, WHO initiated Clean Care is Safer Care

(2005), to reduce healthcare-associated infection by focusing on improved hand hygiene; Safe

Surgery Saves Lives (2008), dedicated to reducing risks associated with surgery; and

Medication Without Harm (2017), to reduce the level of severe, avoidable harm related to medications globally by 50% over five years. However, low-quality and unsafe care continue to exist all over the world, and its burden is highest in the low- and middle-income countries.

In the Ethiopian health system, the 1993 health policy didn’t directly address the quality and safety of healthcare. However, it mentioned that the “development of an equitable and acceptable standard of the health service system” was one of its policy directions, which could be related to the quality of care (1). Subsequently, four health sector development program plans (I-IV) were launched. The first two health sector development program plans were devoted to increasing access to health care by expanding primary health care facilities and initiating the health extension program. During the third and fourth health sector development programs, business process reengineering (BPR) was implemented as an intervention to improve the quality of care.

But it was in the era of Health Sector Development Program IV that quality and safety started to capture much of the attention of the Ministry of Health (MoH). One of the strategic pillars was “excellence in health service delivery and quality of care.” One of the strategic objectives was to “improve quality of health services,” dictating that health services should be delivered as per the prescribed quality standard. Despite the clear description of quality, however, there were no quality structures until the first Health Sector Transformation Plan (2). Ethiopian Food

Medicine and Healthcare Regulation and Control Authority (EFMHACA) was established and oversaw the quality control of drugs, devices, health workforce and professional ethics, and facility health standard enforcements, especially in the private sector (3). The revised health policy of Ethiopia has given due emphasis to the improvement of quality, equity, and safety of healthcare as a policy issue.

Ethiopia during the second growth and implementation plan has implemented the Health Sector

Transformation Plan (HSTP-I) (June 2015 – June 2020), in which transformation in quality and equity was on the agenda. To operationalize the sector-wide plan, the MoH developed and implemented the National Healthcare Quality Strategy (NQS) for the same period of HSTP-I.

The performance of the NQS has been reviewed through mid-term and end-term evaluations.

These reviews show there have been notable achievements along with critical challenges.

Among these achievements was the establishment of structures for quality management and clinical governance starting with the MoH and extending to the facilities. In the MoH-level

Health Services Quality Directorate, the National Healthcare Quality Steering Committee, as well as quality and safety technical working groups, was established. Quality structures at the regional, Zonal, Woreda, and facility levels were created. The Directorate organized the

National Quality Summit, and it has been working on creating learning facilities. Also, the maternal and newborn health (MNH) learning district has been created in 14 districts and 48 facilities to facilitate collaborative learning within the district since 2018. However, the execution of this activity significantly varies among regions. Facilities (both hospitals and health centers) became successful in creating dedicated quality structures. At the community level, there are still no such quality structures except in some woredas currently supported by other partners.

A large group of providers and leaders were trained in QI methodology, especially at the federal and regional levels. Learning structures were initiated at hospitals, such as the Ethiopian

Hospital Alliance for Quality, and health centers, such as members of the Ethiopian Primary

Healthcare Alliance for Quality (EPAQ). Yet hurdles to structured peer learning and inadequacy of financial support were common challenges for these learning structures, especially for EPAQ.

3.2 Rationale

The NQS helped the country to leverage resources, establish the necessary quality structure at all levels, and create a pool of experts in the area of quality. But in the last five years, interest has been renewed at the global level in the quality and safety of healthcare. New interventions and concepts related to healthcare quality and safety have been shared on the global stage.

Hence, Ethiopia needs to incorporate these new concepts and interventions, tailored to the contexts of the country.

Healthcare safety and high-quality universal health coverage are paramount. Especially in low-and middle-income countries, developing bodies of evidence show that problems of healthcare safety are prevalent. Healthcare-acquired infections, unsafe surgery, antimicrobial resistance, falls, and medication errors are some of the high-burden situations harming patients and healthcare workers. Therefore, addressing this problem systematically is mandatory. In this strategic document, we propose interventions for healthcare safety.

Moreover, the emergence of the global pandemic (COVID-19) has revealed the huge challenges and risks facing healthcare globally. The safety of healthcare workers and clients has been significantly impacted. This necessitates a concerted effort to ensure the safety of healthcare.

Building on the success of the first NQS and redressing the gaps by incorporating new interventions, the MoH aims to improve the outcomes and experience of care in the next five years.

