SafeCare - Progress Report 2014

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SafeCare Progress Report 2014


Preface We believe that achieving inclusive healthcare begins by creating trust between stakeholders through a common language. SafeCare helps create this common language by providing transparency on quality, scale and scope of care. The methodology empowers healthcare providers to improve the quality of care for their patients.

In remembrance of Prof. Dr. Joep Lange and Jacqueline van Tongeren While 2014 held many highlights, it was first and foremost the year in which we mourned the loss of our two beloved colleagues. On July 17th Joep Lange and Jacqueline van Tongeren lost their lives on board Malaysian Airlines flight MH17, en route to the International AIDS Conference in Melbourne. Joep was a world class scientist and a visionary leader, most known for his pioneering work in HIV/AIDS care, treatment and research. As founder and chairman of PharmAccess, Joep helped expand this mission with new ways of financing healthcare, setting up impact evaluations and improving quality of care through SafeCare. It is impossible to overestimate the contribution Joep and Jacqueline made.

The SafeCare methodology is specifically designed for resource-restricted settings and focuses on opportunities rather than limitations. The program gives healthcare providers the tools and skills to move forward, and makes quality improvement tangible. Through the certificates, it creates a common language between all players of the health sector, increasing trust and facilitating transactions between providers, banks, insurers and patients. This drives improvements in quality of care and promotes investment in the healthcare market. So far, it has caught the interest of several African governments, who are institutionalizing SafeCare standards and methodology into their healthcare systems. In 2014, we introduced the concept of Centers of Excellence, where we reward clinics that show exceptional progress. Through peer-to-peer learning, they share their best practices to help clinics that are just starting their quality journey, demonstrating the benefits of the program from a financial and social perspective. Other developments include the upgrading of our AfriDB database and linking quality improvement to the PharmAccess Group’s new mobile health programs. For the third year in a row, SafeCare has doubled in size. In 2014, more than 1,600 clinics were improving the quality of their services for over 1.5 million patients per month. So far, almost 450 people have participated in the SafeCare facilitator trainings and with our partners, we have conducted over 1,400 assessments. Learning and analysis is giving us better understanding on the impact - clinical, financial and social - of the program, which will bring a new round of innovation in 2015 that is aimed to help those facilities that are still struggling with the level of care they are providing. The degree to which SafeCare is being embedded at national policy levels, as well as being embraced by many successful healthcare providers themselves, makes us proud of our achievements in the past year. We owe this success to the dedication and motivation of the teams within PharmAccess, but importantly also to our many international partner organizations that have made the system their own. We look forward to continue working together on the road to improving the quality of healthcare delivery in Africa. Nicole Spieker Director SafeCare June 2015



Mission, Vision and Objectives Mission SafeCare aims to improve the quality and safety of healthcare services in resource-restricted settings using incremental standardsbased recognition and by building institutions that can objectively measure and rate levels of quality and patient safety in healthcare providers. Vision SafeCare’s vision 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.



A public-private approach to quality improvement SafeCare stimulates quality improvement throughout the health system. In the private sector, we focus on introducing selfregulation and benchmarking. Our activities in the public sector are geared towards embedding SafeCare methodology into the legislative framework. In most African countries, there is a shortage of institutions and standards that ensure objective measurement and rating of the level of quality of basic healthcare facilities. Existing systems for licensing and accreditation tend to fall short and are almost never customized for resource-restricted settings. In 2011, PharmAccess, JCI and COHSASA founded SafeCare to help fill this gap in the African healthcare system. Through a set of internationally (ISQua) recognized quality standards and a step-by-step improvement path, it offers positive incentives for healthcare providers to move upwards in clinical and business performance. So far, SafeCare has set up operations in Kenya, Tanzania, Nigeria, Ghana and Namibia, and has built capacity of more than 400 assessors to apply the methodology.

Building trust Through the availability of data and benchmarking of quality and risk at the provider level, we reduce the risk and increase the trust needed to facilitate transactions between patients, healthcare providers, financers, and government. This publicprivate partnership approach is based on the following assumptions:

• When quality levels in the health sector

become transparent, patients are empowered to “vote with their feet” and can choose those facilities that offer the highest quality healthcare services. Being able to differentiate between different quality levels provides the opportunity for pay-for-performance mechanisms, so that healthcare providers can attract financial investments, qualify for (national) health insurance contracts and serve more patients. 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.

We strive to embed standards-based quality improvement methodology in the legislative framework of the countries where we work. We do this by building capacity within the government agencies responsible for inspection and quality assurance in the public and private sector. At the same time, our program builds capacity for self-regulation of the private sector. This enables access to better healthcare services for all.

‘SafeCare has served as a benchmark for the entire healthcare system. Once the quality of the private clinics goes up, government hospitals cannot stay far behind.’ Dr. Charles Kandie, Head of Quality & Health Standards at the Kenyan Ministry of Health



International standards, local solutions SafeCare Certificate levels

The challenges and limitations that face healthcare delivery in Africa disqualify most facilities from (inter)national accreditation. Instead of applying a pass-or-fail system, SafeCare measures, stimulates and recognizes incremental achievements.

