SafeCare - Progress Report 2013

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SafeCare Progress Report 2013


Preface The health system in most sub-Saharan countries is underdeveloped and most patients cannot access the quality care they need. SafeCare believes that by creating transparency about scale, scope, and quality of healthcare services we can help build trust between all players in the healthcare system and improve access to quality care, especially for the poor. This principle has enabled SafeCare to flourish, implementing standards that help stakeholders including patients compare quality, and empower them to make informed decisions. To date, SafeCare has already helped over 613 clinics in seven sub-Saharan countries to improve the safety and quality of care provided to an estimated 690,000 patients per month. More than 100 facilities have been awarded a Certificate of Improvement and over 300 people participated in the facilitator and surveyors training. In total, SafeCare has conducted 825 assessments. As such, the SafeCare program has doubled in size in 2013 alone. For the past year, we have focused on building efficiency and (cost) effectiveness to enable rapid expansion and ensure long term sustainability. Building capacity for program management in the country offices has become increasingly important. This includes strengthening in-country leadership and stepping up quality control and data checks by qualified staff. Looking back on the past year, one of the highlights for us was the second SafeCare conference held in Mombasa, Kenya. This event united 65 participants from over ten different countries to share ideas, successes and lessons learnt on sustainable quality improvement. Thanks to their valuable input, we look back on an enlightening and inspiring conference. Our vision for the coming years is to firmly embed the SafeCare methodology in the local legislative environment, to lay the foundation for regulation and enforcement of quality of care. We aim to start in at least two new African countries, and are slowly exploring ideas to even grow beyond the African continent. Also, we look to further link the SafeCare certificates to financial incentives such as pay-for-performance models through insurance and mobile health initiatives, which will lay the foundation for long term self-financing. This allows the full circle of improvement, facilitation and external evaluations to be operational on the ground. Our work is made possible and successful by many invaluable partnerships, and thanks to their support we look back on a fruitful year, and look forward to working together towards our common goal: sustainable quality of care in Africa. Nicole Spieker Director SafeCare July 2014



‘SafeCare standards generate a market for healthcare quality improvement and improve access to care for millions of people in the informal sector in Kenya’ Khama Rogo, Head of the World Bank Group’s Health in Africa Initiative

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.



SafeCare: A public-private approach SafeCare’s activities are initiated in the private sector by introducing self-regulation and benchmarking, and in the public sector by advocating to embed the methodology in the legislative framework. through public partnerships, so that capacity In order to assure and enhance clinical is built with the governments for inspections performance, quality evaluation of healthand uniform standards apply to the public care providers operates at two levels: and private sector. The resulting publiclicensing and accreditation. Generally private approach works well to promote licensing is a mandatory process for providers and healthcare professionals that is the value of internationally recognized quality standards as it creates a virtuous regulated and monitored by the Ministry circle for the healthcare market. SafeCare of Health. Complementary to licensing is standards are ISQua accredited. accreditation, which is usually a voluntary process, but often a requirement for insurance contracts (including national health insurance schemes) and an income generating marketing instrument for the private sector. The benefits of proper licensing and accreditation are multiple; quality levels of providers become transparent, investments can be attracted, insurance contracting is facilitated and patients are empowered in their choice of quality care. However, in most African countries, shortage of capacity and funds causes a market failure in the implementation of licensing and accreditation. In addition, existing accreditation agencies are often unavailable in the country itself plus the standards they implement are not cusAlice Bett, Siloam Hospital, Kericho, Kenya tomized for resource-restricted settings. SafeCare strives to fill this gap. A vital element is our public-private approach; by forming partnerships with private healthcare facilities transparency of care can be created, which will help attract more patients, and therefore more income. Importantly SafeCare also embeds its methodology in the legislative framework

‘We have benefitted greatly from the SafeCare program. Quality of healthcare is a way of marketing yourself. If customers are satisfied with the services received, they will go out into the community and tell this to others, leading in our case to an increase in patients.’

