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Making Health Care Better in Low and Middle Income Economies:

What are the next steps and how do we get there?

© 2012

Making Health Care Better in Low and Middle Income Economies: What are the next steps and how do we get there? Session Report 489

Session 489 Salzburg, April 22 to 27, 2012

Making Health Care Better in Low and Middle Income Economies: What are the next steps and how do we get there?


Brcue Agins, Pierre Barker, Louise Hallman, James Heiby, Edward Kelley, Sheila Leatherman, John Lotherington, Rashad Massoud, Nana Mensah-Abrampah, and Sylvia Sax


Andrea Lopez-Portillo 3

Making Health Care Better in Low and Middle Income Economies: What are the next steps and how do we get there? Session Report 489

Table of Contents Summary Report: 05 Background and Objectives 06 Key Questions

Features: 07 Better Care for All, Every Time

Appendix: 11 List of Participants 13 Daily Newsletters


Making Health Care Better in Low and Middle Income Economies: What are the next steps and how do we get there? Session Report 489

Background and Objectives Many low- and middle-income countries are not on track to achieve the Millennium Development Goals (MDGs) by the 2015 target. For example, only 23 are estimated to be on track to achieve the 75% maternal mortality reduction. This failure is primarily because health-care interventions that are known to save lives are not being implemented for every patient every time they are needed. A gap exists between what is known to work and improve health-care quality and safety and what is being practiced routinely. Fortunately, we have good evidence of how to address this critical gap. With this impetus, our session on ‘Making Health Care Better in Low and Middle Income Economies: What are the next steps and how do you get there?’ was convened at Schloss Leopoldskron from 22–27 April 2012, to chart the way forward for improving health care. Our lead partner was University Research Co.,LLC (URC), together with the support of USAID, the WHO Patient Safety Program,the Institute for Healthcare Improvement),the University of North Carolina, Heidelberg University and HealthQual/NYAIDS Institute. At the session we brought together 58 health leaders from 33 countries to review experiences in improving the quality and safety of health-care services in low- and middle-income countries, synthesize lessons learned from those experiences, discuss challenges and opportunities and recommend next steps to stimulate improvement in such countries. The seminar identified five interconnected priority challenges in improving quality and safety in health care. The first is the ‘inadequate numbers of competent health care workers’, which is worse in rural areas and in countries subject to internal and international brain drains. Health-care workers lack needed skills due to inadequate initial training, transfers and unmet training needs. These factors, and others, lead to low staff morale that in turn increases the challenge to improve quality and safety. The second challenge—recognizing and addressing different perceptions of quality among providers, policymakers and the public—requires open dialog and leads to the third challenge, ‘engagement of civil society’. Without an engaged civil society, public protection and client focus are reduced. (This includes users of health-care systems who are not patients. For example, pregnant women who are delivering in healthcare facilities are users not patients.) This results in our fourth challenge, ‘systems not designed to meet patient needs’, with many health

John Lotherington


Making Health Care Better in Low and Middle Income Economies: What are the next steps and how do we get there? Session Report 489

programs established as vertical, poorly integrated activities in the health system. This leads to our fifth challenge ‘poor health sector planning’, which encompasses lack of comprehensive operational plans, poor integration of vertical programs into health systems and inadequate harmonization of donor programs. At the session we facilitated cross-border learning to address these challenges and compared best practice in overcoming them, drawing on the immense experience from the 33 countries represented. We then synthesized this learning into a call for action, the Salzburg Statement: Better Care for All – Call to Action’, presented at the World Health Organization’s (WHO) 65th World Health Assembly on 23rd May 2012. M. Rashad Masood

Key Questions The session’s key over-arching questions were: • What has worked to date in improving health care in low and middle income countries? • How far has such improvement plateaued in the last decade? • How can we mobilize an upward curve in improvement of both patient and population outcomes? What are the learning tools required? • How can we clarify the terminology, the methodology and the interpretation of results in the field to avoid confusion which can undermine the dissemination of good practice? • How does quality improvement mesh with other elements in health systems strengthening, such as financial support, reform of governance structures, and the mobilization of civil society? • What is the best way of introducing systems thinking and quality improvement to countries which do not have a tradition of using these methods? • How do we move from small scale pilots to large scale improvement projects, designing for scale and sustainability from the outset?

Bruce Agins


Making Health Care Better in Low and Middle Income Economies: What are the next steps and how do we get there? Session Report 489

Better Care for All, Every Time Louise Hallman

Editor, Salzburg Global Seminar

An translated version of this article appeared in Chinese Social Sciences Today, July 2012

In September 2000, world leaders gathered in New York to sign into being the Millennium Development Goals. Focussing on such aims as eradicating world hunger, reducing infant mortality, improving maternal health, and combating the spread of HIV/AIDS, the MDGs set ambitious targets to be met by the year 2015. Since that historic assembly, significant improvements have been made in global health and welfare; however, three years away from the end date, many resource-constrained lower- and middle-income countries are far from being on track to meet their MDGs. For example, currently, only 23 countries are estimated to be on track for achieving the 75% maternal mortality reduction goal by 2015. Whatever progress that had been made, now appears to have reached a plateau. So what do these countries need to be able to make better progress in health care and reach their MDGs? More money, more resources, more hospitals, more doctors? Not necessarily, claim an international group of health care experts. Against this backdrop of stalled progress in global health care, 58 leading doctors, researchers and health ministry workers met at the Salzburg Global Seminar – a

Pierre Barker

Fellows of session 489 - ‘Making Health Care Better in Low and Middle Income Economies: What are the next steps and how do we get there?’

James Heiby


Making Health Care Better in Low and Middle Income Economies: What are the next steps and how do we get there? Session Report 489

unique international institution committed to bringing industry leaders together to find creative solutions to global problems – in Salzburg, Austria, for a session entitled ‘Making Health Care Better in Low and Middle Income Economies: What are the next steps and how do we get there?’. Their conclusions from the intense week of discussions were published as the ‘Salzburg Statement: Better Care for All – Call to Action’ and presented at the World Health Organization’s (WHO) 65th World Health Assembly on May 23. So if money is not the solution, what do these ‘Salzburg Global Seminar Fellows’ suggest in their Statement? The answer: quality improvement. Speaking during the conference, Dr. M. Rashad Massoud, chairman of the Salzburg session and Director of the US Agency for International Development (USAID) Health Care Improvement Project (HCI), said: “Everything we’re talking about here is how can we ensure the patients get the best outcomes possible. What is the best medicine that we know? Can we deliver it to them correctly so that they benefit maximally from this? Can we do this in ways that are not wasteful and inefficient? Can we be mindful about meeting patients’ needs and expectations?