3.3 Approach

The Health Services Quality Directorate, under the oversight of the National HealthCare

Quality Steering Committee, was responsible for organizing and leading the process of developing the strategic plan preparation. Learning from the previous strategic plan development process, maximum engagement of all potential stakeholders was ensured using a three-phase approach. Phase One consisted of situational analysis and goal setting; Phase Two covered intervention and priority areas; and Phase Three involved articulating implementation arrangements and a monitoring framework. Therefore, the preparation was based on a participatory and collaborative approach, ensuring the close engagement of potential stakeholders and partners.

The development process had three teams: the writing team, primarily responsible for the overall drafting of the strategic document; the technical team, which provided technical inputs through consultative workshops; and the National Healthcare Quality Steering Committee, which offered guidance and approval in the overall preparation of the strategy.

The development of the strategy was informed by WHO’s “Handbook for National Quality

Policy and Strategy” and followed the plan commission’s guide to strategic plan preparation

(Strategic Planning and Management) with slight modification. Other influences included an article in Lancet Global Health, “High-quality health systems in the Sustainable Development

Goals era: time for a revolution”; the World Bank Report “Delivering Quality Health Services:

A Global Imperative for Universal Health Coverage”; and a report from the National

Academies of Sciences, Medicine, and Engineering, “Crossing the Global Quality Chasm:

Improving Health Care Worldwide.”

Besides, NHQSS development is largely based on HSTP-II objectives. The following table shows the link of HSTP-II with quality and safety.

Table 1: The link between the HSTP-II strategic objectives and quality and safety strategy

HSTP-II objectives How is healthcare quality linked to these objectives?

1. Accelerate progress toward universal health coverage

The strategic objective emphasized the need for effective essential service coverage. It underscored that effective coverage has three components—needs of the consumer, utilization, and quality of healthcare intervention—and will be tracked as a measurement to realize UHC.

2. Protect people from health emergencies

Creating a resilient system—minimizing shock while providing routine health care—is one of the major features of providing safe care. One of the features of a high-reliability organization is

“commitment to resilience.” Also, a medical emergency is entertained here. A medical emergency is one of the high-risk care processes to which the current safety concepts and practices give due attention.

3. Contribute to the transformation of households

All recent pieces of evidence strongly affirm that high quality of healthcare must be co-produced between the health system and the service users.

This objective laid down the foundation of creating people-centered healthcare.

HSTP-II objectives How is healthcare quality linked to these objectives?

This is one of the doorways to realizing a high-performing primary healthcare system, ensuring continuity of care—from primary to tertiary care—and comprehensive care (1).

4. Improve health system responsiveness

This objective is directly related to key attributes (dimensions) of quality of care: people-centeredness, timeliness, equity.

3.4 Framework, Elements, Definition, and Dimensions of High-Quality

Healthcare

The Ethiopian quality and safety framework was developed in line with Ethiopia’s health system framework of the HSTP-II and based on the Donabedian framework: input, process, and outcomes.

C o n ti n u o u s im p ro v em en t, l ea rn in g an d k n o w le d g e m an ag em en t

Improve Healthcare outcomes

Improve Experience of care

C o n ti n u o u s im p ro v em en t, le ar n in g an k n o w le d g e m an ag em en t

Outcome

Improved effective, efficient, safe, and people-centered care.

Intermediat e result

Health service interventions aiming at quality planning, improvement, and control.

Process

Communit y and user engagemen t and ownership

Improve d financin g for

UHC

Motivated, competent and compassionat e workforce well-organize d and accessibl e care delivery

Well-equippe facilities

Foundation s

Health information systems leadership and governance

Figure 1. The Ethiopian quality and safe framework

Table 2. Description of the components of the framework

S.N Components Description

A. Outcomes of quality of care

1 Healthcare outcomes

Reduced mortality and morbidity.

2 Experience of care

Satisfaction, willingness to recommend, trust (in health workers and care uptake), and retention.

B. Intermediate results

3 Effective care

(evidence-based care)

Care is based on the current knowledge and science and includes systematic patient assessments, accurate diagnoses, provision of appropriate treatments, and proper patient counseling.

