SafeCare Progress Report 2012-2013
Preface To date, SafeCare has already helped over 430 clinics in four sub-saharan countries to improve the safety and quality of care provided to an estimated 700,000 patients per month. More than 70 facilities have been awarded a Certificate of Improvement and over 200 people participated in the facilitator and surveyors training. Together, they have conducted almost 600 s. In February 2013, the first edition of SafeCare was accredited by the prestigious International Society for Quality in Health Care (ISQua). SafeCare was launched in 2011 to provide a solid, secure and realistic framework to ensure that patients receive safe and optimal care despite resource constraints. In less than two years time it grew from an initiative serving providers of the Health Insurance Fund and Medical Credit Fund, to an organization that supports social franchises, multinationals, insurance companies and governments in improving the level of care provided. SafeCare receives backing from the Dutch Ministry of Foreign Affairs, USAID, CDC Foundation and the African Health Market for Equity (AHME) program. Linking SafeCare with MCF s affordable access to credit has proven to be a successful combination in financing sustainable quality improvements in the participating facilities. This in turn helps to increase trust in health care among the clients in the Health Insurance Fund programs. The strategic partnerships with the governments of Kenya, Tanzania, Nigeria and Ghana and the contract between SafeCare and the National Hospital Insurance Fund in Kenya, which was signed in June 2013, are firmly embedding the methodology in the legislative environment of the countries we work in. This rapid growth also brings about organizational challenges. To (adequately) answer the growing demand, the focus in the coming years will continue to be on the development of local capacity. In addition, further linking the certificates to financial benefits will allow a shift to a model where customers are willing to co-pay for the health insurance. This strategy reduces costs, builds local capacity and ownership and is likely to make SafeCare sustainable in the long run. It allows the full circle of improvement, facilitation and external evaluation to be operational on the ground. 1 With a flying start of the initiative since its inception, we look forward to expanding and strengthening our activities across the African continent! Nicole Spieker Director SafeCare September 2013
Quality is a basic right and we who are responsible have to take action. We cannot sit back when Kenyans are losing their lives as a result of poor quality services. The launch of this program is a step in the right direction. Kenyans are starting to feel that the care provided has significantly changed. James Macharia, Cabinet Secretary of the Minister of Health in Kenya Mission, Vision and Objectives The mission of SafeCare is to improve the quality and safety of healthcare services in resource-restricted settings using incremental standards-based recognition and by building institutions that can objectively measure and rate levels of quality and patient safety in healthcare providers. The vision of SafeCare is to become the world standard for benchmarking and improving quality of healthcare providers in resource-restricted settings through stepwise recognition of quality improvement. Objectives: Improving quality of care of primary and secondary healthcare facilities in resource-restricted settings through an external evaluation system based on standards and stepwise quality improvement trajectories. Rating and benchmarking across healthcare facilities, provider networks and resource-restricted countries. To provide information on healthcare provision, its scale, scope and quality to international and national stakeholders. Establish a basis for performance-based payout and funding systems for healthcare improvement. Work in a legal framework that is accepted by the local authorities and may be extended to a national certification and/or accreditation system for both public and private healthcare providers. 3
Rationale There is a shortage of institutions and standards that can ensure objective measurement and rating of the level of quality of basic healthcare facilities in Africa. As a result, quality levels of providers are not transparent, benchmarking is not possible and patients face uncertainty with regard to the quality of health care they seek. Building institutions and creating standards that help patients to make informed decisions about health care will address these issues. In addition, such systemic changes could stimulate providers to improve the quality of care through targeted interventions, motivate performance-based financing mechanisms by (inter-)national donors and investors, and enable local and national healthcare authorities to monitor and regulate healthcare providers. For the above reasons, the three founding organizations PharmAccess, JCI and COHSASA established the SafeCare Initiative. SafeCare acts as the custodian of internationally recognized, unique sets of standards that are realistic for resourcerestricted settings while not compromising on quality levels. SafeCare standards focus on bottom of the pyramid public and private healthcare facilities such as dispensaries and health centers, which constitute the main healthcare delivery channel for low-income settings and which struggle with patient safety and quality demands. The methodology dissects the improvement process of healthcare providers in survey-able, measurable steps. Thus, an improvement trajectory is created that provides positive incentives for healthcare providers to move upwards in quality, ultimately to the level that qualifies them for full accreditation. Whereas the latter objective might remain out of reach for most providers for some time to come, a guided way to work towards that objective will boost client, investor and regulator confidence in the motivation and capacity of healthcare providers to steadily enhance their performance. All quality improvement efforts are supported by innovative data collection