Toward more sustainable health care quality improvement in developing countries: the "little steps" approach

Resource constraints are often identified as a hurdle to the sustainability of large-scale (national and regional) health care quality improvement (QI) programs in developing countries. However, poor fit of a QI model with a given country's context may present the greater challenge.

To explore contextual factors influencing the sustainability of large-scale QI initiatives in developing countries, we performed a systematic literature review.

Large-scale initiatives appear to have received significant attention only recently in these settings, as priority was traditionally given to extending service coverage. Further, these initiatives often relied on QI models originating from developed country settings, which differed significantly from the systems, resource structures, culture, and values found in the target country. The QI programs frequently focused on high-impact/immediate change rather than on program sustainability. Barriers to sustainability were identified during the planning, start-up, and continuation phases. On the basis of our review, greater attention to sustainable methods for large-scale QI in developing countries is needed.

We suggest a "Little Steps" approach that begins by defining QI concepts, goals, and processes in a manner congruent with the target setting and that builds upon existing systems, structures, and values. Despite immediate short-term needs, an approach emphasizing incremental QI achievements may be more effective in yielding sustainable improvements in health care quality at the national or regional level.