Quality in Practice Quality in Practice Quality health care in extreme adversity—an action framework SHEILA LEATHERMAN 1 , LINDA TAWFIK 1 , DILSHAD JAFF 1 , GRACE JAWORSKI 1 , MATTHEW NEILSON 2 , SHAMSUZZOHA BABAR SYED 2 , and MONDHER LETAIEF 3 1 University of North Carolina at Chapel Hill, 2 World Health Organization, and 3 World Health Organization, Eastern Mediterranean Regional Office Address reprint requests to: Linda Tawfik, University of North Carolina at Chapel Hill. E-mail: lindat@email.unc.edu Editorial Decision 12 June 2019; Accepted 24 June 2019 Abstract Quality problem or issue: There are record-setting numbers of people living in settings of extreme adversity and they continue to increase each year. Initial assessment: There is a paucity of validated data on quality and safety across settings of extreme adversity. Choice of solution: This paper argues for an action framework to address the unique challenges of providing quality in extreme adversity. Implementation: We describe a preliminary Quality in Extreme Adversity framework which has been informed by—and will continue to be validated through—literature, data collection, WHO expert consultations and through working in settings of extreme adversity with national author- ities and NGOs. Lessons learned: Poor quality care costs lives, livelihoods and trust in health services. The recom- mended framework, based on evidence and experiential lessons, intends to address the WHO goal for 2019–2023 of ‘one billion people better protected from health emergencies’ (9). Key words: extreme adversity, action framework, fragile, conflict, and violent settings, health care quality Introduction Quality health care is a clear priority in the push for Universal Health Coverage (UHC). Three major reports published in 2018 have affirmed the need for improved quality in health services and highlighted the significant morbidity and mortality attributable to poor quality care: those by the National Academies of Science, Engineering and Medicine (NASEM) [1]; the World Health Organization (WHO), World Bank, and Organization for Economic and Cooperative Development [2]; as well as the Lancet Global Health Commission on High Quality Health Systems in the Sustainable Development Goal Era [3]. These reports identified major gaps in data, policy, strategy in how to address quality in set- tings of extreme adversity (QEA). NASEM asserts, ‘…settings of extreme adversity, such as conflict zones, failed states, and refugee camps, pose severe quality challenges. Research on these settings should be a priority for governments, non-governmental organiza- tions (NGOs), and donors, to identify common quality problems, and to tailor and quickly implement improvement strategies …’ [1]. There are record-setting numbers of people living in settings of extreme adversity and they continue to increase each year [4]. Currently, two billion people live in countries where development outcomes are affected by fragility, conflict and violence (FCV) [5]. By 2030, nearly 50% of the global poor will live in such situations [5]. UHC cannot be achieved without attention to access and quality in such places. As of 2019, 131.7 million people worldwide are in need of humanitarian aid and one in every 70 people around the world are in crisis [4]. Recognizing multiple terminologies in use, extreme adversity is an umbrella term to describe fragile unstable settings, affected by acute or ongoing political turmoil, conflict, and natural disaster, © The Author(s) 2019. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com doi: 10.1093/intqhc/mzz066 International Journal for Quality in Health Care, 2019, 31(9), G133–G135 Advance Access Publication Date: 11 July 2019 G133 Downloaded from https://academic.oup.com/intqhc/article/31/9/G133/5531164 by guest on 28 July 2022