Governing for Quality: Adopting a National Quality Vision and Strategy
Governing for quality means reframing the pursuit of quality health care from a peripheral activity to the mandate of a health system, and making sure that a commitment to quality is actually translated from paper to actions that improve the health of people.225,226 Governing for quality includes several elements: adopting a national quality policy and strategy, improving capacity for management at all levels of the health system, strengthening regulation and accountability, and collecting and learning from health system data.
Governing for quality requires high-level political commitment to a shared vision for improving quality of care and translating this commitment into action across the health system (panel 13). Well aligned policies and strategies should be based on this vision, locally accepted definitions of quality, and national goals for improved outcomes.212 In response to requests from countries for guidance on how to design and implement these healthcare policies and strategies, WHO produced the National Quality Policy and Strategy Handbook.212 The handbook outlines eight elements of the strategy and argues that quality must be elevated nationally and become a priority across sectors. These policies, and the strategy linked to them, should ideally outline the roles and responsibilities of the organisational bodies and actors that participate in sustaining and improving quality of care. A plan for coordinating these elements is also needed, so that quality improvement programmes are harmonised to maximise learning and results at the system level.227
Panel 13: Governing for Quality – Inspiring National Commitment
A shared national vision and strategy for quality is essential to rally the entire health system around a common goal. Political will and high-level commitment are crucial to translating this vision into actionable policy and sustained progress. Some inspiring examples of national quality improvement efforts include:
South Africa’s National Health Insurance Policy: This policy underpins the establishment of a unified health system based on principles of social solidarity, progressive universalism, equity, and health as a public good and a social investment. It outlines a national quality of care framework with standards, norms, and an oversight system to hold both public and private providers accountable.
Ethiopia’s Health Care Quality Strategy: Launched in 2016, this strategy set a national goal of establishing a high-quality, equitable, and people-centered health system by 2020. It defined quality domains, established national quality standards, and outlined a comprehensive implementation plan involving leadership, governance, information systems, and a robust quality assurance program.
Brazil’s Improving Primary Care Quality Initiative: In 2011, Brazil launched the National Program for Improving Access and Quality of Primary Care, setting national standards and incentives to enhance the capacity, organization, and performance of primary care facilities. This initiative engaged municipal leaders, facility managers, and community health workers in a process of continuous quality improvement.
Governing for quality also requires building the management capacity to implement quality strategies at all levels of the health system. This includes strengthening the skills of district and facility-level managers in areas like human resource management, budgeting, data analysis, and quality improvement. Investing in the technical, leadership, and change management capabilities of mid-level managers is crucial, as they play a pivotal role in translating national policies into local action.229
Strengthening regulation and accountability is another key element of governing for quality. Health systems need strong regulatory bodies with clear quality standards, enforcement mechanisms, and the authority to monitor and take corrective action. Regulatory approaches can include licensing and accreditation schemes, facility inspections, and public reporting of quality performance.230 Effective regulation also requires a well-functioning legal system that can adjudicate disputes and hold health system actors accountable.
In addition to regulation, broader accountability mechanisms are needed to ensure that the health system is responsive to the needs and expectations of the population. This involves empowering people to voice their concerns, access information, and participate in decision-making. Social accountability tools like citizen report cards, community scorecards, and public hearings can amplify the voices of users and communities, particularly the poor and marginalized.163,231 Complementary legal accountability mechanisms, such as patient rights charters and grievance redressal systems, provide avenues for recourse when quality standards are not met.
Finally, governing for quality requires the collection, analysis, and use of quality data to drive continuous learning and improvement. This means strengthening national institutions responsible for health system measurement, as discussed in the previous section. These institutions should be empowered to monitor quality, identify areas for improvement, and provide feedback to health facilities and decision-makers. Cultivating a culture of data-driven quality improvement at all levels of the health system is essential for translating measurement into action.
Redesigning Service Delivery to Optimize Quality
Beyond governing for quality, countries must also redesign their service delivery models to optimize quality and health outcomes. This means moving away from a narrow focus on geographical access to services and instead organizing care around the needs of the population and the competencies required to address those needs.
A key aspect of this redesign is strengthening primary care as the foundation of the health system. Primary care should serve as the first point of contact, providing comprehensive and coordinated care for common conditions, health promotion, and disease prevention. This frees up higher-level facilities to focus on managing more complex cases that require specialized expertise and advanced technologies.
To enhance the quality of primary care, countries can consider the following strategies:
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Expand the scope of primary care services: Primary care facilities should be equipped to manage a wider range of health needs, including non-communicable diseases, mental health, and rehabilitation, in addition to the traditional focus on maternal and child health and infectious diseases.232 This requires expanding the skills and competencies of primary care teams through enhanced training and support.