Edward Kelley

“Improvement is what we should be doing in the first place; good quality care is what we should be providing patients anyway.” But what does this mean in reality? A money-focussed solution might suggest that the best way to improve maternal health in Uganda (ranked 32nd worst maternal mortality rate in the world by the CIA World Factbook) would be to train more midwives. But for many women in Uganda, their Sheila Leatherman


Making Health Care Better in Low and Middle Income Economies: What are the next steps and how do we get there? Session Report 489

tradition and culture stops them from ever seeing a midwife, regardless of how many midwives there are. “You are not allowed to say that you are pregnant,” explains Robinah Kaitiritimba, a signatory to the Statement and Executive Director of the National Health Consumers’ Organization in Uganda. “So that means that women will not register with health care givers. It is considered brave for a woman to give birth in alone in a room and not make noise, even if she’s in pain.” Nana Mensah-Abrampah

According to the Salzburg Fellows, the answer is to improve patients’ understanding of the benefit of various forms of health care, not just simply to hire and train more midwives and doctors; this is not only the responsibility of governments and their ministries of health and education, or international donors and non-governmental organizations, or the doctors and nurses who provide the health care, but also of the patients themselves and the communities they live in, which is why they have been included in this call to action. Each of the seven stakeholders have their own several points of action; governments must be “accountable for the improvement of health care through legislation, policies and necessary resources”; health policy leaders should “adopt and promote quality improvement as a cornerstone of better health care”; communities should “actively advocate for quality health care as part of their rights and responsibilities”; development partners and international donors are called to “invest in approaches that drive sustainable context-specific improvements in global health”; NGOs and “those providing technical assistance in global health” should “incorporate evidence-based improvement methods in their work”; health care workers, not only doctors and nurses but also all auxiliary staff are called to “continuously improve the delivery of expert and

Sylvia Sax


Making Health Care Better in Low and Middle Income Economies: What are the next steps and how do we get there? Session Report 489

compassionate care to patients, their families and communities”; and finally, but just as importantly according to the Statement’s authors, patients should “be empowered and at the forefront of promoting a shared vision for better health for all”. Lofty aspirations, but what makes this call to action any different from previous similar efforts, like the WHO’s “Health for All by the Year 2000” or the MDGs? “For one thing,” explains Lani Marquez, Dr. Massoud’s colleague and Knowledge Management and Communication Director for USAID’s Health Care Improvement Project, “the Salzburg Call to Action focuses on the how – what strategies and policies can get us there. “Quality improvement methods enable ordinary health workers to re-organize care delivery processes. They provide a means to implement better practices and streamline and change how care is delivered to yield better results with available resources. By making changes in the current ways of delivering health care, rather than simply adding more resources into dysfunctional systems, quality improvement methods are about changing what we do with what we have – putting the knowledge and the responsibility for improvement in the hands of every health worker, every patient, every district health team, every program manager, and every policymaker.” Even Marquez admits though, quality improvement, just like increased funds and research, is no silver bullet. By the time it was presented in Geneva on May 23, over 500 people from 65 countries across the world, including China, had signed up to the Statement. But words and signatures are nothing unless those called to action in the Statement do just that – act. Louise Hallman


Making Health Care Better in Low and Middle Income Economies: What are the next steps and how do we get there? Session Report 489

Participants of Session 489 by Country or Region Afghanistan Mirwais Amiri Argentina Ezequiel Garcia-Elorrio Azerbaijan Shirin Kazimov

Kenya Ahmed Ahmed Dorcas Amolo Kyrgyzstan Aigul Kalieva Mexico Enrique Ruelas

Uganda Sarah Byakika Robinah Kaitiritimba Humphrey Megere

Salzburg Global Seminar Staff

Ukraine Viktor Boguslavsky

Vice President & Chief Program Officer

Clare Shine John Lotherington Program Director

United Kingdom Tracey Cooper Sir Liam Joseph Donaldson Nigel Rollins

Astrid Koblmueller

Program Intern

Pakistan Syed Jafri

USA Bruce Agins Pierre Baker Donald Berwick Nils Daulaire James Heiby Edward Kelley Sheila Leatherman M. Rashad Massoud Kedar Mate Nana Mensah Abrampah Rob Palkovitz Mary Taylor

Ecuador Jorge Hermida Bernarda Salas Moreira

Philippines Carlo Irwin Panelo

Viet Nam Khoa Nguyen

Egypt Ayman Sabae

Qatar Jamal Al-Khanji

Yemen Arab Republic Saleh Nagi

Ghana John Awoonor-Williams Cynthia Bannerman

Russian Federation Anna Korotkova

Zambia Nanthalile Mugala

Senegal Babacar Ndoye

Zimbabwe Justice Gweshe

Belize Michelle Vanzie Botswana Baile Moagi

Moldova Tatiana Paduraru Andrei Romancenco

Cambodia Vireak Voeurng

Mozambique Antonio Mujovo Januario Machado Reis

Canada Sylvia Sax

Nicaragua Natalia Largaespada Beer

Cameroon Charles Awasom

Niger Maina Boucar Saidou Mallam Ekoye

Colombia Leonardo Pinz贸n

India Amit Paliwal Ivory Coast Josephine Diabate Touobou Jean Nguessan

Program Associate

Louise Hallman Editor

Charles Bain

Tajikistan Mekhriniso Yuldasheva Thailand Duangta Onsuwan Anuwat Supachutikul 11

Making Health Care Better in Low and Middle Income Economies: What are the next steps and how do we get there? Monday, April 23, 2012

Salzburg global seminar SALZBURG DIARIES Journey’s beginning By: Ezequiel García-Elorrio The opening remarks set the scene for a spectacular session in a place where solutions to global problems will be discussed and disseminated. The history of the Schloss Leopoldskron and the Salzburg Global Seminar are very impressive; since after World War II this organization has promoted the gathering of people around the world to provide solutions to global problems. The ambience is fantastic – it will surely make participants to give the most of themselves. During the opening remarks goals were set. The clearest one is to “set an agenda of coming years”. Reviewing where we are and how we got here. Constructing then the action plan for the times to come. Participants represented a wide variety of settings and realities from around the world. So far just listening to everyone’s introductions you can perceive the amount of experience and knowledge in the room. Surely clear objectives and a goal will come from this week-long discussion. This week-long seminar is described as the “beginning of a journey where we all will go together” confirming that we are “not sitting on plateau but moving ahead”. The audience is quite diverse, comprising government, patient representatives, international organizations, researchers and improvers. Almost every point of view is represented. Just to give a sense on the importance of our participation, the questions/debates posted before the seminar were presented to all participants to start the discussion. Hopefully conversations from Salzburg will reverberate around the world and feedback could be provided. Ezequiel García-Elorrio’s blog for the ISQua Knowledge Portal can be found online: participate-during/

“Enormous potential” Global healthcare professionals join debate on quality improvement By: Louise Hallman Welcoming over 60 international healthcare professionals from more than 35 countries, Dr. M. Rashad Massoud expressed his excitement at the “wonderful journey” the participants would take over the next six days at Schloss Leopoldkron for the Salzburg Global Seminar session ‘Health and Healthcare Series IV: Making Health Care Better in Low and Middle Income Economies: What are the next steps and how do we get there?’ The session has been two years in the making, and will follow on from previous sessions’ discussions to debate the progress made so far in meeting such targets as the Millennium Development Goals and the role of quality improvement in meeting such public health targets. Whilst improvements in health care have clearly been made in the past number of years, this progress has since “plateaued”, making it necessary for health care professionals to address the issues and challenges that still lie ahead. Joining the “crucially important meeting” via a pre-recorded video, Don Berwick, former president and CEO of

the Institute for Healthcare Improvement, USA, highlighted the great opportunity such a global gathering of healthcare experts would experience over the coming week. “In developed healthcare systems in the Western developed world, we have a crust to drill through,” he said. “We have an existing legacy production system that for complex reasons has not been orientated around those six aims [safety, effectiveness, patientcenteredness, timeliness, efficiency and equity] for the continual improvement of performance as its primary driver… “I have the feeling that low and middle income countries have a thinner crust. There’s more opportunity there because in some senses you’re building on a relatively less developed platform of management and process thinking. The opportunity in lower and middle income countries is to do it right the first time. “I think the potential is enormous.” A ‘Salzburg statement’, along with several reports, will be produced at the end of the week-long intensive discussions. Don Berwick’s video will be available on the “SalzburgSeminar” YouTube channel.

