More than five million people die in low- and middle-income countries every year because of poor quality of care – even more than the 3.6 million people who die due to a lack of access to care.
SafeCare creates transparency on quality of care, thus contributing to a virtuous cycle of trust throughout the health system. SafeCare comprises standards and a stepwise certification approach to improve the quality of care in healthcare facilities, tailor-made for the realities of resource-limited settings.
SafeCare connects thousands of healthcare facilities, payers, and stakeholders, public and private, to improve the quality of care and outcomes for millions of patients.
Tackling quality challenges with a standard-based approach
Many causes of death are preventable if adequate quality care is provided. But with limited resources, staff shortages, and lack of basic services such as electricity and running water, improving the quality of healthcare can be challenging. Moreover, implementing quality standards is often perceived as costly and an investment of time one does not perceive to have.
Yet there is a huge opportunity to benefit from improved quality. Introducing quality standards creates transparency, raises patient safety, improves efficiency, and builds overall trust in the healthcare system. It connects payers to healthcare providers, leading to more resources and investments.
Quality as key component of universal healthcare coverage
Healthcare facilities face many significant challenges. As the first point of entry for healthcare services ranging from antenatal checkups to minor emergency surgical procedures, primary healthcare centers (PHC) are the go-to place for a growing population. Here, a combination of crowded conditions, not enough medication, and inadequate infection prevention are contributing to the vicious cycle of low-quality care.
The lack of quality results from various insufficiencies – of investment in health, knowledge among healthcare providers, and regulatory systems – which lead to shortages in basic infrastructure, working equipment, and medicine, as well as demotivated staff. Also, most healthcare investments are focused on tertiary hospitals, leaving most people with low-quality healthcare services.
Universal healthcare coverage (UHC) is a key component of securing this much-needed financing, yet poor-quality care is in turn a structural barrier to achieving UHC. Without quality care, UHC remains an empty promise.
Transparency and improvement of quality
SafeCare believes it is possible to break this cycle: there is always room to improve, to develop a sustainable level of quality care, for anyone willing to take the time and make the effort. We work with partners to get their facilities to the highest level of quality possible, and we help public partners institutionalize quality in their healthcare ecosystems.
Healthcare facilities can only improve when they know their level of quality, so the first step is to measure the quality of their care processes using a standards-based approach. As a result, patients can trust in the quality of healthcare facilities, encouraging them to pre-pay through health insurance. Investors are willing to invest in healthcare facilities using SafeCare quality standards and that have a steady flow of patients. And to boost investments in health, SafeCare links facilities to the Medical Credit Fund (MCF) for loans and provides support to MCF’s clients to materialize quality investments and measure impact.
We help facilities improve on the challenges that have the
biggest impact on patients. Our internationally accredited quality standards cover both management and clinical aspects of care, such as operation checklists, which can reduce mortality and complications in the surgical environment by 30%. In 2023, the presence and usage of this checklist improved from 27% to 43% in SafeCare facilities. Also, the implementation of triage improved from 23% to 48%. Both examples show that facilities improve but that many facilities still lack critical procedures that impact patients' health. Overall, 74% of the facilities improved.
However, this improvement is lower than in previous years, with many countries’ healthcare providers experiencing a drop in quality performance. Continuous focus on quality improvement is needed to sustain quality. But in the current economic climate, staff turnover has increased, and alongside dwindling finances, countries like Nigeria are losing qualified healthcare staff to developed countries.
Incentivizing a culture of quality
A culture of quality means that quality is top of mind and integrated into the daily practice of healthcare providers and that staff members are motivated to take part in a journey to better care.
Every stakeholder in the health ecosystem must prioritize and steer quality improvement. SafeCare motivates action by embedding quality in the ecosystem and providing incentives that stimulate facilities and healthcare workers.
Behavioral studies have provided us with a better understanding of where this motivation lies, and we have applied this in our approach – including in the SafeCare Quality Platform, which connects facilities in the region and inspires behavior change among staff. The Quality Platform allows healthcare facilities to work on their quality improvement independently, with real-time progress and benchmark data available.
Over 1,600 healthcare staff from 490 facilities used the Quality Platform in 2023, downloading more than 14,000 supporting documents, such as templates and guidelines. Through gamification, awarding of continuous professional development points, badges, and benchmarking, the platform is designed to enhance the motivation of all staff members. Harnessing the power of positive competition, PharmAccess country offices organized award ceremonies for high achievers, thereby sparking a sense of healthy competition.
