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Improving Quality of Care in Primary Healthcare Facilities in Rural Nigeria using SafeCare Standards and Methodology (N. Ndili*1, N Spieker1, M. Oludipe1, U. Okoli2, E. Ezeokeke3,) 1PharmAccess Foundation 2 SURE P, 3 SOML Abuja, Nigeria


Nigerian patients have limited access to quality care due to inefficient resource allocation and limited health insurance coverage. There is limited institutionalized systems and standards that can ensure objective measurement of the level of quality of basic healthcare facilities. The Federal Ministry of Health SURE-P project engaged PharmAccess to support a quality improvement initiatives in 40 primary health facilities from October 2013 to March 2015.


§To benchmark and guide quality improvement in public primary healthcare facilities in Nigeria using SafeCare standards
§To study applicability of the methodology for institutionalization.


§The SafeCare (SC) standards, which are based on the International Society for Quality in Health Care’s Principles for Standard Development (ISQua), define required structures, processes and solutions that can be achieved in low and middle income countries. SC methodology is divided into 5 measurable steps guiding facilities towards quality healthcare delivery and potentially reaching international accreditation level. The standards cover management functions, clinical, clinical support and ancillary services.
§In this study, 40 facilities were selected from 5 States and randomly divided into 2 groups. All 40 facilities were assessed at baseline and end line using SC standards. Data was uploaded unto SC’s web based data management system which generates numerical scores on a 1-100 scale for compliance levels. Following the baseline assessment, facility specific quality improvement plans (QIP) with activities on priority areas were developed and handed over to all facilities. One group, the treatment-A (TrtA) facilities identified a Quality Lead (QL) in each facility. A total of 20 QLs and 15 Quality Facilitators (QFs) were trained to implement quality improvement using the SC Approach. The QFs visited the TrtA facilities weekly to provide them with support towards the implementation of their QIPs. During these visits, facility staff were trained on management of health records; infection control measures, stock management, storage of flammable materials and patients’ rights. Progress in the facilities was monitored by SafeCare Assessors. Treatment-B (TrtB) facilities did not receive this support. 


The mean score for TrtA facilities at baseline was 36% and 48% at end line; compared to 36% and 35% respectively for TrtB facilities. TrtA facilities increased in overall scores (5-23%), while TrtB facilities varied between - 3% and 3%. TrtA facilities improved notably in areas in which they received facilitation support.

Key success factors noted were: community support by the Ward Development Committee; senior cadre of the Officer-in charge of the facility and positive staff responsiveness to capacity building and technical support. Five TrtA facilities that had all 3 factors present improved the most by an average of 20%, while those with one or more of these factors improved the least (an average of 7%). Challenges faced revolved around the unwillingness of facility leadership to invest in quality.


Improving quality and access to care in Nigeria will require a coordinated effort between stakeholders and institutions in health systems. SafeCare has developed quality standards and a scalable assessment methodology to facilitate transparent transactions that can help build trust between stakeholders, and lay a foundation for country-led quality monitoring systems. The system has proven successful in rural, public facilities in Nigeria and in private facilities through earlier studies.

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