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Abstract
Objectives Improving the quality of care requires specific, comprehensive and continuous attention from the administration of a health system. However, information on evaluations of national and subnational policies and strategies for quality is lacking. This study aims to map studies evaluating policies and strategies for quality in health systems around the world.
Design This is a scoping review based on the guidelines of the Joanna Briggs Institute (JBI), guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR).
Data sources The search for articles was carried out in the Embase, Medline/Pubmed, Scopus, Web of Science and Cumulative Index to Nursing and Allied Health Literature databases and in the grey literature in July 2024.
Eligibility criteria Publications describing a tool for evaluating interventions for quality in the health system and studies containing at least one conceptual framework related to the evaluation of policies and strategies for quality in the health system, in any language, were included.
Data extraction and synthesis Data selection was carried out independently by two reviewers, whose conflicts were resolved by consensus and the decision of a third reviewer. The findings were synthesised using a data extraction protocol adapted from two theoretical frameworks on National Quality Policies and Strategies proposed by the WHO.
Results The data search resulted in 133 potentially eligible studies, of which 14 studies were included in the review. We found 27 countries that had evaluated their policies or strategies, most of them in Asia (11) and Africa (9). Six studies used instruments to evaluate interventions for quality at the health system level. An instrument used in Afghanistan, Armenia, Guatemala and Mexico proved to be potentially useful for dissemination in other countries. Among the elements recommended by the WHO for the implementation of strategic policies for quality, the most present were governance and organisational structure.
Conclusions Although the evidence provides an indication of how countries have implemented their quality policies and strategies, we identified the need for tools to assess their impact on health systems.
- Health policy
- Quality Improvement
- Health Services
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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STRENGTHS AND LIMITATIONS OF THIS STUDY
The study follows the guidelines recommended in the literature by the Joanna Briggs Institute, guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews checklist for greater rigour and transparency.
In this scoping review, a comprehensive search was carried out in peer-reviewed journals and grey literature, with no time limitations.
This review focuses on ‘analyzing the QPS implementation process against WHO criteria’ without assessing its impact.
This review did not capture policies or strategies that were not explicitly identified as a ‘quality policy or strategy.’
Introduction
Problems related to the quality of care account for 58% of preventable deaths in low-income and middle-income countries.1 The Lancet Global Health Commission on High-Quality Health Systems reveals that simply solving the problem of lack of access to health services is not enough to improve the health status of the population and that poor quality of health has killed more people than difficulties in access.1 2 Progress in improving the quality of healthcare around the world has been slow and uneven, as there are international variations in its development.3 4 The gains are neither universal nor are they sufficiently broad and sustainable, especially for the most vulnerable population groups; there is, however, a certain degree of convergence among countries in the implementation of Quality Policies and Strategies (QPS).4 5
Quality improvement has, for most countries, been key to health systems reform and service delivery.6 All countries face challenges in ensuring patient access, equity, safety and participation, and in developing skills, technology and evidence-based medicine, with available resources.7 Thus, the WHO recommends that all countries develop a national QPS that supports health services and professionals. These QPS should be implemented not only at the health facility level (microsystem level) but at the entire national or subnational health system level.5 8 9 However, in an environment dominated by the scarcity of resources, in which several simultaneous health priorities emerge, making investments in quality of care becomes a major challenge.5 All health systems already carry out activities aimed at quality of care, but in order to measure their progress, they need to be evaluated. The implementation of a QPS must consider the strengths and weaknesses of the implemented actions, to accurately identify the baseline, as well as to establish objectives and monitor progress.8 Some assessment models have been proposed by institutions, such as the WHO, the Health Foundation, the Institute of Medicine (IOM) and the Institute for Healthcare Improvement (IHI), but it is a new area with few models or instruments available.10 11 Authors such as Shaw and Kalo,7 for example, have described a self-assessment tool to help identify existing mechanisms and future opportunities for quality improvement in national systems. Bengoa et al 8 proposed a questionnaire for self-assessment of the status of interventions to improve quality in health systems. Yet, the difficulty of finding and comparing possible instruments to assess QPS at the system level hinders compliance with WHO recommendations and progress in this area.6 Our interest in this review is to find and compare experiences that may be useful to assess the situation of health systems and for the implementation of a QPS at a national or a subnational level.