4 Safe care Absence of preventable harm.

S.N Components Description

5 People-centered care

People-centered care means that health systems ensure: (1)

Continuity from illness prevention to palliation, between services and between levels of care (primary to speciality), throughout the life course; (2) Coordination across different care settings, in ways that meet the particular needs of the individuals and their carers;

and (3) Comprehensiveness that broadens the portfolio of care— from health promotion through palliative care.

5 Efficient care Reduce waste of time, resources, energy, and ideas.

C. Foundations

7 Engagement and empowerment of users and community

Share information on quality and safety; support the users and community to improve their literacy; develop active users and community. Engage and empower community and users to make them not only beneficiaries but also enable them to hold the system accountable.

8 Leadership and governance

Leadership: political commitment, change management; policies:

regulations, standards, norms, and policies for the public and private sector, institutions for accountability, supportive behavioral architecture, roads, transport, water and sanitation, electric grid, and higher education.

8 Healthcare financing

Financing: funding, fund pooling, insurance, purchasing, provider contracting, and payment.

9 Data and information systems for quality

Developing timely, accurate quality measures of health care services, users’ experiences, and outcomes achieved. Institutions for evaluation, measurement, and improvement, learning communities, and trustworthy data; a culture of quality, use of data, supervision, and feedback.

10 Accessibility and organization of service delivery platforms

Number and distribution of facilities, public and private mix, service mix, and geographic access to facilities; care organization:

roles and organization of primary, secondary, and tertiary care, and engagement of private providers; connective systems:

emergency medical services, referral systems, and facilitation of community outreach.

11 Motivated, competent, and compassionate health workforce

Health workers, planners, managers: number and distribution, skills and skill mix, training in ethics and people-centered care, supportive environment, education (both pre-service and in-service), teamwork, and retention.

12 Well-equipped health facilities having adequate medicines, The health facilities have adequate infrastructure, basic amenities

(water, electricity, sanitation facilities), equipment, supplies, medicines, devices, and technologies.

S.N Components Description devices, and technologies

D. Continuous improvement, learning, and knowledge management

13 Every health system should strive to create a culture of learning and use it for the continuous improvement of the health care system. For this to happen, every health facility—or organization in the health system—should manage its learning needs based on the existing and identified gaps. Therefore, strong learning and knowledge management structures should be in place at all levels of the healthcare system.

3.5 Core Elements of Quality Management

Leveraging all three core elements of quality management—quality planning, quality improvement, and quality control—holistically is one of the key foundations of this National

Healthcare Quality and Safety Strategy.

3.5.1 Quality Planning

Quality Planning (QP) 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.

3.5.2 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.

3.5.3 Quality Control

Quality control (QC) is a normative process that includes quality assurance, wherein a system seeks to ensure that quality is maintained or improved, and errors are reduced or eliminated.

Processes consist of both internal quality assurance and external quality assurance.

3.6 Definition and Dimensions of Quality

Quality and safety in Ethiopia are defined as:

3.6.1 Healthcare quality

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

3.6.2 Healthcare safety:

The absence of preventable harm from healthcare; and reduction of risk of unnecessary harm to an acceptable minimum. (Adapted from WHO)

3.6.3 Dimensions of Quality

Similarly, this strategy adopted WHO’s dimensions of quality:

Figure 1: The Dimensions of Quality

Table: Descriptions of the dimensions of quality

S.

N

Dimension Description

1 Safety Absence of preventable harm

2 Effective Care is given as per current knowledge and recommendation

3 Efficiency Reduction of waste

4 Equity Care delivered uniformly without discrimination based on geography, gender, disability, ethnicity, or language

5 Timely Reducing waits and sometimes harmful delays for both those who receive and those who give care

6 People-centered

Care respects and responds to individual and community preferences, needs, and values

7 Integration Comprehensive care is provided in a coordinated way across the continuum of care

4 CURRENT STATE ANALYSIS

This section provides an assessment of the current state of quality and safety in Ethiopia. It examines quality and safety from the perspective of high-quality healthcare system dimensions.

It also includes the SWOT (Strength, Weaknesses, Opportunity, and Threat) analysis and stakeholder analysis.

4.1 Healthcare outcomes

This refers to reduced mortality and morbidity, and positive health markers such as quality of life, function, and wellbeing, and absence of serious health-related suffering. The following table shows some selected indicators at the health institutions level (2):

Table 2.2: Health institution-level indicators

Indicators Achievement

(2011 EFY)

Institutional maternal mortality, per 100,000 births 44

Early institutional neonatal death rate (per 1000 births) 5.4

Stillbirth rate (per 1000 births) 13.9

Percentage of low-birth-weight (LBW) newborns 3.3

Inpatient mortality rate 2.4

Number of Women who reported ever experiencing symptoms of a fistula among those whose last birth was attended by a skilled provider per 1,000

(2007-2016.)

