In recognition of strong quality improvement systems being essential for achieving priority health outcomes, in 2011 PharmAccess (PAI) developed the SafeCare standards and stepwise quality improvement methodology under a formal partnership with the Council of Health Service Accreditation of Southern Africa (COHSASA) and the Joint Commission International (JCI). The methodology benchmarks the performance of health facilities in the provision of quality care and formally recognises this through certification. After the official launch of the standards, PharmAccess started enrolling health facilities in Ghana, Kenya, Nigeria, and Tanzania into the programme. By early 2014, 164 facilities in Tanzania had been enrolled and 28 per cent of them had improved by 10 per cent within 18 months of enrolment. Patient numbers increased by 5 per cent within six months. Following these encouraging results, HDIF funded PharmAccess to take the innovation to scale, with the ambition to achieve a tipping point that would influence a systematic and sustainable change in quality improvement in the Tanzanian health sector.
In order to scale up, PharmAccess aimed to enrol 400 facilities into the programme and support them to undertake a stepwise improvement in quality of services as measured through the SafeCare methodology. In addition to supporting facilities in providing better care, technical support was offered so that facilities could access affordable loans through local banks to invest in quality improvement or to expand services. To systematise quality improvement changes throughout the private health system, PharmAccess embedded the SafeCare approach into the existing health policy and infrastructure of Tanzania. PharmAccess worked in close collaboration with the Ministry of Health, Community Development, Gender, Elderly and Children (MoHCDGEC) and also partnered with three national private sector umbrella organisations to implement project activities: the Association of Private Health Facilities in Tanzania (APHFTA), Christian Social Services Commission (CSSC), and Private Nurses and Midwives Association of Tanzania (PRINMAT). At the beginning of the project, PharmAccess provided technical support to their partners to undertake the project activities. Then, the technical assistance (TA) partners took charge of implementation at facility level and PharmAccess remained responsible for coordination, mentoring, technical support upgrades and issuing certificates of recognition.
- Seventy per cent of facilities improved by more than 20 per cent in the SafeCare score on the subsequent assessment after the entry or baseline assessment.
- In addition, some facilities found that engaging in SafeCare helps their efforts in implementing the SafeCare-generated Quality Improvement Plan and to address other MoHCDGEC health-care improvement initiatives.
- Implementing partners have included the SafeCare methodology as the approach to improve quality of services. For example, CSSC now has more than 200 sites across those enrolled into the quality programme.
- MoHCDGEC’s adoption of the basic tenets of the SafeCare model into other initiatives and frameworks has created a strong policy driver for a standard-based quality improvement approach.
- The approach of PharmAccess for collaborating with MoHCDGEC and partnering with private and public health stakeholders has been key for nationwide acceptance of clinical standards of care for benchmarking quality of services.
- The benchmarking and recognition through certification have both stimulated peer-to-peer learning across the members’ network, and some facilities have adopted the ‘can-do’ attitude, aspiring to achieve and even better the achievements of their peers.
- The work of the TA partners in supporting member facilities has been recognised as they are seen by MoHCDGEC as national influencers. The esteem and influence gained by these bodies through their work on quality and business improvement incentivises further investment in quality and stimulates systematic organisation change to strengthen their capacity to sustain what has been achieved.
- In addition to the economic factors that stalled bank lending, some of the facilities did not have a financial management system that could inform development of a business plan and thus few facilities accessed loans. Using technology to enable facilities to adopt an effective financial management system could be the key for improving business performance.
Gender Equity and Social Inclusion
Despite national commitments to reducing maternal mortality and ending the preventable deaths of newborns and children under five, maternal, neonatal and child health (MNCH) services in Tanzania often struggle to provide adequate care. The majority of the 110 facilities enrolled in the programme received extra support to improve the quality of maternal, newborn and child health (MNCH). Service use improved by 30 per cent, and about 25 per cent of these facilities improved compliance with standards specific for MNCH by 50 per cent.
Principles for digital development
Design for scale: Achieving scale is a goal that has been taken into consideration by PharmAccess in designing the project. Achieving scale can mean different things in different contexts, but it requires adoption beyond an initiative’s pilot population and often necessitates securing funding or partners that take the initiative to new communities or regions. This project was a scaling-up of SafeCare, which was launched in 2011. PAI in collaboration with MoHCDGEC are developing a business case which will be presented to different donors and partners in an effort to solicit more funds to scale the innovation to reach all facilities in Tanzania. To support health facilities undertake a stepwise improvement approach, the implementation of SafeCare is linked to another PharmAccess programme, the Medical Credit Fund (MCF), which supports facilities to improve business performance and move up the quality ladder through access to affordable credit.
SafeCare has been successfully embedded in the country’s health system, and measurable and visible improvements in quality of care have been recorded by some facilities. This has created a growing demand from facilities and umbrella organisations’ management, an incentive for continuation. Yet while the umbrella organisations have each adopted and integrated SafeCare and business improvement into their strategies, identities, and member services, financing is a paramount challenge to the continuity and/or expansion of SafeCare. Though a sizeable proportion of facilities enrolled in SafeCare express a willingness to pay for services, they indicate being able to afford a monthly or quarterly fee far lower than the actual cost of the service. Further innovation by PharmAccess and its key partners is required to produce a business model that will sustain and scale the achievements.