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While a growing body of evidence suggests that healthcare workers in low and middle-income countries often provide poor quality of care, the reasons behind such low performance remain unclear. The literature on medical decision-making suggests that cognitive biases, or failures related to the way healthcare providers think, explain many diagnostic errors. This study investigates whether one cognitive bias, overconfidence, defined as the tendency to overestimate one's performance relative to others, is associated with the low quality of care provided in Senegal. It links survey data on the overconfidence of health workers to objective measures of the quality of care they provide to standardised patients – enumerators who pose as real patients and record details of the consultation. We find that about a third of providers are overconfident – meaning that they overestimate their own abilities relative to their peers. It shows that overconfident providers are 26% less likely to manage patients correctly and exert less effort in clinical practice. These results suggest that the low levels of quality of care observed in some settings could be partly explained by the cognitive biases of providers, such as overconfidence. Policies that encourage adequate supervision and feedback to healthcare workers might reduce such failures in clinical decision-making.

The massive roll-out of new and repurposed medicines in low-income and middle-income countries (LMICs) highlights the need for more efficient pharmacovigilance systems, including use of digital technologies. This study reports a large pragmatic cluster-randomised controlled trial to assess the effectiveness of the smartphone app Med Safety in improving suspected adverse drug reaction (ADR) reporting by healthcare workers to Uganda's National Pharmacovigilance Centre. Between Aug 11, 2020 and Nov 1, 2022, 367 clusters (healthcare facilities providing dolutegravir-based combination antiretroviral therapy in Uganda) received the allocated intervention (184 in the intervention group and 183 in the control group), with 2464 health-care workers (1211 in the intervention group and 1253 in the control group). In the intervention group, health-care workers received pharmacist-delivered training in Med Safety and traditional ADR reporting methods. The control group received the same training as the intervention group except for Med Safety training. The primary outcome was the cluster-level ADR reporting rate at the end of follow-up (at least 12 months) and was analysed in all sites that received the allocated intervention. Med Safety use was found to increase ADR reporting rates among health-care workers in Uganda, particularly non-serious and dolutegravir-related ADRs. These findings suggest that integrating digital technologies into pharmacovigilance systems could strengthen drug-safety monitoring in Uganda and other LMICs.

On 18 December 2024, the World Health Organization (WHO) prequalified the first diagnostic test for glucose-6-phosphate dehydrogenase (G6PD) deficiency which can help to safely deliver WHO-recommended treatments to prevent relapse of Plasmodium vivax (P. vivax) infection. The prequalification of this G6PD diagnostic test marks a significant milestone in facilitating safe and effective P. vivax malaria treatment, reaffirming WHO’s dedication to ensuring equitable access to life-saving health solutions globally. Some 500 000 people die each year from malaria, most of them children.

Unsafe care results in over three million deaths each year globally and it is estimated that over half of these deaths are preventable. The majority of harm occurs in low resource setting, where systemic factors relating to context, complexity of care, organisational behaviour, human factors, wider socio-political influences and significant workforce shortages contribute to an increased risk of adverse events. The scope and nature of challenges impacting patient safety in low resource settings remain under-studied and largely undocumented. The journal Frontiers in Health Services is inviting articles to contribute to the Research Topic that explore the challenges of providing high-quality care in low resource settings. It is also looking for studies that explore the strategies, methodologies and evidence of good practice that might be used to overcome these challenges in a wide range of low resource settings across both high- and low-income contexts, and across all healthcare disciplines, including mental health. Research papers may include (but are not limited to): Empirical research studies that aims to explore and/or improve quality and safety of care in low-resource settings globally. Review articles that identify and describe strategies and policies that have led to improvements in patient safety in low resource settings. Evidence syntheses that explore patient safety or quality of care for specific populations in resource-constrained settings globally. Impact evaluation of patient safety and/or quality improvement initiatives, and their generalisability to low-resource settings. Articles which capture the range of methodologies that might be used to measure and evaluate patient safety and quality of care Studies which explore the role of patient and public involvement in patient safety for low resource settings. Manuscript Summary Submission Deadline 20 January 2025 Manuscript Submission Deadline 10 May 2025

In this letter to The Lancet, Thomas Cueni, Director General of the International Federation of Pharmaceutical Manufacturers and Associations argues that the need to focus on equitable rollout of vaccines in the event of a future pandemic is a key global health priority. He proposes that Governments, pharma companies and other stakeholders should focus on the challenges that led to the inequitable rollout of vaccines, which he identifies as vaccine nationalism and need for more diverse manufacturing. He highlights an industry proposal for equitable response to future pandemics supported by vaccine manufacturers and biotechnologies. the proposal involves manufacturers setting aside a percentage of pandemic tools for allocation to susceptible populations in low-income countries.