and reporting tools, allowing for real-time facility and online monitoring. In addition, the data collected on clinical performance allows for prioritization of financial resource allocation which enables a more efficient use of available resources. Threefold adjustments Adjustments incorporated in SafeCare to make the standards suitable for resourcerestricted settings are threefold. First, the definition of the norms that substantiate standards were reviewed and made appropriate to local settings. For example, in western settings regular updating of the knowledge of medical staff is organized through a formal credit system of training institutes. As this system is not available in most African countries, the methodology has come up with an alternative system of evaluating training needs of medical staff in light of the availability within the country. Second, SafeCare has come up with the best of the rest solutions, for standards that facilities are unable to comply with due to a failing environment. For example, Entry Level 0 Poor SafeCare I SafeCare II if a country simply does not have a central medical waste collection system, lower end facilities could use a cement pit to dispose of used needles. Third and most critical was the introduction of differentiation of non-compliant performance. On a scale from 0-100, international accreditation starts at a composite score of 85. All individual or aggregate scores below this mark thus indicate failure to achieve accreditation. In practice, however, it matters to recognize that a score of 50 is better than a score of 30 and that 70 is better than 50. Therefore, SafeCare has Regular Independent Assessment SafeCare III SafeCare IV SafeCare V 1 2 3 4 5 6 Accreditation Excellent Certificate definition 6. Excellent quality systems in place: healthcare provider has a proven track record of continuous quality improvement, is in substantial compliance with the SafeCare standards, and meets the decision rules for accreditation by independent organization COHSASA. 5. Demonstrates long-term commitment to continuous quality improvement, ready for accreditation program and self sufficiency of continuous quality improvement. Very limited technical assistance required. 4. Strong quality systems in place, but high-risk areas still in need of attention. Limited technical assistance required. 3. Medium quality strength, acceptable but vulnerable to changing environment. Focus on self-evaluation of quality improvement processes using quality indicators, guidelines and standard operating procedures. 2. Modest quality strength, requiring medium technical assistance. Healthcare quality is still likely to fluctuate. Focus on the securing of quality systems and processes especially in high risk areas. 1. Very modest quality, with continued need for periodic technical support. Focus on implementation of processes and quality systems and the availability of financial means to ensure availability of proper infrastructure and assets. 0. Poor quality however the organization has shown leadership commitment and a strong desire to provide safe health care and recognizes that significant improvements are needed to reach levels of consistent, efficient, safe quality care for each patient. It has fluctuating quality healthcare provision due to the unavailability of services at times. The SafeCare methodology recognizes five steps of quality improvement leading towards accreditation, based on international standards tailor made for resource-restricted settings. introduced a stepwise recognition process that allows for rewarding uptake of quality through the SafeCare scoring system of levels (0 to 5). The picture above captures the classification of these scoring levels. Again, this classification allows recognition of the best of the rest in a failing environment. A negative and discouraging scoringsystem (non-compliance) is thus transformed into a positive and encouraging one (achieving higher levels). It quickly identifies those weak facilities that need extra supportor investment and recognizes achievements made. 5
Services got better, there is more cleanliness, the staff is more attentive and the environment has improved. Interview Peter K. Tanui (1975) 7
SafeCare: a public-private approach Transparency of quality of care is at the heart of creating trust with patients in the healthcare system. Quality assurance of healthcare providers operates at two levels: licensing and accreditation. Generally, licensing is a mandatory process for providers and healthcare professionals, that is regulated and monitored by the Ministry of Health, and recognizes basic, safe levels of care. Accreditation is usually a voluntary process, although it is often a requirement for insurance contracts (including national health insurance schemes) and is an income generating marketing instrument for the private sector. Complementing these two processes is quality improvement. This is usually the domain of specialized for-profit or non-profit organizations and helps the facilities meet the standards as set by licensing and accreditation. However, in most African countries, shortage of capacity and funds causes a market failure in the implementation of licensing and accreditation. First, the capacity of the Ministry of Health to develop standards and perform inspection visits is limited and the same enforcement mechanisms do not appear to apply for public and private facilities alike, creating asymmetries in the sector. Second, accreditation agencies are often not available in the country itself and meeting accreditation standards is not achievable for most providers. As a result, no information on the scale, scope and quality of care is available. The concept of SafeCare fills this gap in the African healthcare system: quality levels of healthcare providers are identified and certified, which benefits all stake-holders as it creates trust in the market, and actively supports quality improvement. The activities of SafeCare were initiated in the private sector by independent recognition of quality improvement of care using the standards. This introduced selfregulation and benchmarking of the