14a IMPROVE ACCREDITATION, REGULATION, AND QUALITY STANDARDS… FOR QUALITY CARE AMIDST ABSOLUTE INFRASTRUCTURE AND RESOURCE CONSTRAINTS THE CHALLENGE Accreditation and re-accreditation requirements differ in existence, scope, and use across and within countries. These differences affect facilities and cadres of workers at all levels. Estimates approximate that less than 60 percent of developing countries require medical school graduates to pass national certification exams, a figure that drops below 40 percent for Africa and Southeast Asia.i Even where minimum standards exist, they can have low uptake due to a perceived or real absence of incentives (regulatory or financial) to pursue accreditation. Different capacities to pay for and devote resources to accreditation may result in gaps along the urban-rural divide in terms of the number of accredited facilities and services offered. MINIMUM QUALITY STANDARDS EXIST ONLY AT SUB-NATIONAL LEVELS OR NOT AT ALL In certain countries, accreditation and re-accreditation requirements simply do not exist at the national level. For example, China had no national policy for accrediting medical schools in 2008, although it was in the process of developing a set of minimum standards based on guidance from the World Federation for Medical Education.ii In other cases, accreditation policies vary sub-nationally. Four states in Brazil launched their own accreditation efforts during the 1990s.iii Even pre-service education requirements differ substantially. A systematic review identified three categories of pre-service training for community health workers across and within many countries: “individuals with little or no formal education with a few days or weeks of training;” “individuals with some form of secondary education and similar training;” and “individuals with some form of secondary education and training over several months to a year.”iv Japan Trust Fund for OCTOBER 2018 Scaling Up Nutrition IMPROVE ACCREDITATION, REGULATION, AND QUALITY STANDARDS… FOR QUALITY CARE AMIDST ABSOLUTE INFRASTRUCTURE AND RESOURCE CONSTRAINTS Even When National Quality Standards Exist, They May Not Be Accreditation Widely Used or Enforced standards vary Even when national quality standards exist, their use may be limited because they are greatly and outdated or ill-defined. Few districts in Indonesia use the national Minimum Service sometimes do not Standards (MSS) for those reasons and none use the family planning MSS at all.v In addition, exist at all. re-accreditation evaluations may occur over long time lags, reducing pressure to standardize. Accreditation in Ethiopia is granted only when an institution is first established since the country lacks an official re-accrediting body for medical schools.vi Even when medical institutions fail inspections, they can frequently contest penalties for poor quality care. Existing standards Appeals can delay closures of very low-quality facilities and fighting penalties can be costly for may be ignored local monitoring and enforcement agencies. In the latter case, the potential costs may because they are disincentivize strict accreditation and reaccreditation standards. Often, health facility inspectors can also have little power to enforce consequences for subpar quality out of date, ill- performance.vii defined, or unenforced. For Incentives Can Cut Against Pursuit of Accreditation example, the Accreditation can be expensive and difficult to achieve, leading many institutions and national family providers to opt out if there is no counteracting incentive in its favor. Only a few studies have planning reported on the costs of pursuing accreditation; based on available papers, a global review suggests that the incremental costs of accreditation comprise between 0.2 and 1.7 percent of standards in facilities’ annual budgets.viii In Zambia, costs for a national hospital accreditation program Indonesia are not totaled about $10,000 per hospital for the first year, with a possible reduction in costs during used by any subsequent cycles after removing start-up expenses; this expense, in a country that spent just districts in the $7 per capita on public health expenditure at the time, was considered unsustainable without country. donor assistance and discontinued after its first year.ix Achieving international accreditation for hospitals can cost as much as $700,000—a sum out of reach for many facilities in low- and middle-income countries (LMICs).x THE PATH FORWARD: GLOBAL EXPERIENCE AND INNOVATIONS Evidence is mixed Creating Incentives for Incremental Quality Improvement and about the best Accreditation motivators for Several countries have accreditation and re-accreditation policies in place, but they are participation. typically voluntary. Evidence is mixed on what leads to more effective regimes. One survey of Noted factors global accreditation bodies points to quality improvement as the most common reason for include regulatory pursuing accreditation, but also indicates that commercial considerations are highly pressure and a influential.xi Evidence from high-income countries suggests that increased participation in accreditation processes may only occur when there is strong regulatory pressure or hard belief that financial incentives.xii Engagement with underlying quality data may help motivate health accreditation