‘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

likely to fluctuate and there is a risk of unsafe

Accreditation Level

Level 2 The facility is starting to put processes in place for high risk procedures however the quality of services provided is still likely to fluctuate and the risk of unsafe situations remains high. Level 3 The facility is starting to operate according to structured processes and procedures, however not all high risk procedures are controlled, thus the quality of services provided can still fluctuate. Level 4 The facility is accustomed to operate

Level 3

Level 4

Level 5


according to standardized procedures, and has started to monitor the implementation of their procedures and guidelines. Most of high risk

Level 2

achievable within reasonable time frames, thus demotivating healthcare providers to embark on an improvement trajectory. Governments of low and middle income countries face the problem of lack of enforcement options for quality standards. If implemented, such standards would require substantial investments for a vast number of both public and private providers. As a consequence, the required minimal quality scores are often lowered and asymmetries frequently exist in the enforcement of quality standards between the public and private sector. Innovative healthcare standards, a grading process, and stepwise quality improvement are particularly needed when licensing and accreditation systems cannot (yet) be adequately implemented.

Level 1 The quality of the services provided is

procedures are monitored and controlled and the quality of services provided is less likely to

Level 1

Many healthcare facilities in low and middle income countries lack very basic requirements like running water, electricity or sanitation. Often, they are faced with unreliable supply chains and chronic shortages of human and material resources. Yet, they provide a wide range of services offered frequently by medical generalists (from outpatient care and pharmacy services, and often including inpatient care, laboratory testing, diagnostic imaging, and minor surgical procedures) that in high income countries would typically be provided by specialists at secondary or tertiary hospitals. Given this setting, existing international quality standards are often not

Certificate definition

fluctuate. Level 5 The facility is regularly monitoring the implementation of treatment guidelines and standard operating procedures through internal audits, and is ready to begin the process of applying for accreditation from an international agency. Accreditation Level The facility 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.

Step-by-step Many healthcare facilities do in fact have the capability and the motivation to improve, but the gaps between current practice and best practice cannot be bridged in a single step, and alternative ‘best of the rest’ solutions are often needed. SafeCare addresses this issue. Rather than applying a pass-orfail system, SafeCare measures and recognizes incremental improvement. As facilities demonstrate continued improvement, their progress is rewarded with SafeCare Certificates (Level 1-5) to recognize improved clinical and business performance.

SafeCare thus transforms quality assessment into a positive and encouraging experience. Facilities that demonstrate substantial leadership and improvement beyond that of their peers are recognized as “Centers of Excellence” and are held up as inspirational examples for other facilities to follow.

Local solutions The basis of this methodology consists of internationally recognized, ISQua-accredited clinical standards that have been designed specifically to address the unique and complex challenges in these contexts. For example, as access to accredited training

is often limited, SafeCare has developed an alternative system of evaluating training needs in light of available resources. It also goes by the ‘best of the rest’ principle: if there is no central medical waste collection system, a cement pit for needle disposal will suffice. In many cases, meeting the SafeCare standards is not only a question of funding, but also a matter of coming up with creative solutions to common challenges.



Service elements in healthcare delivery SafeCare has defined 13 service elements in healthcare delivery. Each service element contains a number of criteria that are assessed in order to ascertain the level of compliance with the standards. Non-compliant criteria that represent a high risk in terms of safety, quality, or financial sustainability are identified as the highest priority for resolution. Management and Leadership Management and leadership work collaboratively to develop the plans and policies

Operating Theater and Anesthetic Services Services in the operating theater and

needed to fulfill the mission of the facility and to coor-

anesthetic services carry high risk. It is essential that

dinate and integrate the health service’s activities.

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

Patient and Family Rights and Access to Care

personnel, and those responsible for supplying and maintaining equipment.

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

A health facility needs an appropriate number


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

Diagnostic Imaging Service

and training personnel are best accomplished through

When a diagnostic imaging service is provided,

a coordinated, efficient and uniform process.

there are radiation safety programs in place, and individuals with adequate training, skills, and ex-

Management of Information

perience are available to undertake diagnostic imaging

Aggregated data from patient visits and

procedures and interpret the results.

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

Medication Management

opportunities for improvement. By participating in

The patient, physician and nurse work to-

external performance databases, a health facility

gether to monitor patients on medications.

can compare its performance to that of other similar

The purposes of monitoring are to evaluate the response

health facilities.

to medication, to adjust the dosage or type of medication and to evaluate adverse effects.

Risk Management Health facilities work to provide a safe,

Facility Management Services

functional and supportive facility for patients,

Buildings, grounds, plant and machinery

families, personnel, volunteers and visitors. To reach

are provided and maintained, and do not

this goal, facilities, equipment and medication must be

pose hazards to the occupants. Utility systems (such

effectively managed.

as electrical, water, oxygen, ventilation and vacuum - systems) are maintained, to minimize the risks of

Primary Healthcare Services

operating failures.

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.

Support Services Laundry, housekeeping and catering or support services work with other organizational leaders and managers to improve the quality

Inpatient Care

of service delivery throughout the organization to

Providing the most appropriate care in a

management, leadership, human resource development,

setting that supports and responds to each

infection control, environmental safety and quality

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




‘SafeCare has a well-tested system that gives us standards by which to measure quality in our facilities and a methodology which can empower our healthcare workers to take ownership of the process of rising up the quality ladder.’ Olaokun Soyinka, Ogun State Commissioner for Health, Nigeria

‘Before, only a select number of larger healthcare facilities could attain accreditation. SafeCare has opened up a new avenue for smaller facilities to work on improving their quality. You can really see the joy on their faces.’ Elizabeth Kwamboka Nyambane, Relationship Manager Medical Sector, Chase Bank, Kenya


Service element

Spotlight on St. Patrick Health Care Centre For Ann Maina, SafeCare was an eye-opener. It helped her establish the gaps at St. Patrick and set in motion clear interventions to improve her facility’s quality of care. ‘SafeCare makes you feel like a professional.’