private sector and encouraged its members to comply with quality standards that are internationally endorsed. Creating transparency of care, SafeCare helps providers attract more patients and therefore generate more income. Some of the major representative bodies of the private sector, e.g. APHFTA in Tanzania and K-MET in Kenya, work with PharmAccess and the Medical Credit Fund in adopting the SafeCare methodology for its membership. These bodies further function as policy and advocacy organizations, ensuring private sector needs are met. To embed the methodology in the legislative framework of the countries we work in, we engage in strategic partnerships with the governments of Kenya, Tanzania, Nigeria and Ghana and government agencies such as the National Hospital Insurance Fund (NHIF) in Kenya and the National Social Security Fund (NSSF) in Tanzania. Through government partnerships and regulation, SafeCare is recognized as (one of) the external evaluation systems that sets standards and certifies quality of care. In Tanzania, the government has even adopted the methodology as the national system for stepwise certification towards accreditation. This public partnership helps build the capacity within the government to perform inspections, and sets the same standards for the public and the private sector. The resulting public-private partnership (ppp) approach works well for promoting the values of quality standards and entitles private facilities to public benefits such as contracts with the NHIF and the NSSF and compliance with government regulation by the Ministry of Health. Increased transparency and compliance in turn attracts private funds and investments needed to increase the total amount of money in the healthcare system. Most importantly, this ppp approach creates transparency, efficiency and cost effectiveness by exchanging data on the quality of care between the public and private sector. In the banking system, banks pay for their credit rating reports. Through our ppp approach, this situation could also become true for the health sector, with health facilities paying for their performance s and certificates. The main incentive for facilities to perform better is by linking certificate levels to contracting with public and private health plans, such as the NHIF. Thus, a virtuous circle of locally funded quality improvement activities will be initiated, where the clinics pay for their and for assistance in quality improvement, implemented by partner organizations. Resulting in higher certification levels, an increase in patient numbers and beneficial insurance contracts. The process is supported by affordable loans to finance the necessary improvements. This will catalyse towards a tipping point, and the activities will spill over to the market system as a whole, including both public and private sector players. 9
SafeCare helps to create the right environment and all the right components to offer high levels of care. Interview with Nicholas Sowden, Managing Director and co-founder of Penda Health and Shezaad Zainulbhai, Director of Operations Shezaad: Penda is a company that provides high quality healthcare for low- and middle income people. We want to offer very high quality care at affordable prices and, most importantly, with a friendly approach to our patients while making them as healthy as possible. In the clinic, we have seven full time staff. On average we see about 25 patients a day, about 800 patients per month. We do outpatient services only. Nicolas: SafeCare helps to create the right environment and all the right components to offer high levels of care. The people, the staff, the organization, the policies, the infection prevention; really the entire environment and all the components. There is a significant number of areas in which we don t have the expertise. SafeCare can help with infrastructural and procedural things. This helps us create a place that we are comfortable that no infection will occur; a place that we are confident that anyone can come in and get the care that they need without that care being compromised. And that is where the real value of SafeCare comes in. Nicholas: We started the SafeCare program somewhere in November 2012, this was just getting to know the team and the SafeCare program. And this February, we had our first audit. Shezaad: After that first visit we received really good feedback from the SafeCare team. They said that we were the highest ranked first time visit for any facility in the program. We sell that to everybody, all our investors, our partners and the patients, we talk about it all the time. If we can communicate that we are approved by a third party authority this could help build confidence and make sure patients follow their treatment plans. Externally, SafeCare brings transparency to partners, suppliers and insurance companies. Furthermore, I think it helped us recruit staff better. As I said, we advertise that we take quality seriously and that has led to more applications. Also, the preparations for the motivated the staff, it was something each had a role to play in, it was really a team building effort. Afterwards, the feedback that we were actually doing quite well, really increased the team spirit. 11 Shezaad: You see, we understand how to create medical quality around protocols. But we are young and new entrepreneurs and constructing a medical program from the ground up is really difficult. Nicholas: We got level one and we are only six items away from a level two. So the plan that we are working on now is to skip level two and go directly to a level three within twelve months.