It is hoped that the results found in this analysis will support the choice of an instrument that can be culturally adapted in countries or states that have administrative autonomy for the governance and organisation of its health systems. In addition, the results of this review can assist the WHO working group on National QPS (NQPS) to the development of future guidelines for monitoring and evaluating in the QPS.
Based on these arguments, this study aims to map evaluation studies on QPS in health systems around the world. Specifically, it seeks to (a) identify studies on the evaluation of QPS in health systems, (b) identify available instruments to evaluate strategic interventions for QPS in health systems and (c) describe the QPS found in the studies using the framework of elements recommended by the WHO.
The results of this review may be useful for countries and states wishing to assess their QPS at the system level. This type of effort is necessary to foster the dissemination and implementation of integrated strategies for the quality of care in health systems.
Methods
This is a scoping review based on the guidelines of the Joanna Briggs Institute (JBI).12 The revision follows the model originally proposed by Arksey and O'Malley,13 updated by Levac, Colquhoun and O'Brien.14 The study was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR).
The scoping review protocol has been registered in the Open Science Framework (OSF) to identify ongoing reviews and avoid unnecessary duplication of research and is available at: https://doi-org.ezproxy.u-pec.fr/10.17605/OSF.IO/2KMTS.
Step 1: Identification of the research question
For the formulation of the guiding questions of this study, we used the elements proposed in the mnemonic PCC, in which the letter ‘P’ represents the population; ‘C’ is the concept; and ‘C’ is the context, as described in online supplemental table 1 (Research questions).
Supplemental material
Step 2: Identification of relevant studies
Data sources
The search for articles was performed in the open and controlled databases: Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, Latin American and Caribbean Literature in Health Sciences (LILACS), Medline/Pubmed, Scopus and Web of Science, with no date restriction. To obtain a wide spectrum of results, the search was complemented with data obtained from the grey literature, which included technical documents published on the following websites: the WHO, the Pan American Health Organisation (PAHO), The European Observatory on Health Systems and Policies (OECD), The Health Foundation and the IOM. In addition, technical documents obtained by the snowball technique were included, based on the bibliographical references cited in the studies identified in the databases and in the grey literature.
Search strategy
The search in the databases took place in July 2024. A specific search strategy was defined, based on the inclusion and exclusion criteria, which made it possible to identify relevant studies that were close to the topic.
The descriptors were used in English, according to the keywords, Health Sciences Descriptors (Decs) and Medical Subject Headings (MESH) controlled ‘Health Systems’, ‘Patient Safety Policy’, ‘Patient Safety Strategy’, ‘Quality Strategy’, ‘Quality Policy’, ‘National’ And ‘Subnational’. To refine the search, the expression terms were combined with the boolean operators ‘AND’ and ‘OR’. The search strategy with the studies obtained from the database is described in online supplemental table 2 (Search strategy). Regarding the search in the grey literature, we opted for the use of natural language (uncontrolled vocabularies), due to the need to expand the results, obtaining a broader and more sensitive strategy.15
Step 3: Selection of studies
The documents were selected based on pre-established eligibility (or inclusion) criteria. The selection (both in the title/abstract screening and in the full-text screening) was performed independently by two reviewers. Conflicts were resolved by consensus and the decision of a third reviewer. To manage the search results, the ‘Rayyan’ software was used, in the free version. The manager assisted in the collection, storage and organisation of references, as well as facilitated blinding and sharing among reviewers.
Eligibility criteria (inclusion)
For the identification and selection of relevant publications on the subject, the following inclusion criteria were used: (a) systematic reviews, narrative reviews, government reports, or working groups that described some tool for evaluating interventions for quality in the health system; (b) publications with at least one conceptual framework related to the evaluation of QPS in the health system, in any language.
Exclusion criteria
The exclusion criteria were (a) documents that did not meet the study concept, (b) publications that did not adequately describe the strategies implemented in the national policies and strategies for quality in health systems, and (c) incomplete studies in the design phase. Duplicate studies were counted only once.
Step 4: Data Mapping
Data extraction
Data collection was guided by a data extraction form, which generated the text mining database, developed electronically in the Microsoft Excel programme, and filled out independently by the two researchers.
