Stewardship of quality of care in health systems: Core functions, common pitfalls, and potential solutions

National Ministries of Health in low- and middle-income countries (LMICs) have a key role to play as stewards of the quality agenda in their health systems. This paper uses a previously developed six-point framework for stewardship (strategy formulation, intersectoral collaboration, governance and accountability, health system design, policy and regulation, and intelligence generation) and identifies specific examples of activities in LMICs in each of these domains, pitfalls to avoid, and possible solutions to these pitfalls. Many LMICs now have quality strategies with clear vision statements. There are good examples of quality agencies and donor collaboration councils to coordinate activities across different sectors. There are multiple options for accountability, including public reporting, community accountability structures, results-based payment, accreditation, and inspection. To improve health system design, available tools include decision support tools, task-shifting models, supply chain management, and programs to train quality improvement staff. Policy options include legislation on disclosure of adverse events, and regulations to ensure skills of health care providers. Lastly, health information tools include patient registries, facility surveys, hospital discharge abstracts, standardized population and patient surveys, and dedicated agencies for reporting on quality. Policy-makers can use this article to identify options for driving the quality agenda and address anticipated implementation barriers.