Achievements & Lessons Learned Clinic improvement cycle loans During the course of 2012, SafeCare experienced significant growth. A total of 430 healthcare facilities have implemented the SafeCare methodology for guiding their improvements, using it as a benchmarking exercise for quality. By mid 2013, these facilities had offered health services to over 700,000 patients per month, including maternal and child health and HIV/AIDS treatment. Five steps in the ongoing improvement cycle towards better health care. SafeCare quality improvement The building of local capacity is at the core of the SafeCare process, A total of 224 participants have been trained in the Safe- Care methodology. Of these, 57 are Certified Facilitators, allowing them to evaluate the facilities quality of services and provide technical assistance. A total of 27 have obtained their Surveyor qualification, entitling them to independently perform SafeCare Certification Visits. The local SafeCare teams have performed a total of almost 600 s. 74 facilities have received a Certificate of Improvement after successfully implementing their quality improvement plans. The SafeCare program is at the core of the Medical Credit Fund and Health Insurance Fund programs, ensuring quality of supply is in place to create trust with the patients, the insurance companies and the banks. However, the program continues to attract interest from other stakeholders and organizations. In November 2012, Safe- Care commenced working with an additional 4 implementing partners under the African Health Markets for Equity (AHME) program. This five-year partnership strives to improve health outcomes by enhancing the quality of care in 800 private health facilities in Ghana, Nigeria and Kenya. The AHME program is led by Marie Stopes International (MSI) and funded by Bill & Melinda Gates Foundation and the UK s Department for International Development (DFID). The social franchises of Population Services International (PSI) and MSI in Kenya, Nigeria and Ghana, and Society for Family Health (SFH) in Nigeria will be recipients of SafeCare under this program. The consortium is further complemented by International Finance Cooperation (IFC) and Grameen Foundation. The work on the USAID funded APHIAplusHCM program in Kenya continues to grow and allows the methodology to be available for partners such as PSI, FHI360 and K-MET. Following our public-private approach, SafeCare continued its collaboration with governments and related agencies. The strategic partnerships with the NHIF in Kenya and the National Social Security Fund (NSSF) in Tanzania are planned to take shape in 2013. Significantly, the Ministry of Health and Social Welfare of Tanzania has signed a Memorandum of Understanding with PharmAccess to adopt SafeCare methodology as a basis of the national stepwise certification towards accreditation system. The program will also start in 2013 and is funded by CDC Foundation. Focus areas Based on the data collected in the participating facilities, SafeCare has identified three main operation focus areas for 2013. First, it aims to further increase the efficacy of technical assistance by the development of guidelines and formats to effectively start SafeCare Program repayments and possibly a next loan more patients, receiving better health care implement quality improvement activities. Second, a rigorous revision of its information systems is planned to meet the rapidly growing demand for benchmarking and management information. Lastly, the development of self- methodologies helps to improve the efficiency of progress monitoring at the facilities, creating the opportunity to provide more targeted, tailor made technical support. At a strategic level, further linking the certificates to financial benefits such as insurance contracts, loans and procurement- clinic SafeCare health insurance program deals will ensure sustainability on the ground. In addition to strengthening its current partnerships, SafeCare strives to engage with national quality improvement initiatives such as Ministries of Health and large donors, investors and franchise organizations operating at a country level in SafeCare s target countries, to ensure we are part of the legislative framework in the countries we work in. training 13
Customer care will be better, staff is more knowledgeable, and the outcome of the patients care is improving. And because we include everybody, from cleaner to buyer, staff motivation has also gone up. Maggy Agola, Head of quality department at KMET 15
Our Safecare standards are designed to help bridge the gap between today and a better tomorrow, bringing improved quality of care and patient safety in a stepwise approach. To guide the facilities on this journey, SafeCare uses 13 service elements that together represent the different aspects of healthcare delivery. Experience has taught us that between the first and second SafeCare Assessment, facilities have addressed improvement priorities such as renovations of the facility s infrastructure; acquisition of equipment; and infection control and hygiene measures. Common areas for further improvement are management and leadership and human resources, patient rights and access to care, medication management, and the continuous maintenance of infrastructure and equipment. These improvement requirements are found to be challenging for many facilities, as many lack the knowledge and skills to address these areas effectively. For this reason, facilities need continuous support from SafeCare, such as technical advice, implementation tools, benchmarking information and best practice examples. and Leadership and leadership work collaboratively to develop the plans and policies needed to fulfill the mission of the facility and to coordinate and integrate the health service s activities. Patient and Family Rights and Access to Care Health facilities work to establish trust and open communication with patients and to understand and protect each patient s cultural, psychosocial and spiritual values. Human Resource A health facility needs an appropriate number of suitably qualified people to fulfill its mission and meet patient needs. Recruiting, evaluating and training personnel are best accomplished through a coordinated, efficient and uniform process. of Information Aggregated data from patient visits and treatment provided help the health facility understand its current performance and identify opportunities for improvement. By participating in external performance databases, a health facility can compare its performance to that of other similar health facilities. Risk Health facilities work to provide a safe, functional and supportive