Stepwise accreditation in Tanzania: no impact on process quality
Authors: Sanam Roder-DeWan, Talhiya Yahya
Journal: The Lancet Global Health (2021)

Health facility accreditation is routinely drawn from the poorly stocked arsenal of interventions to improve the quality of health care in low-income and middle-income countries (LMICs), despite often scarce evidence to support effectiveness.1Kruk ME Gage AD Arsenault C et al.High-quality health systems in the Sustainable Development Goals era: time for a revolution.Lancet Glob Health. 2018; 6: e1196-e1252Summary Full Text Full Text PDF PubMed Scopus (735) Google Scholar In The Lancet Global Health, Jessica King and colleagues2King JJC Powell-Jackson T Makungu C et al.Effect of a multifaceted intervention to improve clinical quality of care through stepwise certification (SafeCare) in health-care facilities in Tanzania: a cluster-randomised controlled trial.Lancet Glob Health. 2021; (published online Aug 4.)https://doi.org/10.1016/S2214-109X(21)00228-XSummary Full Text Full Text PDF Scopus (1) Google Scholar address this conspicuous gap in the literature with their rigorous cluster-randomised controlled trial of the SafeCare model, a stepwise accreditation scheme implemented in Tanzania. They document no effect of the SafeCare model on quality processes of care. The SafeCare trial enrolled 237 faith-based or private, for-profit facilities split evenly between control and exposure to SafeCare, a standards-based model designed specifically for resource-constrained settings such as Tanzania. All facilities were assessed using the SafeCare standards, but intervention facilities also received support, including quality improvement plans, clinical and business training, mentorship, and opportunities to apply for loans. In many ways, SafeCare is the gold standard for accreditation in LMICs, whereas facilities might otherwise need substantial improvement to compete for international accreditation. The SafeCare measures themselves were accredited by the International Society for Quality in Healthcare and the approach has been implemented and refined since 2011 in 14 African countries. Unlike most accreditation studies that only document changes in the standards used to assess facilities, (ie, whether a facility become better at taking the test),2King JJC Powell-Jackson T Makungu C et al.Effect of a multifaceted intervention to improve clinical quality of care through stepwise certification (SafeCare) in health-care facilities in Tanzania: a cluster-randomised controlled trial.Lancet Glob Health. 2021; (published online Aug 4.)https://doi.org/10.1016/S2214-109X(21)00228-XSummary Full Text Full Text PDF Scopus (1) Google Scholar King and colleagues took great care to pursue more elusive and valuable outcomes that capture the actual processes of care. They observed clinical encounters between patients and clinicians to document adherence to infection prevention and control practices (IPC) and sent standardised patients to facilities to assess the clinical management of four common conditions. IPC compliance was observed in just over half of all interactions (8181 [56·9%] of 14 366 interactions in the intervention group and 8336 (54·7%) of 15 242 interactions in the control group) and correct clinical management occurred in less than a third of cases in both study groups (120 [27·0%] of 444 standardised patients were managed correctly in the intervention group and 136 (29·2%) of 465 standardised patients were managed correctly in the control group), with no significant difference between groups after 18 months. The robust outcome measures and overall study quality make these null results compelling and important. So, why was no effect observed? Facility quality as measured by the study outcomes (IPC and clinical case management) was remarkably poor, which eliminates the common measurement challenge of improving from an already high baseline; these facilities had plenty of room to improve. Could poor implementation have dampened a measurable effect? Although possible, the study did document a small but significant improvement in the measured standards themselves and all intervention facilities received a bespoke quality improvement plan. More importantly, if an arguably agile and experienced organisation was not able to implement their flagship programme in just over 100 intervention facilities (there are over 7000 in Tanzania), what does this say about scalability? A key to understanding the results is recognising that although the SafeCare standards are globally endorsed, they focus largely on inputs to care (eg, on whether tools and equipment are available, or whether guidelines are posted in service areas). Such inputs are necessary, but