Making Health Care Better in Low and Middle Income Economies: What are the next steps and how do we get there?

Monday, April 23, 2012

Schloss Leopoldskron was built in 1736 by the Prince Archbishop of Salzburg, Leopold Anton Eleutherius Freiherr von Firmian. It was restored by reknowned theater director Max Reinherdt in the 1920s before being bought by the Salzburg Global Seminar in 1959. It is overlooked by Festung Hohensalzburg, literally “High Salzburg Fortress”.

TALKING P O I N T Do we need more data? “

Work that is not documented is not done, so definitely documentation would help to improve quality - at then end the day you have to be able to see what you have done. There are two issues: crediable documentation and also making documentation easier... If we have this system where you can plug in the information at the time the activity was going on, or at worst at the close of the day, then you cannot go back at the end of month and change the information for that day. Charles Nde Awasom, Medical Director, Ministry of Health, Cameroon

There’s data for public reporting purposes and there’s data for actual clinical management application. If you connect the two, you have a data source that serves two purposes and is essentially incredibly important to the clinicians themselves... You can’t improve something that you know nothing about. The vast majority of the time [in my research] the data element is collected and sent somewhere on a district level or a regional healthcare system or government’s national health system and the clinic never learns how it’s represented in public health records. Kedar Mate, Director for Developing Countries Programs, Institute for Healthcare Improvement, USA

It is helpful [to have more data], but you can do a lot without it, by sampling,

by rigorous independent monitoring, particularly of vaccination programs, and having extensive documentation, like a lot of high income countries do, doesn’t necessarily mean that you use data more intelligently. Sir Liam Donaldson, former Chief Medical Officer, UK

It is true that in developing country settings you do have a lack of for sure documentation needs to be improved, but it’s really about what you do with it. In a lot of countries there is tons of data but it’s not developed with clinicians in mind so it’s not relevant and it’s not given to them even if it were relevant so they can do something with it. Ed Kelley, Head of Strategic Programs, WHO Patient Safety, Switzerland

A lot of our problems stem from inadequate documentation but more importantly, I think we generate a lot of data that is definitely not used optimally. We don’t have adequate information systems to connect information at community level. If you don’t have a health information system that works well across all levels, you are losing out a lot of vital information that will enable you to put interventions in place that are going to target the community best. Nanthalile Mugala, Director for Technical Support, Integrated Systems Strengthening Program, Zambia

Got a question you’d like to have debated? Tweet us! @salzburgglobal

Making Health Care Better in Low and Middle Income Economies: What are the next steps and how do we get there? Tuesday, April 24, 2012

Salzburg global seminar SALZBURG DIARIES Journey continued By: Ezequiel García-Elorrio James Heiby from USAID chaired the Monday morning session where key topics on the present situation of Quality Improvement were discussed. After a great warm up, ‘the knowledge café’ began, with all participants rotating among eight specific topic stations. Experiences and thoughts were shared and finally a facilitator per topic summarized discussions and comments. Key messages on lessons learnt were: 1. Widely available and simplified data is critical for future QI in LMICs. 2. Cost effectiveness should be included in the QI agenda, stating what should be measured and how it should be done. 3. Organizational structures for quality improvement at the different levels need to be developed to promote capacity building. 4. Knowledge dissemination constitutes a challenge in terms of translation, dissemination and the culture of sharing. 5. Scaling up needs commitment, community involvement, planning and standardized methods. 6. Leaders need to be involved from the inception of the initiative and should receive economic arguments to “buy” interventions and programs, and finally should facilitate the social society involvement. 7. QI methods can and must be applied to processes in healthcare besides clinical care, for example: logistics, human resources and service management. 8. Research is critical to support improvement techniques although mixed methods are needed to create a body of evidence that could be of use for implementers and decision makers. Evaluation also needs a bigger space to disseminate findings beyond the ones generated by research. A great session and a great methodology. I believe this was an incredible way to share experiences and to leverage an already expert audience.

HR voted greatest challenge Community involvement close second By: Louise Hallman Human resources – the lack and poor use thereof – topped the healthcare challenge chart, as voted for by Salzburg Global Seminar session participants yesterday afternoon. Monday afternoon’s session, led by Sheila Leatherman, Research Professor at Gillings School of Global Public Health, University of North Carolina, USA, saw participants to split into groups to identify challenges in two categories: how to improve quality and how to improve healthcare system delivery. Heated debates arose as participants reported back to the full room. Should “patients’ needs” be added to “patients’ preferences”? Could the issue of staff competency be considered in the same human resources issue bracket as the inadequate numbers of staff? Once the participants – from such wide-ranging backgrounds as physicians, academics, government officials and donors – had negotiated and agreed upon the nuances of the challenges, they were then asked to vote on what they believed were the two greatest challenges they faced in improving healthcare. Coming out resoundingly on top with 17 votes was human resources,

including but not limited to inadequate numbers of health care workers, high turnover, maldistribution geographically, staff morale and unfilled training needs. Community and civil society involvement followed with 16 votes; this issue called for more civil society engagement and client-focus in advocacy, feedback, public protection and responsiveness. In third place was poor planning, encompassing lack of comprehensive operational plans, vertical programs that lack integration and inadequate harmonization of donor programs. Designing a system to meet patient preferences and needs and facilitating the process of addressing different perceptions of quality among providers, policymakers and the public both garnered 12 votes. Lagging behind were limited capacity and capability to implement QI strategies – 7; leadership behavior – 6; involvement of patients and staff in the process of improving care – 6; absence of QI skills in the head of frontline managers – 6; inadequate information and poor communication – 6; interface of strategy and implementation – 4; optimization of technical skills – 3; poorly articulated arguments to donors and decision makers about the value of improvement and the costs of poor health – 2; and finally inadequate leadership with just one vote.

Making Health Care Better in Low and Middle Income Economies: What are the next steps and how do we get there?

Tuesday, April 24, 2012

Prof. Sheila Leatherman hosted a “fishbowl discussion” as part of the session on Challenges Ahead. She was joined by Cynthia Bannerman, Head of Quality, Department of Health, Uganda, Natalia Largaespada, Director - Maternal and Child Health, Ministry of Health, Belize, Niaz Mohammad Popal, Ministry of Health, Afghanistan and Robinah Kaitiritimba, Executive Director, National Health Consumers’ Organization, Uganda.

TALKING P O I N T Donors in healthcare One issue that was raised in the day’s sessions was that of the role of donors in healthcare improvements. Several participants shared their views with Planning Committee Member Sylvia Sax.

“I don’t want donor money because it has strings attached.

“Donors want short term

solutions. When the money is gone after two years, we cannot continue the programs put in place.

Donors come with their own solutions and expect them to be implemented.

Donors put in parallel initiatives and reporting systems.

SGS editor Louise Hallman asked donor representatives for their response.