facility for patients, families, personnel, volunteers and visitors. To reach this goal, facilities, equipment and medication must be effectively managed. Primary Health Care Services Certain activities are basic to patient care, including planning and delivering care to each patient, monitoring the patient to understand the results of the care, modifying care when necessary and completing the follow-up. Inpatient Care Providing the most appropriate care in a setting that supports and responds to each patient s unique needs requires a high level of planning and coordination. Delivery of the services is coordinated, integrated and monitored. Operating Theatre and Anaesthetic Services Services in the operating theatre and anaesthetic services carry high risk. It is essential that there is collaboration between the personnel in the theatre, the infection control and health and safety personnel, and those responsible for supplying and maintaining equipment. Laboratory Services Laboratory investigations and rapid reporting systems are essential for patient and the implementation of treatment plans. Laboratory services must be available when required by the organisation. Diagnostic Imaging Service When a diagnostic imaging service is provided, there are radiation safety programmes in place, and individuals with adequate training, skills, and experience are available to undertake diagnostic imaging procedures and interpret the results. Medication The patient, physician and nurse work together to monitor patients on medications. The purposes of monitoring are to evaluate the response to medication, to adjust the dosage or type of medication and to evaluate adverse effects. Facility Services Buildings, grounds, plant and machinery are provided and maintained, and do not pose hazards to the occupants. Utility systems (such as electrical, water, oxygen, ventilation and vacuum - systems) are maintained, to minimize the risks of operating failures. Support Services The managers/supervisors of services such as laundry, housekeeping and catering or support services work with other organizational leaders and managers to improve the quality of service delivery throughout the organization to management, leadership, human resource development, infection control, environmental safety and quality improvement. The acceptability of Kenyans to use the NHIF facilities will be higher because they know the quality of care there is good. This will also increase their willingness to pay more money. Dr. Midiwo, General Manager Benefits & Quality Assurance for the NHIF 17
CLINIC LEVEL V 0 Clinics and results 431 Total number of health facilities in program 180 Kenya 34 average overall score SafeCare Most room for improvement Risk of Information 68 highest overall score SafeCare Top 3 service elements Diagnostic imaging service Operating theatre and anaesthetic services 503 Number of s 431 CLINIC TYPE Number of clinics currently in the program SafeCare Essentials PATIENTS & CARE 184 319 52 = SafeCare 77 Private 13 Public 10 Faith Based 31 Rural 28 Peri 42 Urban Number of certificates rewarded Type of facility SafeCare Certificates IV 1 III 2 II 2 I 39 Entry 8 level clinics UNIVERSITY TEACHING HOSPITAL 0 REFERRAL CENTER 3 DISTRICT HOSPITAL 53 PRIMARY HEALTH CENTER 97 BASIC HEALTH CENTER 190 NURSE CLINIC 11 111 Ghana 34 average overall score SafeCare Most room for improvement Risk 57 highest overall score SafeCare Top 3 service elements Diagnostic imaging service 40 Nigeria 44 average overall score SafeCare Most room for improvement 90 highest overall score SafeCare Top 3 service elements Human Resource 100 Tanzania 36 average overall score SafeCare Most room for improvement Risk Inpatient Care 71 highest overall score SafeCare Top 3 service elements Diagnostic imaging service 6,515 Total number of staff 15-90 IMPROVEMENT AREAS Range of score SafeCare 3,571 Medical staff 40,605 Immunizations 2,296 Para-medical staff 2,778 Support staff Top 3 service elements Diagnostic imaging Primary health care services 626,727 Total number of patient visits to the facilities per month Inpatient Care Treatment indicators 28,318 Family planning 97,203 Malaria 29,483 HIV Most room for improvement Risk Human Resource Support services 19 Human Resource of Information Primary health care services Operating theatre and anaesthetic services Risk Operating theatre and anaesthetic services Laboratory Services Facility Services Support services Human Resource Primary health care services Inpatient Care 44 = Number of training sessions since start program CAPACITY BUILDING Clinical Trainings Clinical care 41 Lab 4 Pharmacy 5 Quality management 14 Admin 4 191 Number of facilitators trained 23 Number of local surveyors trained Technical Assistance PAI Ghana KMET Kenya PSI Kenya AAR Kenya Hygeia Nigeria APHFTA Tanzania MEMS SFH Human Resource Medication Data until 30 June 2013
Our Ambition The ambition of SafeCare is to be recognized as the worldwide standard for basic healthcare facilities in resource-restricted settings. To achieve this, for 2013 and onwards the focus will be on: The strengthening and expansion of SafeCare as a service provider to the private sector of the Medical Credit Fund, AHME (African Health Market for Equity), APHIAplusHCM (AIDS, Population and Health Integrated Assistance) and Health Insurance Fund programs. Expansion of collaboration with the public sector such as the Ministry of Health, NSSF in Tanzania and the NHIF in Kenya. Capacity building of local surveyors and facilitators. Advocacy activities to promote the SafeCare methodology as the world standard for resource-restricted settings. Add financial and marketing value to the certificates to increase sustainability and move towards a co-payment model. Kenya In Kenya, the SafeCare work is expected to increase tenfold in the next two years. Besides HIF and MCF programs, SafeCare is a partner in the APHIAplusHCM program, which aims to strengthen Kenyan health systems and includes the implementation and expansion of the Kenyan SafeCare certification body. The target facilities are members of social franchising networks such as Tunza (PSI), Goldstar (FHI360) and