This report by the World Health Organization (WHO) identifies major global gaps in water, sanitation and hygiene (WASH) services. It outlines that: one third of health care facilities do not have what is needed to clean hands where care is provided one in four facilities have no water services 10% have no sanitation services. This means that 1.8 billion people use facilities that lack basic water services and 800 million use facilities with no toilets. Across the world’s 47 least-developed countries, the problem is even greater, with half of health care facilities lacking basic water services. In addition, the extent of the problem remains hidden because major gaps in data persist, especially on environmental cleaning. The report describes the global and national responses to the 2019 World Health Assembly resolution on WASH in health care facilities. More than 70% of countries have conducted related situation analyses, 86% have updated and are implementing standards and 60% are working to incrementally improve infrastructure and operation and maintenance of WASH services. Case studies from 30 countries demonstrate that progress is being propelled by strong national leadership and coordination, use of data to direct resources and action, and the mutual benefits of empowering health workers and communities to develop solutions together. The report includes four recommendations to all countries and partners to accelerate investments and improvements in WASH services in health care facilities: Implement costed national roadmaps with appropriate financing. Monitor and regularly review progress in improving WASH services, practices and the enabling environment. Develop capacities of the health workforce to sustain WASH services and promote and practice good hygiene. Integrate WASH into regular health sector planning, budgeting and programming to deliver quality services, including Covid-19 response and recovery efforts.

In fragile, conflict-affected and vulnerable settings there is an urgent need for action on quality of healthcare, given the significant health needs of the populations in these environments and the increasing numbers of people for whom such settings are home. The Quality of care in fragile, conflict-affected and vulnerable settings: tools and resources compendium represents a curated, pragmatic and non-prescriptive collection of tools and resources to support the implementation of interventions to improve quality of care in such contexts. Relevant tools and resources are listed under five areas: ensuring access and basic infrastructure for quality shaping the system environment reducing harm improving clinical care engaging and empowering patients, families and communities. Cross-cutting products are also signposted. The compendium is a companion to the World Health Organization resource Quality of care in fragile, conflict-affected and vulnerable settings: taking action.

Fragile, conflict-affected and vulnerable (FCV) settings is a broad term describing a range of situations including humanitarian crises, protracted emergencies and armed conflicts. In FCV settings delivery of quality health services faces significant challenges, including disruption of routine health service organization and delivery systems, increased health needs, complex and unpredictable resourcing issues, and vulnerability to multiple public health crises. Despite the difficulty of addressing quality in FCV settings, the need is acute, given the significant health needs of the populations in such environments and the increasing numbers of people for whom FCV settings are home.   WHO is working with Member States, the Global Health Cluster, and technical and academic partners to support action to address quality in FCV settings. Building on the foundations of the WHO National quality policy and strategy initiative, WHO has developed a technical document, “Quality of care in fragile, conflict-affected and vulnerable settings: taking action”. The document outlines a practical approach to action planning and implementation of quality interventions in FCV settings and is accompanied by a curated compendium of tools.

Improving patient safety during anesthesia and surgery is a major public health issue, with safety standards varying from country to country. Anesthesia safety is often hampered by complex problems in low income countries. This survey assesses the unmet anesthesia needs in Ethiopia. The author concludes that anesthesia safety in Ethiopia appears challenged by substandard continuous medical education and continuous professional development practice, and limited availability of some essential equipment and medications. The study states that while patient monitoring and anesthesia conduct are relatively good, World Health Organization surgical safety checklist application and postoperative pain management are very low, affecting the delivery of safe anesthesia conduct.