The data extraction protocol was adapted from two theoretical frameworks on NQPS, proposed by the WHO: (1) ‘Quality of Care: A Process for making strategic choices in health systems’,8 and (2) ‘Handbook for national quality policy and strategy: a practical approach for developing policy and strategy to improve quality of care’.6
Step 5: Compilation, summary and reporting of results
The extracted data were grouped with details of the studies, seeking to answer the research questions (see online supplemental table 1). Furthermore, to understand the characteristics of the published policies and strategies, we used as a reference the conceptual model that encompasses eight elements for the elaboration of NQPS developed by the WHO and by the countries that pursue national initiatives for quality: (1) national health objectives and priorities, (2) local definition of quality, (3) stakeholder mapping and engagement, (4) analysis of the situation (quality status), (5) organisational and governance structure for quality, (6) methods and interventions for improvement, (7) health information management systems and data systems, and (8) quality indicators and essential measures.6
We also used the model proposed by Bengoa et al 8 on interventions for quality improvement in health systems. The model has six domains for choosing strategic interventions: (1) leadership, (2) information, (3) patient and population involvement, (4) regulation and standards, (5) organisational capacity, and (6) models of care.
Results
The search strategy in all databases resulted in 112 documents, and 73 after eliminating the duplicates (39). During the screening of the titles and abstracts, 64 articles were included for full-text screening. Finally, nine studies met the eligibility criteria. The grey literature search resulted in 21 potentially relevant publications involving NQPS, and five documents fully met the inclusion criteria. At the end of the search strategy, 14 documents were included in the review. The flow diagram in figure 1 shows the details of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) review process of identification, selection and inclusion of studies.
Flow diagram process of identification, selection and inclusion of studies—Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).
Evaluation studies of quality policies and strategies in health systems available for analysis and the context in which they were carried out
The publications included quality policies or strategies from countries on the European continent (Estonia and Denmark), North America (Canada, Mexico and the USA) and Central America (Guatemala). Studies were also identified that included nine countries on the African continent, such as Ethiopia, Ghana, Kenya, Malawi, Mali, Nigeria, Sudan, Sierra Leone and Tanzania. In addition to these, studies were selected that evaluated the implementation of NQPS in countries on the Asian continent, including Afghanistan, Armenia, Bangladesh, Cambodia, Kazakhstan, India, Indonesia, Jordan, Lebanon, Malaysia, the Philippines and Vietnam.
Among the types of studies selected from the databases are six case studies, two literature reviews and an experience report on the evaluation of the implementation of quality policies and/or strategies in one or more countries, referring to national health systems or subsystems. In the grey literature, two technical manuals and three technical assistance consultancy reports were selected.
The selected articles were published between 2006 and 2023, of which four were published in the first 7 years (2006–2013) and five in the last (2014–2023) (see online supplemental table 3). In the grey literature, documents published between 2002 and 2022 were found (see online supplemental table 4). Practically, all selected studies address the implementation of quality policies or strategies in national health systems, except one study that describes the experience of a subnational health system in the USA.16
The implementation of strategies and policies for quality improvement was supported by international agencies and institutions such as the WHO, the World Bank, the United States Agency for International Development (USAID), the European Commission, Healthcare Excellence Canada and the Bill & Melinda Gates Foundation.16–20
Available instruments for assessing the quality of care in health systems
Six studies were identified that included instruments for evaluating quality strategies in health systems. Of these, two were found in databases17 19 and four in the grey literature.21–24 A tool published by PAHO to assess Essential Public Health Functions (EPHFs) in the Americas was found in the grey literature.25 Although it is not a tool focused exclusively on the evaluation of NQPS, it addresses important elements of the evaluation of the quality assurance of individual and collective health services related to PHEF 9. The tool consists of a questionnaire containing the 11 essential public health functions, each with its definition and specific indicators, the version of which was updated in 2020.25
In our search, we found other examples such as Estonia’s experience with the use of the self-assessment questionnaire, proposed by the Council of Europe and the WHO Regional Office for Europe, as a framework for evaluating the quality activities of its national health system.19 This is a self-assessment questionnaire proposed by the Council of Europe and the WHO Regional Office for Europe as a framework for assessing national quality activities.19 The instrument includes four domains for assessing national quality activities:
Policy—comprehensiveness and consistency of the government’s values, vision and strategies for quality improvement, based on evidence and consultation.
Organisation—existence of effective mechanisms to integrate and implement national policy across national and local government and between all stakeholders.
Methodology—promotion of effective methods for quality improvement at national and local levels.