National Hospital Insurance Fund, World Bank, Ministry of Health Kenya and PharmAccess present SafeCare to the press during the 2nd SafeCare Conference SafeCare creates a framework for transparency of information and benchmarking of quality and risk, creating the trust needed to facilitate transactions between patients, providers, financers, and governments. Providing patients with access to reliable information about quality may empower them to “vote with their feet” and select those facilities that offer high-quality care. Benchmarking Providers of health facilities and differentiating according to relative levels of quality and risk

provides the opportunity for (supply-side) quality improvement mechanisms, such as pay-for-performance. Furnishing investors with reliable data about the risks in the healthcare market permits them to make more accurate long-term projections about financial investments. Enabling governments to evaluate providers on the basis of quality and risk strengthens their ability to deliver effective regulation and enforcement through licensing, certification, and accreditation mechanisms.



‘Aligning the NHIF’s accreditation system with SafeCare methodology will create a transparent evaluation system’ Mr. Simeon Kirgotty, CEO, Kenya National Hospital Insurance Fund (NHIF)



‘The impact of implementing SafeCare standards has been very rewarding. It has improved both the confidence of our staff and our clients’

Dr. Layi Bello Medical Director of the Subol Hospital Subol Hospital is a private hospital in Lagos, Nigeria. They provide a wide range of services including primary and secondary care, catering to corporate and HMO clients. Dr. Layi Bello explains:

“At Subol Hospital, we are committed to providing first class and unique healthcare services to all, irrespective of social class. It is our vision to become the caregiver known for providing affordable and quality services to all. In order to achieve this goal, our facilities need to continuously invest in quality improvement in all our services. SafeCare has been our guiding beacon. We were first introduced to SafeCare in 2011, after joining the Hygeia Community Health Insurance Program (HCHP). The services of the hospital was assessed at the time and huge

gaps were identified using the standards provided by SafeCare. We scored low in the categories of risk management, laboratory and support services. Our passion to improve our services stimulated our commitment to fully implement SafeCare’s quality improvement plan that was developed especially for us. We decided to expand our facility to accommodate the planned initiatives effectively. Our waiting room, for example, was expanded which helped improve the management of patient flow. Moreover we improved our laboratory, resulting in higher quality and faster

test results. We also improved our medication management system, ensuring that the temperature is constantly monitored and that all medicines are neatly organized. Small structural improvement were also implemented such as warning signs for high risk areas to improve the safety of our clients and staff. The impact of implementing SafeCare standards has been very rewarding. It has provided the confidence if both our clients and our staff. Moreover it has also brought recognition of private companies, who now want to partner with us. It is a sign that we need to continue implementing SafeCare.”



Figure 1 SafeCare levels of improvement

Certificate definition

Our Standards

Level 1: Very modest quality strength. The facility is licensed to provide healthcare services but the day-to-day processes are not guided by policies or

SafeCare has developed standards for healthcare providers in resource-limited settings. By measuring the level of quality through a set framework, SafeCare creates transparency and provides a stepwise approach to work towards improved quality of care and patient safety and to reduce risk. To guide the facilities on this journey, SafeCare has defined 13 service elements that represent the different aspects of healthcare delivery.

‘SafeCare helps to create the right environment and all the right components to offer high levels of care’ Shezaad Zainulbhai, Director of Operations, Penda Health, Kenya

Level 2: Modest quality strength. The facility is Advanced Assessment

starting to operate according to structured processes and procedures, some of which are captured in written guidelines and SOPs. However healthcare quality is still likely to fluctuate. Accreditation Level

Level 5 Level 4

Basic Assessment

Level 3: Medium quality strength. The facility is accustomed to operating according to standardized procedures, and has started to monitor implementation. Healthcare quality can still fluctuate in high risk situations due to lack of securing of procedures. Level 4: Strong quality systems. The facility is regularly monitoring the implementation of treatment

Level 3

guidelines and standard operating procedures through internal record reviews and (clinical) audits. Most high risk processes and procedures are controlled. Level 5: Continuous quality improvement systems.