Diagnostics function as a compass in healthcare. They help determine the cause of a person’s condition, thus steering the healthcare provider towards the appropriate treatment or care pathway to address a disease and determine whether the approach is working. Despite their value in the healthcare delivery system, innovation, implementation, reimbursement and accessibility include barriers that constrain the use of diagnostics, particularly in low- and middle-income countries (LMICs), where increased availability could lower healthcare costs while saving lives. How can leaders increase affordable access to essential diagnostics globally? How can diagnostic advances be supported without contributing to growing disparities across the globe? This report seeks to address these questions through a landscape review of the global diagnostic ecosystem – including identifying key stakeholders, barriers and enablers along the product life cycle and the effectiveness of diagnostics – while highlighting the various challenges, opportunities and potential solutions across high-income countries and LMICs.

The 17 September marks World Patient Safety Day, and this year the focus is on ‘Safe maternal and newborn care’. Recently there has been greater research attention on patient safety in low- and middle-income countries due to the global awareness of the need to improve safety standards for all patients, including in maternal care. In this blog, I highlight the scale of maternal and newborn death in low- and middle-income countries, the contributing factors to this, and the need to improve maternal health and safety. The 17 September marks World Patient Safety Day, and this year the focus is on ‘Safe maternal and newborn care’. Patient Safety Learning has recently published a blog highlighting and summarising this topic.[1] While issues of unsafe care are a global challenge, they disproportionately impact on low- and middle-income countries. 134 million adverse events occur in hospitals every year in such countries, contributing to 2.6 million deaths.[2] Research in patient safety has primarily been associated with high income countries, but more recently there has been greater attention on low- and middle-income countries due to the global awareness of the need to improve patient safety standards for all patients, including maternal care.[3] Worldwide, around 295,000 women died during and following pregnancy and childbirth in 2017.[4] Approximately 810 women and 6,700 newborns die every day from preventable causes related to pregnancy and childbirth.[5] These global statistics are shocking and highlight the attention that is needed to address maternal safety. Of all the global maternal deaths, 94% occur in low- and middle-income countries.[4] This reflects inequalities in access to quality health services and highlights the global gap between rich and poor.[3] Of the many health statistics monitored by the World Health Organization (WHO), the largest gap between rich and poor nations is seen in maternal mortality levels.[7] Sub-Saharan Africa and Southern Asia accounted for approximately 86% of the estimated global maternal deaths in 2017.[4] Adolescent girls are more likely than older women to die due to complications related to pregnancy and childbirth; this is the leading cause of death for adolescent girls in low- and middle-income countries.[8] Infants also suffer greatly – of the approximate 8 million infant deaths each year, around two-thirds occur in the first month of life in low income countries.[6] Moreover, about 2 million babies are stillborn every year, with over 40% occurring during labour.[5] Maternal deaths occur as a result of complications that can transpire during and following pregnancy and childbirth, most of which are preventable or treatable.[4] The major complications that account for nearly 75% of all maternal deaths include severe bleeding after childbirth, infections and pre-eclampsia.[4] Additionally, for every woman who dies, at least 30 others are injured, often in disabling and socially devastating ways.[8] For example, obstetrical fistula is common in poor communities in sub-Saharan Africa and South Asia, where access to maternal health services is limited.[9] Most of neonatal and perinatal deaths are the result of poor maternal health and inadequate care during pregnancy and delivery and the critical immediate postpartum period.[6] The main factors that prevent women from receiving or seeking care during pregnancy and childbirth in low- and middle-income countries are poverty, distance to facilities, lack of information, inadequate and poor-quality services, and cultural beliefs/practices.[4] For instance, 35% of Senegalese women who live in rural areas deliver their children at home, often without a skilled midwife or birth attendant present, which poses dangers to both mother and child.[7] Care by trained staff is vital in preventing maternal deaths in low-income countries, yet only about half of births in such countries occur in health facilities.[9] Poor person-centred maternity care (PCMC) is one of the main factors driving both the low proportions of facility-based deliveries and high maternal mortality.[8] There is also a strong connection between the low societal status of women in low income countries and the risk of maternal illness and death.[6] The reality is that most maternal deaths are preventable, as the healthcare solutions to prevent or manage complications before, during and after childbirth are well recognised. It is particularly important that all births are attended by skilled health professionals because timely management and correct treatment can preserve the life of both mother and baby.[4] To improve maternal health in low- and middle-income countries, barriers that limit access to quality maternal health services must be identified and addressed at both health system and societal levels.[4] While additional resources are essential to patient safety improvement in low-income settings, such resources on their own will not be enough to secure the changes needed.[9] Recognising the scale of this problem, improving maternal health is now one of WHO’s key priorities.[6] Whilst many other health indicators have improved over the last two decades, maternal mortality rates in low- and middle-income countries have remained high and progress in reducing maternal and newborn mortality has been very slow.[8] Unsafe maternal care represents a serious and considerable danger to patients in low income countries – primarily due to scarce resources, weak infrastructure, cultural beliefs and limited skilled professionals – hence it should be a high priority public health problem that needs drastic attention.[10] References Patient Safety Learning. Safe maternal and newborn care: World Patient Safety Day 2021. The G20 Health and Development Partnership and RLDatix. The Overlooked Pandemic: How to transform patient safety and save healthcare systems, 2021. Elmontsri M, Banarsee R, Majeed A. Improving patient safety in developing countries – moving towards an integrated approach. JRSM Open, 2020; 9(11). World Health Organization. Maternal mortality, 2019. World Health Organization. World Patient Safety Day 2021, 2021. Donnay, F. Maternal survival in developing countries: what has been done, what can be achieved in the next decade. Gynecology & Obstetrics, 2000; 70(1). Plan International. What pregnancy looks like in 10 developing countries, 2018. Rosenfield A, Min C, Freedman L. Making Motherhood Safe in Developing Countries. The New England Journal of Medicine, 2007; 356:1395-1397. Aveling E, et al. Why is patient safety so hard in low-income countries? A qualitative study of healthcare workers’ views in two African hospitals. BMC, 2015; 11(6). Wilson R, et al. Patient safety in developing countries: retrospective estimation of scale and nature of harm to patients in hospital. BMJ, 2012; 344.

