Intended for healthcare professionals


Improving the delivery of safe and effective healthcare in low and middle income countries

BMJ 2012; 344 doi: (Published 14 February 2012) Cite this as: BMJ 2012;344:e981
  1. M Rashad Massoud, director1,
  2. Nana Mensah-Abrampah, quality improvement fellow1,
  3. Pierre Barker, senior vice president, low and middle income countries2,
  4. Sheila Leatherman, research professor3,
  5. Edward Kelley, head, strategic programmes and coordinator4,
  6. Bruce Agins, medical director5,
  7. Sylvia Sax, lecturer 6,
  8. James Heiby, medical officer 7
  1. 1USAID Health Care Improvement Project, Bethesda, MD 20814, USA
  2. 2Institute for Healthcare Improvement, Cambridge, MA 02138, USA
  3. 3University of North Carolina, Gillings School of Public Health, NC, USA
  4. 4WHO Patient Safety, Geneva, Switzerland
  5. 5AIDS Institute, New York State Department of Health, New York, USA
  6. 6University of Heidelberg, Heidelberg, Germany
  7. 7United States Agency for International Development, Washington, DC, USA
  1. nmensah{at}

Research is needed into creating workable systems that can deliver and sustain interventions

Many resource constrained countries are unlikely to attain their millennium development goal targets by 2015,1 despite major global efforts and much progress (figure).2 3 For example, only 23 countries are currently estimated to be on track to achieve the target of a 75% reduction in maternal mortality.4 In addition, the rate of new HIV infections continues to outpace the number of HIV positive patients who start treatment—for every five people newly infected with HIV only two begin treatment each year, and about 5.5 million people needing treatment for HIV in low and middle income countries still do not receive it.5 6


Health millennium development goal scorecard for World Health Organization regions. Adapted, with permission, from the WHO report2

At the heart of bridging the gap between knowing what interventions can improve health and delivering appropriate healthcare to patients is the delivery of efficacious interventions in ways that allow their implementation. A statement from the African Academies of Science meeting in Accra, Ghana, in December 2009 pointed out that the lives of four million women, newborns, and children in sub-Saharan Africa could be saved each year if well established, currently available, affordable healthcare interventions could be implemented across the region.7

If we want to see a different kind of outcome, we have to change the system. Stakeholders need to be willing to change the status quo. A key question is, how can we change the conversation about improving health systems from just “where will we get more resources?” to include “what ideas can we harness to improve the system?” It is possible to improve the delivery of effective interventions in resource constrained settings. A recent study of 27 collaborative improvement projects that covered a range of global health priorities in 12 low and middle income countries found that 88% were able to achieve 80% compliance with evidence based standards and maintain it for more than a year of observation.8

What is needed is research into creating systems capabilities that will allow healthcare providers to continually adapt interventions so that they work for more patients in more contexts. Successful implementation of interventions depends on the recognition of the different epidemiological and contextual conditions that exist, and the interactions between them.9

The greater the scope and scale of improvement in healthcare systems, the greater the need for effective leadership to drive this change. The Salzburg Global Seminar, “Improving health care in low and middle income economies: what are the next steps and how do we get there?”, to be held in Salzburg, Austria, from 22 to 27 April 2012 ( will bring together 60 global health leaders from more than 20 countries to consider, among other things, how to sustain successful improvement efforts and strengthen health systems globally.

The capacity of low and middle income countries to change their healthcare systems in order to deliver better outcomes can be enhanced only by the involvement of high level government figures and health systems providers within the country. Change must involve care providers throughout the system, from highest level policy makers to practitioners at the sharp end of care delivery—in homes, where much of healthcare takes place—through primary healthcare centres, regional hospitals, and tertiary centres. Only by ensuring that simple, evidence based, high impact interventions reach all patients every time that they are needed can the millennium development goals be achieved, so that countries can avoid continuing to fall behind in health status.


Cite this as: BMJ 2012;344:e981


  • Competing interests: All authors have completed the ICMJE uniform disclosure form at (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Provenance and peer review: Commissioned; not externally peer reviewed.


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