Level 2

are offered at basic health facilities in LMICs (i.e. health shops, basic and primary health centers). Such health facilities offer a wide range of services (e.g., inpatient care, laboratory testing, diagnostic imaging, and minor surgical procedures including anesthesia) that in high-income countries would typically be provided by specialists at secondary or tertiary hospitals. Such basic health facilities, which constitute more than 85% of all registered health facilities in African settings, require standards designed specifically to address the unique management challenges of healthcare delivery in their context. SafeCare acts as the custodian of these internationally recognized, ISQuaaccredited clinical standards specifically designed for resource-restricted settings.


The facility has instituted measures to monitor and evaluate policy implementation and the findings

Level 1

Existing healthcare quality standards and assurance methods are often found to be insufficient for two reasons. First, they do not accurately reflect the context in which healthcare is delivered in resource-restricted settings in low and middle income countries (LMICs). Many of these facilities are missing very basic requirements such as running water, electricity and/or sanitation and are faced with unreliable supply chains, and chronic shortages of human and material resource. Achieving international quality standards is often not possible within reasonable time frames, thus demotivating healthcare providers to embark on a quality improvement trajectory. Second, existing standards are not designed around the range of services that

procedures resulting in potential high risk of unsafe

are reviewed to ensure that appropriate corrective action is taken if necessary. The management team is engaged in evaluating quality of care, and the facility is ready to begin the process of applying for accreditation from an international agency. Accreditation Level: Excellent quality systems. The facility has a proven track record of continuous quality improvement, is in substantial compliance with the SafeCare stand­ards, and meets the decision




Making the SafeCare standards realistic and appropriate for resource-restricted settings requires certain adjustments. For example, in western settings regular training sessions for medical staff is organized through a formal credit system, however this is unavailable in most African countries. SafeCare has developed an alternative system of evaluating training needs in light of available resources. Moreover, SafeCare works with ‘the best of the rest’ solution, where classification takes into account the

rules for accreditation by independent organization COHSASA.

best solution in a failing environment. For example, if there is no central medical waste collection system, a cement pit for needle disposal will suffice. This idea is also incorporated in the scoring of Safe-Care’s thirteen service elements, always rewarding uptake in quality, leading the facility through the five certificate levels. see Figure 1. A negative and discouraging scoring system, including non-compliance, is transformed into a positive and encouraging one.



Service elements Management and Leadership

Operating Theatre and Anaesthetic Services

Management and leadership work collaboratively to develop the plans and policies needed

Services in the operating theatre and anaes-

to fulfill the mission of the facility and to coordinate

thetic services carry high risk. It is essential that there

and integrate the health service’s activities.

is collaboration between the personnel in the theatre, the infection control and health and safety personnel,

Patient and Family Rights and Access to Care

and those responsible for supplying and maintaining

‘It is not just about improving the quality of the clinic in terms of equipment or renovations. Perceived quality of care in the eye of the patient is just as important.’ Dr. Edward Nketiah-Amponsah, senior lecturer, University of Ghana


Health facilities work to establish trust and open communication with patients and to understand

Laboratory Services

and protect each patient’s cultural, psychosocial and

Laboratory investigations and rapid reporting

spiritual values.

systems are essential for patient assessment and the implementation of treatment plans. Laboratory

Human Resource Management

services must be available when required by the organ-

A health facility needs an appropriate number


of suitably qualified people to fulfill its mission and meet patient needs. Recruiting, evaluating

Diagnostic Imaging Services

and training personnel are best accomplished through

When a diagnostic imaging service is provided,

a coordinated, efficient and uniform process.

there are radiation safety programmes in place, and individuals with adequate training, skills, and

Management of Information

experience are available to undertake diagnostic imag-

Aggregated data from patient visits and

ing procedures and interpret the results.

treatment provided help the health facility understand its current performance and identify oppor-

Medication Management

tunities for improvement. By participating in external

The patient, physician and nurse work to-

performance databases, a health facility can compare its performance to that of other similar health facilities.

gether to monitor patients on medications. The purposes of monitoring are to evaluate the response to medication, to adjust the dosage or type of medica-

Risk Management

tion and to evaluate adverse effects.