Located on a bustling commercial road of Nairobi’s densely populated Kayole area, St. Patrick Health Care Centre is one of the go-to healthcare providers for the mainly poor and low-income population. Most patients are self-employed in retail activities, handicrafts or personal services like barbers and taxi drivers. The privately-owned facility has 17 staff members and 26 beds, and is open 24 hours a day, 7 days a week. Ann Maina opened St. Patrick with her husband Patrick in 2002. Ann is a nurse by profession, with over 20 years of working experience in private practice. They joined SafeCare in early 2012. “It was difficult sometimes in the beginning because SafeCare requires a new way of thinking, both for us and for our staff,” Ann says. “It’s about accountability, transparency and establishing procedures – in all departments, from the cleaners to the medical personnel. But now that our staff has seen

‘SafeCare opened our eyes as to how patients perceive the quality of care.’

Laboratory services

Ann Maina

what the program can do, they are fully on board and committed to continue to improve our quality.”

were neatly in place.” They repaid their first loan within six months. Their improved track record and financial management enabled them to secure a Ksh 5 million (USD 50,000) loan from a bank to invest in their laboratory and the further expansion of the facility.

Establish gaps

Improvement path

Shortly after joining SafeCare, St. Patrick obtained a loan as well as business training through the Medical Credit Fund (MCF). With the Ksh 500,000 (USD 5,000) loan, they purchased computers, installed a computerized management system, internal phone lines and a CCTV system. They also invested in financial accounts by an external auditor and minor infrastructural improvements. SafeCare was an eye-opener for them. “We were not running the facility in the right way,” Ann explains. “We had no administration office, no systems. We used to work from our pockets, writing on patient cards and counting the shillings at the end of the day. SafeCare helped us to establish our gaps and set in motion interventions to improve ourselves. Now, our record keeping is accurate, we have audited accounts and a digital client history that can be accessed at any time. The system has also helped minimize fraud and track the expiration dates of drugs in our pharmacy.” The experience they gained in qualifying for their first loan through the MCF program was instrumental in building a financially sound organization. “Through the training and on-site support, we learned how to draft a business plan and what documents to deliver to the bank. Our records

“When the National Hospital Insurance Fund (NHIF) used to visit us for an evaluation, we never knew what they were looking for. There was no manual or checklist and we never received advice on how to improve. After we started SafeCare and the NHIF visited us again, it was a whole other story. We had standard operating procedures (SOPs) in place, we had an organized flow of clients, a well-stocked pharmacy, fire extinguishers and many other improvements that impressed them.” So much so, that the NHIF brought their staff to St. Patrick to learn more about SafeCare and how it helped St. Patrick improve their quality of care. St. Patrick then became NHIFaccredited for civil servants as well as for the general public, ensuring a bigger client and income flow. Patient visits have risen from almost 600 to more than 2000 a month, especially now that they have also managed to contract corporate clients and private medical insurance companies. “SafeCare has helped us to reposition ourselves and increase our market value,” Maina says. “The program is even being pushed by the market now, there is demand for it from healthcare providers. In the end, we all want a system that cuts across the whole country. We could be treating your brother and you could be treating mine.”

St. Patrick’s SafeCare assessment scores for laboratory services improved from:

81% 49% St. Patrick upgraded the lab two years ago, moving it to a larger room, installing separate sinks for staining and handwashing, and purchasing more equipment such as TB and HIV testing kits. “We used to have to outsource many tests, but now other facilities refer people to us and labs send us their samples,” says medical laboratory technologist Eric Okeyo. “We closely monitor our services with performance reports and have installed an SOP for every test, a tracking chart for expiration dates and guidelines for the maintenance of our equipment. We also have a visible price list with the expected report time for results.” The number of lab tests have more than doubled, from 400 to about 850 per month. “The lab now generates a lot of income and has become the financial backbone of the hospital.”


Service element


Medication management


SafeCare score improved from 67% (Level 2) to 81% (Level 3)

Perception of care

St. Patrick’s SafeCare assessment scores for medication management improved from:

79% 70% Improvements to the pharmacy include privacy, efficiency and inventory management. The dispensing window was moved so that clients can consult the pharmacist out of earshot of the waiting room and there is a separate room for sensitive cases. “With the automated hospital management system, I can open patient files and see what medication they’re already taking,” pharmacist Carol Bilha explains. “I don’t need to walk to the lab to collect test results, it’s all there. Also, the system monitors our stock so we don’t run out.” Medicines are now stored in a locked cabinet. Hazardous and flammable materials are stored separately. “We no longer leave medicines in the direct light on the window sill. Sometimes we let clients keep medication like insulin here if they don’t have a fridge at home.” The pharmacy now serves up to 200 people a day.

“SafeCare opened our eyes as to how patients perceive the quality of care.” The changes that Ann and Patrick made may seem small, but they have had a huge impact on customer satisfaction. When St. Patrick admits new inpatients, they are given an orientation of the facility and are introduced to other patients so that they feel more comfortable. Maina even installed a mirror in the maternity ward, where they do about 40-50 deliveries a month. Smiling: “Once women deliver, many want to go back to normal life and put on lipstick.” The waiting room was also adjusted. “Our facility is located on a busy street. Before, we had the seats in our waiting room facing outside. Now, we have moved the TV to the opposite corner and turned the seats around to give people inside more privacy.” Where the walls of the facility used to be plain, they are now painted in bright colors and cartoon figures. “Children often don’t want to leave!” There is a clock and a sign with the visiting hours on the wall, as well as a plaque with St. Patrick’s vision for the facility. They also installed a suggestion box to gather patient feedback. “We never thought of these things before. Everything we’re doing here now is SafeCare.”

