Bulletin of the World Health Organization
Volume 95, Number 1, January 2017, 1-84
http://www.who.int/bulletin/volumes/94/11/en/

PERSPECTIVES
Improving health-care quality in resource-poor settings
Bejoy Nambiar, Dougal S Hargreaves, Chelsea Morroni, Michelle Heys, Sonya Crowe, Christina Pagel, Felicity Fitzgerald, Susana Frazao Pinheiro, Delan Devakumar, Sue Mann, Monica Lakhanpaul, Martin Marshall & Tim Colbourn
http://dx.doi.org/10.2471/BLT.16.170803
Excerpt
Elements to consider when improving health-care quality in resource-poor settings:
Systems thinking
Health systems are dynamic complex adaptive systems, where all parts need to be considered. These parts are (i) the inter-relationships between the patient, clinical and nonclinical workers in the health system; (ii) the different levels of the health system ranging from the community to tertiary referral system; and (iii) the required human and material resources and training, supervision and management structures.
Participatory approach
Participatory, grounded and bottom-up approaches involving health-care professionals, patients and communities as well as researchers-in-residence are important to understand health systems. Participation also increases buy-in to quality improvement efforts and enables design and implementation of interventions that are effective in specific contexts, consider sociocultural beliefs and build accountability.
Accountability
The people involved in making health systems work must be accountable to the individuals and local communities the health system is serving. Data for decision-making is important as it can be used to encourage and track quality improvements and, when useful metrics are chosen, can also be a mechanism by which the health system can be held accountable.
Evidence-based
Evidence on what works to improve quality of care in low-resource settings is scarce. We propose an evidence-based approach that supports data harmonization while at the same time maintaining the highest standards of scientific and academic rigor.
Innovative evaluation
Both plausibility and probability evaluation designs should be used as part of a research strategy to rigorously determine whether quality improvement interventions can work and how, why and in what circumstances they work. Using a range of research strategies from theory-based evaluation to cluster randomized controlled trials is important.