Health facilities work to provide a safe, func-

Facility Management Services

tional and supportive facility for patients, families, personnel, volunteers and visitors. To reach

Buildings, grounds, plant and machinery are

this goal, facilities, equipment and medication must be effectively managed.

provided and maintained, and do not pose hazards to the occupants. Utility systems (such as electrical, water, oxygen, ventilation and vacuum - systems)

Primary Health Care Services

are maintained, to minimize the risks of operating

Planning and delivering care to each patient,



monitoring the patient to understand the results of the care, modifying care when necessary and

Support Services

completing the follow-up.

Laundry, housekeeping and catering or support services work with other organizational

Inpatient Care

leaders and managers to improve the quality of service

Providing the most appropriate care in a

delivery throughout the organization to management,

setting that supports and responds to each

leadership, human resource development, infection

patient’s unique needs requires a high level of planning and coordination. Delivery of the services is coordinated, integrated and monitored.

control, environmental safety and quality improvement.


‘My future ambition with SafeCare is to further instill the culture of quality improvement in all our facilities, owned and managed by the healthcare facilities themselves.’

National Hospital Insurance Fund in Kenya Martin Ngari, General Manager of the Benefits and Quality Assurance department The National Hospital Insurance Fund (NHIF) is the primary provider of health insurance in Kenya with a mandate to enable all Kenyans to access quality and affordable health services. Martin Ngari explains:

“We have been working with SafeCare since 2011, and they have been assisting us in the expansion and improvement of quality improvement strategies by defining standards and setting up guidelines and protocols. SafeCare is unique because it offers a global angle and perspectives in matters concerning quality improvement. NHIF was already undertaking quality initiatives locally, however the international focus and benchmarking opportunities facilitate results in a more comprehensive and up-to-date approach.

Through the implementation of SafeCare we have, for example, reached great results in the improvement in information management. Health facilities have become more aware of how important it is. This has helped to ease the entire supervisory process and improve the mutual working relationship. Working with SafeCare also adds to the sustainability of established quality improvement activities since quality improvement quality plans are built up in a step-wise manner. One of the main benefits for NHIF is that SafeCare assists in instilling continuous quality improvement activities which are driven by the health facilities themselves, and not by us. This involvement of the community is a strong pillar of successful health programs. SafeCare places the ownership and responsibility with the health facilities, which enables NHIF to focus its time on other matters of its mandate.

The facilities respond well because SafeCare encourages completion per level and provides a detailed guideline to work with. The inclusion of the education programs and health facility visitations also contribute to great improvements. The feature that I personally like the most about SafeCare is its attention to detail through the elaborate surveys since it allows one to identify gaps even within the smallest of details. This results in a much deeper type of quality assessment. My future ambition with SafeCare is to further instill the culture of quality improvement in all our facilities, owned and managed by the healthcare facilities themselves.“ 15


‘I think what we really need is quality assurance. We doctors know what the term means but we don’t know how to go about it’ Dr Afolabi Olajide, Folabi Medical Centre (FMC), Lagos, Nigeria

‘Since we have improved our quality, customers have gained trust in our facility and we have seen a 40% increase of patients.’ Pharis Yikobera, Arafa Dispensary, Dar es Salaam, Tanzania