Continuing the journey In terms of risk management, Maina explains that her staff has learned about things like infection control and the importance of hand washing. “We used to throw away needles in the regular bin. Now we have a waste management system: we separate different types of waste in color-coded bins and we have an incinerator for clinical waste.” She has made a point of sharing knowledge with the community. Her facility now has health campaigns to educate people about hygiene and organizes events for pregnant women to share experiences and demystify child birth.


Service element

Human resource management


Revenues increased from Kshs 230,000 to Kshs 717,410 per month



# of patient visits increased from 595 to 2,078 per month



# of female patients increased from 356 to 1,406 per month



# of malaria tests increased from 65 to 128 per month



St. Patrick’s SafeCare assessment scores for human resource management improved from:


% of medical staff trained in infection control increased from 10% to 90%.


While St. Patrick started with just a one story building, construction is underway to start offering services on the third floor. The second floor now houses the administration offices, a dental unit, in-patient wards and the kitchen for the inpatients. They have added a dentist’s office, an ultrasound and have upgraded their lab to include a broad range of tests, from cholesterol and liver function tests to thyroid tests and pap smears. They also progressed from being predominantly cash-based to accepting more modes of payment like ATM cards, Visa and M-Pesa. The next step is installing an operating theater. “Our female clients want to give birth here because they feel at home, but they would feel more assured if we had a theater.” Maina is eager to continue improving quality of care and reach Level 5. “SafeCare needs a lot of commitment, but you feel like you’re in another world. It makes you feel like a professional.”

High healthcare staff turnover is a challenge in Kenya, and St. Patrick’s situation is no different. On average, over one third of their personnel leaves every year, although staff retention has now improved. Ann and Patrick have completed and updated their personnel files, drafted job descriptions and now facilitate continuous medical education every week. Karen Anyango, one of the nurses who has been at St. Patrick for almost four years, praises Ann’s hands-on management style. “She can be tough, but we also call her ‘mom.’ She encourages us to ask questions and improve in our work, and her door is always open.” Every Wednesday and Friday, the staff comes to work in specially designed St. Patrick uniforms. Ann: “We have grown to a full-fledged facility and all our staff is proud to be a part of it.”



CLINIC LEVEL assessments


Clinics and results 366


Number of assessments since start program




Assessed using SafeCare Essentials

Assessed using SafeCare Standards Basic or Advanced

Awa rd e d Sa fe Ca re Leve l










I 251 Total active certificates




37 average overall assessment score SafeCare Standards

highest overall assessment score SafeCare Standards

Most room for improvement

Top 2 service elements

Human Resource Management



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



Diagnostic imaging service







Faith Based


PATIENTS & CARE Laboratory Services

Management of Information

Patient rights & access to care

71,641 Family planning


38,587 410





average overall assessment score SafeCare Standards

highest overall assessment score SafeCare Standards

Most room for improvement

Top 2 service elements

Risk Management

Laboratory Services






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

highest overall assessment score SafeCare Standards

Most room for improvement

Top 2 service elements

Patient rights & access to care

Operating Theatre & Anaesthetics

Primary Health Care


Para-medical staff

Total number of patient visits to the facilities per month

13,042 Support staff

Top 3 service elements

Risk Management

Diagnostic imaging service

Support services

98,147 Immunizations 391,175 Malaria 90,214 HIV

IMPROVEMENT AREAS Most room for improvement

14-90% Range of assessment score

Support services


Total number of staff



Medical staff

Trea t m e nt i n d i ca to rs

Risk Management

Diagnostic imaging

Laboratory Services

Patient rights & access to care

Risk Management

Human Resource Management

Support services

Laboratory Services



Patient rights & access to care


Facility Trainings


Number of facility trainings given

1,628 Total number of health facilities in program Data until December 2014

Clinical care Lab Pharmacy Quality management Admin

35 8 7 27 20

Number of attendees SafeCare facilitator training

86 Number of facilitators trained

49 Number surveyors trained

Technical Assistance PharmAccess Foundation KMET Kenya PSI Kenya APHFTA Tanzania Medical Credit Fund SFH Nigeria Marie Stopes International FHI 360

Data until December 2014



SafeCare staff

Georgine Mbeki

‘The most rewarding part of my job is seeing quality care being given to people at the bottom of the pyramid.’

Senior Assessor Nairobi, Kenya

“Quality can be a very diffuse concept, with many possible different interpretations. When it comes to healthcare, many people perceive quality as having a lot of money and building very big structures. I believe quality is when you offer something that is acceptable and measurable, and leads to an outcome that has a positive impact on people’s lives. SafeCare gives quality a clear definition. It has also put a stop to this myth that to attain quality you need a lot of resources. Quality is not just for the rich. Although we work in resourcerestricted settings, we help facilities address their gaps so that they can compete and even provide the same kind of quality that people only expect at bigger facilities. We identify the key priorities in their service delivery, and then they really don’t need a lot of money to scale up their facility. They just need to be awakened. The capacity building that we do doesn’t need a big budget, because many features are already in place. Often, it’s a matter of solidifying systems or helping facilities to understand government policies so that they

can apply for accreditation with health insurance companies. Capacity building of staff is key. We found that providers were often not aware of how patients perceived their facility. We work with them to help them structure consultations, to provide friendly treatment, to have the right drugs in stock or to ensure the facility is clean. All these things contribute to the patient’s experience and the image of the facility. It takes time to embrace the change, but at the end of the day this holistic approach is contributing to great strides forward in healthcare delivery. Empowering SafeCare is causing a lot of ripples in the healthcare sector. All the providers that I have met in the field since 2012 see it as a God given program. Many of the private practitioners are either retired or nearly retired. They have a lot of clinical knowledge, but no business knowledge. They have invested their savings in structures but then are not able to manage the business side. So when we introduce them to SafeCare, there is a feeling of growth,

a feeling of taking control of something they found unmanageable before. I’m so proud to be a part of this program that is helping to increase transparency and build systems that work. To see small facilities in remote areas embracing the program and developing into a main referral point in their region. Often, they relocate because their patient numbers have increased so much that they need to expand their facility in order to meet the demand for their services. The most rewarding part of my job is seeing quality care being given to people at the bottom of the pyramid, care that is equal in the quality given to those who are better off. 19