3.6

4.2 Experience of care:

This refers to satisfaction, willingness to recommend, trust (in health workers and care uptake), and retention. It is the result of the quality-of-care people receive from the healthcare system.

Confidence (or trust) in the health care system affects people’s preference for where to receive care. Due to a lack of confidence in the healthcare system, people are bypassing the lower level of care: 40% of people in a study in Ethiopia sought routine maternal and childcare (including antenatal care, family planning, and vaccinations) from hospitals (3). In addition to having an intrinsic value, this has an impact on retention in care and adherence to treatments, and these result in improving confidence in health systems (4). Patients’ experience of the quality of health care is not seriously assessed by health facilities in Ethiopia; if at all it is assessed, it is not done so authentically.

Disrespect and abuse are common in childbirth and maternity services in Ethiopia. A systematic review and meta-analytic study revealed that half of the mothers (49.5%) experienced disrespect and abuse while they were giving birth in healthcare institutions. The prevalence of physical abuse, non-confidential care, abandonment care, and detention were

13.6%, 14.1%, 16.4%, and 3.2 % respectively (5).

4.3 Effective/evidence-based care

Evidence-based care starts at the time when a patient meets the treating health worker and encompasses systematic patient assessments, accurate diagnoses, provision of appropriate treatments, and proper patient counseling. Evidence-based guideline adherence in antenatal care, family planning, and sick child care was 47%, 34%, and 35 % respectively (3).

Incorrect diagnosis is common in Ethiopia. A clinical vignette administered for health workers revealed that the percentage of health workers who identified the following cases—malaria and anemia, neonatal asphyxia, postpartum hemorrhage, and tuberculosis—correctly were 11%, 45%, 58%, and 52% respectively (3).

Poor quality of care results in the underuse of proven interventions—or overuse of ineffective interventions (3, 6). Some proxy indicators in HIV and TB programs may provide information about the care people are receiving. The UN AIDS target of the second 90 and the third 90 achievements were 85% and 95% respectively (7).

4.4 Safe and timely care

A range of safety problems is more prevalent in health care settings. These include adverse drug events, healthcare-associated infections, injuries due to surgical and anesthesia errors

(including wrong-site surgery), improper transfusion and injection practices, falls, burns, and pressure ulcers (8). Despite limited data on safety measurement at the system level, some institution-based studies show that the prevalence of surgical-site infection in Ethiopia was

12.3% (9); about half (47%) of health workers encountered adverse drug reactions (10). Acute blood transfusion reaction prevalence was 5.2% (11).

Delays in interventions for life-threatening illnesses such as labor complications, stroke, and trauma could cut short a life. Timeliness of care is at the heart of high-quality health systems.

Cure in most cancers is possible if the treatment is given in a timely fashion; and early treatment prevents further damage and transmission in diseases such as diabetes, hypertension, and tuberculosis. Emergency triage of patients within 5 minutes of their arrival was 88%. One of the areas in which timeliness of care was severely compromised was cancer treatment—the median time to get curative radiotherapy was around 150 days (12). Nationally, the delay in elective surgical admissions was 51 days (13).

4.4.1 People-centered care

This implies continuity, coordination, and comprehensive care at all levels.

Continuity of care means continuity from illness prevention to palliation; between services

(e.g., maternity and pediatrics); and between levels of care (e.g., primary to specialist care).

Continuity of care has two important features: a health system’s ability to retain people for care; and the ability of patients to get a treating health worker who is familiar with their medical history. Coordinated comprehensive care (integrated health services) (14) means health services that are managed and delivered so that people receive a continuum of health promotion, disease prevention, diagnosis, treatment, disease management, rehabilitation, and palliative care services, coordinated across the different levels and sites of care within and beyond the health sector, and according to their needs throughout the life course. These two dimensions are very critical in the management of non-communicable diseases and chronic communicable diseases such as HIV. Such kinds of care require complex interplay among health workers—in a facility horizontally—and among platforms of care—from the community to tertiary platforms and beyond.