K-MET. SafeCare is also a partner of the AHME program which started in 2012 and aims to expand external certification methodology to the social franchises of PSI, MSI and SFH in Kenya, Nigeria and Ghana. For national programs, SafeCare has entered into a collaboration agreement with the NHIF as a Technical Assistance partner for the implementation of SafeCare standards into the NHIF accreditation system, to be introduced into 280 healthcare facilities across the country which started in June 2012. SafeCare is providing the Ministry of Health technical assistance on their quality improvement methodology. Tanzania In addition to the HIF and MCF networks, in Tanzania, over 172 clinics of the armed forces (TPDF/TPPI) are in a quality improvement program that has been supervised by PharmAccess under a PEPFAR/ USAID agreement over the past five years. The SafeCare methodology has been introduced into these clinics last year with a phase 1 program which started in March 2012. The SafeCare methodology will be introduced to the health insurance schemes of the National Social Security Fund (NSSF) in Tanzania. The work with the Ministry of Health & Social Welfare to adopt SafeCare as the national standard for stepwise certification will continue. SafeCare has made us well informed, it has meant that we give intrusive care, that we have improved our capacities. All the processes within the facility have improved and we continue to improve every year. We are now SafeCare level 2 and are hoping to move to level 3 next year. Samuel Tanui, Administrator at Kaiboi Mission Hospital Nigeria Besides the implementation of the HIF, AHME and MCF programs as mentioned in the overview, in Nigeria SafeCare is entering into collaboration with the Federal Ministry of Health to provide technical assistance to adopt SafeCare methodology into a national institutionalized quality improvement and recognition methodology. SafeCare has signed contracts with Shell to certify their healthcare facilities in Beyalsa and Ogun State. Ghana In Ghana, SafeCare works with MCF and AHME clinics to guide and evaluate clinics in quality improvement. In addition, 64 facilities are using the SafeCare essentials tool to guide and measure improvement of progress in a WOTRO research program (part of the national research council in the Netherlands) together with the NHIA (National Health Insurance Authority) and a Ghanaian PhD student, to study the link between insurance, quality of care and patient experience. 21
Contracting During SafeCare s start-up phase, innovations were supported by (MPS medefinanciering ) of the Dutch government and by the Health Insurance Fund (a grant from the Dutch Ministry of Foreign Affairs). This allowed SafeCare to develop the standards, field test the methodology, apply for ISQua accreditation, introduce the software, data collection and reporting methodology and do the initial capacity building on the ground. The SafeCare quality improvement and evaluation activities of facilities that are participating in programs supported by partners in the PharmAccess Group (HIF and MCF) are at the core of our work and income. However, the program quickly started attracting new contracts and donors, allowing for significant leverage of its funding. New contracts through the AHME consortium led by Marie Stopes International (funded by the Bill & Melinda Gates Foundation and the UK Department for International Development (DFID)) and APHIAplusHCM (funded by USAID) have significantly increased the financial selfsufficiency of SafeCare. Besides the private sector contracts, SafeCare managed to obtain key public sector contracts through a Memorandum of Understanding with the Tanzanian Ministry of Health and Social Welfare and the NHIF in Kenya. Although additional funding is still required, we expect the program to be selfreliant within the next three to five years, with funding and contracts from both public and private stakeholders. Programs Contracting SafeCare PROGRAM START DATE TIME FRAME SAFECARE REVENUES Health Insurance Fund Program: the HIF Program uses the SafeCare methodology in Nigeria, Kenya, Tanzania and Namibia as a quality improvement and evaluation approach. Medical Credit Fund Program: the MCF Program uses the SafeCare methodology in Ghana, Kenya, Nigeria, Tanzania and Namibia as the quality improvement and evaluation component of their program. APHIAplus-HCM Program Kenya: USAID funded consortium aims to strengthen Kenyan health systems and includes the expansion of the Kenyan SafeCare certification body. African Health Markets for Equity (AHME) Consortium: funded by Gates Foundation and DFID and led by MSI introduces SafeCare external certification methodology to the social franchises of PSI, MSI and SFH in Kenya, Nigeria and Ghana. TPDF/TPPI, Tanzania: over 172 clinics of the uniformed forces (TPDF/TPPI) are in a quality improvement program that has been supervised by the PharmAccess Group under a PEPFAR/USAID agreement over the past 5 years. The SafeCare methodology is introduced in 55 clinics during the start-up phase of the program. Royal Shell Nigeria: SafeCare certifies Shell healthcare facilities in Ogun State, Nigeria. 2011 Continuous 3,000,000 USD (2013) 2011 Continuous 425,000 USD (2013) April 2012 3 years 840,000 USD November 2012 5 years 4,050,000 USD (2013) March 2012 5 years tbd December 2012 7 months 135,000 USD Ministry of Health & Social Welfare (MOH&SW), Tanzania: SafeCare has signed an MOU with the MOH&SW to provide technical assistance to adopt SafeCare methodology into a national institutionalized stepwise certification towards accreditation methodology. Funded by CDC Foundation. January 2013 2 years 550,000 USD National Hospital Insurance Fund (NHIF), Kenya: SafeCare has signed a collaboration agreement with the NHIF and IFC as a Technical Assistance partner for the implementation of SafeCare standards into the NHIF accreditation system to be introduced in 280 healthcare facilities accross the country. March 2013 3 years 718,000 USD 23 National Social Security Fund (NSSF) Tanzania: SafeCare will be the standard used for benchmarking and improving quality of care provided by NSSF contracted facilities in Tanzania. Start-up project of 20 facilities. tbd 1 year 68,000 USD The National Primary Healthcare Development Agency (NPHCDA) Nigeria: SafeCare has entered into collaboration with the NPHCDA to provide technical assistance to adopt SafeCare methodology into a national institutionalized quality improvement and recognition methodology. October 2013 17 months 450,000 USD
