Quality care is a critical component of universal health coverage (UHC). Yet, while there is much focus on access to healthcare, this UHC component is often deprioritized.

Nigeria continues to work towards achieving UHC. However, it ranks poorly based on the World Bank’s Universal Health Coverage Service Index, scoring 38 out of 100 points.

Nigeria’s poor healthcare standards are evident in the shortage of health personnel, decrepit health facilities, non-functional or insufficient basic medical equipment, poor attitude of some healthcare workers towards patients, and long waiting times at health facilities.

Under the leadership of Prof. Muhammad Pate, the Coordinating Minister for Health and Social Welfare, the current government has indicated that quality is a key consideration for ongoing health reforms. Quality of care is a core component of one of the four pillars on which the Nigeria Health Sector Renewal Initiative rests and has often been reemphasized by the Minister in public statements.

Measuring quality

One of the major challenges to improving quality standards is the lack of quality measurement mechanisms. How do we measure quality? What are the indicators or metrics for measuring quality?

Being clear about how we measure quality is essential because that allows us to identify the components of quality care and puts us on a path to achieve it. You cannot improve on what you don’t measure. While several quality improvement methodologies exist, and a few private hospitals in Nigeria have adopted international certification and accreditation standards, these are not common or utilized across the country.

Furthermore, while some States monitor quality in healthcare facilities through the Ministry of Health and other agencies, quality metrics are often unknown. Moreover, existing international accreditation programs are frequently unachievable within reasonable timeframes in environments with underdeveloped healthcare infrastructure, unstable supply chains, and chronic shortages of human and material resources.

To address these quality-related challenges, PharmAccess, an international non-profit organization, has supported public and private health facilities to implement its SafeCare initiative in low- and middle-income countries (including Nigeria) for over a decade.

A review of the SafeCare initiative, its achievements, and challenges can provide insights into measuring and improving the quality of care in Nigeria.

SafeCare’s impact

Early reports on the implementation of SafeCare in Nigeria showed that 75% of facilities improved in Nigeria as a whole, with some facilities going as far as changing management to meet healthcare quality targets.

Nigeria has unacceptably high maternal and newborn mortality rates. Implementing SafeCare Standards can amplify maternal and child health quality of care interventions, as highlighted by Pathfinder International in the presentation “Effectiveness of SafeCare Methodology in Improving Quality of Maternal and Newborn Care: Case Study from Saving Mothers Giving Lives (SMGL) 2.0 Project in Kaduna, Nigeria” at the International Maternal Newborn Health Conference in South Africa in May 2023.

Key recommendations from Pathfinder include:

• Quality improvement programs that provide platforms for benchmarking among facilities, including learning across facilities can improve maternal and newborn health outcomes,
• An innovative QI program like SafeCare – when used with focused support in the form of mentoring and supportive supervision and other initiatives like maternal and perinatal death surveillance response (MPDSR) – can sustainably improve quality of care and health of mothers and newborns.

Much of the impacts of SafeCare, largely beneficial in increasing the quality-of-service delivery, are documented by PharmAccess. Understanding the successes of the program requires the Government and others (academia, research think tanks, etc.) to study its methods and results.

Moving forward

Quality cannot be overlooked in the efforts towards UHC in Nigeria. The emphasis on quality as a key pillar in the ongoing health reforms by the Government portends better health outcomes. This must not remain mere words on paper but must be actively realized.

One of the ways to achieve quality improvement is to consider a systematic, contextualized approach to measure quality. The SafeCare initiative, which has been implemented for over a decade, with key insights from public and private healthcare facilities in Nigeria, embodies this approach. Understanding this initiative is one step towards implementing quality improvement in health service delivery across the country.

One of the key strengths of the SafeCare initiative is the political buy-in evident in Lagos, Ogun, Delta, and Kwara States, with explicit improvements in quality attested to by the facilities. Replicating SafeCare across other States and at the Federal level would most likely improve quality across the country, engender greater uniformity, and result in better outcomes and greater confidence in the national health system.

While evidence has shown that implementing SafeCare, particularly in the urban areas, has led to elevated quality in healthcare, some evidence suggests that SafeCare works too in rural and hard-to-reach communities where facilities are lacking. The 15 health facilities in hard-to-reach riverine communities of the Niger Delta and Bichi Excellence Hospital and Maternity located in a rural community in Northern Nigeria were examples of best-performing providers implementing SafeCare under the Access to Finance program and FCDO Lafiya project respectively.

As is increasingly evident, quality is as important as access. Adopting an initiative such as SafeCare may provide a tried-and-tested approach to improving quality and, ultimately, health outcomes in Nigeria.

Read the full report on the Health Ethics and Law Consulting website.