will providers to pursue accreditation based on their ethical obligations to provide high-quality make a real patient care; one review argues that “in order for health care leaders and professionals to difference in embrace the philosophy of accreditation, they must view it as making a discernible difference quality and in in quality and safety as well as a sound business decision.”xiii business prospects. OCTOBER 2018 2 IMPROVE ACCREDITATION, REGULATION, AND QUALITY STANDARDS… FOR QUALITY CARE AMIDST ABSOLUTE INFRASTRUCTURE AND RESOURCE CONSTRAINTS To drive increased uptake through incentives, countries can opt for “carrots,” “sticks,” or Where some combination of the two. “Carrots” could include access to prestigious or in-demand accreditation is programs and responsibilities for graduates of accredited medical schools; financial bonuses optional, using for accredited providers; or the opportunity to participate in pay-for-performance or voucher accreditation to schemes. In the Philippines, for example, special administrative and financial autonomy is restricted to accredited institutions,xiv while some Indian insurers offer higher reimbursement select providers for rates for accredited hospitals.xv “Sticks” could include restrictions on the graduates from non- empanelment- accredited medical schools, or on the eligibility of non-accredited institutions to receive based national reimbursement through nationally-funded universal health coverage or social health health plans can insurance programs. In Malaysia, for example, graduates of non-accredited schools are not have a powerful given licenses until they pass exams at accredited schools;xvi and in several LMICs—including effect. Kenya, the Philippines, Nigeria, and Thailand—insurers require accreditation as a pre-requisite for reimbursement.xvii In some countries where accreditation is not mandatory, use of accreditation to select providers for empanelment-based national health plans can create exceptionally strong financial incentives for accreditation, essentially crowding out non- accredited providers.xviii Tiered accreditation systems can also help incentivize incremental quality improvements in settings where achieving the highest quality standards may seem too costly or unrealistic in the immediate future.xix In the U.S., the National Committee for Quality Assurance offered new health management organizations (HMOs) the option to pursue a separate accreditation on a pass/fail basis,xx while tiered accreditation in Lebanon offers accreditation for different In India, professional time horizons and levels (3 years, 18 months, partially accredited, and failed) based on councils have performance. However, few studies empirically evaluate the effects of switching accreditation supported quality systems.xxi In Brazil, a health insurance company paired incentives for achieving different tiers control by educating of accreditation with support to facilities in navigating the accreditation process (see the public, Spotlight). investigating Professional Medical Bodies as Partners in Quality Control complaints about Where human and financial resources to enforce quality standards are low, authorities can unqualified enlist professional medical groups as partners in the quality control process. In India, for practitioners, and example, professional councils have carried out awareness campaigns against the practice of reporting such medicine by unqualified practitioners; investigated complaints about unqualified providers to practitioners; and reported such providers to government departments.xxii To ensure authorities. complaint mechanisms are used in the future and accountability is maintained, governments need to be prepared to follow up on any tips. SPOTLIGHT UNIMED-Belo Horizonte Service Network Qualification Projectxxiii UNIMED-Belo Horizonte (UBH) is a large private insurance company and medical cooperative in Brazil’s Minas Gerais state. In 2005, UBH introduced a novel pay-for-performance program for participating hospitals. The program—formally called the Service Network Qualification Project—sought to improve quality and patient care in its network of contracted hospitals by encouraging and facilitating their pursuit of accreditation. OCTOBER 2018 3 IMPROVE ACCREDITATION, REGULATION, AND QUALITY STANDARDS… FOR QUALITY CARE AMIDST ABSOLUTE INFRASTRUCTURE AND RESOURCE CONSTRAINTS In Phase 1 of the program—launched in 2002—UBH laid the groundwork by reforming its contracting models and introducing accreditation-style audits at contracted facilities to assess and improve infrastructure. However, hospitals responded to the audits with hostility, reporting pressure but insufficient reimbursement rates to make the identified structural improvements. In a second phase, beginning in 2005, UBH responded to provider feedback with stronger financial incentives to pursue accreditation—a “carrot” versus “stick” approach. Hospitals received a 7% boost in per diem rates simply for beginning the accreditation process; incentives rose to 9% for achieving Level 2 accreditation and 15% for achieving Level 3 accreditation. UBH also offered to defray the costs of accreditation-related inspections: UBH would pay 50%, while the hospital would cover the other half. By 2009, 19 out of 45 in-network hospitals had received accreditation, covering 