Resources—identifying responsibility for financing and providing the basic knowledge, skills and information needed for quality improvement.
Another tool identified was used to assess the quality of the health system in Afghanistan26 and is based on the tool proposed by Bengoa et al.8 This tool was also identified in three other publications in the grey literature (Armenia, Guatemala and Mexico), being the most cited among the results.22–24 According to the authors, the tool was designed to assess the quality of medical care through a self-assessment questionnaire for the detailed analysis of the six quality interventions proposed by the WHO. The tool is based on six domains, including:
Leadership—for the best results to be achieved, strong leadership and support for quality needs to come from national and community leaders, as well as leaders of health service delivery organisations.
Information—this is key, as any quality improvement depends on the ability to measure change in processes and outcomes, and on stakeholders having access to the information that changes what they do.
Patient and population involvement—this domain is essential for quality improvement, as individuals and communities play many roles in health systems. Directly or indirectly, they will fund care, work in partnership with health professionals to manage their own care, and sometimes be the final arbiter of what is acceptable and what is not in all dimensions of quality.
Regulation and standards—the use of regulation and standards seeks to change performance through the application of externally developed measures.
Organisational capacity—quality issues in this domain apply to the entire health system; at the national level, there must be the capacity to lead policy development, drive implementation and keep performance under review.
Models of care—the development of new models of care will normally aim to address all the dimensions of quality and will seek to improve results by organising integrated responses.
The tool developed by Bengoa et al 8 was also used to assess the quality improvement of healthcare systems and patient safety initiatives in Lebanon and Jordan.17 The analytical framework used focused on the macro and meso levels. The macro level includes national health systems, the meso level includes health organisations and the micro level includes clinical teams. However, in this study, an adapted analytical framework was used which considered both the macro and meso levels.17 For the assessment at the macro level, the following components were considered:
Context of health systems—governance; financial and delivery arrangements of the health system in each country.
Policies and legislation—presence of an explicit and comprehensive national quality and patient safety policy and incentives and barriers to participation in quality and patient safety improvement initiatives.
Organisations and institutions—coordination of quality improvement and patient safety initiatives; responsibility and mechanisms for implementing and monitoring quality improvement and patient safety initiatives; quality support structures (existence of a national clinical governance council, national society for quality in health).
Methods, techniques and tools—licensing of health professionals and health institutions; systems for reporting adverse drug events; national healthcare accreditation programmes and national performance indicators.
At the meso level, the following were analysed:
Health infrastructure and resources—infrastructure for improving quality and patient safety; human resources for health; health information system and financial resources.
Most of the documents identified did not mention the use of any structured instrument. Only six of the 14 documents analysed explicitly mentioned an instrument. Of these, three studies used the structure proposed by Bengoa et al.8
Characteristics identified in the documents analyzed in relation to the essential elements recommended by the WHO on National Quality Policies and Strategies (NQPS)
The conceptual model adopted to analyse the studies has been used to support countries in the formulation of national or subnational quality policies and strategies aimed at improving the quality of healthcare.6 It addresses important characteristics of the process of formulating the policy for the quality of healthcare, with the WHO indicating the steps that should be followed.6 8
Among the elements recommended by the WHO for preparing the NQPS, the ‘local definition of quality’ and the ‘local definition of quality’ were the least present elements.19 22–24 26–29 ‘Governance and organizational structure for quality’ was the most present element, being cited in all studies.4 16–20 22–29 The synthesis of the selected studies in online supplemental table 5 follows the WHO elements for the elaboration of the NQPS and the interventions for quality improvement.
Discussion
Our research highlights the state of the art of QPS studies at system level that are available in the literature, and their characteristics in relation to the components recommended by the WHO,6 as well as the existing tools for evaluating these policies and strategies. This is an emerging field of research, with most initiatives supported by international organisations, trying to complement the common micro-level approach to quality improvement. The number of studies is still limited but diverse enough to draw some lessons and to identify practical approaches and tools for the building and implementation of QPS at system level.
Evaluation studies of quality policies and strategies in health systems are still scarce but geographically diverse and supported by international agencies
All health systems, explicitly or implicitly, develop activities to improve the quality of healthcare; however, only nine studies were identified in the databases on the evaluation of NQPS and five on the websites of institutions such as the WHO. This result may be related to the fact that this is a recent topic, which gained the most intensive support from the WHO, only after the inclusion of quality in the United Nations Sustainable Development Goals (SDGs) in 2015.
