Evidence of Interventions and Strategies to Bridge the Quality Improvement Gap Led by HCW at the Frontline in SSA: A Scoping Review

Introduction: Poor-quality health care is a significant cause of preventable deaths, especially in low- and middle-income countries. Quality improvement (QI) is multifaceted. To move QI in health care into everyday practice, it is essential to engage the frontline. The objective of this scoping review is to investigate frontline health-care worker (FHCW) line-led QI in Sub-Saharan Africa (SSA). Methods: We conducted a scoping review to identify, map, and synthesize evidence on health-care worker (HCW)-led QI initiatives in SSA using electronic databases such as PubMed, Cochrane, Embase, CINAHL, Scopus, and Psychinfo to identify peer-reviewed literature published between January 2000 and January 2021. To identify grey literature, we used the same search terms in Google search to a maximum of 10 pages or no new information. Evidence was scored based on the six criteria described by Backhouse et al, which clearly distinguish QI from clinical audit and research. Inclusion criteria were studies that involved FHCWs to test 'change ideas' and used data systems to measure improvement in service delivery. Results: A total of 75 records were identified, 52 from the peer-reviewed search and 23 records from the grey literature. Only 15 of 47 countries had publications describing QI initiatives. Most QI initiatives were multicomponent and included knowledge transfer, skills building, mentorship, and learning visits. Most QI initiatives aimed at reproductive, maternal, neonatal, and child health (n = 23), and human immunodeficiency virus (HIV) (n = 14) service delivery. Only six had experimental designs. No publications were identified prior to 2012, and rapid escalation of published QI initiatives from 2012 to 2020 occurred. Conclusion: QI is in the very nascent stage in SSA. Most large-scale public health QI initiatives are sector-specific, siloed, and donor-driven. QI initiatives within sector-specific programs have not moved horizontally and have had limited ability to change the broader system. Key words: quality improvement, SSA, health workers