Lekha K Shruti, Ramani Sudha, Joshi Harsha, Verma Preet, Malhotra Sumit, Puwar Tapasvi, Kumar Chandramani, Shah Ankita, Sinha Anish, Saxena Deepak
Indian Institute of Public Health, Gandhinagar, Gujarat, India.
Johns Hopkins India Private Limited, New Delhi, India.
PLOS Glob Public Health. 2025 Jan 21;5(1):e0004180. doi: 10.1371/journal.pgph.0004180. eCollection 2025.
High-quality health systems are key to improving population health outcomes globally. In India, the National Quality Assurance Standards (NQAS) is a certification policy adopted by the government to improve the quality of care in public health facilities. This policy aims to assess public health facilities through a set of comprehensive, pre-defined standards derived from global best practices. However, only a small number of districts in the country have been able to effectively complete certifications as mandated. Bhavnagar, a district in the state of Gujarat in western India, is a positive deviant that has certified the majority of its primary health facilities. This study attempts to delineate factors that have led to successful quality certifications in Bhavnagar. Qualitative data was collected between December 2023-February 2024, and includes in-depth interviews of staff from state, district, and facility levels (n = 20), and group discussions with facility staff (n = 2). Data has been analysed from the lens of the 'policy triangle', comprising actors (policymakers, managers, implementers), context (political support), content (the policy and interpretation), and processes (plans, implementation, and evaluation). We found that Bhavnagar's political context is supportive of quality certifications, with the district's top managers directing the certification process. The district's mid-level operational team on quality has engaged with innovative solutions to solve checklist-related hurdles in infrastructure like establishing a temporary fire-escape or installing screens between rooms for additional space. A peer-mentoring system, wherein staff from already certified primary health facilities act as mentors to prospective ones, has been instituted. This study consolidates empirical lessons for boosting quality certifications in similar contexts. Further, it engages with quality as not just a technical issue, but a political one that is dependent on actors, their relationships, and the implementation context. In doing so, it deepens current understandings of quality improvement strategies in health systems globally.
高质量的卫生系统是改善全球人口健康状况的关键。在印度，国家质量保证标准（NQAS）是政府为提高公共卫生设施的护理质量而采用的一项认证政策。该政策旨在通过一套源自全球最佳实践的全面、预先定义的标准来评估公共卫生设施。然而，该国只有少数几个地区能够按要求有效完成认证。印度西部古吉拉特邦的巴夫那加尔区是一个积极的典范，其大部分初级卫生设施都已获得认证。本研究试图勾勒出导致巴夫那加尔成功进行质量认证的因素。定性数据收集于2023年12月至2024年2月期间，包括对州、区和设施层面的工作人员进行深入访谈（n = 20），以及与设施工作人员进行小组讨论（n = 2）。数据已从“政策三角”的角度进行分析，“政策三角”包括行动者（政策制定者、管理者、实施者）、背景（政治支持）、内容（政策及解释）和过程（计划、实施和评估）。我们发现，巴夫那加尔的政治环境支持质量认证，该地区的高层管理人员主导认证过程。该地区的中级质量运营团队采用了创新解决方案，以解决基础设施方面与清单相关的障碍，比如建立临时消防通道或在房间之间安装隔板以增加空间。已经建立了一个同行指导系统，即来自已获得认证的初级卫生设施的工作人员担任未来认证设施的指导者。本研究总结了在类似情况下促进质量认证的经验教训。此外，它将质量视为不仅是一个技术问题，而且是一个政治问题，这取决于行动者、他们的关系以及实施背景。通过这样做，它加深了目前对全球卫生系统质量改进策略的理解。