An intrinsic part of what donors are trying to do is support the governments, not to impose a specific agenda. Intrinsically, improvement has got to be owned by the government, by the country itself. And the solution is a product of dialogue between the donor and the country. Jim Heiby, Medical Officer and Contracting Officer’s Technical Representative, USAID Health Care Improvement Project, Washington, DC, USA

“Anything we do needs to be

something that’s needed by the government and that they would like... The role of the donor is several fold: we can provide resources, in the form of money or in the form of technical inputs. But we can also use voice, often at a global level to try and move an entire sector a specific way... I think the best way we can have an affect and have impact is to support a country’s leadership and to try and leverage each other. We shouldn’t be independently investing here, there or wherever. The whole needs to be greater than the sum of its parts... So it’s about integrated work, led by governments. Mary Taylor, Senior Program Officer, The Bill and Melinda Gates Foundation, Seattle, USA

One of the important things for donors is to know the real situation of the governments, or what is going on in healthcare, what priorities there are, what exact problems there are, what the priorities of the ministry of health are. And then it’s very important to communicate with them and involve them in the process from the help get them on your side while you are implementing something you know will be good for them and it will be easier to transfer to them after you leave. Shirin Kazimov, Health Project Management Specialist, USAID, Azerbaijan

Who do you agree with? Carry on the discussion. Tweet us! @salzburgglobal

Making Health Care Better in Low and Middle Income Economies: What are the next steps and how do we get there? Wednesday, April 25, 2012

Salzburg global seminar SALZBURG DIARIES By: Ezequiel García-Elorrio Silvia Sax from Heiderberg University in Germany chaired the Tuesday morning session on Overcoming Issues of Confusion. Another highly participatory methodology was used to allow everyone’s opinion. Considering the level of expertise in the room a very interesting topic was brought to discussion and much was said about typical confusions when talking about health care. From brief presentations made by participants from different regions of the world, we could reflect on the fact that the issue of confusion is keen to everyone, given we all “suffer” from all the contradictions and heterogeneous use of terms. I participated and witnessed very lively discussions that were very fruitful whenever producing conclusions. Below you can read the topics discussed and some issues of confusion: Healthcare QI Terminology: naming and concepts; differing models using same fundamentals; problems when implementing and using terminology. QI Mechanisms: what are the different mechanisms?; what works in each setting?; role of technical assistance. Whose role is to lead improvement in healthcare quality?: government role: ownership of initiatives and community; role of donors: the advocacy issue. Interpreting and acting on results: data use for decision makers; use and report of data using a common framework. Overall the group set up a list of recommendations (see ISQua Knowledge Portal for the summary for the session) that will help to construct the final recommendations at the end of the week. Many contributions were made and this was maybe one the most difficult sessions to narrow suggestions to a short and prioritized list.

Participants vote on matters of confusion in healthcare improvement


Seventh and eighth blocks Calls to expand “6 building blocks” By: Louise Hallman Participants the Salzburg Global Seminar called on the WHO to expand its “six building blocks of health systems” in Tuesday afternoon’s QI and Health Systems Strengthening session. Presented by Ed Kelley, Head of Strategic Programmes and Coordinator, WHO Patient Safety, Geneva, Switzerland, the session considered the existing building blocks inadequate in improving the healthcare systems of lower and middle income countries. Published in 2010, the WHO “six building blocks of health systems” cover: 1. Service delivery 2. Health workforce 3. Information 4.Medical products, vaccines and technologies 5. Financing 6. Leadership and governance (stewardship)

In his summary, Kelley said, “It is clear that the ‘six building blocks’…include major action areas where the application of improvement methods can achieve significant results.” However, common concern amongst the Seminar contested that community mobilization and patient perspective should also be added to the existing list. Reflecting on all the comments and suggestions made through the group work of the afternoon, Kelley added in his summary: “Though [its] a broad set of areas to address, key lessons emerged that may form the beginnings of an overarching strategy to more explicitly link quality and safety improvement to the larger health systems strengthening effort.” These key lessons included mobilizing clients and reforming financing systems, strengthening quality in health information systems and building the healthcare workforce.

Making Health Care Better in Low and Middle Income Economies: Wednesday, April 25, 2012 What are the next steps and how do we get there?


Dr. M. Rashad F. Massoud By: Louise Hallman Trying to pin Dr. M. Rashad Massoud down long enough for an interview is no mean feat. The smiling Americanbased, British-educated Palestinian doctor is seemingly always on the go. The morning sessions start at 9am and he might have been up until 1am, perfecting the next day’s line-up, updating the e-conferencing website, or discussing the improvement of quality improvement with other participants into the small hours, but the tiring schedule never shows. Dr. Massoud is no stranger to the Salzburg Global Seminar. Now chairing the session ‘Making Health Care Better in Low and Middle Income Economies: What are the next steps and how do we get there?’, Dr. Massoud first came to Salzburg as a fellow in 2001. A student of Don Berwick, the outgoing Administrator of the Centers for Medicare and Medicaid Services and the former president and CEO of Institute for Healthcare Improvement in the USA, Dr. Rashad attended a session on Patient Safety and Medical Error. This first visit to Schloss Leopoldskron convinced Dr. Rashad of the value of the Seminar. “The first seminar I came to,” Dr. Massoud explains over a hastily poured coffee, “followed the Institute of Medicine’s report ‘To Err is Human’ in which medical errors were described as between 48,000 and 98,000 errors per year, half of which are easily preventable. And what [Don Berwick, session chair] did, because safety was a poorly developed area generally speaking in healthcare, he brought in experts from aviation, from space, from road traffic accidents, from psychologists to meet with people who are in the area of improvement and that was the beginning of a major thrust in patient safety today. In fact some of the people who were here in 2000 are today some of the leaders in safety and healthcare. That was an amazing experience... “The whole patient safety movement – a lot of them were here and that’s how the work started. The meeting here was cer-

tainly a significant milestone in the development of the safety effort in healthcare and it really moved things forward.” Dr. Massoud agrees he has similar high hopes for his session this week. “I’d really like us to take the opportunity of this magnificent setting,” he says turning to look out of the Meierhof, across the lake and to the Untersberg mountain. “The environment we have, the focus that we get out of having 60 people in the same place – not just for the session but for all the interactions outside of the sessions. Having been here already – these interactions were even more valuable than the formal sessions themselves.” Indeed – Dr. Massoud is almost as great an advocate of late night discussions in the Schloss’ Bierstube as he is of improving healthcare. “So if we can put all this together,” he continues, “what I’d like to come out with is a thoughtful way that all of us who are representing different groups – host country national governments, improvement efforts, representing implementers in the field, donor agencies, other stakeholders – all of us should think through how do we maximise and leverage everything we have that would enable us to improve healthcare in a different way, take the healthcare improvement effort, which has so far been very successful, to a whole other level.” The session itself has been two years and dozens of hours of Skype conference calls in the making and brings together over 60 healthcare professionals, from physicians, donors, improvement advocates, government officials to civil society leaders, from over 35 countries. “When John Lotherington [SGS Program Director for Health] approached me with the idea of a seminar on improvement science…my idea was that we probably don’t need just another conference or meeting to talk about it, however what we could do is a strategy conversation – something that would enable us to think through what have we accomplished to date, what are the challenges ahead and design an agenda that would take us through the next five to ten years. Everything followed from there. I invited partner organisations, colleagues to join the planning committee. We started to think through what would that agenda look like, what are the themes we have to discuss, who are the people we need to have in the room?” Much of this week’s session has fo-

Dr. M. Rashad F. Massoud cussed on ‘Quality Improvement’, and although the physician-cum-Director of USAID’s Health Care Improvement Project is a strong advocate of the school of thought (that more isn’t always better – more resources, more money, more hospitals – and that healthcare professionals should strive to deliver the best level of care from the resources they have and constantly improve upon that level of care) he is not overly keen on the term. “If there was one thing I could do here it would be remove the word ‘quality’,” he laughs. “Everything we’re talking about here is how can we ensure the patients get the best outcomes possible. What is the best medicine that we know? Can we deliver it to them correctly so that they benefit maximally from this? Can we do this in ways that are not wasteful and inefficient? Can we be mindful about meeting patients’ needs and expectations? Improvement is what we should be doing in the first place; good quality care is what we should be providing patients anyway.” His enthusiasm for the topic is clear from the outset, driving conversations from the breakfast table first thing in the morning, through the day’s sessions, right up to in the Bierstube – the Seminar’s own on-site bar – last thing at night. “He’s like this all the time,” says his research assistant, Nana Mensah Abrampah. Dr. Massoud just laughs, shrugs, and hurries off for another meeting.