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Implement team-based care models: Organizing primary care around multidisciplinary teams can improve coordination, continuity, and the comprehensiveness of services. Teams can include physicians, nurses, community health workers, and allied health professionals working together to address the diverse needs of patients.233
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Strengthen referral systems: Robust referral linkages between primary, secondary, and tertiary levels of care are essential for ensuring that patients receive the right care at the right time. This requires clear referral protocols, effective communication mechanisms, and reliable feedback loops.234
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Leverage digital health technologies: Digital tools can enhance the efficiency, responsiveness, and quality of primary care, enabling functions like electronic medical records, telemedicine, decision support, and remote monitoring. However, the introduction of digital solutions must be accompanied by investments in infrastructure, workforce skills, and change management.235
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Decentralize service delivery: Bringing services closer to communities through outreach clinics, mobile teams, and community-based platforms can improve access, especially for hard-to-reach populations. This decentralized model should be complemented by strong linkages to facility-based care and robust supervision and support.236
Beyond primary care, countries must also optimize the role of higher-level facilities, such as district and regional hospitals, to ensure the appropriate management of complex conditions. These facilities should be staffed by skilled specialists, equipped with advanced technologies, and integrated with the broader health system through strong referral networks. Strategies to enhance hospital quality include:
- Defining clear service delivery models and facility types based on population needs and competencies
- Implementing triage systems and clinical protocols to ensure timely and appropriate care
- Strengthening management practices, such as inventory control, patient flow management, and quality assurance
- Investing in the continuous professional development of hospital staff
- Fostering collaborative learning across facilities to share best practices and problem-solve
Ultimately, the redesign of service delivery should be guided by the principle of maximizing health outcomes rather than simply expanding geographical access. This means carefully aligning the competencies of each care platform with the health needs of the population and ensuring seamless integration across levels of the health system.
Transforming the Health Workforce to Provide High-Quality, Respectful Care
The health workforce is the backbone of any high-quality health system, and transforming this workforce is a critical component of the quality improvement agenda. This transformation involves three key elements: 1) adopting competency-based education and training, 2) fostering a culture of respect and support for all health workers, and 3) optimizing workforce management and deployment.
Competency-Based Education and Training
Health worker education and training programs must shift away from a focus on theoretical knowledge toward developing the specific competencies required to deliver high-quality, people-centered care. This includes not only clinical skills, but also communication, teamwork, empathy, and the ability to engage with communities. Competency-based curricula should be developed in partnership with regulatory bodies, professional associations, and health system leaders to ensure alignment with evolving service delivery needs.237
In addition to pre-service training, continuous professional development programs are essential for updating the skills of the existing workforce. These programs should be tailored to the specific roles and responsibilities of different cadres, from frontline community health workers to specialist physicians. Mentorship, supervision, and on-the-job training also play a crucial role in reinforcing competencies and promoting the translation of knowledge into practice.
Fostering a Culture of Respect and Support
Health workers cannot deliver high-quality care if they themselves are not respected and supported. Organizational culture and management practices within the health system must shift to prioritize the wellbeing, motivation, and professional fulfillment of all staff, from the most senior leaders to the most junior support personnel.
This cultural transformation involves several key elements:
– Promoting ethical behavior, empathy, and person-centered care as core professional values
– Providing a safe, clean, and well-equipped work environment
– Offering competitive remuneration, benefits, and career development opportunities
– Implementing effective performance management systems that provide constructive feedback
– Establishing mechanisms for health worker grievances and dispute resolution
– Recognizing and celebrating excellence in service delivery
When health workers feel valued, respected, and empowered, they are more likely to provide compassionate, high-quality care to their patients.
Optimizing Workforce Management and Deployment
Beyond cultivating the right competencies and culture, health systems must also ensure the appropriate deployment and management of their workforce. This includes strategies such as:
- Conducting periodic health workforce assessments to align skills with population needs
- Implementing effective recruitment, retention, and distribution policies to address shortages and imbalances
- Optimizing skill-mix by deploying the right cadres of health workers to the appropriate care platforms
- Strengthening supervision, support, and accountability mechanisms at all levels
- Investing in digital tools for workforce planning, management, and performance monitoring
When the health workforce is well-equipped, motivated, and effectively deployed, it can serve as a powerful driver of quality improvement and health system transformation.
Igniting People’s Demand for Quality
The final universal action for improving quality is to ignite people’s demand for high-quality care. This means empowering individuals, families, and communities to actively participate in shaping the health system and holding it accountable for delivering quality services.
There are several key strategies for stimulating this demand for quality:
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Health Literacy and Awareness: Investing in health education programs that improve people’s understanding of their health rights, entitlements, and what constitutes quality care. This equips individuals and communities to make informed choices and voice their expectations.
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Community Engagement: Establishing formal mechanisms for community participation in health system governance, planning, and monitoring. This can include community advisory boards, facility management committees, and participatory performance reviews.