Clinics and results Ghana



33 average overall assessment score SafeCare Standards

highest overall assessment score SafeCare Standards

Most room for improvement

Top 2 service elements

Human Resource Management


100 =

Number of assessments

SafeCare Essentials

SafeCare Standards

Number of certificates rewarded
















Diagnostic imaging service


average overall assessment score SafeCare Standards

highest overall assessment score SafeCare Standards

Most room for improvement

Top 2 service elements

Risk Management








Number of health facilities currently in the program





Faith Based


Diagnostic imaging service





Sa fe Ca re Ce r t i fi ca tes








227 19


PATIENTS & CARE Management of Information

Primary health care services

Operating theatre and anaesthetic services

8,710 Medical staff

18,032 93





average overall assessment score SafeCare Standards

highest overall assessment score SafeCare Standards

Most room for improvement

Top 2 service elements

Risk Management

Laboratory Services


36 6




average overall assessment score SafeCare Standards

highest overall assessment score SafeCare Standards

Most room for improvement

Top 2 service elements

average overall assessment score SafeCare Standards Most room for improvement

Total number of staff

Medication Management

Risk Management

Support services



Para-medical staff

Total number of patient visits to the facilities per month



Support staff

highest overall assessment score SafeCare Standards

Support services

168,759 Malaria 49,551 HIV

IMPROVEMENT AREAS Top 3 service elements

Risk Management

53,736 Immunizations

Top 2 service elements

Diagnostic imaging service

Most room for improvement

15-90 Range of assessment score SafeCare Standards

Support services

40,181 Family planning Trea t m e nt i n d i ca to rs

Risk Management

Diagnostic imaging

Primary health care services

Risk Management

Inpatient Care

Management of Information

Human Resource Management

Primary health care services

CAPACITY BUILDING Management and Leadership

Operating theatre and anaesthetic services



Number of training sessions since start program

613 Total number of health


Clinical Trainings Clinical care Lab Pharmacy Quality management Admin

30 8 5 22 14

Number of facilitators trained

49 Number of local surveyors trained

Technical Assistance PharmAcces Foundation KMET Kenya PSI Kenya APHFTA Tanzania MCF SFH Nigeria Marie Stopes Kenya Marie Stopes Nigeria FHI 360

facilities in program *SafeCare has also conducted assessments in Congo and Zimbabwe

Data until December 2013




Mister Sister Clinics receives first SafeCare Certificate of Improvement in Namibia

NHIF, World Bank and PharmAccess partner to improve healthcare standards in Kenya

‘With the guidance of SafeCare experts I was able to draft a detailed quality improvement plan... now my facility has a wellfunctioning quality management system.’

‘Quality is a basic right and we who are responsible have to take action. This program is a step in the right direction.’

Following a successful 2012, the SafeCare team enthusiastically continued with ongoing programs plus sought out new opportunities to bring access to quality healthcare that step closer for all. 2013 saw several highlights of which we have selected a few special ones to share. Second SafeCare Conference On September 26th and 27th 2013, the second SafeCare conference took place in Mombasa, Kenya, with the theme: Quality in Practice; Towards Sustainable Quality of Care in Africa. During these two days, international experts gave presentations on different topics relating to quality improvement, quality assurance and healthcare financing. In addition, panel discussions were held to encourage participants to interact and engage in information exchange. International experts from academia, African ministries of health, national and private insurance companies, non-governmental organizations, healthcare facility networks as well as regulations and inno-

vators shared ideas, successes and lessons learnt on sustainable quality improvement. How to achieve transparency and sustainability of quality on a national scale was at the heart of the discussions.

‘The government cannot just come up with regulations and expect everything to be okay. Changing health outcomes and saving lives is what we are trying to address.’ Senior Advisor to the Ministry of Health Nigeria, Kelechi Ohiri

James Macharia, Cabinet Secretary of the Minister of Health in Kenya

Bas Rijnen, Operations Manager, Mister Sister Mobile Clinics in Namibia

SafeCare programs have almost doubled in size in 2013 In 2013, SafeCare has worked with over 613 clinics in Kenya, Tanzania, Nigeria, Namibia and Ghana. In general all these facilities have made great progress in their quality improvement journey, scoring higher after each assessment, demonstrating the benefits of the SafeCare program.

AHME 2013 was the first full active year of the African Health Markets for Equity (AHME) program. AHME is a five-year partnership led by Marie Stopes International and funded by the Bill & Melinda Gates Foundation and the UK’s Department for International Development (DFID). AHME aims to improve health outcomes by enhancing the quality of private healthcare for the poor in

Ghana, Nigeria and Kenya. As part of this program, the healthcare providers in the partners’ franchise networks have access to SafeCare’s quality improvement program plus MCF loans and support in business improvement.

