Research on health-care quality improvement in low- and middle-income countries: is it a worthy investment?

This special issue offers an opportunity to reflect on the status of quality improvement research in low- and middle-income countries (LMICs). Quality improvement is difficult to achieve in any setting where busy health professionals are dedicating their full effort to delivering care. Research on quality improvement may be an even lower priority when resources are scarce. In low-income countries, where it is difficult to marshal resources to support quality improvement, supporting evaluation and research may especially daunting. In LMICs, local context can dominate research on quality improvement in ways that researchers in high-income countries may find difficult to appreciate. Research teams with needed capabilities may not be readily available. Secondary data sources that support evaluation in high-income countries may not exist. Primary collection of reliable and valid research data is difficult. Funding to support research and evaluation may be scarce, especially if donors are attempting to spread interventions that they already believe to be effective. Given the odds against research in such settings, the papers in this special issue represent important triumphs. Several authors have overcome key barriers, demonstrating that improvement, learning and research are possible in challenging settings where diverse populations are served. The papers address initiatives by governments, health centers, hospitals and local communities. They include populations such as maternal, neonatal and pediatric groups as well as adults with chronic conditions. The work comes from many continents and examines health-care quality from the level of the patient to the level of the policies that shape entire health systems. The papers reveal that the interventions and tools that best fit the lower-income country context are still a work in progress. They highlight how much remains to be studied and understood to optimally promote quality improvement. They highlight the urgent need to assist government policy-makers, health professionals and other participants to save lives and reduce the vast burden of suffering. In highlighting research on LMICs, this special issue also drew our attention to the challenges inherent in publishing and disseminating such research. A recent systematic review [1] of research from LMICs in peer review journals included in MEDLINE and our own experience suggests that scientists face important barriers to publication. Relative to authors from high-income countries, authors and papers from LMICs are probably underrepresented [2]. Anecdotally, many quality improvement projects are in progress around the globe and many are producing important insights, but we have the impression that too many of these projects produce insights that are not widely shared or disseminated through peer-reviewed publication. The rationale for quality improvement research in LMICs is similar to that in any country [3]. It is important to measure quality using local data, to analyze and prioritize quality problems and to develop solutions that have been evaluated rigorously so that they will be persuasive to key policy-makers [4]. Nevertheless, as the discussion of a recent Salzburg seminar suggests, much of what has been accomplished in LMIC may not be disseminated widely or to key audiences. What are the hurdles for publication of this research and how might they be overcome in the face of scarce resources? Our first observation is that many research papers on quality of care in LMICs are descriptive or “discovery driven” rather than hypothesis driven. In each country, describing the current status of quality is important. Such descriptions provide an important baseline for understanding how to intervene. However, the science of quality improvement can be advanced only through the testing of hypotheses. The ideal descriptive paper not only establishes baseline observations of the quality of care and the country context, but addresses an explicitly defined research question—one that has not been extensively answered by prior studies. Defining such research questions and the data and methods necessary to address them is a creative effort requiring a deep understanding of the prior scientific literature and ingenuity in the use of available data. The second observation is that quality improvement science in high-income countries is increasingly focused on evaluating interventions [5,6]. However, interventions are inherently more expensive to conduct than observational research and this may create a disadvantage for researchers in LMICs. Interventions conducted on a scale necessary to support effective quantitative evaluation may be rare. With fewer opportunities for researchers in LMICs to carry out projects, it is difficult to develop research infrastructure and the research skills necessary to carry out complex evaluations. The third observation is that peer-review standards for journals that are indexed in MEDLINE or EMBASE may be challenging, especially for authors writing in English as a second language. Barriers related to scientific composition and language may impede the publication of important results. Editors and peer reviewers may have limited capacity to provide the scientific and editorial support that some papers require. The last observation is that local contexts affect the interpretation of all quality improvement studies. The local contexts of high-income countries are often familiar to peer reviewers in high-income countries, but the LMIC contexts may be foreign to these peer reviewers. Describing and explaining the importance of context is more important when the context is unfamiliar. Implementing a familiar intervention in a novel context may represent an important scientific advance, but one that can be captured only if the context is sufficiently described. The barriers described above are not intended to place the burden on scientists from LMICs. On the contrary, the global scientific community has an obligation to assure that quality improvement science is relevant not just in high-income countries, but wherever improvement might reduce suffering and mortality. An accompanying editorial describes important steps that are needed to support quality improvement science. To overcome the dissemination and publication barriers requires closely coordinated actions. We see three opportunities. First, support for training for researchers in LMICs is critical. Junior researchers gain research and scientific composition skills through mentorship from senior researchers. Mentorship for researchers, a scarce resource in LMICs, should be supported and extended. Visiting training opportunities supported or offered by professional research societies and foundations and remote training that takes advantage of the internet to create communities of research and practice may be especially useful [7]. Model institutional partnerships have been forged between some research teams in high-income countries and in LMICs. One of the major efforts to date, the WHO Patient Safety [6] program, has worked to expand quality improvement capacity by sharing methods, education and dissemination and funding of new research projects [9]. The program generated new patient safety campaigns, new networks of colleagues and peers, products for implementation and research and funding for over twenty research projects. Expanding and replicating such a program could extend the infrastructure for quality improvement research at a critical time. Secondly, dissemination opportunities other than through peer-reviewed publications may be both more timely and more supportive of investigators. Internet-based repositories that record and enable sharing of customized, evidence-based quality improvement solutions may be highly relevant to those working in LMICs [9]. A repository for evaluation work that may not constitute research publishable in peer-reviewed journals may nevertheless provide useful information about the translation of improvement methods to various settings. Third, networking of researchers is potentially easier than ever before. Currently available technologies can facilitate the sharing of expertise globally. Websites sponsored by the International Society for Quality, the WHO, the Institute for Healthcare Improvement and other organizations could foster virtual communities that enhance collaboration of researchers evaluating quality improvement. Finding support for such tools may be difficult in an era of economic challenges and austerity, but failure to support such initiatives represents a lost opportunity given the capacity of the Internet to enable such networking. After more than 20 years of research, quality improvement in LMICs may be at the ‘end of the beginning’ [10]. As patients in lower resource settings gain access to needed care, incorporating the lessons of quality improvement science and enhancing the policies that can lead to higher performance health-care systems becomes increasingly urgent. By illustrating some of the research under way in LMICs, we hope that this special issue contributes to global efforts to enhance quality improvement, evaluation and research in these challenging settings. We would like to thank Dr Sheila Leatherman her valuable comments.