SafeCare brings efficiency in health care. Efficiency means they will be able to save money to buy better equipment, hire better doctors and expand the capacity. The National Hospital Insurance Fund (NHIF) of Kenya, the World Bank Group s Health in Africa Initiative (HiA) and PharmAccess Foundation have signed a contract to introduce internationally recognized healthcare standards to the NHIF insurance program. Dr. Midiwo, General Manager Benefits & Quality Assurance for the NHIF, explains: SafeCare arose out of need from NHIF. It is not externally brought to us. Our capacity has come to a point that we need to move to another level, so I sought the help of SafeCare. Our own clinical model cannot bring us further; we need something better than what we have. We have a few good hospitals but very many bad ones as well. Using the standards of SafeCare will help us improve the quality of care in the facilities many Kenyans don t want to go into because of the low quality of care provided. If we succeed in this, and I am very positive that we will, the willingness of Kenyans to use the NHIF facilities will be higher because they know the quality of care there is good. This will also increase their willingness to pay more money. In the contract we have agreed to aim for certification of the NHIF within three years. Working with SafeCare will incrementally increase the capacity within the NHIF. Yet, using the internationally accredited standards right from the start. We are going to begin with quality s in 20 facilities and then move to 250 this year. Once we have the in-house capacity we are able to up-scale it. You know, it is hard to get to the first 50; it is easier to get to the next 200 when you have all officers trained to official surveyors and facilitators. In the next three to four years we should be able toup-scale it to all of our 1080 facilities. SafeCare, or any good accreditation instrument, brings efficiency in health care. Efficiency means they will be able to save money to buy better equipment, hire better doctors and expand the capacity. We have good doctors, they can do an operation but the quality of care in the ward is what is complicating issues. Not the operation itself. For this reason we want to bring SafeCare on the forefront of each hospital. This is what must happen; this is what we must do. The facilities in turn will attract more clients. We have seen it happen in well-functioning facilities in the program. If they listen to the clinical guidelines, identify the gaps and make the necessary improvements, they will be 100 percent full. SafeCare will do what I have seen happen before with clinics who successfully implemented the clinical guidelines. The clinics will definitely profit. What s more, we have built in an incentive to do better. We have agreed that the better a facility is performing according to the methodology, the more health financing they will receive. That will be the real incentive for hospitals to improve their facilities. We will go higher and higher once we have found our way to continuously improve. I think we will get there; we will be among the very few organizations in Africa to acquire ISQua certification. 25
SafeCare partners PharmAccess Based in Amsterdam, the Netherlands, PharmAccess has experience in over 30 countries in Africa in upgrading and quality improvement of basic healthcare providers such as (nurse-driven) facilities, health centers and district hospitals. PharmAccess expertise particularly concentrates on early quality improvement activities, including providing local assistance to providers with refurbishments, purchasing of bio-medical assets and building skills through interactive workshops. The quality improvement process is monitored through a rigorous data collection and analysis system. In addition, PharmAccess improves the financial situation of health providers by (where possible) connecting to existing or new healthcare insurance programs to secure income on the demand side and by business training on the supply side to improve access to affordable financing, including loans and investments. COHSASA Based in Cape Town, South Africa, this organization is accredited by the International Society for Quality in Health Care (ISQua) as a competent healthcare evaluation body, and its standards are recognized as meeting the principles set out by ISQua. COHSASA has been working in the field of quality improvement and accreditation for over 15 years. During this time, COHSASA has worked in over 530 (different types of) facilities from tertiary hospitals to basic clinics in the public and private sectors in South Africa, the SADEC region and other parts of Africa. Countries in which programs are operational include the Republic of South Africa, Swaziland, Lesotho, Namibia, Botswana, Zambia, Rwanda and Nigeria. JCI Based in Illinois, U.S.A, JCI is the international arm of The Joint Commission, the United States health care accreditation body. JCI has been working with health care organizations, ministries of health and global organizations in over 80 countries since 1994, and has accredited over 400 public and private health care organizations. Its focus is on improving the safety of patient care through the provision of accreditation and certification services as well as through advisory and educational services aimed at helping organizations implement practical and sustainable solutions. In June 2011, JCI received a four-year accreditation by ISQua that provides assurances that the standards, training and processes used by JCI to survey the performance of health care organizations meet the highest international benchmarks for accreditation entities. The Quality Team, (PharmAccess) Nicole Spieker Program Director Quality Tobias Rinke