Wednesday, April 25, 2012 Making Health Care Better in Low and Middle Income Economies: What are the next steps and how do we get there?


Patients’ needs and preferences Can the two ever be the same? Sparked by a debate that emerged when establishing the key challenges to healthcare improvement on Monday afternoon, an addition to the program was made to air the views of participants on the matter of patients’ needs versus their preferences. Are the two as diametrically opposed as they first appeared in Monday’s session? Can one exist without the other? And can they ever be married together? Or should they always be considered separately? Louise Hallman spoke to the two main discussants – Robinah Kaitiritimba and Pierre Barker – to try to establish some of these answers.

Robinah Kaitiritimba, Executive Director, National Health Consumers’ Organization, Uganda

Pierre Barker, Senior Vice President, Institute for Healthcare Improvement, USA

‘Patients’ preferences’ is the choice that patients make for different reasons and ‘patients’ needs’ is that which is necessary. I think both of them are important. I think patients’ preferences are extremely important and patients’ rights must be the most important thing. But I think it’s important to consider circumstances. Where patients’ cultures and traditions overrides the freedom to make the kind of choice that would improve life. For instance, woman in the process of childbirth and pregnancy have to make certain because of what culture and traditions demand; you are not allowed to say that you are pregnant…so that means that women will not register with healthcare givers. It is considered brave for a woman to give birth in alone in a room and not make noise, even if she’s in pain. So it’s extremely important that those kinds of circumstances are considered in order to be able to serve the needs of patients. We should begin to think about marrying the patients’ interests and the choices they make. The right to choose should be proceed by a lot of information and education and empowerment. The right choice should be the informed choice.

We still have a lot of work to do, particularly in accessing the needs of people deep in the community. So I think we know what to do, although we don’t do it very well, when patients come to see doctors and nurses, but I think we are way behind in our ability to access and respond to the needs of people in the community that are totally determined by context and culture. Preferences are culturally determined and needs are medically determined. I think both are absolutely crucial – I don’t think it’s an either/or issue. I think [patients’ preferences and patients’ needs] should always be considered together. They both need to be addressed; it’s just a question of how you design your response. You have to be very thoughtful about both of them because the needs are going to be addressed through patient education and the preferences are going to be addressed through deep engagement in community structures. And then there’s the personal level; there are preferences that are not totally culturally determined and they all need to be addressed at the point of care.

Making Health Care Better in Low and Middle Income Economies: What are the next steps and how do we get there?

Wednesday, April 25, 2012

Mozarts Geburtshaus, 9 Getreidegasse. The Mozart family lived here for 26 years, from 1747 to 1773. Wolfgang Amadeus Mozart, was born here on January 27, 1756. It is now a museum and exhibits include Mozart’s child violin, his concert violin, his clavichord, his harpsichord, portraits such as the unfinished oil painting “Mozart at the Piano”.


What role does consumer choice have in improving healthcare in lower and middle income countries?

Consumers’ choice is not really only related to the individual’s choice but it relates to the collective’s choice. If the choice for the collective consumer is limited then an individual’s right to choice ends where the rest of the collectivity’s start. Jorge Hermida, Director, HCI Programs - Latin American Region, URC, Ecuador

I think it is fundamental if you want to improve healthcare, the quality of healthcare, consumers’ choice is a key element. That implies that first you have to recognise that, and second you have to give elements to the people so that they can make choices - giving information, allowing them to participants, empowerment. This is not an easy thing to do... If they have a choice in selecting a physician for their care, there are some areas with only one physician so they have no choice! ...But you have to it. I see it as a key element for pressing the system to provide quality health services. If that doesn’t happen, the health system won’t be as responsive as it should be. Enrique Ruelas, Senior Fellow, Institute for Healthcare Improvement, Mexico

Consumers in most circumstances have less opportunities to make choices about their healthcare. The bulk of the population live below the poverty line and in the remote areas. It is not a matter of choice for them but rather a matter of access to the nearest health facility... In cities people have health facilities but then again the poorer tend to be going for public hospitals and they have limited choices. Those with better socioeconomic status and can afford better and higher quality prices for healthcare services, they will go for private hospitals because the perception is the quality is better... And then we have a small percentage of people who really can afford health services outside the country. Mirwais Amiri, Senior Quality Improvement Advisor, URC, Afghanistan

The primary consumer in healthcare is the patient. So when we are talking about low and middle income countries, the only way consumers’ choice can even be an issue is when affordability and access to services are there. And before there is affordability and access, the only choice the consumers have will be to either live or die. Ayman Sabae, Master’s Student, International Healthcare Management, Innsbruck, Austria/Egypt

Got a question you’d like to have debated? Tweet us! @salzburgglobal

Making Health Care Better in Low and Middle Income Economies: What are the next steps and how do we get there? Thursday, April 26, 2012

Salzburg global seminar SALZBURG DIARIES Hearts and minds for QI By: Ezequiel García-Elorrio On Wednesday the sun was shining and the weather was very mild – the right ambience for a critical discussion on leadership, a key factor for every QI initiative around the world. Dr. Bruce Agins, Medical Director of the New York State Department of Health AIDS Institute chaired the morning session; his set of panelists gave their views on the subject. We first had the chance to listen to a presentation from Rwanda’s Health Minister, Dr. Agnes Binagwaho, about situational leadership and the experience from local initiatives; a very instructive description on how to get things done in limited resource settings and changing environments. She seemed like a very committed and strong person, very satisfied with the accomplishments so far. We then participated in a panel discussion where the panel’s views on leadership prompted stimulating discussion. One the things that was said and struck me, was something said by Sir Liam Donaldson: “We have to win the heads and win the hearts” in order to succeed. After the break we had a small group discussion with the following topics: 1. How do leaders effectively carry out the designing of and planning for quality? 2. How do leaders effectively engage community in quality improvement efforts? 3. How do leaders effectively select strategies to communicate initiatives and results? 4. How do leaders implement coordinated strategies at all levels of the public system? 5. How do leaders effectively implement quality improvement efforts? Several suggestions were made [please read the online summary of the session] and will also be incorporated in the final document of the Session. Two other comments that impacted me were: “Please never give up” and “Quality Improvement is an evolution not revolution”. There was so much wisdom around.