Examining the retention of care across services: Antenatal four coverage was 43%; three doses of pentavalent immunization was 61%; postnatal visit within two days of delivery was 34%

(15). The tuberculosis treatment success rate was 95%.

Regarding the integration of care, all patients who come for one category of complaints should be examined for all potential other problems as well. For example, patients with tuberculosis should be tested for HIV; children under two years of age who come in for another complaint should be checked for growth and monitoring, etc. Around 87% of TB patients were tested for

HIV in Ethiopia.

4.4.2 Foundations of high-quality health systems

These foundations should be in place to provide high-quality health care. The foundations, which include the six-plus building blocks of the health system, are: users and community engagement, quality governance and accountability, healthcare financing, data, and health information systems for quality, accessibility, organization of service delivery platforms, competent and empowered health workforce, and well-equipped health facilities with adequate medicines, devices, and technologies.

4.4.3 Continuous learning, improvement, and knowledge management

Creating a learning organization (learning system) could help to identify defects and strengths continuously, and based on its real-time assessment, provide remedial actions in real-time.

Learning organizations are proactive, and they continuously identify defects and act on them.

Components of the learning organization (learning system) include transparency, reliability, improvement, measurement, and continuous learning; leadership plays a critical role at the center (16). In the last five years, two improvement methods, Kaizen and the Model for

Improvement have been used to bring improvement as an engine and vehicle for improvement respectively.

4.5 SWOT Analysis

Table 3: SWOT analysis is prepared based on the quality framework.

Dimensions Strength Weakness

Better health

Confidence in the experience of care, effective coverage

- Trends in general morbidity and mortality in some priority areas are improving.

- Experience of care/patient satisfaction is measured.

- Limited data on morbidity and mortality due to poor quality and/or non-utilization of care.

- Limited/lack of data to gauge confidence/trust in the health system.

- Confidence/trust in the health system is presumed to be low.

- Experience of care is not linked to service improvement; unclarity on how to measure patient satisfaction.

- Focus is on crude coverage rather than effective coverage.

Evidence-based care

- Presence of some clinical protocols and treatment guidelines;

available audit tool (HSTQ).

- There is no designated system to continually avail, update, use and audit the clinical protocols.

- The clinical audit tool (HSTQ) is too complex to use quarterly, and it is not updated on time.

- Weak monitoring of evidence-based practice both at private and public facilities.

- Weak compliance with evidence-based practice.

People-centered, safe, timely, and efficient care

- Awareness is increasing that care in Ethiopia is suboptimal (not timely, etc.).

- National and subnational effort to improve continuity of care.

- Well-delineated care delivery platforms.

- Some efforts to improve efficiency and improve the processes of care.

- Data on the safe provision of care is very limited and not measured well.

- The health service does not support open culture, transparency, or systems thinking.

- Suboptimal integration and comprehensiveness across service components.

- Missed opportunity for prevention and early detection in the health facilities is very high.

- Waste due to poor clinical processes and/or unsafe care is not well-understood.

- The efficiency of health care processes is not well-measured.

Dimensions Strength Weakness

Engagement of community and users

- Availability of platform to engage the community.

- Presence of some initiatives to engage the community

(community scorecard, town hall meeting, health facility boards).

- Lack of adequate effort on quality- and safety-related demand creation.

- Lack of proper and measurable community engagement for quality and safety.

- Absence of a clear community engagement mechanism and guidelines.

- Minimal engagement of patients and their association in ensuring the quality of care.

- Lack of simplified/easily understandable tools to improve quality and safety.

- Patient and family literacy and engagement in their care are very low.

Accountable leadership and governance

- Quality is given due attention;

structures have been created; the

HSTPs identified quality as major agenda.

- Health facilities established governing boards.

- Capacity building of leaders at the federal and regional levels was initiated.

- Presence of different directives and guidelines; some are tracked on

DHIS2 (EHSTG,

EHCRIG, health facility regulation standards, etc.).

- Previous NQS lacked a clear implementation plan.

- Quality structures created are not working optimally: weak steering committee, quality directorate could not mainstream quality and was unable to create coordination and collaboration.

- Lack of clear accountability mechanism for quality.

- Unstable leadership: high turnover, lack of succession planning.

- Lack of continuous practical training on leadership for quality.

- Unclear scope and functions of quality structures at all levels.

- Nonexistent quality and safety structures at private facilities.

- Poor governance for quality audit tools and protocol implementation.