Software upgrade: AfriDB 2.0

Highlights SafeCare’s fourth year of operations included highlights such as celebrating the 1000th clinic, developing a new training curriculum and seeing our colleague recognized as an emerging leader at the ISQua conference. In 2014, SafeCare welcomed the 1000th clinic into the program. This milestone was celebrated at the Ahadi Maternity Healthcare Clinic in Kenya, one of the facilities that has made exceptional progress. “Previously, we could not provide critical healthcare management and patients had to be referred to hospitals which are 35 kilometers away,” said Grace Njuguna, proprietor of Ahadi. “We are now able to offer these services. In fact, we have seen a 20 percent increase in the number of patients.”

Centers of Excellence Many facilities in the program have made significant achievements in improving quality, reducing risks and expanding their business. To recognize their progress and capitalize on their potential, SafeCare launched the Centers of Excellence program. Facilities that are selected as a Center of Excellence are awarded a special certificate in a public ceremony in their

community or at a local, high profile conference. This presents them as a leader in quality improvement and encourages them to use their influence to inspire other facilities in their region to improve. Our vision is that Centers of Excellence will become hubs of knowledge sharing, demonstrating the benefits of investing time and resources in quality improvement.

Healthy Business training SafeCare and Medical Credit Fund developed a new training curriculum to build a tighter integration between the financial, managerial, and clinical aspects of quality. The Healthy Business training sessions focus on building business skills such as financial and human resource planning as well as clinical and technical skills such as health information management and standardized operating procedures. Trainings are provided in a group setting to enable healthcare facility managers to learn from each other’s approaches.

‘Ahadi is a prime example of what can be achieved if all partners and especially the staff create a mindset geared towards continuously improving services for their patients.’ Nicole Spieker, Director SafeCare

Data collection and analysis are at the core of the SafeCare program. Our assessors and technical assistance partners are actively involved in every stage of the assessment, monitoring, and evaluation process through our web-based software platform AfriDB. It has also been installed at several partners’ offices, such as at the Tanzanian Ministry of Health and the Kenyan NHIF. In 2014, we launched an extensive software upgrade (AfriDB 2.0) to make it more transparent, secure, efficient, and user-friendly for our internal and external partners. Multiple users and responsibilities

• AfriDB 2.0 allows multiple users to review and edit data simultaneously. • AfriDB 2.0 has a more secure system for data submission and review with customized roles for assessors, reviewers, and administrators.

Stable and secure data storage

• Data-collection software is accessible with tablets and laptop computers, and is even available offline for use at facilities without internet access. • Data is routinely backed-up using enterprise data storage facilities. • Automated performance reports are available with one click.

Improved data accuracy

• When entering assessment data, AFriDB 2.0 immediately notifies surveyors of potential conflicts in the data so that they can be addressed promptly. This improves data accuracy, consistency, and reliability. • AfriDB 2.0 enables surveyors to refer to the SafeCare scoring guidelines on their tablet, even in areas without internet access.

Customized quality improvement plans • After each assessment, AfriDB 2.0 guides the facility managers and SafeCare surveyors through the steps to create a detailed quality improvement plan that will help the facility progress to the next SafeCare level. • Monitoring and evaluation are built into the quality improvement plan, allowing SafeCare to measure each facility's progress toward completion of their quality improvement plan.

ISQua conference In October 2014, over 1,000 delegates from 68 countries attended the ISQua conference in Rio de Janeiro, Brazil. SafeCare staff and partners presented our PPP approach at the international level, in panel discussions and presentations involving national health insurance agencies, quality improvement organizations, and accreditation bodies. SafeCare chaired a session titled ‘Jumpstarting and sustaining quality in developing countries’ and was also involved in a WHO session where the SafeCare methodology was presented as a lead example of patient safety in primary healthcare in resource-restricted settings. We are very proud to announce that Emmanuel Aiyenigba,


a senior surveyor on our team in Nigeria, was recognized as the first Emerging Leader of ISQua!


Strategic partnerships & programs Over the years, SafeCare has attracted new donors and set up many new partnerships in order to create a solid financial base and leverage our impact on the ground. The large number of long-term contracts with a broad spectrum of partners has helped to build SafeCare’s brand as an independent quality improvement program. Existing partnerships with 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 been instrumental in forging new connections in both the public and the private realm. Public contracts include the Ministry of Health & Social Welfare and the National Social Security Fund (NSSF) in Tanzania, the National Hospital Insurance Fund (NHIF) in Kenya and the National Primary Healthcare Development Agency (NPHCDA) in Nigeria.