Development and successful pilot of the first pharmacy standards 2013 saw a special highlight for SafeCare Kenya; the development and piloting of pharmacy standards. As part of SafeCare’s participation in the Pfizer Global Health Fellowship, SafeCare and the Medical Credit Fund worked with three experts from Pfizer to develop these standards and business tools for stand-alone pharmacies. After successful piloting in Kenya these standards will be applied to all pharmacies enrolling in SafeCare.



Programs Contracting SafeCare

Contracting The healthcare facilities in programs supported by the PharmAccess Group have been at the core of our work from the onset. However, over the years we have also been able to scale-up our activities, attract new donors and set up new contracts and partnerships. 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 APHIAplus HCM (funded by USAID) have significantly increased the financial self-sufficiency of SafeCare. Besides the private sector contracts, SafeCare managed to obtain key public sector contracts through contracting with the Tanzanian Ministry of Health and Social Welfare (January 2013) and the NHIF in Kenya (March 2013). In October 2013, the Sure-P program in Nigeria started, which is a collaboration between SafeCare and The National Primary Healthcare Development Agency (NPHCDA). Although additional

funding is still required, we expect the program to be self-reliant within the next three to five years, with funding and contracts from both public and private stakeholders. Furthermore, in 2013 we have seen an increase in demand for the use of the SafeCare methodology and tools in individual (groups of) clinics. An example of this is the project for SHOPS in Kenya, where the SafeCare team performed a quality scan of 80 facilities (a subset of the facilities in the National Health Care Costing Study) using the SafeCare Essentials. Consulting firms such as Acumen and KPMG have contracted SafeCare to perform due diligence assessments for investment opportunities.





Health Insurance Fund Program: the HIF Program uses the SafeCare methodology in Nigeria, Kenya, Tanzania and Namibia as a quality improvement and evaluation approach.



3,000,000 USD (2013)

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.



425,000 USD (2013)

APHIAplus-HCM Program Kenya: USAID funded consortium aims to strengthen Kenyan health systems and includes the expansion of the Kenyan SafeCare certification body.

April 2012

3 years

840,000 USD

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.

November 2012

5 years

4,050,000 USD (2013)

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.

TPDF: 2012

5 years

Total project value: 21,714,513 USD

TPPI: 2008

5 years

Total project value: 9,981,453 USD

Royal Shell Nigeria: SafeCare certifies Shell healthcare facilities in Ogun State, Nigeria.

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

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.


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

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.

October 2013

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 (Sure-P Program).

October 2013

17 months

68,000 USD




SafeCare staff

Private sector

Noah Koech

Bonifacia Benefo Agyei

Christine Kapkusum-Mbae Acumen

Tea Farmer in Koisagat, Kenya

‘Since the start of the program the quality of care in our facility has really improved. The queues have been reduced, allowing me more time to work on my farm. We used to have to wait for many hours before getting treatment, and then the medicines we needed would not be in stock. We are also attended to much better. Before we would sell part of our livestock to pay for the bills, receive poor care, and when you don’t get better you would have to sell more livestock. This costs us a lot of money, which we don’t have. Now we have seen our savings grow, allowing us to build a new brick house. When my daughter was born, the staff in our clinic were able to help us right away and the delivery went well. It takes away a lot of stress and worries.’

Quality Surveyor Ghana

‘‘As a quality advisor I supervise and oversee all quality development activities in Ghana. My job is very rewarding because I feel that through my activities a better level of quality is being provided in the facilities. I can see that health consumers are demanding quality in care delivery and providers are finding it necessary to ensure the implementation of standards. Before the focus was on increasing the quantity of healthcare provision, however, I can see a gradual paradigm shift to include quality. In order to do this, health facilities need to overcome a lot of challenges including the lack of capacity and know-how. Financing remains a big problem in Ghana. Despite this, I think SafeCare should be adopted simply because the quality of care provided by a health facility has direct influence on the health of the community it serves and therefore it is a great investment.’