Rwanda’s Minister of Health, Dr. Agnes Binagwaho joined panelists from Namibia, Thailand, the UK, Uganda and the US to talk about leadership


“Leaders must never give up” Wise words from Rwandan MoH By: Louise Hallman Participants at the Salzburg Global Seminar were urged on Wednesday to continue to strive for quality improvement in healthcare by the Minister of Health for Rwanda, Dr. Agnes Binagwaho. Dr. Binagwaho joined the Seminar to speak on ‘Strengthening Leadership and Policy for Improving Care in Low and Middle Income Economies’ via video link from Kigali. She spoke on her own personal experiences of leading quality improvement, particularly highlighting the importance of engaging all stakeholders, including the population, in improving healthcare, as politicians like herself rarely stay in office for more than two years. The session also saw an international panel - from Namibia, Thailand, the UK, Uganda and the US, as well as Rwanda - convene to share their views and successful experiences of leading healthcare improvements. Community level engagement was brought

up repeatedly through out the session, with participants during their breakout workshops yet again drawing attention to the limitations in traditional thinking. One of the key suggestions to be made by Salzburg participants addressed the need to lead change through all levels of healthcare systems, not just national, but regional, district and community. Another suggestion was that leaders must establish clear direction and set priorities that are then communicated to the public, championing transparency in performance and displaying integrity in addressing those promised priorities. Session chair, Bruce Agins, highlighted in his report: “As they stay attuned to their environment and changing landscape, leaders in particular need to stay attuned to the care provided to those most vulnerable in their nations and drive improvement to meet their needs which may often require specific efforts to ascertain.” All suggestions made by the groups will be incorporated into the Salzburg Statement.

Making Health Care Better in Low and Middle Income Economies: What are the next steps and how do we get there?

Thursday, April 26, 2012

Sir Liam Donaldson presents the Swiss Cheese Model of Accident Causation. Presenting the case of Mamma Sessay, an 18-year-old mother in Sierre Leone, who died due to complications in labor with twins, Sir Liam proposed that Mamma had been failed at several points and efforts were needed to “fill in the holes” to avoid future maternal mortailty.

TALKING POINT What is the number one most important attribute for a good leader to have?

“Sensitivity to the needs of his staff.” Rob Palkovitz, Professor,

Human Development & Family Studies, University of Delaware, USA

“Puts the client first.”

Jean Nguessan, Country Director, URC, Cote d’Ivoire

“To be able to visualize, five, ten years ahead.” Amit Pawal, Consultant, USAID & GTZ, India

“Effective communication.”

Nana Mensah-Abrampah, Quality Improvement Fellow, URC, USA

“Communication and compassion.” Sylvia Sax, Lecturer,

Institute of Health, University of Heidelberg, Germany

“Be inspiring to the people they lead.” Sarah Byakika, Assistant

Commissioner for Quality Assurance, Ministry of Health, Uganda

“A good team that can point out the real priorities and ensure the strategic ones are being taken and put into the agenda. Tatiana Paduraru, National Consultant on Foreign Assistant, Ministry of Health, Moldova

“Tolerance...they have to

work with different donors and organizations... It is important for leaders to understand what other people would like and try to choose key issues. Aigul Kalieva, Chief of Neonatal Services, Ministry of Health, Kyrgyzstan

“A vision, along with empathy to others.”

Shirin Kazimov, Health Project Management Specialist, USAID, Azerbaijan

“Trust his team.”

Anna Korotkova, Deputy Director for International Affairs, Federal Institute for Health Care Organization, Russian Federation

“Ability to see different sides to an issue.” Carlo Irwin Panelo, Chief of Party, Health Policy Development Program, USAID, Philippines

“Integrity...straightforward, accountable, be visionary.” Baile Moagi, Director, Health Inspectorate, Ministry of Health, Botswana

“A vision...chart out a path and all other things will fall into place.” Charles Nde Awasom,

Medical Director, Ministry of Health, Cameroon

“Insight...if a leader isn’t

able to learn from mistakes and to support people when mistakes are made, they will never reach their potential for delivery. Tracey Cooper, President, ISQua, Ireland

“Unflagging dedication and commitment to the goal of improvement.” Bruce Agins, Medical Director, AIDS Institute, New York State Department of Health, USA

Making Health Care Better in Low and Middle Income Economies: What are the next steps and how do we get there? Friday, April 27, 2012

Salzburg global seminar SALZBURG DIARIES Day of action By: Ezequiel García-Elorrio Pierre Barker from IHI chaired a very interactive session on sustainability on Thursday morning covering: “Sustainability in not permanence but integration into the culture of the healthcare system” To begin every participant scored on a special designed matrix the way their own country is doing on the different aspects of QI effort implementation and dissemination. The results were the aggregated. We then explored different perspectives that may help sustainability. They were: Policy, funder and politician’s vision. Alignment of managers and providers, data system adoption, QI capacity needs, role of the technical advisors and the role of the civil society were also topics of discussion. Some thoughts that come from it were: 1. Demand of quality from the civil society is crucial to give continuity to QI efforts. 2. Tension within current needed systems to collect data for the QI process. 3. Capacity of the community to improve the demand from the civil society 4. Advisors had the challenge of demonstrating the effectiveness of the interventions specially whenever communicating the to the outside world. 5. Harmonization and coordination of donors is the will from the funder’s perspective. 6. Politicians should include quality as a national policy to give QI efforts sustainability. 7. Developing a common language is critical to create a policies across countries. In the self-assessment of the countries most of them fell in a category where that so far mostly were in the middle of the river or starting to cross it. Not the best scenario but an opportunity to do it the right way considering the gathered experience. It’s been a busy morning and the best is to come. Lots of ideas and suggestions are consolidating for a productive closure session.

Senior IHI Fellow, Enrique Ruelas presented his ‘10 Commandments to deal with politicians’ during Pierre Barker’s ‘Sustaining Execution’ session


Preaching to the unconverted “You may lose the battle, but you won’t lose the war” By: Louise Hallman On the penultimate day of the Salzburg Global Seminar on ‘Making Health Care Better in Low and Middle Income Economies: What are the next steps and how do we get there?’, participants were given a new set of commandments to consider: ‘Ten Commandments for Dealing with Politicians’. Enrique Ruelas, Senior Fellow at the Institute for Healthcare Improvement, Mexico, shared his commandments with the group as part of the Thursday morning session on ‘Sustaining Execution’ covering introducing QI systems to countries unfamiliar with the methodology and designing sustainability into healthcare initiatives from the start. Mr. Ruelas’ commandments offered an insight into the psyche of politicians and included selling the concept of QI in

healthcare to politicians, not arguing with them, and also aligning your position with existing initiatives. The full list can be seen overleaf. Reflecting on the morning’s session, Bruce Agins, chair of the previous day’s session on leadership said: “There clearly is no one way to communicate the benefits or importance of QI... One has to know and read your audience to adapt your message appropriately, i.e. scanning and reading the environment effectively to tailor and craft your message.” As with previous sessions, all key suggestions made by the group were collated by the session chair to be included in the final session to be held on Friday morning entitled ‘Next Steps’. Participants will not only reflect on the outcomes of the week-long Session but also produce a Salzburg Statement to be shared with key stakeholder groups.

Making Health Care Better in Low and Middle Income Economies: What are the next steps and how do we get there?

TALKING POINT What positive outcome will you take back to your colleagues from this session at Salzburg Global Seminar?