better outcomes are produced when inputs to health care are used appropriately to care for patients.3Donabedian A The quality of care. How can it be assessed?.JAMA. 1988; 260: 1743-1748Crossref PubMed Scopus (4152) Google Scholar In short, SafeCare might not have measured, or incentivised, what matters; this is an issue shared by accreditation schemes in high-income and low-income settings alike.4Jha AK Accreditation, quality, and making hospital care better.JAMA. 2018; 320: 2410-2411Crossref PubMed Scopus (15) Google Scholar It is possible that if the standards had targeted processes of care, which is certainly more difficult to do, facilities would have worked to improve them. Finally, the authors touch on weak regulation, a potentially fatal flaw in the underlying intervention theory, and the effect it could have had on trial results. Private sector health care is notoriously difficult to regulate, and although Tanzania has made important strides in providing oversight, private facilities fall largely outside of the country's regulatory radar.5Montagu D Goodman C Prohibit, constrain, encourage, or purchase: how should we engage with the private health-care sector?.Lancet. 2016; 388: 613-621Summary Full Text Full Text PDF PubMed Scopus (66) Google Scholar Social accountability mechanisms that build on facility relationships with communities can help compensate for weak government regulation. The programme's theory of change builds on a market version of this type of accountability; health facility users observe and value improvements in quality, which leads to increased utilisation and revenues, which in turn motivates further improvements. Unfortunately, although certificates of SafeCare status were distributed and often posted in facilities, formal links to communities were not created. This left people to independently assess quality of care, which is difficult to do, and is especially so for assessing technical quality. External accountability channels were essentially closed. Relying on market forces to drive quality improvement could even backfire. A profit-maximising facility manager might capitalise on the inscrutability of quality and intentionally deliver low-quality services to widen the profit margin. The intervention was not anchored in broader governance structures and was potentially exposed to the uncertainties of health-care markets.6Arrow KJ Uncertainty and the welfare economics of medical care. 1963.Bull World Health Organ. 2004; 82: 141-149PubMed Google Scholar Perhaps these findings are unique to accreditation schemes in the private sector or programmes implemented by non-government entities. Findings from a process evaluation of the Government of Tanzania's Star Rating facility quality assessment programme7Yahya T Mohamed M Raising a mirror to quality of care in Tanzania: the five-star assessment.Lancet Glob Health. 2018; 6: e1155-e1157Summary Full Text Full Text PDF PubMed Scopus (11) Google Scholar—coordinated by one of us (TY) and studied by the other (SRD)—suggest that both are possible. Overall, Star Rating documented large improvements in quality across all facilities, but private for-profit ownership was associated with a 29% lower probability of improvement in a fully adjusted model (95% CI −0·37 to −0·22).8Gage AD Yahya T Kruk ME et al.Assessment of health facility quality improvements, United Republic of Tanzania.Bull World Health Organ. 2020; 98 (58A): 849Crossref PubMed Scopus (4) Google Scholar Moreover, facility managers and providers explicitly identified Star Rating's affiliation with Tanzania's Ministry of Health as a key enabling factor for improvement. It is difficult to determine how widely to generalise the results of King and colleagues' study, but easy to recognise that assumptions about standards-based quality improvement approaches need to be tested before interventions are adopted and scaled. Leaders should expect robust evaluations such as this one when deciding how to improve quality of care in health systems. We declare no competing interests. Thank you to Mickey Chopra for helpful feedback on this Comment Effect of a multifaceted intervention to improve clinical quality of care through stepwise certification (SafeCare) in health-care facilities in Tanzania: a cluster-randomised controlled trialSafeCare did not improve clinical quality as assessed by compliance with IPC practices and correct case management. The absence of effect on clinical quality could reflect a combination of insufficient intervention intensity, insufficient links between structural quality and care processes, scarcity of resources for quality improvement, and inadequate financial and regulatory incentives for improvement. Full-Text PDF Open Access