Growing demand In 2014, the demand for SafeCare methodology and tools continued to grow. We have started consultancies with private hospitals in both Nigeria and Kenya, consisting of assessments, quality improvement plans

and facilitation visits. Acumen and KMPG contracted SafeCare to perform due diligence assessments for investment opportunities. Through a new partnership with the Private Sector Health Alliance of Nigeria (PHN), SafeCare is conducting assessment and training interventions at 60 private healthcare facilities. The past year also saw the start of the Business of Quality (BoQ) program in Tanzania, which we are rolling out under DFID’s Human Development Innovation Fund. The BoQ program provides training for 400 predominantly rural clinics at the lower end of the quality spectrum to help them improve their business performance as well as their clinical quality. The BoQ program was leveraged by ELMA Foundation to support additional interventions focusing on maternal, neonatal and child health.

mHealth Africa’s expanding mobile communications sector offers huge opportunities in the field of healthcare. In Kenya, PharmAccess is rolling out innovative programs around mobile health wallets that contain funds earmarked for healthcare. In 2014, SafeCare conducted a quick scan to assess 50 facilities for possible inclusion in the mHealth program. SafeCare also partnered with Safaricom and AMREF to improve access to maternal and newborn care in Samburu. Some of our partnerships and programs are highlighted on the next page.


Gabriele Beacco CEO Ruaraka Uhai Neema Hospital Nairobi, Kenya In July 2014, Ruaraka Uhai Neema Hospital contracted SafeCare for a quality improvement track consisting of a first assessment, a quality improvement plan facilitation visits and a second assessment at the end of the contract year.

“After five years of operations as a hospital, we felt it was important to arrange for an external party to evaluate us and ensure that we are working in the right direction and achieving the right milestones. We approached SafeCare as it offers an independent and objective assessment as well as solid followup with clear targets towards positive change and improvement. When you are involved in day to day activities, you think everything is fine but there is always a need for improvement. While we already had the goal of ensuring high quality services, but there was no concrete plan how to go about it. Also, our management team was not all speaking the same language. SafeCare engages personnel on all levels. Initially, some staff were hesitant, as they felt the program required them to confess their weaknesses. In time, they realized that the program was not there to find fault but to support them to do better.

‘SafeCare offers an independent and objective assessment as well as solid follow-up with clear targets towards positive change and improvement.’ SafeCare helped us see the need for guidelines across departments, including administration. We thought we had protocols, but in fact most of those guidelines were just in our heads, not on paper where all staff could access it. We have now hired a human resource manager to help develop manuals. We have also improved the waste management system and installed a second sink in the kitchen. During the building phase of our pediatric unit, SafeCare staff helped us to focus on specific structural aspects in the design of the new department. The pedi-

atric unit is now up and running smoothly. We found the guidance for quality improvement extremely valuable. SafeCare is very detailed and practical. It not only identifies problems, but offers a way to take action to address that problem. This makes SafeCare unique, I have never come across anything like it.”



A closer look at some of our partnerships and programs:

Health Insurance Fund

Medical Credit Fund

SafeCare standards and stepwise improvement methodology were developed and first implemented in the health insurance schemes funded by the Health Insurance Fund, providing insight into and improving the quality of the participating healthcare providers. SafeCare standards and methodology continue to be a pivotal element in all interventions focused on bringing demand and supply for quality healthcare together, such as mHealth solutions.

Medical Credit Fund facilitates loans to private healthcare providers through African banks. The loans enable the clinics to improve the quality of their services and (further) develop their business potential, thereby increasing access to quality healthcare. From the start of operations in 2010, Medical Credit Fund has contracted SafeCare to conduct quality assessments in participating clinics, identifying most urgent needs and improvement priorities, as well as offering technical support.

African Health Markets for Equity (AHME) AHME is a multi-stakeholder partnership led by Marie Stopes International and funded by the Bill & Melinda Gates Foundation and the UK’s Department for International Development (DfID). Other partners are Society for Family Health (Nigeria), Population Services Kenya and PharmAccess Group. AHME aims to improve health outcomes by enhancing the quality of private healthcare for the poor in Ghana, Nigeria and Kenya. It does so by increasing the scale and scope of the partners’ franchise networks and linking the healthcare providers in these networks to demand-side financing. Medical Credit Fund and SafeCare facilitate access to loans as well as support in business and quality improvement through SafeCare’s stepwise recognition process.

Human Development Innovation Fund (HDIF) / ELMA Foundation Ministry of Health & Social Welfare (MoHSW), Tanzania SafeCare, supported by CDC Foundation, provides technical assistance to the MoHSW to work towards institutionalization of a national ‘stepwise certification towards accreditation’ system using the SafeCare standards. During the 5 year partnership, the SafeCare standards have been officially adopted and disseminated by MoHSW and the approach has been advocated to health facilities and other stakeholders.

In Tanzania, SafeCare has been granted funds from DfID’s Human Development Innovation Fund (HDIF) for the Business of Quality program. It builds on existing PharmAccess programs, combining use of the SafeCare standards and quality improvement methodology with access to credit and health insurance. Implementing partners in this program are Association of Private Healthcare Facilities in Tanzania (APHFTA) and Christian Social Services Commission (CSSC). The program is specifically designed to improve both business performance and clinical quality in 400 clinics, benefitting Tanzania’s rural poor. ELMA Foundation supports additional interventions in a selection of 100 facilities, geared towards complementing the efforts of the Tanzanian MoHSW to improve maternal, neonatal and child health. The aim is to increase scale and accessibility of these services in the private sector.

National Hospital Insurance Fund (NHIF), Kenya SafeCare, in partnership with IFC, is implementing SafeCare standards and stepwise certification into the NHIF contracting system. NHIF staff has been trained and is currently independently performing SafeCare assessments, supported by PharmAccess.