“That the patient matters and

quality improvement is all about the patient. Natalia Largaespada Beer, Maternal and Child Health Technical Advisor, Ministry of Health, Belize

“Quality isn’t really my

field...I was confused, and I guess I didn’t really grasp the importance of quality or the huge impact it has [until now]. Michelle Vanzie, Director of Policy Analysis and Planning Unit, Ministry of Health, Belize

“From this meeting I will

have a lot of friends! [I will

have] a lot of challenges. We have discussed a lot of issues on quality so when I go back, I think my vision will be different. Babacar Ndoye, Coordinator, National Program Against Nosocomial Infections, Ministry of Health, Senegal

“This meeting has brought

great light to ideas on what we can share with our country, not to show that QI is a program but a science. I think we can present, we can advocate to leadership that this is the QI methodology. Januario Reis, Clinical Site Monitoring Specialist, USAID, Mozambique

“The one this is the validation

of the enthusiasm around using quality improvement to enhance the healthcare of poor around the world and create a quality movement to really make great progress very quickly in healthcare. Sheila Leatherman, Research Professor, Gillings School of Public Health, UNC, USA

Friday, April 27, 2012

THE 10 COMMANDMENTS How to deal with politicians 1. Politicians always think they know best…because they are politicians. Do not make them feel otherwise. 2. Politicians always have great ideas… although maybe their ideas are the ones you gave them. 3. Do not argue with them…sell! Good sellers always offer a benefit first and then the product as concrete and clear as possible. 4. Align your proposals with other existing initiatives to add weight. 5. Bring on board as many stakeholders as possible, this increases your power. 6. Show your power but never say you have it…that might be interpreted as a

threat - politicians will understand you have it. 7. Expose the laggards…but be kind. 8. Give visibility to what you are doing. 9. Make quality improvement an inspiring cause to be embraced…not an argument or a method. 10. Pull, they will push. The more you push, the more resistance you may create. The more you pull, others will want to join. Make politicians feel that the train is moving and therefore, either they jump in or be left behind. Finally, be very enthusiastic, patient and tenacious. Politicians come and go. Your cause will always be. You may loose a battle but will never loose the war.

Making Health Care Better in Low and Middle Income Economies: What are the next steps and how do we get there? Session Report 489

Salzburg Global Seminar Staff Stephen L. SALYER, President & Chief Executive Officer Patricia BENTON, Chief Financial Officer Clare SHINE, Vice President & Chief Program Officer C. Lynn MCNAIR, Vice President, Philanthropic Partnerships

Program and Administrative Staff Kathrin Bachleitner, Program Associate Thomas Biebl, Director, Marketing and Communications Ian Brown, Manager, Salzburg Global Fellowship Rachel Feldman, Philanthropic Partnerships Associate Robert Fish, Associate Director, Communications Jochen Fried, Director of Education Joana Fritsche, Program Sales Manager David Goldman, Associate Director of Education Louise Hallman, Editor Astrid Koblmüller, Program Manager Camilla Leimisch, Assistant, Registration Department Andrea Lopez-Portillo, Communications Program Associate Tatsiana Lintouskaya, Program Director John Lotherington, Program Director Sharon Marcoux, Financial Associate Christie Mason, Assistant to the President Carleigh McDonald, Philanthropic Partnerships Associate Paul Mihailidis, Program Director, Salzburg Academy on Media and Global Change

Edward Mortimer, Senior Program Advisor Raffael Niedermüller, Technology Associate Bernadette Prasser, Program Officer Michi Radanovic, Assistant Director Finance & HR Assistant Ursula Reichl, Assistant Director Finance Manuela Resch-Trampitsch, Director Finance Marie-Louise Ryback, Director, Holocaust Education and Genocide Prevention Initiative

Karen Schofield-Leca, Director, Philanthropic Partnerships, US Astrid Schröder, Program Director, International Study Program Susanna Seidl-Fox, Program Director, Culture and the Arts

Nancy Smith, Director, Gender and Philanthropy Julia Stepan, Program Associate John Tkacik, Director, Philanthropic Partnerships, Europe Cheryl Van Emburg, Director of Administration Martin Wiesauer, Technology Associate

Schloss Leopoldskron Conference Center Staff Richard Aigner, Conference and Event Manager Anthony Fairweather, Receptionist Margit Fesl, Housekeeping Manager Markus Hiljuk, Director, Conference Center Florian Hoffmeister, Service Manager Ernst Kiesling, Catering Manager Alexander Reigl, Receptionist Matthias Rinnerthaler, Superintendent Shahzad Sahaib, Night Porter Karin Schiller, Sales Manager Andrea Schroffner, Conference and Event Assistant Martina Trummer, Front Office Manager Nadine Vorderleitner, Conference & Event Assistant Christine Wiesauer, Assistant Front Office Manager

Seminar Interns Charles Bain Program Deirdre Doran, Library Ana Dragovic, International Study Program Gintare Stankeviciute, Salzburg Global Fellowship


Making Health Care Better in Low and Middle Income Economies: What are the next steps and how do we get there? Session Report 489


Bruce Agins is a medical director for the New York State Department of Health AIDS Institute and oversees a staff of 40, involved in HIV treatment guidelines development, quality management and education programs. He is the principal architect of New York’s HIV Quality of Care Program and has 20 years of HIV-specific quality improvement (QI) experience. He is principal investigator of HIVQUAL-US and the National Quality Center. He has participated as faculty in national HIV QI Collaboratives and chaired the faculty of the national HIV QI Collaborative for state HIV agencies. Dr. Agins is director of HEALTHQUAL International, an initiative to build capacity for QI globally. He has extensive experience in the field of international QI and participated in consultations with WHO devoted to quality management in resource-limited settings. He is a graduate of Haverford College and Case Western Reserve School of Medicine and received an M.P.H. from the Mailman School of Public Health at Columbia University.

Pierre M. Barker is the senior vice president of the Institute for Healthcare Improvement (IHI) in Cambridge, MA. He is responsible for IHI’s expanding portfolio of large-scale health systems improvement initiatives in lowand middle-income countries. Previously he served as senior advisor to IHI’s programs in Africa and India, and as director of IHI’s South Africa projects. Dr. Barker, a pediatrician by training and a South African by birth, is a renowned authority on improving health systems, particularly in the areas of maternal and child health and HIV/ AIDS care. Before joining IHI he was medical director of University of North Carolina Children’s Hospital clinics and was responsible for leading health system-wide initiatives on improving access to care and chronic disease management. He advises the WHO on health systems strengthening and redesign of HIV care and infant feeding guidelines.

Louise Hallman is the editor at Salzburg Global Seminar, where she manages online and print editorial content as well as other in-house journalism and marketing projects. In her role she creates, commissions and edits content for, manages social media platforms, contributes articles and features to external publications, and liaises with visiting members of the press. Ms. Hallman holds Master’s degrees in international relations and Middle East studies from the University of St. Andrews and multimedia journalism from Glasgow Caledonian University. Prior to joining SGS in April 2012, she worked for WAN-IFRA as the manager and publication editor for the SIDAfunded ‘Mobile News in Africa’ project and the International Press Institute, as a press freedom advisor and in-house journalist, where she focused on Latin America and Europe.

James Heiby is a medical officer in the Global Health Bureau of USAID in Washington, DC. On the basis of an earlier 12-country quality assessment study, in 1990, he developed the first USAID project dedicated to addressing quality of care issues in USAID-assisted countries. Since then, he has continued to lead the Agency’s program in adapting modern quality improvement to the needs of health systems in lower- and middle income countries. The current Health Care Improvement (HCI) Project is the fourth 5-year project in this program. Working with a number of USAID country missions, the program has expanded from a $5 million annual budget initially, to over $30 million under HCI, working in over 30 countries. Throughout this period, the program has included an expanding research and evaluation component. Prior to joining USAID in 1978, Dr. Heiby served in the Bureau of Epidemiology of the Centers for Disease Control in Atlanta. He received an M.D. from Johns Hopkins University in Baltimore and an M.P.H. from the Harvard School of Public Health in Boston, and completed his clinical training at New York HospitalCornell Medical Center.