There are estimated 24 000–60 000 women who are pregnant and incarcerated worldwide and they often lack access to antenatal care at the same level as that available in their communities. Despite clear international standards that mandate equivalent care for people in prison, pregnant women in these settings face significant barriers to adequate antenatal care. The needs of pregnant women are often overlooked in prisons designed to house men . We must not forget this vulnerable and hidden cohort of women. Molly Skerker et al. explore the challenges for pregnant women in prisons worldwide.

The International Standards for a Safe Practice of Anesthesia (ISSPA) were developed on behalf of the World Federation of Societies of Anaesthesiologists and the World Health Organization. It has been recommend as an assessment tool that allows anaesthetic providers in developing countries to assess their compliance and needs. This study from Tao et al. was performed to describe the anaesthesia service in one main public hospital during an 8-month medical mission in Cambodia and evaluate its anaesthetic safety issues according to the ISSPA.

The safety of anesthesia characteristic of high-income countries today is not matched in low-resource settings with poor infrastructure, shortages of anesthesia providers, essential drugs, equipment, and supplies. Health care is delivered through complex systems. Achieving sustainable widespread improvement globally will require an understanding of how to influence such systems. Health outcomes depend not only on a country's income, but also on how resources are allocated, and both vary substantially, between and within countries. Safety is particularly important in anesthesia because anesthesia is intrinsically hazardous and not intrinsically therapeutic. Nevertheless, other elements of the quality of health care, notably access, must also be considered. Surgical and anesthesia services must not only be provided, they must be safe. The global anesthesia workforce crisis is a major barrier to achieving this. Many anesthetics today are administered by nonphysicians with limited training and little access to supervision or support, often working in very challenging circumstances. Many organisations, notably the World Health Organization and the World Federation of Societies of Anaesthesiologists, are working to improve access to and safety of anesthesia and surgery around the world. Challenges include collaboration with local stakeholders, coordination of effort between agencies, and the need to influence national health policy makers to achieve sustainable improvement. It is conceivable that safe anesthesia and perioperative care could be provided for essential surgical services today by clinicians with moderate levels of training using relatively simple (but appropriately designed and maintained) equipment and a limited number of inexpensive generic medications. However, there is a minimum standard for these resources, below which reasonable safety cannot be assured. This minimum (at least) should be available to all. Not only more resources, but also more equitable distribution of existing resources is required. Thus, the starting point for global access to safe anesthesia is acceptance that access to health care in general should be a basic human right everywhere.

