The right question for Africa
Progress in achieving the Millennium Development Goals (MDGs) in Africa, based on progress reports from WHO and other international agencies, is far off target in many areas. Yet, it is precisely in these areas that improving the quality and safety of health care can have the biggest impact, namely in MDGs 4 and 5 focused on mothers and children. Sub-Saharan Africa in particular still accounts for half of the 8.8 million deaths in children under five worldwide (1). For mothers in sub-Saharan Africa, the risk of dying is still very much higher than elsewhere in the world, 1 in 22 compared with 1 in 8 000 in industrialized countries and there has been little progress on improving this in all the run up to 2015. (2) Why is it, though, that when the crisis of maternal, neonatal and child mortality in Africa is raised by global experts and policy wonks, the issue of safe health care is not discussed?
The answer lies in the nature of the question.
The right question
When WHO started the Patient Safety programme in 2004, health systems around the world were only just beginning to focus on issues surrounding the quality of health care delivery and the importance of measuring and assuring quality of care as a basic system goal. Since 2004, much work has been done around the globe to establish the systems of quality measurement and assurance. In OECD countries, initial efforts at cross-country measurement of quality and safety included only a handful of countries. Now, the Health Care Quality Indicators Project provides regular data to the OECD's Health-at-a-Glance. Ministers gathered in Paris this year to focus on the issues raised by these in terms of differences across countries in quality and safety.
Although these investments have not been completely matched outside the OECD, there have been investments in quality and safety systems in all WHO regions in the last five years. All regions, that is, with the exception of the African Region, where in most countries there is not even a quality unit in the Ministry of Health, much less national expertise on safety . The question, rather than asking why safety and quality has not "caught on" in Africa, should be how can we ourselves be more effective at addressing the basic issues of maternal, neonatal and child mortality?
In Africa, the task of improving health care is daunting for many reasons, some of which are discussed in the excellent editorial in this issue by Dr Sam Zaramba of Uganda, my former colleague on the WHO Executive Board for many years. In fact, in the early years of successful implementation of our First Global Patient Safety Challenge, Clean Care is Safer Care, where we "challenged" ministers of the world to sign up to improve their country's record on health care-associated infection, we had massive uptake in all regions of the world. All except Africa.
Adapting methods to lower-resource settings
So, we at WHO set out to show how patient safety and quality methods could be adapted to lower resource settings. We worked with our colleagues in the Eastern Mediterranean Regional Office and countries in the region to build capacity in assessing adverse event rates in East and North Africa. We worked with ministries to develop the capacity for local production of alcohol-based handrub to combat health care-associated infection in West Africa. We established pilot sites for our Surgical Safety Checklist work in East Africa. And, we worked with local organizations to expand our Patients for Patient Safety Network right across Africa.
These efforts have yielded progress, not just because they were based on sound evidence and the experience of knowledgeable partners, but also because they were adapted to the local situation. In our hand hygiene work, we looked to provide guidance for alcohol-based hand rub use in Muslim majority countries. In our safe surgery work, we encouraged and facilitated local adaptations of the WHO Surgical Safety Checklist. In our research work, we recently completed a Methodological Guide for Data-Poor Settings. Finally, just this year, we held the first local Patients for Patient Safety workshop in Africa and have used patients themselves from Africa to help us develop a new mobile phone-based tool for mothers to use in the high-risk seven days following delivery of their baby.
These efforts to build improvement on local adaptation and knowledge have continued in the creation of the African Partnerships for Patient Safety. This project, discussed elsewhere in this edition, is based on a grant from the UK Government and focuses on 12 "action areas" of safety and quality identified by the ministers of health at the 2008 African Regional Committee meeting. The project works to create centres of safety and quality excellence in Africa, supported by partners in the UK and across Europe. While the experience is still in its infancy, the lessons from the first wave of six countries have shown that partnerships can be the foundation on which local improvements and national policy shifts in quality and safety can happen.
We have learned a lot about how to advance the safety and quality agenda in Africa in the past five years. However, it is clear that we do not have the formula exactly right for addressing safety and quality in Africa. Future work needs to focus on both the "technical" solutions as well as the "adaptive" solutions that help change behaviour over the long term. We at WHO need to work more closely with other partners in Africa to ensure synergies in our agendas. Finally, our greatest task is to show more explicitly, with hard data, how applying safety and quality improvement tools can improve maternal, neonatal and child mortality in Africa. When we as a global quality and safety community have done this, we will be able to stop questioning ourselves and allow ourselves to start demanding that the global development community step forward with us to support improved safety and quality in Africa.
- UN (2010). United Nations Millenium Developm,ent Goals Report.
- AFRO (2008). World Health Organziation Regional Office for Africa. Patient Safety in African Health Services: Issues and Solutions. Report of the REgional Director. Regional Committee for Africa. Fifty eighth session. Yaounde, Republic of Cameroon.