Making Health Care Better in Low and Middle Income Economies: What are the next steps and how do we get there? Session Report 489

Edward Kelley serves as coordinator and head of strategic programs for WHO Patient Safety in Geneva, Switzerland. In this capacity, he coordinates both strategic management and external relations and business development for the world’s only global health care safety initiative, with responsibility for teams working in health care associated infection, technology, capacity building, reporting and learning and patient and community empowerment. Prior to joining WHO, Dr. Kelley directed the only ongoing national examination of health care quality and disparities in the United States as the director of the US National Healthcare Reports for the US Department of Health and Human Services in the Agency for Healthcare Research and Quality. He also directed the 28-country Health Care Quality Improvement Project of the Organization of Economic Cooperation and Development. Dr. Kelley’s research and project work has produced numerous publications in the areas of health systems performance measurement and improvement, value for money in health care, cost and quality interactions and the clinical areas of pediatric infectious disease, respiratory illness, cardiac care and cancer survival.

Sheila Leatherman is a research professor at Gillings School of Global Public Health, The University of North Carolina. She conducts research and policy analysis globally, focusing on health care quality and health systems reform, as well as the nascent field of integrating microfinance and community health programs as a strategy for poverty reduction and improved health outcomes. She was elected to the Institute of Medicine at the US National Academy of Sciences in 2002. Through research and policy advising, she has worked with Afghanistan, Australia, Benin, Bolivia, Burkina Faso, Canada, Cambodia, India, Peru, Philippines, Singapore, South Africa, South Sudan, Tanzania and the UK. She has published widely in the field of health care quality including national quality chart books in the US, UK and Canada and articles in peer-reviewed literature on health policy, quality measurement and health reforms. In 2007, she was awarded the honor of Commander of the British Empire by Queen Elizabeth for her work over a decade as an independent evaluator of the impact of government reforms on quality of care in the NHS.

John Lotherington is a program director at Salzburg Global Seminar, with particular responsibility for the Salzburg Global health care programs. Prior to that, he was director of the 21st Century Trust in London. He began his career in history education and maintains an interest in that area. His publications as editor and author include The Communications Revolution; Years of Renewal: European History 1470-1600; The Seven Ages of Life; The Tudor Years; introductions to The Florentine Histories by Niccolo Machiavelli, The Book of the Courtier by Baldassare Castiglione, and Inferno by Dante Alighieri. He is chair of the Foundation for Democracy and Sustainable Development and a Fellow of Goodenough College in London.

Nana Mensah-Abrampah is an international public health professional. She is a quality improvement fellow with the USAID HCI and collaborates closely with the director of the HCI Project on global health issues, including program implementation, finance, health systems strengthening and quality improvement mechanisms. In 2011, she helped develop The Africa Consultative Workshop for Health Care Improvement, which was the first of its kind in assessing how core competencies for quality improvement can be integrated into the education and training of health workers in Africa. Ms. Mensah-Abrampah holds a B.Sc. in economics from the University of Mary Washington. Her publications include “Improving the delivery of safe and effective healthcare in low and middle income countries” (BMJ 2012) and “Key Steps in Improving Health Care: Technical Plenaries and Exercises” (USAID HCI Project 2011).


M. Rashad Massoud is senior vice president for the Quality and Performance Institute and director of the US Agency for International Development (USAID) Health Care Improvement (URC) Project in Washington, DC. He served as senior vice president at the Institute for Healthcare Improvement (IHI), overseeing their strategic partnerships - the key customers working with IHI on innovation, transformation and large scale spread. Dr. Massoud joined URC in 1998, leading several improvement efforts around the globe, including working on developing the World Health Organization’s (WHO) strategy for design and scale-up of antiretroviral therapy to meet the 3x5 target and large scale improvement in the Russian Federation. He also founded, and for several years led, the Palestinian health care quality improvement effort. He was a founding member and chaired the multi-country Quality Management Program for Health Care Organizations in the Middle East and North Africa and worked as a medical officer with the United Nations Relief and Works Agency. Dr. Massoud has also consulted for and collaborated with several NGOs, KPMG, UNICEF, the World Bank, USAID and WHO.

Sylvia Sax is an international public health consultant and lecturer in the Institute of Health at the University of Heidelberg in Germany. She is currently providing consultancy support to governments in Kazakhstan on upgrading their healthcare accreditation system, in Malawi on results based financing and in Kenya on healthcare quality management. Her areas of expertise include healthcare quality management, healthcare accreditation, health system strengthening, health provider motivation, and results based financing. She is a doctoral candidate in the Institute of Public Health, University of Heidelberg, and received an M.P.H. from the University of Otago, Christchurch, and a B.Sc. in nursing from the University of Illinois, Chicago.

Salzburg Global Seminar is grateful to the following donors for their generous support of Session 489 University Research Co., LLC Bill and Melinda Gates Foundation GIZ The Nippon Foundation USAID World Health Organization Salzburg Global Seminar would like to thank the Session speakers for their assistance in developing this program and for generously donating their time and expertise, and to all the participants that contributed their intellectual capital and superior ideas. FOR MORE INFORMATION CONTAC T:

John Lotherington

Astrid Koblmueller

Clare Shine

Program Director

Program Associate

Vice President and Chief Program Officer Š 2012

Salzburg Global Seminar Salzburg Global Seminar was founded in 1947 by Austrian and American students from Harvard University. Convinced that former enemies must talk and learn from each other in order to create more stable and secure societies, they set out to create a neutral international forum for those seeking to regenerate Europe and shape a better world. Guided by this vision, we have brought over 31,000 participants together from 160 countries for more than 500 sessions and student academies across cultural and ideological barriers to address common challenges. Our track record is unique – connecting young and established leaders, and supporting regions, institutions and sectors in transition. Salzburg Global’s program strategy is driven by our Mission to challenge present and future leaders to solve issues of global concern. We work with partners to help people, organizations and governments bridge divides and forge paths for peace, empowerment and equitable growth. Our three Program Clusters - Imagination, Sustainability and Justice - are guided by our commitment to tackle systems challenges critical for next generation leaders and engage new voices to ‘re-imagine the possible’. We believe that advances in education, science, culture, business, law and policy must be pursued together to reshape the landscape for lasting results. Our strategic convening is designed to address gaps and faultlines in global dialogue and policy making and to translate knowledge into action. Our programs target new issues ripe for engagement and ‘wicked’ problems where progress has stalled. Building on our deep experience and international reputation, we provide a platform where participants can analyze blockages, identify shared goals, test ideas, and create new strategies. Our recruitment targets key stakeholders, innovators and young leaders on their way to influence and ensures dynamic perspectives on a given topic. Our exclusive setting enables our participants to detach from their working lives, immerse themselves in the issues at hand and form new networks and connections. Participants come together on equal terms, regardless of age, affiliation, region or sector. We maintain this energy and engagement through the Salzburg Global Network, which connects our Fellows across the world. It provides a vibrant hub to crowdsource new ideas, exchange best practice, and nurture emerging leaders through mentoring and support. The Network leverages our extraordinary human capital to advise on critical trends, future programs and in-region implementation.


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John Lotherington

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general info.

Making Health Care Better in Low and Middle Income Economies  

Many low- and middle-income countries are not on track to achieve the Millennium Development Goals (MDGs) by the 2015 target. For example, o...

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