The United Nations 2015 Millennium Development Goals targeted a 75% reduction in maternal mortality. However, in spite of this goal, the number of maternal deaths per 100,000 live births remains unacceptably high across Sub-Saharan Africa. Because many of these deaths could likely be averted with access to safe surgery, including cesarean delivery, Epiu et al. set out to assess the capacity to provide safe anaesthetic care for mothers in the main referral hospitals in East Africa. The authors identified significant shortages of both the personnel and equipment needed to provide safe anaesthetic care for obstetric surgical cases across East Africa. There is a need to increase the number of physician anaesthetists, to improve the training of non-physician anaesthesia providers, and to develop management protocols for obstetric patients requiring anaesthesia. This will strengthen health systems and improve surgical outcomes in developing countries. More funding is required for training physician anaesthetists if developing countries are to reach the targeted specialist workforce density of the Lancet Commission on Global Surgery of 20 surgical, anaesthetic, and obstetric physicians per 100,000 population by 2030.

This is a study evaluating the implementation of a patient safety programme across a paediatric department at the largest public hospital in Guatemala. In their conclusion, the authors note that implementing such programmes in low-resource settings requires recognition of facilitators such as staff receptivity and patient-centredness as well as barriers such as lack of training in patient safety and poor organisational incentives.

Although there have been significant advancements over the past decades, substantial gaps in safety and quality remain in healthcare delivery, especially in low- and middle-income countries (LMICs) and the public sector. Even within the same country, there are notable geographical disparities in equitable access to safe care. Healthcare organizations (HCOs) and countries worldwide face numerous challenges and have competing priorities for focused interventions, often struggling to invest adequately in safety and quality. In alignment with the Global Patient Safety Action Plan 2021-2030 and JCI’s vision, JCI introduces Patient Safety Pathways. This pioneering initiative aims to develop, strengthen, sustain, and enhance patient safety initiatives with actionable plans, especially for organisations in the early stages of establishing their patient safety and quality infrastructure. JCI is working in collaboration with countries and organizations to advance safer patient care. The Patient Safety Pathways initiative focuses on the needs of HCOs starting their journey towards eliminating avoidable patient harm by creating pathways for incremental improvements and transformative changes. This collaboration includes working with Ministries of Health (MOHs), national and international HCOs, and patient advocacy organizations at various stages of development to enhance the quality of healthcare and patient safety. The Pathways Initiative components: Patient Safety Grand Rounds A series of online discussions to engage thought leaders in patient safety at policy, systems, and healthcare delivery levels through open dialogue, collaborative learning, problem-solving, and sharing of best practices and success stories. JCI Training of Trainers Develop a cadre of trainers as “Patient Safety Champions.” These champions will be equipped with the necessary knowledge and tools who in turn can help develop skills and competencies for healthcare professionals, fostering a culture of safety at the national and organizational level. Needs assessment and technical support Tailored technical support to selected HCOs from LMICs, based on their identified needs and gaps.

Hospital accreditation programmes are globally recognised as an important tool for enhancing quality and safety in healthcare; however, many programs in low- and middle-income countries (LMICs) are discontinued shortly after their establishment. This scoping review synthesized published evidence on factors influencing the establishment and sustainability of hospital accreditation programs in LMICs, to provide guidance to health stakeholders involved in these processes.  The included studies reported upon a broad range of patterns, innovations, influencers, enablers, and barriers concerning accreditation program establishment in LMICs. Key questions emerged, including the degree of government involvement, incorporation of international standards versus development of bespoke standards, the use of local versus external surveyors, the use of financial and other incentives to promote engagement, and mandatory versus voluntary approaches of program implementation. Resource constraints were recognised as the most important barriers to sustainable establishment, while the influence of global accreditation and donor agencies were viewed as presenting both positive and negative impacts. Health stakeholders are encouraged to reflect upon and apply the ACES-GLEAM framework, incorporating the guiding principles outlined in this paper, to help establish hospital accreditation programs in LMICs in a way that facilitates sustainability and effectiveness over time.