Managing the quality of health care in developing countries

Quality of health care is a multidimensional and multifaceted concept interwoven with value judgments about what constitutes good quality. This lack of linearity partly explains the large number of definitions of the concept of quality, the many approaches to measure and assess it, and the variety of approaches to assure and improve quality. This state-of-the-art paper offers a choice of definitions and presents available models and approaches to measure, assure and improve quality. It proposes a conceptual model based on three basic elements - structure, process, and outcome - to guide efforts in selecting and organizing indicators. It cites numerous examples of and sources for indicators, practice guidelines and performance standards. Structural inputs (buildings, equipment, drugs, medical supplies, and vehicles, personnel, money, organizational arrangements) are concrete and quantifiable and are a necessary but not a sufficient condition for good quality. Process is what is actually done to and for the patient in giving and receiving care. Process is the key element to assure quality, assuming an adequate minimal supply of inputs. A correct process has a high probability of a satisfactory health-improving outcome. Project design should emphasize process measures and incorporate the philosophy and methods of quality improvement to assess and improve the service delivery processes purposefully and continuously. Outcomes are the end results of the correct process of patient care and of the timely availability of the necessary inputs. Outcome is measured using indicators of mortality, morbidity and functional impairment. Favorable outcomes however can be affected by factors not under the direct control of the health worker. Cultural factors, housing, diet, environment, genetics, all have some impact on the outcome of an intervention. Outcomes are not clearly and unequivocally related to the process actions of the health workers. It is therefore more effective to improve the health care delivery process continuously and to make sure that the most critical inputs are available. Important empirical relationships remain to be documented: between quality and cost, between quality and the way health services are organized, financed and managed, and between quality and health care and changes in mortality and morbidity rates. An extensive and up-to-date bibliography of articles and books on quality in general and health care quality in particular is provided.