- Improvement initiatives are driven by donors.

- Accreditation is considered a luxury by top leadership.

- Lack of mechanism for rewards and incentives.

- Double standard in enforcing regulations between public and private health facilities.

- Engagement of professional associations and patient associations is weak.

- Lack of clear structural distinction among service purchasers, regulators, and providers.

- Public health facilities do not renew their license yearly.

Improved financing for

UHC

- Increased budget allocation for health care at each level.

- Presence of health care financing strategy.

- Private-wing services in selected hospitals.

- CBHI

implementation for service improvement.

- Performance-based financing schemes are in the pilot stage.

- Absence of budget line for improving quality in the health care system.

- Lack of budget allocation at the program level for quality.

- Non-proportional allocation of budget for the need for medical equipment and supplies.

- Quality improvement initiatives do not get adequate finances.

- Poor progress in health insurance coverage.

- Blanket coverage on health insurance scheme rather than attaching to the quality of care.

- Weak triangulation of health insurance with quality and safety.

- Performance-based financing mechanisms for both health care facilities and health care providers are still not approved.

- Lack of efficient, effective, and timely utilization of allocated budget.

- Weak implementation of public-private partnership.

Strong data and health information

(HIS) system for quality

- High leadership commitment to data and information.

- The development and incorporation of key performance indicators (KPIs) for service monitoring in the existing HIS

- The presence of the DHIS2 platform

- Weak monitoring and evaluation (M&E) framework of the previous NQS

- Absence of quality-adjusted (effective coverage) measures

- Poor data quality resulting from poor capturing, reporting, generation, and use at all levels.

- Limited human resources capacity to generate, analyze and utilize data.

- The adverse event reporting mechanism is almost nonexistent; safety and occupational data are very limited.

- Weak local and external data quality assurance at all levels.

- Weak information use culture, especially at the point of generation.

- No transparent and publicly reported measures for quality and safety.

- Low effort to scale up electronic medical records.

Accessible and well-organized service delivery

- Improved physical access for service.

- Increased public and private ambulance services.

- Presence of approved comprehensive essential health service package.

- Despite increasing access, there are major quality and equity issues among regions and people.

- Private health facilities are not well-linked with public ones.

- People bypass the lower health care system and overcrowded referral hospitals.

- Healthcare delivery is not yet aligned with the essential health service package (EHSP)

- Some tertiary care services are not accessible to all people.

- Limited capacity to provide coordinated emergency care services; referral system coordination is very limited.

Motivated, competent, and compassionate healthcare workforce

- Efforts to build the capacity of healthcare providers in quality and safety.

- Initiation of an advanced level of quality improvement training.

- Presence of national CPD strategy.

- The engagement of health professional associations is increasing.

- Multiple strategies and initiatives

(HRH strategy, CRC strategy, HRIS)

- Trained staff turnover at all level.

- Critical shortage of trained staff.

- Lack of scope-based clinical practice for healthcare providers.

- Implementation of CPD and CRC are weak.

- Gap in monitoring the effectiveness and efficiency of in-service training.

- Lack of effort in the integration of quality of care in the pre-service education.

- Lack of well-equipped skill lab in the healthcare facilities.

- Improving quality is not linked with the job description of health professionals.

- Absence of a clear career path for quality officers at different levels.

- Limited capacity of health professional associations in quality and safety.

Well-equipped health facilities with adequate devices, medicines, and technologies

- Data on service provision and readiness is regularly available.

- Efforts are being made to improve general service readiness of health facilities.

- Introducing new diagnostic and treatment technologies.

- Health facility infrastructure and general service readiness inadequacy.

- Purchasing system is not real-time.

- Most public health facilities suffer from a shortage of drugs, supplies, reagents, and equipment; medicine and equipment are not state-of-the-art.

- Lack of accessible and timely medical equipment, maintenance systems, and workshops at the national, regional, and zonal levels.

- Inadequate capacity for medical equipment and supply quantification, monitoring of specification.

- Lack of efficient use of resources at all levels.

Continuous learning and improvement

- Availability of structured learning platforms (EHAQ, EPAQ, quality summits).

- Poor knowledge management and translation practice/system in place.

- Learning platforms are irregular, are not well-budgeted, and learning is not structured.

- A system of quality audits is not well-instituted and is generally lacking.

- Lack of documentation of lessons learned from

QI initiatives.