Outlook 2015 and beyond Over the next few years, SafeCare will focus on a new round of innovations and connect to the opportunities around mHealth. We will also continue building the infrastructure to scale up operations and expand into new markets. Basic assessment Since SafeCare started operations, we have seen the needs for standards of partner organizations expand. As the program scales up and is adopted by national programs such as the Tanzanian Ministry of Health for regulation purposes, but also by our mobile health program (in partnership with CarePay), there is a need for a rapid screening approach, which will identify if basic safety measures are in place in a facility. This complementary program enables greater efficiency in rapid pre-qualification or screening assessments and will be a vital component of ensuring a minimum level of safety of facilities entering a program. To meet this need, we have adapted our

‘The impact of SafeCare on the ground is huge. The issues it addresses can seem simple, but the program is opening doctors’ eyes to what needs to be done. And the patient always recognizes small things.’ Peter Mbithi Matolo Head of SME/Retail / K-REP Bank

lighter ‘Basic assessment’ tool. Replacing the old Basic assessment, the new Basic requires fewer human resources to complete yet provides facilities and SafeCare quality managers with insights into the greatest quality improvement priorities. Facilities meeting these Basic requirements can qualify for the full SafeCare recognition process. This new tool will be introduced in a majority of facilities linked to CarePay in 2015.

Revised standards Building on our experience in practice and in response to the valuable input from SafeCare surveyors, facilities and partner organizations, we are revising and updating the SafeCare standards. The improved standards will remove duplication of criteria and make the process easier to use for all stakeholders. With reduced time spent on collecting data, assessors will be able to provide more targeted and customized quality improvement support, helping to meet the overall objective of SafeCare.

Streamlining operations By further streamlining our client-centered approach, we aim to achieve efficiencies in terms of time, scale and costs in the PharmAccess programs offered to the clinics aimed to help meet standards adherance. Clinics contracted by PharmAccess are assigned a single relationship manager to whom they can address all their questions, after which specialized services by clinical quality or business advisors can be allocated based on need. Also, facilitation and

training services will be offered to clinics at different capacity levels: beginner, intermediate and advanced.

New markets In 2014, PharmAccess Group, through SafeCare and Medical Credit Fund began exploring opportunities in Uganda. In partnership with IFC (Health in Africa Initiative), Bank of Uganda and the Ugandan government, we are in discussions to provide loans and business and quality technical assistance to small and medium healthcare facilities that provide services for the lowest quintiles of the community. Unique to this approach is the endorsement and strong support from the Ugandan government to strengthen the private sector. This includes a co-investment in the loan fund by the public sector, which makes it the first loan fund of its kind in Africa. Besides exploring these new markets, we will continue to develop our programs in Kenya, Tanzania, Ghana and Nigeria.

mHealth Since rolling out the first pilot programs in 2013, mobile health (mHealth) has become an integral part of the PharmAccess approach. In Kenya, the mobile payment platform M-Pesa offers unprecedented opportunities to increase efficiencies in healthcare delivery and connect more people to quality healthcare, by lowering the transaction costs and significantly increasing access to demand side finance mechanisms especially for the poor and the informal sector. SafeCare will be engaged in the mHealth program by pre-qualifying facilities with quality assessments and quality improvement plans when they enroll in the mHealth program. After quality benchmarks and ratings are established, it will be possible to incentivize quality improvement with pay-for-performance reimbursement mechanisms.



'We have seen that quality improvement through the stepwise SafeCare approach is feasible even in resource constrained public facilities. Enrolment of other facilities into the SafeCare program would well save our people.' Dr Aloyce Andronicus Rwelamira Mlandizi Health Center, Pwani Region, Tanzania



SafeCare Founders

Team SafeCare

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.

The Netherlands Nicole Spieker Director Quality Elsemiek Snijders-Storm Deputy Director 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 Officer

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 has 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.

Kenya Millicent Olulo Program Director Kenya Kasmil Masheti Operations Manager Jacinta Mburu Senior Assessor Margaret Mwakiridia Senior Assessor Mary Njoki Wachira Senior Assessor John Nziu Senior Assessor Elly Wandago Senior Assessor Emmanuel Milimo Senior Assessor Petronilla Wesango Senior Assessor Georgine Mbeki Senior Assessor Irene Kasyoki Senior Assessor Catherine Nyawira Assessor

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 healthcare 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.

Tanzania Peter Risha Program Director Tanzania Nicodemus Butamanya Senior Assessor Johnson Yokoyana Senior Assessor Edith Ngirwamungu Senior Assessor Anunsiatha Mrema Senior Assessor Liberatha Shija Senior Assessor Elizabeth Amuli Senior Assessor Bayoum Awadhi Senior Assessor Piensia Nguruwe Senior Assessor Lemali Mbise Senior Assessor Venna Lyimo Senior Assessor Emmanuel Tluway Assessor Ghana Maxwell Akwasi Antwi Program Director Ghana Bonifacia Benefo Agyei Senior Assessor Gabriel Fiadorme Senior Assessor Joseph Asumang Peasah Assessor Mary Asantewaa Assessor Theresa Boakye-Poku Assessor Namibia Wilet Pothas Senior Assessor Sylvia Ashikoto Assessor

Nigeria Dupe Oludipe Program Director Nigeria Emmanuel Aiyenigba Senior Assessor Jimi Odetola Senior Assessor Anire Asumah Senior Assessor Peggy Imoniovu Senior Assessor Joshua Kolawole Assessor Funsho Egbedeyi Assessor Ojo Olukayode Assessor Azuka Okeke Assessor Ugo Anaeto-Okeke Assessor