In 2023, we enhanced and focused on the data insights available through SafeCare and how that can be used for informed decision-making. Ministries and regulators used the platform and its data to target policies and improve quality of care. For example, in Nigeria, the Lagos State Health Management Agency (LASHMA) used SafeCare to institute differential tariffs based on the quality ranking of healthcare providers.
Going forward we will use our growing database of healthcare insights, and our quality mapping approach through self-assessments to collaborate with partners like the International Finance Corporation (IFC) and World Health Organization (WHO), to actively advocate for change at a global level. We will jointly publish and share insights about challenges on the ground and explore opportunities to develop a central hub for information and insights learning.
Growing our presence in Africa and Asia
Partnerships are a core component of the SafeCare approach. By engaging with partners, particularly large consortia with international reach, we are scaling our impact globally and creating local institutions. By the end of 2023, our quality models – including SafeCare and building blocks for quality assurance based on SafeCare standards – were used by 32 partners, supporting over 2,678 healthcare facilities with more than 6 million patient visits per month.
In 2023, we started our technical assistance for the USAID IREME program in Rwanda, supporting the institutionalization of quality. We engaged with new partners to explore scaling SafeCare in Uganda.
We implemented SafeCare in Pakistan and Afghanistan through our partnership with Aga Khan Health Services (Asia).
We see an increasing demand for SafeCare from Aga Khan facilities that we can serve through our partnership. This shows how we make a difference together to ensure better quality care for patients.
We also had an expert role in our partnership with Manyata – a quality improvement and certification initiative provided by the National Federation of Obstetric and Gynecological Societies of India (FOGSI). More than 80 Manyata assessors undertook over 600 assessments in 25 states through the tool, which was created with the support of PharmAccess. The digital tool transformed the way quality monitoring is done and will enable scaling and presenting quality data to all stakeholders involved.
Institutionalizing quality sustainably
To scale the impact of SafeCare, we need to deliver it sustainably to more countries; we do this by growing our pipeline of new public and private partners in Africa and Asia. In 2023, we supported our existing partners in the development of their business model, which can be used as an example to similar networks in other countries.
Additionally, digital innovation, including the Quality Platform, enables SafeCare to optimize and increase users’ focus on quality through low-cost, remote, and digital support, helping our partners to become more effective and efficient.
While there is currently still a lack of incentive to invest, it is increasingly clear that quality of care and better business are correlated. In our experience, working on quality improvement is generally perceived to make financial business sense. Incoming patients ensure sustained revenue streams, and satisfied patients lead to word-of-mouth recommendations, assuring loyalty and bringing in new patients. It also means less leakage of funds through overspending on tests and overdue medication, and better organization structures translate to more efficiency.
According to SafeCare research, there is a good business case for quality improvement: although it requires investment, it ultimately helps facilities to be financially sustainable. We looked at proxies of business performance and found significant associations between quality and the number of both patient visits and staff. On average, a one-point increase in quality score was associated with an increase of 14.4 patient visits a month, and a seven-point increase in quality score was associated with an increase of one staff member. Facilities that started with a high-quality score at baseline achieved significantly larger increases compared to those that started with a low-quality score. We will continue to analyze these results in 2024.
Med4All
PharmAccess is applying digitally enabled group purchasing to tackle the serious challenge of the circulation of poor quality or fake drugs in sub-Saharan Africa. In Ghana, the digital platform Med4All aims to make quality medicines widely accessible at affordable prices.
In 2023, Med4All successfully delivered 90% of all medicine orders to 45 healthcare providers, with prices 21% lower than the open market. All medicines on the platform met FDA quality criteria, and they were delivered to healthcare facilities as fast as 72 hours in the city. Med4All was recognized as a finalist for the AbilityNet Tech4Good Award in 2023.
Patients are becoming more aware of the quality of medicines administered within healthcare facilities, enhancing their trust and experience. The reduction in stockouts positively impacted outpatient department attendance in 2023. However, international supply chain distribution limited fulfillment and we faced difficulties in expanding to more providers.
In 2024, the focus will be on redefining and optimizing the business case to facilitate and ensure sustainability of the initiative. This includes financing solutions through the Medical Credit Fund and contracting of an off-the-shelf digital platform that can support next steps.
Director of Med4All, Antoinette Squire, presents at the Reuters Pharma Digital Health Europe in London.