- Lack of a strong support system at woreda and zonal levels.

- Lack of evidence of translation or scale-up.

- System for institutional memory does not exist.

- Lack of learning culture in the health facilities.

Opportunity Threat

- Government commitment to quality of care.

- The global evolving concept of quality of care.

- Donor and development interest in the quality-of-care initiatives.

- Increase in community demand for high-quality healthcare.

- Global pandemic (example: SARS-CoV-2).

- Political instability and natural disaster.

- The existing civil service law and the inability to make the health system independent from it.

- Health science education culture overlooks quality and healthcare safety (silos in education, poor teamwork, and collaboration, punitive environment, lack of systems thinking).

- The legal environment is not supportive of the new concept of quality and safety (example: punitive attitude).

Opportunity Threat

- The willingness of some of the health colleges to integrate quality into pre-service education programs.

- Low quality of pre-service education

- Basic infrastructure (water, electricity, and roads) inadequacy creates a lot of stress in trying to provide high-quality and safe care.

4.6 Stakeholder Analysis

Stakeholders are key players in the health sector, and their analysis is crucial to ensure healthcare quality and safety in the sector and the success of the health program. During the planning process of the health interventions, it is important to consider the needs and interests of those who have a “stake” in the health sector. The following table shows the stakeholder analysis.

Table 4: Stakeholder analysis table

Stakeholders Behaviors we desire Their needs

Resistance issues

Institutional response

Community, patients, and their families

Participation, engagement, and ownership Access to high-quality and safe health services, empowerment

(informed, supported, competent)

-Dissatisfaction

-Community mobilization, ensure engagement and ownership

High health literacy

-Opting for unsafe alternatives

-High-quality and safe service and providing information

High health-seeking behavior

Underutilization

Health workforce

-Committed and competent in providing high-quality and safe care

-Conducive environment -Dissatisfaction -Motivation

-Participation and engagement

-Transparency and responsiveness

-Unproductive -Involvement

-CPD

-Incentives -Attrition -Making them the real owner of their institution

-Capacity building -Sabotage

All directorates, agencies, regional

-Ownership and engagement

-Access to state-of-the-art concepts, skills, and tools of

-Fails to mainstream the concepts of

-Engage in the national quality and safety governance

Stakeholders Behaviors we desire Their needs

Resistance issues

Institutional response health bureaus

(RHBs), zonal health departments, woreda health offices, and health institutions quality and safety interventions quality and safety

-Mainstreaming healthcare quality and safety in their plans and activities

-Capacity building, being informed and supported

-Fragmented move to ensure safety and quality

-Proper coordination, implementation of the quality intervention, and monitoring

-Cascading the strategy, allocating enough resources and structures to ensure quality and safety

-Undermine the needs for quality and safety

-High quality and safety will be their motto

Parliament, Prime

Minister’s

Office, Council of

Ministers, regional governments

Ratification of policies and proclamations

-Implementation of proclamations, policies, etc.

-Administrative measures

-Put in place a strong M&E system and comprehensive capacity building mechanisms

-Resource allocation

-Delivering high-quality and safe care

-Influence on budget allocation

-Public reporting

-Plans and reports

Line

Ministries

(Education, Attorney

General, Work harmoniously to make the healthcare environment

Evidence-based plan and reports -Fragmentation -Collaboration

-Engagement and being informed

-Low health literacy -Transparency desire Their needs

Resistance issues

Institutional response

Water, Finance, Labor, Women’s and Youth

Affairs) conducive to high-quality and safe healthcare -Technical support

-Considering health as a low priority

-Advocacy

Health professional training institutes

Knowledgeable, skilled, and ethical health professionals trained

Technical and policy support, guidance

Curriculum revision

Policy and leadership support

Development partners

-Harmonized and aligned

Develop accountable, transparent, and responsive quality and safety governance

-Fragmentation -Government leadership

-Participation

-Involved in planning, implementation, and M&E

-High transaction cost -Transparency

-More financing

-Inefficiencies -Efficient resource use

-Technical support

-Build financial management capacity

NGOs, CSOs, and professional associations

-Harmonization and alignment

Involvement in planning, implementation, and M&E

-Dissatisfaction -Transparency, advocacy

-Participation, resources, and

Techncial assitance

-Fragmentation -Capacity building

-Participation in licensing and accreditation

-Scale down -Financial support desire Their needs

Resistance issues

Institu…