31 South Africa (COHSASA) Jacqui Stewart Deputy CEO; Chief Operations Manager Giel van Schalkwyk Chief Surveyor Grace Labadorios GP Accreditation Standards Coordinator Riël le Roux Surveyor Edith Palmer-Harrington Surveyor United States (Joint Commission International) Paula Wilson President and CEO Paul van Ostenberg Vice President International Accreditation, Standards and Measurement Cecily Pew Director Board and Committee Activities

Introducing the PharmAccess Group The PharmAccess Group is dedicated to making health markets work for people in Africa. When Prof. Joep Lange (1954-2014) founded PharmAccess in 2001, the objective was to turn groundbreaking scientific research on triple-combination drug therapy into action by bringing HIV/AIDS treatment to the people who needed it most. PharmAccess joined forces with private companies like Heineken to set up workplace programs for their employees and dependents. These schemes proved that treatment in Africa was feasible and that the delay in delivering it was a political choice. This helped lay the foundation for large-scale international action: today, more than 10 million people living with AIDS have access to life-saving drugs. PharmAccess continues to be widely recognized as a pioneer in increasing access to improved healthcare. Building on our work on the front lines of HIV/AIDS treatment, our focus has broadened to making healthcare systems more effective and more inclusive. Reversing the vicious cycle that stifles progress requires innovations that explore new directions, challenge the status quo and provide real world solutions. PharmAccess builds trust on both the supply and the demand side of the healthcare market and leverages donor contributions to reduce risks and increase investments in health. We address market inefficiencies through an integrated approach: improving quality of care through clinical and business standards, introducing mHealth applications, providing access to loans for healthcare providers, facilitating access to health insurance and other health financing options, and conducting impact research for evidence-based innovation. On a solid base of local and international public-private partnerships, and with the support of many international development stakeholders including the Netherlands Ministry of Foreign Affairs, we help improve healthcare delivery and affordability for patients and increase market transparency for investors. PharmAccess employs a multidisciplinary team of almost 200 professionals. While our headquarters are in Amsterdam, we are firmly rooted in Africa with over 60% of our staff based in Kenya, Tanzania, Ghana, Nigeria and Namibia.

Our partners Public donors and investors African Development Bank, Asian Development Bank, Department for International Development (DfID), Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ), Dutch Ministry of Foreign Affairs, Entrepreneurial Development Bank (FMO), German Development Bank (KfW), International Finance Corporation (IFC), International Labour Organization (ILO), Life Sciences & Health for Development (LS&H4D), Netherlands Organization for Scientific Research (NWO), Overseas Private Investment Corporation (OPIC), Rijksdienst voor Ondernemend Nederland (RVO), Saving Lives at Birth (USAID, Bill & Melinda Gates Foundation, UKaid, NORAD, Grand Challenges Canada), United States Agency for International Development (USAID) Strategic partners Government and parastatal organizations Ghana: National Health Insurance Authority (NHIA), National Health Insurance Scheme (NHIS) Kenya: Ministry of Health, National Hospital Insurance Fund (NHIF) Nigeria: Cross River State, Kwara State Government, Lagos State Government, National Primary Health Care Development Agency (NPHCDA), Ogun State Government Tanzania: Ministry of Health and Social Welfare, National Health Insurance Fund (NHIF), National Social Security Fund (NSSF), Uganda: Government of Uganda Multilateral organizations and agencies African Health Markets for Equity (AHME), Agence Française de Développement (AFD), Belgian Development Agency (BTC), Global Fund to Fight AIDS, Tuberculosis and Malaria, Global Partnership for Effective Development Cooperation, International Federation of Health Plans (iFHP), The International Society for Quality in Health Care (ISQua), Joint Learning Network, World Bank Group, World Economic Forum Foundations and associations Aids Fonds, Amref Health Africa, Association of Private Health Facilities in Tanzania (APHTA), Christian Social Services Commission (CSSC),

Private investors and donors Achmea Foundation, Algemene Pensioen Groep (APG), Bill & Melinda Gates Foundation, Calvert Foundation, Centers for Disease Control and Prevention (CDC) Foundation, Clinton Foundation, Deutsche Bank Americas Foundation, Dutch Postcode Lottery, ELMA Philanthropies, Goldman Sachs, M-PESA Foundation, Pfizer, President’s Emergency Plan For AIDS Relief (PEPFAR), Rockefeller Foundation, Safaricom Foundation, Soros Economic Development Fund, Stichting AmsterdamDiner Foundation

East Africa Healthcare Federation, Kisumu Medical and Education Trust (K-MET), Nigerian Healthcare Federation, Stop AIDS Now! Research institutions African Population and Health Research Centre (APHRC), Lagos University Teaching Hospital, Strathmore Business School (SBS), University of Ilorin Teaching Hospital Multinational corporations Achmea, Aegon, Heineken, KPMG, OLAM Group, Pfizer, Philips, Safaricom, Shell, SNS Reaal, Unilever, Vodafone Social franchise networks Marie Stopes International, Population Services International (PSI), Society for Family Health (SFH) Partner banks BancABC (Tanzania), Bank of Africa Tanzania, Chase Bank (Kenya), Diamond Bank (Nigeria), First City Monument Bank (Nigeria), HFC Bank (Ghana), K-Rep Bank (Kenya), National Microfinance Bank (Tanzania), uniBank (Ghana) Insurance companies and administrators AAR, Africa Medilink Ltd, Hygeia Health accreditation organizations Council for Health Services Accreditation for Southern Africa (COHSASA), Joint Commission International (JCI)

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graphic design by Studio Saiid & Smale