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Transparency and Information Sharing: Proactively sharing information with the public about health system quality, including performance data, patient feedback, and grievance redressal. This promotes accountability and enables communities to make evidence-based decisions.
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Empowered Patient Roles: Shifting the patient-provider dynamic to position people as active partners in their own care. This includes promoting shared decision-making, self-management support, and patient involvement in quality improvement initiatives.
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Strategic Partnerships: Cultivating collaborations between the health system, civil society organizations, and community groups to amplify the voices of marginalized populations and advocate for quality improvements.
By igniting people’s demand for quality, health systems can tap into a powerful force for change. When communities are engaged and empowered, they can hold providers and policymakers accountable, identify context-specific quality gaps, and co-create solutions that are responsive to their needs.
The four universal actions outlined in this section – governing for quality, redesigning service delivery, transforming the health workforce, and igniting people’s demand – provide a comprehensive framework for improving the quality of health systems in low- and middle-income countries. While the specific implementation strategies will vary based on context, these actions address the systemic foundations required to deliver high-quality, people-centered care at scale.
Targeted Opportunities for Quality Improvement
In addition to the universal actions, countries can also pursue targeted quality improvement strategies that address specific challenges or leverage existing strengths within their health systems. These targeted opportunities can be implemented concurrently with the foundational reforms, serving as complementary approaches to drive quality improvements.
One promising targeted strategy is district-led collaborative learning, which harnesses the power of networks and peer-to-peer exchange to foster quality improvements. In this model, multidisciplinary teams from health facilities within a district or region come together regularly to identify quality gaps, share best practices, and collectively test and implement solutions.238 The collaborative learning approach promotes mutual accountability, encourages a culture of continuous improvement, and leverages the expertise and energy of frontline providers.
Another targeted opportunity is performance-based financing (PBF), which links health facility funding to the achievement of predefined quality and coverage targets. PBF aims to motivate providers and managers to improve service delivery by aligning financial incentives with desired outcomes. While the effectiveness of PBF in improving quality has been mixed, careful design and implementation, combined with other quality improvement strategies, can enhance its impact.239
Facility-level quality improvement collaboratives represent another targeted approach. These collaboratives bring together teams from multiple health facilities to test and scale up quality improvement interventions, often with the support of external facilitators. The collaborative model harnesses the power of peer learning, shared goal-setting, and the implementation of Plan-Do-Study-Act cycles to drive measurable improvements in specific areas of care.240
Accreditation is a targeted strategy that sets and enforces quality standards for health facilities. When designed and implemented effectively, accreditation can incentivize providers to invest in infrastructure, equipment, and workforce competencies to meet the required quality benchmarks. However, accreditation alone is not sufficient; it must be complemented by other quality improvement efforts to translate standards into meaningful changes in care delivery.241
While these targeted strategies have shown promise in certain contexts, their effectiveness and sustainability often depend on the strength of the underlying health system foundations. Therefore, countries should consider implementing these approaches in tandem with the universal actions outlined earlier, ensuring that targeted efforts are supported by robust governance, service delivery redesign, workforce transformation, and community engagement.
Monitoring and evaluating the impact of all quality improvement efforts, at both the national and subnational levels, is crucial to driving continuous learning and adaptation. Development partners can support countries in this endeavor by aligning their technical and financial assistance with the country’s quality improvement agenda and by investing in rigorous implementation research to expand the evidence base on effective strategies.
Conclusion
Achieving high-quality health systems that consistently deliver care that improves or maintains health outcomes, are valued and trusted by all people, and respond to changing population needs is a complex and ambitious undertaking. However, the stakes are too high to settle for anything less. Poor-quality care is responsible for millions of preventable deaths and trillions of dollars in economic losses each year in low- and middle-income countries.
This Commission has presented a comprehensive framework for transforming health systems to provide high-quality, people-centered care. The four universal actions – governing for quality, redesigning service delivery, transforming the health workforce, and igniting people’s demand – establish the foundational elements required to drive systemic change. These actions must be complemented by targeted quality improvement strategies that address specific challenges and leverage existing strengths within each context.
Ultimately, the path to high-quality health systems will require unwavering political commitment, sustained investment, and a shared sense of responsibility across all stakeholders – from policymakers and health system leaders to frontline providers and empowered communities. By embracing this ambitious quality agenda, countries can fulfill the promise of universal health coverage and ensure that all people, regardless of their socioeconomic status or geographic location, have access to the high-quality care they deserve.
The time to act is now. Let us empower local champions, harness community-driven solutions, and build resilient health systems that serve the needs of people both in times of stability and during emergencies. Together, we can make quality the DNA of health systems worldwide.
Sample Proposal on “Greening Our Communities: Sustainable Solutions for a Greener Future
https://pmc.ncbi.nlm.nih.gov/articles/PMC7734391/
https://www.undp.org/pacific/stories/empowering-community-champions-sustainable-development-rmi
