Quality (168) District-level activities for improving quality health services (2)

26 July, 2021

On behalf of WHO, Treasa asks "From your experience, what are the biggest challenges for district health managers in tackling quality of care issues? Have you seen any practical solutions that should be shared wider?"

As background, the WHO Quality Health Services: a planning guide refers to 'district' as a clearly defined administrative area, where there are local government and administrative structures that take over many of the responsibilities from the national government and where there is a general hospital for referral.

'Activities at the district level influence implementation of quality health services at the facility and community levels. The district level is the key interface between health facilities and higher levels, and is responsible for operationalizing national strategic direction on quality. It is at this level that planning, implementation, monitoring and supervision of activities to improve quality of health services in facilities and communities are carried out' (WHO Quality Health Services: a planning guide, page 23).

Quality health services: a planning guide (2020) https://www.who.int/publications/i/item/9789240011632

We would be particularly interested to hear from HIFA members who have experience as district health managers, from any country and especially from low- and middle-income countries. If you do not have such experience yourself, perhaps you may like to forward this to a contact who does have such experience? We need to hear from them in order to learn and help inform future WHO guidance.

Questions that occur to me, and which we might ask to District health managers (and to ourselves) include:

1. What does quality mean to you in your context?

2. How do you measure quality?

3. How important is the concept of 'quality' in your day-to-day work, as compared with other challenges?

4. To what extent is there a culture of quality in your district? How might this be better supported?

5. To what extent does your district operationalise national strategic direction?

6. What support does your district provide to facilities within the district to increase quality? What mechanisms are in place to respond to their needs?

Throughout this discussion, our colleagues at WHO have emphasised the importance of coordination and communication across the three main levels of the health system: national, district, and facility. Being 'in the middle', the district level is critical for this. But how it might work in practice is unclear to me (and I suspect to many of us). For example, to what extent is national strategy directive versus supportive? Are there any examples of countries where strategic direction, operationalisation, support, and deliver of services are clearly in harmony and even synergistic? I might guess that in some settings, levels of quality may be variable and dependent on the aptitudes of specific district health managers (and facility managers)? And what about political and financial factors, whether personal or organisational - how do they affect the quality of health services?

Lots of questions!

Your comments on any of these are welcome, whether or not you have experiences as a district health manager.

Thank you.

Neil Pakenham-Walsh, HIFA Coordinator, neil@hifa.org www.hifa.org