Portfolio Manager, Kenya

‘We are investors and at that time looking for an independent assessment of the quality of the health care at one of our facilities, for which we contracted SafeCare. Through the assessment it became clear that the facility just needed a few small improvements to reach SafeCare level four, which gives a lot of comfort to continue investing in the health facility. The SafeCare program is affordable, and it was very clear which improvements need to be made. I enjoyed the interaction with the SafeCare team, and felt their dedication to the joint dedication to low income groups. We hope to expand to 70 clinics, and would love to do repeat assessments to show improvement.’



SafeCare partners The three founding organizations PharmAccess, Joint Commission International (JCI) and Council for Health Service Accreditation of Southern Africa (COHSASA) established SafeCare in 2011 to address the shortage of institutions and standards that can ensure objective measurement and rating of quality basic healthcare facilities in Africa. Based in Amsterdam, the Netherlands, PharmAccess stimulates both the demand and supply side of the healthcare sector through quality improvements and clinical standards, loans for healthcare providers, health insurance, health infrastructure consultancy, HIV/AIDS corporate programs, mHealth and impact research with a wide range of public and private partners. By mobilizing public and private funds to lower risk and build trust, PharmAccess have been able to leverage large amounts of international and local capital for Africa’s underfunded health systems, making the healthcare market more attractive for investors. As healthcare delivery and affordability continue to improve, patients, doctors, insurance companies, banks and governments gain access to the tools they need for social and economic development. Based in Cape Town, South Africa, COHSASA 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. Based in Chicago, U.S.A. JCI works to improve patient safety and quality of health care in the international community by offering education, publications, advisory services, and international accreditation and certification. In more than 100 countries, JCI partners with hospitals, clinics, and academic medical centers; health systems and agencies; government ministries; academia; and international advocates to promote rigorous standards of care and to provide solutions for achieving peak performance.

PharmAccess Amsterdam Nicole Spieker Program Director Quality Elsemiek Snijders-Storm Deputy Director Tobias Rinke de Wit Analysis and Learning Hanneke Peeters Operations Manager John Dekker Manager Laboratory Services and Procurement Aletta Kliphuis Quality Chief Surveyor Annedien Plantenga Quality Manager Nienke Meijland Quality Program Support Toon Luttikhuis Financial Consultant Mike Johnson Research Associate Tanzania Peter Risha Program Director Heri Marwa Surveyor Nicodemus Butamanya Surveyor Johnson Yokoyana Surveyor Edith Ngirwamungu Surveyor Anunsiatha Mrema Facilitator Liberatha Shija Facilitator Elizabeth Amuli Facilitator Regina Mushi Facilitator

Nigeria Dupe Oludipe Program Director Emmanuel Aiyenigba Surveyor Jimi Odetola Surveyor Kendra Njoku Surveyor Anire Asumah Surveyor Peggy Imoniovu Surveyor Joshua Kolawole Facilitator Kenya Milicent Olulo Orera Program Director Kasmil Masheti Operations Manager Jacinta Mburu Surveyor Margaret Mwakiridia Surveyor Mary Njoki Wachira Surveyor John Nziu Surveyor Elly Wandago Surveyor Emmanuel Milimo Surveyor Petronilla Wesonga Surveyor Georgine Mbeki Surveyor Irene Kasyoki Surveyor Catherine Nyawira Facilitator

Ghana Maxwell Antwi Program Director Bonifacia Agyei Surveyor Gabriel Fiadorme Facilitator Joseph Asumang Peasah Facilitator

Namibia Wilet Pothas Facilitator Asia Hoko Facilitator Sylvia Ashikoto Facilitator

Cape Town (COHSASA)