Some countries have defined a minimum set of priorities for intervention, for instance, countries such as Ghana in ‘Project Fives Alive!’ implemented with the support of the IHI, whose focus was on improving access and quality of care across a spectrum of maternal, newborn and child health activities.27 30 Afghanistan proposed a set of goals focusing on improving health outcomes (the goal of the strategy) in priority areas of maternal and newborn care, child and adolescent health, nutrition, disability, mental health, and communicable diseases.26 At the Centres for Medicare and Medicaid Services (CMS) in the USA, the following priorities have been defined: (1) improving patient safety; (2) provide effective, efficient and accessible care; (3) involve individuals and families in their health; (4) improve communication and coordination of care; (5) advanced prevention; (6) foster healthy communities; and (7) eliminate health disparities.16
The predominance of experiences of NQPS in countries of the Global South and the support of international agencies or institutions are noteworthy.31 Agencies such as the WHO were conceived in the post-war period to provide technical cooperation among member countries through initiatives to support them in health problems and improve health systems. Since the end of the 1990s, the WHO has taken the leading role in advising governments on the progress of health system reforms.32
The offer of support by institutions such as the World Bank and many international donors and agencies is based on the argument that aid to the least developed countries would be more effective if it were linked to political advice.32 The evaluation of the impact of the bank’s activities shows that the real origin of the effectiveness in the sector has more to do with the reforms resulting from the policy advice that accompanies the loans than with the loans themselves.33
On the instruments available to assess the quality of care in health systems
Improving the quality of health services requires specific and continuous attention, practised with a rigorous methodology, in which there is room for innovation and experimentation in the ways of doing things, but which must always be accompanied by measurement.34 35 In this context, the use of a structured instrument in the definition and implementation of the NQPS can be useful in identifying the gaps and priorities to be addressed, contributing to improving the quality of health systems.
In our analysis, we found some relevant examples of how the instrument developed by PAHO to measure Essential Public Health Functions has the potential to highlight critical areas of the structure, institutional capacity and management process of EPHFs. This is because it allows managers and their teams to identify weaknesses and opportunities for action.21 25 36 There will certainly be a renewed instrument in line with the new version of the EPHFs.25 Overcoming difficulties and strengthening the government’s capacity to improve the health of the population, the main objective of EPHFs involves the processes of formulating, implementing and evaluating policies. It is a necessary and fundamental management technology for decision-making.37
Estonia’s experience has indicated the strengths and weaknesses of the current organisation of quality activities in the country’s health system and ways to improve. Strengthening coordination with explicit quality monitoring was considered an essential factor for improvement.19
The self-assessment questionnaire used to evaluate Afghanistan’s healthcare system sought to identify gaps in the system and improve the quality of healthcare.8 26 This tool and a framework for analysing and creating quality improvement strategies were proposed by Bengoa et al 8 and have been widely used in countries such as Armenia, Guatemala and Mexico.22–24 According to the authors, this tool is an integral part of a cyclical process that reflects a frequently adopted approach to quality improvement that involves understanding the problem, planning, taking action, studying the results and planning new actions in response.8
The tool used to assess health system quality improvement and patient safety initiatives in Lebanon and Jordan aimed to compare existing initiatives to improve quality and patient safety in the two selected countries across five macro-level and meso-level components.
The decision to use a particular method must be conditioned by the characteristics of each health system and, above all, the feasibility of its use.34 During the research, it was observed that most of the instruments follow the recommendations or model suggested by the WHO6 8 in their analytical structures. This finding reflects the importance of using a systematised method to evaluate NQPS.
However, there is a lack of publications on tools to assess the progress of implemented actions. The lack of measurement and monitoring of the activities carried out contributes to the enormous waste that exists in the operation and provision of health services. It seems to us that the definition and perception of the need for a structured instrument for the design and implementation of quality policies and strategies is still an evolving field, although it is not something new.
