Quality improvement (QI) in the context of extremely limited healthcare access presents unique challenges, as the primary focus is often on increasing service quantity to meet needs. Access and quality in such situations can be at odds, as is the case with surgical care in resource-limited healthcare systems around the world. However, volumes and quality must advance in tandem to prevent inadvertent harm. In many healthcare systems, patients abandon treatment due to poor quality care despite reaching the hospital.1 These challenges are further magnified in very low-resource settings, where public hospitals serve populations in the lowest economic strata. Such realities underscore the vital importance of QI in such settings to build trust of communities in their healthcare system and providers.

An important contribution to the sparse body of literature in this space is the study by Barker et al in this issue of BMJ Quality & Safety.2 The authors describe their work to increase the caesarean section (C-section) rate at public sector hospitals in the Indian state of Bihar to improve needed care for pregnant women. The setting of this study is one of the most resource-constrained parts of India and in the world. Public hospitals in this region manage up to 1000 births per month, yet C-section rates are alarmingly low, under 3%. This starkly contrasts with the majority of the world, where overuse of C-sections is the norm,3 indicating serious concerns about surgical access in this population.

The intervention aimed to improve C-section rates by integrating a multifaceted QI approach into a larger package of leadership recognition and resources for obstetric care across the state. This included QI trainings to the intervention hospitals, starting out with an orientation of state and hospital-level health leaders, conducting two workshops and organising three learning sessions over a year, paired with monthly visits by programmatic QI coaches. Each participating hospital formed a dedicated QI team comprising, among others, nurse and physician champions, improvement coaches and the hospital medical superintendent, the highest ranking administrative position in the Indian health system. These teams provided regular updates to the local civil surgeon’s office, which led mortality reviews and QI meetings. In total, they had a 10-month baseline, 16-month intervention period during which their QI collaborative was active, followed by a 9-month sustainability period when the external support for the QI teams was withdrawn. Over the course of this project, they achieved a threefold increase in C-section rates (their outcome of interest), which decreased post-intervention, but remained nearly double the baseline rate. In comparison, hospitals across the state receiving the same government-led launch and technical support for optimising obstetric resources like clinical protocols and clinical personnel, but without the QI training and intervention, showed negligible improvement despite a similar baseline. While the COVID-19 pandemic disrupted endline observations, the findings remain compelling.

Arguably, the most important contribution of this work lies in its emphasis on embedding their initiative within local government structures, while codeveloping solutions with the local healthcare providers in the intervention facilities themselves. These providers often face systemic challenges, including inadequate compensation, excessive workloads and limited career advancement opportunities, making such opportunities to have an impact on their healthcare system even more important. The authors also highlight the pragmatic adaptations required to implement QI in low-resource settings, particularly in the public sector.

An important takeaway from this study is that the definition of access should not be restricted to prehospital transport and reaching the hospital. Increasing utilisation of existing resources is a key issue at public sector hospitals, as patients often reach the hospital only to be denied care or to abandon treatment due to poor quality, thus eroding trust in the healthcare system.1 Technically, this was more of a quantity improvement project than a quality project since the stated primary focus was on increasing surgical volume rather than enhancing quality of care. Accordingly, outside of the dedicated QI training and teams, interventions targeted personnel, infrastructure and resources. Per Donabedian, process and structure changes are both required to affect outcomes. Measurement of process metrics like adherence to standards or complication rates can be emphasised in future work to help understand how this approach improved quantity. While the authors mention the impact of health system-level factors, the extent and strength of such relationships can also be clarified further in this context.

A multifaceted approach like this study that pairs QI training to clinical practice change/improvement interventions should probably be a mandatory component of every field project. The importance of having a dedicated local team for QI cannot be overemphasised, as healthcare workers on the frontlines are often too busy getting their job done to have the bandwidth for QI4 5; this is probably worse in low-resource healthcare systems.6 Championed by Pronovost, this approach emphasises the coupling of technical interventions with an adaptive intervention to ensure effective delivery of it.7–9

Who is on the QI teams matters as well, with team composition being highlighted as an important factor. The authors note that a lack of leadership support did not allow hospitals in group 2 to resolve local barriers, limiting their improvement. While detail is provided about the key stakeholders on their QI teams, more contextual data about the QI team dynamics such as attendance and what was discussed would provide valuable insights. We recently published some work where we used a multifaceted approach to decrease bloodstream infections at a hospital in a similar low-resource health system setting.10 Like this study, our QI teams were composed of a physician, nurse and hospital executive as champions, along with a QI specialist. Effectiveness was similarly correlated with higher baseline rates, and rates worsened again after the QI teams were disbanded. We found that consistent attendance of more than 88% of the time of all stakeholders, particularly the physician and executive champion, was associated with statistically significant improvement. This suggests that improvement initiatives in such settings may depend more on hierarchical structures and approvals than grassroots efforts. A nursing-led approach similar to those in western healthcare systems may not work as well due to hierarchies and gender inequity prevalent in the sociocultural environment of low-resource settings. This underscores the need for robust process evaluation, including qualitative data collection, to explore the barriers to and enablers of change in such settings and how these may differ from those in the Global North.

The authors commendably report not only their successes but have been ruthlessly honest about the failures in implementing their QI effort. They report heterogeneity in group 1 which showed the improvements, which could have impacted the outcome of interest. This should ideally be separated and inventoried, so that the effect of the QI package is more apparent. Furthermore, a statistical test of significance on the changes in C-section rates between the baseline, intervention and observation periods would have helped interpret the results more objectively. Context is also important when looking to reproduce such work in other resource-limited settings. Two task-sharing initiatives for non-specialised doctors implemented in Bihar over the past two decades, namely the Emergency Obstetric Care and the Life Saving Anesthesia Skills programmes, have impacted the availability of local skilled manpower in ways that might be immediately apparent or replicable.11 The authors also shared that the hospital which had the lowest baseline C-section rate in their intervention cohort did not improve until the later part of the collaborative after the obstetric care-related resources were infused. This raises questions about a minimum resource threshold for clinical improvement that is worth further exploration, particularly in settings with fewer baseline resources. Previous studies in Bihar have identified key infrastructure and resource-related factors influencing C-section rates, including the availability of blood, presence of functioning operating rooms, a skilled obstetrician and anaesthetist and patient proximity to the healthcare facility.12

This study offers a practical roadmap for implementing improvement projects in low-resource settings. It provides an approach for Institutional Review Board approvals for multicentred work in international settings that might lack individual ones. It also highlights the importance of public–private partnerships, such as those between the local government (Bihar), a local non-governmental organisation (CARE India) and an academic content expert (Institute for Healthcare Improvement). The authors also demonstrate how a QI approach can piggyback onto existing initiatives, such as the LaQshya programme,13 while addressing pragmatic challenges like site selection biases introduced by government requests. This also helped tackle the important issue of feasibility of QI initiatives in resource-limited settings, with the authors ensuring that important resource limitations like technical personnel and equipment were sourced through local government.

By addressing both the opportunities in application and challenges of implementation in Bihar, this study provides valuable lessons for improving access through QI in similar contexts worldwide.

Not applicable.

Not applicable.