de Wit Analysis and Learning Hanneke Peeters Senior Quality Manager Christine Deurman Senior Quality Manager John Dekker Manager Laboratory Services and Procurement Aletta Kliphuis Quality Chief Surveyor Annedien Plantenga Quality Manager Nienke Meijland Project Support Peter Risha Program Director SafeCare Tanzania Edith Ngirwamungu Quality Manager Tanzania Johnson Yokoyana Quality Manager Tanzania Dupsie Oludipe Senior Quality Manager Nigeria Emmanuel Aiyenigba Quality Manager Nigeria Peggy Imoniovu Quality Manager Nigeria Kendra Njoku Quality Manager Nigeria Anire Asumah Quality Manager Nigeria Jimi Odetola Quality Manager Nigeria Milicent Olulo Senior Quality Manager Kenya Jacinta Mburu Quality Manager Kenya Margaret Mwakiridia Quality Manager Kenya Mary Njoki Quality Manager Kenya John Nziu Quality Manager Kenya Kasmil Masheti Quality Manager Kenya Elly Wandago Quality Manager Kenya Emmanuel Milimo Quality Manager Kenya Petronilla Wesonga Quality Manager Kenya Irene Kasyoki Quality Manager Kenya Maxwell Antwi Quality Manager MCF/SafeCare Ghana Bonifacia Agyei Quality Manager MCF/SafeCare Ghana Gabriel Fiadorme Quality advisor Ghana Joseph Asumang Peasah Quality advisor Ghana The Quality Team, Cape Town (COHSASA) Stuart Whittaker CEO Jacqui Stewart Deputy CEO; Chief Operations Manager Ziyanda Vundle Quality and Facilitation Manager Grace Labadarios GP Accreditation Coordinator Giel van Schalkwyk Chief Surveyor Chris Bloem Surveyor Riël le Roux Surveyor The Quality Team, Chicago (Joint Commission International) Paula Wilson President and CEO Paul van Ostenberg Vice President International Accreditation, and Measurement Cecily Pew Director Board and Committee Activities 27
The PharmAccess Group SafeCare is part of a group of non-profit organizations with a shared goal. The PharmAccess Group is working towards achieving inclusive health care for Africa. Many African governments struggle to meet the demand for health care of their populations. Population growth and the rise of non-communicable diseases are increasing the burden placed on their health systems even further. As public healthcare providers are often few and far between, overcrowded, understaffed and poorly stocked, many people pay out-of-pocket for health care at private clinics whose quality also leaves much to be desired. The fact that health insurance remains out of reach for most people means that, when they are injured or become ill, they can become trapped in a downward spiral of lost income paired with high and unexpected healthcare costs. Also, without solid institutions and proper standards, there is no way to ensure the quality of health care services. These shortcomings of the health system come at a price for the individuals, but also for their communities and even their countries. After all, healthy populations are a major driver of economic growth. Integrated approach The PharmAccess Group aims to improve access to quality health care for people in sub- Saharan Africa. Our integrated approach consists of complementary initiatives that aim to increase resources, efficiency and effectiveness within the healthcare system. By combining standards for quality improvement, loans for healthcare providers, health plans and in-depth impact research we simultaneously stimulate the demand for and supply of healthcare services. The expertise within the PharmAccess Group includes health plans and healthcare quality, financing and infrastructure. Our work also includes consultancy and HIV/AIDS corporate programs as well as healthcare innovations using mobile technology (mhealth). With the financial support of the Dutch Ministry of Foreign Affairs and other donors, we have been able to leverage our own investments, mobilizing additional resources from third party donors, local governments, investors, local banks, private clients and insurance premiums. As such, we are helping a growing number of people, from patients to medical professionals, gain access to the tools they need for social and economic development, thereby scaling up functioning health systems. Our approach has generated considerable international attention, including a G20 award that President Obama presented to us for our innovative healthcare financing model. This model helps to increase trust among patients, doctors, insurance companies, banks, government and international investors, thereby increasing their willingness to pay for or invest in health care in Africa. With a growing number of valued African and international partners, donors and investors from both the private and the public sector, we continue to work towards more inclusive health care in Africa. Our partners, donors, investors and clients The PharmAccess Group works with: The Dutch and African governments, including the Tanzanian and the Nigerian Ministry of Health International (donor) organizations such as the World Bank/IFC, United States Agency for International Development (USAID), International Labour Organization (ILO), DfID, Clinton Foundation, Bill & Melinda Gates Foundation, Deutsche Bank Americas Foundation, Calvert Foundation, Overseas Private Investment Corporation (OPIC), Soros Economic Development Fund, CDC Foundation, Marie Stopes International, Society for Family Health and PSI. Multinational corporations such as Heineken and Shell. Strategic partners such as Kisumu Medical and Education Trust (KMET), Association of Private Health Facilities in Tanzania (APHFTA), Kenya s National Hospital Insurance Fund (NHIF) and Tanzania s National Social Security Fund (NSSF). Banking partners such as BancABC and National Microfinance Bank in Tanzania, KREP Bank in Kenya, unibank and HFC Bank in Ghana and First City Monument Bank in Nigeria. Insurance companies such as Hygeia, AAR, Africa Medilink Ltd and MicroEnsure. Health accreditation organizations such as Council for Health Services Accreditation for Southern Africa (COHSASA) and Joint Commission International (JCI). Photography by Karijn Kakebeeke Graphic design by Studio Saiid & Smale
Trinity Building C Pietersbergweg 17 1105 BM Amsterdam Phone: +31 (0) 20 566 7643 Fax: +31 (0) 20 566 9440 info@safe-care.org www.safe-care.org