Characteristics of the documents analyzed regarding the essential elements recommended by WHO: all are present, but in many cases some relevant components are missing
One of the WHO’s recommendations for the development of NQPS is its alignment with national health goals and priorities.6 The review identified that countries such as Lebanon and Jordan still lack explicit national quality improvement policies that clearly define government strategic objectives to achieve quality in the healthcare system.17 A quality strategy should articulate national health priorities and goals that are specific, measurable and have a deadline for completion.28
Strategy formulation means defining a clear vision for quality.28 The WHO, when it launched the NQPS project, proposed that countries formalise their definition of quality and then conduct a situational analysis of their current quality status.6 8 Countries should assess their baseline to develop an explicit local definition of what ‘quality’ means. The analysis of the state of quality is to know the local context within which the quality strategy operates.27 This was one of the least present elements for the elaboration of the NQPS in the results found.
Regarding stakeholder mapping and involvement, we found that in some countries, there are processes and forums aimed at stakeholder involvement operating throughout the health system. For example, the Ethiopian Hospital Quality Alliance is a forum for hospitals to collaborate on activities such as surgical checklists and measuring patient experience.18 Suriname has developed a cross-sectoral collaboration framework with eight cross-sectoral policy working groups formulated from a consensus workshop and a steering group for monitoring the strategy.28
Strengthening the national quality direction and stewardship is key to overcoming fragmented quality improvement initiatives in countries and boosts their uptake.8 38 In the analysis of the articles, we identify those responsible for the functions related to quality. In most countries, a structure for quality defined in the organisational chart has been created or already existed, led by the Ministry of Health itself.18 26 However, we found a variety of structures for this function. For instance, in Afghanistan, although there was a Quality Unit with overall responsibility for the development of the document, the process involved a Task Force and a Core Group composed of representatives from the main departments of the Ministry of Health, partner organisations and hospitals.26 In Lebanon and Jordan, accountability for quality at all levels of service provision and/or between the different entities involved in quality was not explicit in the document.17 This lack of a clear definition of responsibilities can lead to misunderstandings about tasks, assignees, redundancies and gaps.28
Governance and organisational structure for quality are critical to the success of NQPS. Support from existing leaders at all levels of the system contributes to the implementation of the initiative in a horizontal and participatory manner.6 8 Many high-income countries have organisations that coordinate quality improvement activities across health sectors at the levels of ‘quality improvement organizations,’ such as Spain, the USA and Canada, with the creation of provincial health quality councils.16 23 28 39 Spain, with a public and universal health system, has instituted a person responsible for coordinating continuous improvement activities for quality in each health region, at all levels of care (primary, secondary and tertiary).39
In an NQPS, the rights of service users and the community should be at the heart of quality policy throughout the health system.8 Quality improvement interventions must be in alignment with the community to facilitate organisational change.38 In many countries, at least on paper, the rights of service users and communities are at the heart of quality policy. Service users and communities are properly involved in the governance of all parts of the health system. As an example, Afghanistan drafted a ‘Patient’s Bill of Rights’.26
Quality care requires investments in several sectors, especially in information technology (IT) systems, data systems and monitoring. They must be based on a culture of transparency, with adequate facilities to publicise the results of quality indicators.27 In this regard, the evaluation of quality progress requires the formulation and definition of a set of indicators that will feed into monitoring systems.8 9 This is acknowledged in most, but not all, of the reviewed documents. In some cases, for instance, in Estonia, patient administration systems are designed to generate indicators, indices and data for clinical administrative review.19 Service level agreements identify agreed quality targets; however, specific indicators to measure quality progress are still lacking.19 Other countries such as Lebanon and Jordan do not have a national centre for the collection and dissemination of comprehensive comparative information on health system performance. It seems that both countries lack national sets of standardised and comparable indicators for benchmarking and improving performance.17 In other studies, there is no description of health information management systems and data systems. However, for the success of quality monitoring, health data and information systems must be integrated and support national quality efforts.5 8
Regulation through policies, laws or regulations guides the behaviour of citizens, care providers and organisations to the extent that they establish rules of conduct in support of quality healthcare.8 Having a legal requirement for quality improvement strategies is an important tool for the progress and implementation of a policy, along with the activities of national governments, professional associations, and societies.4 Standards should be evidence-based and should reflect normative guidance, being constantly updated and adapted to the national context.8 28 Of the experiences evaluated, only in Lebanon and Jordan was the commitment to quality improvement and patient safety not explicitly decreed.17