69% of network hospital admissions. ENDNOTES i Tim Evans et al., “Addressing the Challenges of Health Professional Education: Opportunities to Accelerate Progress Towards Universal Health Coverage” (Doha, Qatar: World Innovation Summit for Health, 2016), http://www.wish.org.qa/wp- content/uploads/2018/01/IMPJ4495_WISH_Workforce_REPORT_WEB.pdf. ii Marta van Zanten et al., “Overview of Accreditation of Undergraduate Medical Education Programmes Worldwide,” Medical Education 42, no. 9 (September 2008): 930–37, https://doi.org/10.1111/j.1365-2923.2008.03092.x. iii Gerard M. La Forgia and Bernard F. Couttolenc, “Hospital Performance in Brazil : The Search For Excellence,” En Breve (Washington, DC: World Bank, 2008), https://openknowledge.worldbank.org/handle/10986/10284. iv Abimbola Olaniran et al., “Who Is a Community Health Worker? - A Systematic Review of Definitions,” Global Health Action 10, no. 1 (2017): 1272223, https://doi.org/10.1080/16549716.2017.1272223. v Global Health Workforce Alliance, “Mid-Level Health Workers for Delivery of Essential Health Services: A Global Systematic Review and Country Experiences” (World Health Organization, 2012), http://www.who.int/workforcealliance/knowledge/resources/ghwa_mid_level_report_2013.pdf. vi Fitzhugh Mullan et al., “Medical Schools in Sub-Saharan Africa,” The Lancet, Health Policy, 377, no. 9771 (March 26, 2011): 1113–21, https://doi.org/10.1016/S0140-6736(10)61961-7. vii Kabir Sheikh, Prasanna S. Saligram, and Krishna Hort, “What Explains Regulatory Failure? Analysing the Architecture of Health Care Regulation in Two Indian States,” Health Policy and Planning 30, no. 1 (February 2015): 39–55, https://doi.org/10.1093/heapol/czt095. viii Virginia Mumford et al., “Health Services Accreditation: What Is the Evidence That the Benefits Justify the Costs?,” International Journal for Quality in Health Care 25, no. 5 (October 1, 2013): 606– 20, https://doi.org/10.1093/intqhc/mzt059. ix Ngoyi Bukonda et al., “Implementing a National Hospital Accreditation Program: The Zambian Experience,” International Journal for Quality in Health Care 14, no. 1 (2002): 7–16; Wu Zeng, Adrian Gheorghe, and Dinesh Nair, “A Discussion Paper of Health System Level Approaches to Addressing Quality of Care in Low- and Middle-Income Countries” (World Bank, September 2016), https://www.rbfhealth.org/sites/rbf/files/Approaches%20for%20Adressing%20QoC.pdf. x Akhil Tandulwadikar and Rajeshwer Chigullapalli, “World-Class via Accreditations,” Asian Hospital and Healthcare Management (blog), accessed September 27, 2018, https://www.asianhhm.com/. xi Charles D. Shaw et al., “Profiling Health-Care Accreditation Organizations: An International Survey,” International Journal for Quality in Health Care 25, no. 3 (July 1, 2013): 222–31, https://doi.org/10.1093/intqhc/mzt011. OCTOBER 2018 4 IMPROVE ACCREDITATION, REGULATION, AND QUALITY STANDARDS… FOR QUALITY CARE AMIDST ABSOLUTE INFRASTRUCTURE AND RESOURCE CONSTRAINTS xii Charles D. Shaw et al., “Sustainable Healthcare Accreditation: Messages from Europe in 2009,” International Journal for Quality in Health Care 22, no. 5 (October 1, 2010): 341–50, https://doi.org/10.1093/intqhc/mzq043. xiii Kedar S. Mate et al., “Accreditation as a Path to Achieving Universal Quality Health Coverage,” Globalization and Health 10 (October 17, 2014), https://doi.org/10.1186/s12992-014-0068-6. xiv Jose Cueto et al., “Accreditation of Undergraduate Medical Training Programs: Practices in Nine Developing Countries as Compared with the United States,” Education for Health (Abingdon, England) 19, no. 2 (July 2006): 207–22, https://doi.org/10.1080/13576280600783570. xv Helen Smits, Anuwat Supachutikul, and Kedar S. Mate, “Hospital Accreditation: Lessons from Low- and Middle-Income Countries,” Globalization and Health 10, no. 1 (September 4, 2014): 65, https://doi.org/10.1186/s12992-014-0065-9. xvi Cueto et al., “Accreditation of Undergraduate Medical Training Programs.” xvii Smits, Supachutikul, and Mate, “Hospital Accreditation.” xviii Mate et al., “Accreditation as a Path to Achieving Universal Quality Health Coverage.” xix Mate et al. xx M. Casey, “State HMO Accreditation and External Quality Review Requirements: Implications for HMOs Serving Rural Areas,” The Journal of Rural Health: Official Journal of the American Rural Health Association and the National Rural Health Care Association 17, no. 1 (2001): 40–52. xxi W. Ammar, R. Wakim, and I. Hajj, “Accreditation of Hospitals in Lebanon: A Challenging Experience,” Eastern Mediterranean Health Journal 13, no. 1 (2007), http://apps.who.int/iris/handle/10665/117235. xxii Sheikh, Saligram, and Hort, “What Explains Regulatory Failure?” xxiii Paulo Borem, “Pay-for-Hospital-Accreditation: The Experience of Unimed, Belo Horizonte, Brazil” (January 28, 2010), http://siteresources.worldbank.org/EXTPBFTOOLKIT/Resources/7364043- 1386179884606/7364432-1387478139421/Unimed-BH-RBF_HOSPITAL_incentive_program.pdf; Paulo Borem et al., “Pay-For-Performance in Brazil: Unimed-Belo Horizonte Physician Cooperative” (Health Systems 20/20 project, Abt Associates Inc, January 2010), https://www.hfgproject.org/wp- content/uploads/2015/02/Pay-for-performance-in-Brazil-UNIMED-Belo-Horizonte-Physician- Cooperation.pdf. REFERENCES Ammar, W., R. Wakim, and I. 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