Joint Commission International

Stuart Whittaker CEO Jacqui Stewart Deputy CEO; Chief Operations Manager Ziyanda Vundle Quality and Facilitation Manager Grace Labadarios GP Accreditation Standards Coordinator Giel van Schalkwyk Chief Surveyor RiĂŤl le Roux Surveyor Edith Palmer-Harrington Surveyor

Paula Wilson President and CEO Paul van Ostenberg Vice President International Accreditation, Standards and Measurement Cecily Pew Director Board and Committee Activities


PharmAccess Group SafeCare is a member of the PharmAccess Group. This group of organizations is dedicated to inclusive quality health care for people in sub-Saharan Africa. We believe that healthy populations are a major driver of social and economic development and that health is a (semi) public good. Many African governments, however, struggle to meet the healthcare needs of their citizens, while privately operated clinics often lack the means to improve their services. Without reliable institutions, health markets in these countries suffer from low trust and high transaction costs. Investors, entrepreneurs and banks are reluctant to invest in healthcare in the face of such impediments. As a result, many hospitals are overburdened, understaffed and poorly stocked. Healthcare providers are often unable to finance quality improvements. Patients receive low quality of care, have no way to measure or compare this quality, and generally have little faith in the system. As such, their willingness to pre-pay through mechanisms like health insurance remains low. Without insurance, they have no choice but to pay out-of-pocket for healthcare and often become trapped in a downward spiral of high unexpected costs paired with lost income when they fall ill. These demand- and supply-side constraints result in a healthcare value chain characterized by a vicious cycle of low and unpredictable demand, perpetuated by low quality supply of services.

Integrated approach In order to reverse this vicious cycle, the PharmAccess Group aims to build trust throughout the system. We mobilize public and private resources for the benefit of patients and doctors through quality improvements and clinical standards, loans for healthcare providers, health insurance, health infrastructure consultancy, HIV/AIDS corporate programs, mHealth and impact research. In our view, the journey towards inclusive healthcare begins with enabling quality improvement at healthcare facilities. Once hospitals and clinics can demonstrate quality of care through improvements like shorter waiting times, well-trained staff, functioning equipment and readily available medicines, patients and investors will gain trust in the healthcare system. We build institutions and create standards that help patients to make informed decisions about healthcare. Such systemic changes stimulate healthcare providers to improve their quality 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. Our approach sets in motion an upward spiral of trust, capital, financial services, quality and availability of health services, thereby scaling up functioning health systems. This has sparked considerable international interest, including the OPIC Impact Award for Access to Finance and the G20 SME Finance Challenge

award for our innovative financing model. By using public and private funds to lower risk, we have been able to leverage large amounts of international and local capital for Africa’s underfunded health systems. As the healthcare market becomes more attractive for investors, and as healthcare delivery and affordability continues to improve, patients, doctors, insurance companies, banks, government and international investors gain access to the tools they need for social and economic development.

Our partners, donors, investors and clients With a growing number of highly valued African and international partners, donors and investors from both the private and the public sector, we continue to work towards inclusive health care for all. Government partners, including the Dutch government, Kenya’s National Hospital Insurance Fund (NHIF), Tanzania’s National Social Security Fund (NSSF) 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), Department for International Development (DfID), Clinton Foundation, Bill & Melinda Gates Foundation, Deutsche Bank Americas Foundation, Calvert Foundation, Overseas Private Investment Corporation (OPIC), Soros Economic Development Fund and CDC Foundation Research partners such as Amsterdam Institute for Global Health and Development (AIGHD) and Amsterdam Institute for International Development (AIID) Multinational corporations such as Heineken, Shell, Aegon, Achmea, SNS Reaal and Pfizer. Specialized healthcare partners such as Kisumu Medical and Education Trust (KMET), Association of Private Health Facilities in Tanzania (APHFTA), Marie Stopes International, Society for Family Health and Population Services International (PSI) Banking partners such as BancABC and National Microfinance Bank in Tanzania, KREP Bank and Chase Bank in Kenya, uniBank and HFC Bank in Ghana and First City Monument Bank and Diamond 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)


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