The ability at the national level to focus attention on a quality agenda and sustained leadership for the health system presupposes that governments will need to make investments in the general building blocks of the health system with organisational and governance structures.9 These will serve the objectives of ensuring accountability and monitoring, clear quality metrics to improve the effectiveness and efficiency of improvement interventions, and tools/resources to systematically collect and learn from quality improvement efforts.9 38
The organisational and governance structures relate also with the issue of the incentives for quality improvement. We did not find a common pattern of consideration and initiatives addressing these topics. For instance, in Estonia’s case, there are no specific quality targets, and the costs of quality activities are not explicitly defined, except for the costs of continuing training of professionals. The strategy does not identify either incentives to motivate staff to participate in quality improvement.19 In the case of Lebanon, while there are no policies identifying incentives to participate in quality improvement and patient safety initiatives, the Lebanese Ministry of Health links accreditation status to contracting with public and private hospitals. In Jordan, contractual arrangements with health organisations are minimal, making it difficult controlling quality in the growing private sector. Incentive systems that bind contractual agreements, regulations, accreditation status and performance indicators are absent. In both the Lebanon and Jordan cases, there are no strategies regarding training and capacity building of the health workforce on how to implement, monitor and evaluate initiatives to improve quality and patient safety.17
Quality is often seen as a luxury that only rich countries can afford. The results found in our study prove that this is not just a prerogative of these countries. Building quality health services requires a culture of transparency, engagement and openness about outcomes, which are possible in all societies, regardless of income level. Our analysis provides several insights into the implementation of NQPS, based on the experience of countries around the world, ranging from the selection of priority indicators to monitor progress, prioritising the analysis of maternal and child mortality indicators,18 to the combination of strategies to improve patient care at the frontline of service delivery, with the development of systemic capacity at all levels, through national leadership and policy formulation, as identified in the Afghanistan case study.26
In all the countries studied, the reorganisation of healthcare delivery is perceived as an opportunity for quality improvement. Mechanisms have been identified that allow the development of new models of care operated with the involvement of health service providers, service users and communities. At the same time, the variation in the implementation of some countries’ policies and strategies became evident.
Limitations and future studies
The limitations of the scoping review method preclude a comparison of the most effective interventions or assessment tools among those identified. Furthermore, although no temporal or linguistic restrictions were imposed, few studies and approaches for the assessment of NQPS were identified. The search, conducted solely with English terms, may have excluded publications from certain countries, particularly those pertaining to grey literature documents.
A considerable number of countries have established a variety of legal instruments, regulatory policies and implementation mechanisms with the objective of regulating the quality of health services in both the public and private sectors. However, these are frequently not codified as explicit ‘quality policies or strategies,’ and thus were not included in this review.
Conversely, the study delineated experiences pertinent to the assessment of NQPS and underscored the necessity for additional research to substantiate the efficacy of the instruments used for the evaluation and enhancement of these policies.
Conclusion
The investigation delineated the stakeholders engaged in the development and evaluation of the NQPS and underscored the necessity for the creation of models and tools for the assessment of quality strategies within health systems. A systematic analysis, using the elements recommended by the WHO, provides a valuable description of the most and least included components, which may warrant attention in future initiatives.
One of the most encouraging findings of our analysis was the presence of a governance structure in the majority of the experiences examined. Conversely, while the evidence offers some insights into how countries have implemented their quality policies and strategies, the research indicates a paucity of scientific evidence regarding the evaluation of their impact on health systems. In this regard, the discussion surrounding the significance and necessity of a structured approach to monitoring and evaluating the efficacy of quality programmes and initiatives merits further consideration.
It is anticipated that the findings of this review will contribute to an expansion of knowledge and attention to this significant and emerging topic. The results may prove valuable for policymakers and managers seeking to evaluate and enhance their policies and strategies for quality of care. It is strongly recommended that studies be developed to provide support and assistance to nations in the comprehensive design and evaluation of the NQPS, monitoring progress in the quality of their health services.
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information.
Ethics statements
Patient consent for publication
Ethics approval
Not applicable.
Footnotes
Contributors MCdSP is the guarantor. ZAdSG proposed and guided the study. The conception and development of this study were the responsibility of MCdSP. Both authors participated in the discussion of the theoretical and methodological aspects of the study. MCdSP and ACSGC searched the databases and participated as reviewers in the selection of publications for the study. ZAdSG participated as a third reviewer, clarifying the conflicts. PJSH contributed a critical review of the manuscript in general. All authors reviewed the protocol and approved its final version for publication.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.