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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.

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 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.

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.

This editorial in The Lancet Infectious Diseases reflects on the consequences of the infected blood scandal, in which more than 30,000 people in the UK were infected after receiving contaminated blood products in the 1970s and 1980s. It examines the systems in place for blood donation and transfusion in low and middle income countries (LMICs) and argues that the chance of a blood scandal coming to light in LMICs is much higher. This is because blood donations in many LMICs go against the WHO recommendation of national blood systems being based on blood supply from voluntary donors. Instead, they rely heavily on paid-for donations and family or replacement donations, which are unsafe due to the higher prevalence of bloodborne infections.

The Bulletin of the World Health Organization is a fully open-access monthly journal of public health with a special focus on low and middle-income countries.

To overcome this preventable disease we need to invest in failing infrastructure and tackle humanitarian crises at cholera’s roots, says Petra Khoury in this BMJ article. Once thought to be close to eradication, cholera is back—dehydrating and killing people within hours and ravaging communities across six continents. Despite the alarming numbers of cases and deaths over the past year, decision makers are averting their eyes, leaving people to die from a preventable and treatable disease. The healthcare community should sound the alarm for immediate actions. A strong and global emergency response is urgently needed, but it is only a first step. More than ever the world must invest in water and sanitation systems and prepare communities before outbreaks occur.

Globally, the under-five mortality rate (U5MR) fell to 38 deaths per 1,000 live births in 2021, while under-five deaths dropped to 5.0 million. Although this demonstrates a decrease, this immense, intolerable and mostly preventable loss of life was carried unequally around the world , and children continue to face widely differing chances of survival based on where they are born. In contrast to the global rate, children born in sub-Saharan Africa are subject to the highest risk of childhood death in the world with a 2021 U5MR of 74 deaths per 1,000 live births – 15 times higher than the risk for children in Europe and Northern America and 19 times higher than in the region of Australia and New Zealand This report outlines and analyses figures from The United Nations Inter-Agency Group for Child Mortality Estimation (UN IGME) to examine levels and trends in child mortality around the world during 2022. Key findings Almost everywhere in the world, a child born today has a better chance at surviving to age 5 than in 1990, but inequities persist among and within countries Divergent chances of survival start from the earliest ages Globally and across all regions, the probability of dying between the ages of 5 and 24 is lower than for children under 5 years old, yet more than 2 million children, adolescents and youth aged 5—24 died in 2021

A large proportion of avoidable harm and adverse events occur in fragile, conflict-affected and vulnerable (FCV) settings. This article in the BMJ Open outlines the online Delphi study approach that will be taken to generate a consensus on the most relevant patient safety interventions for FCV settings. The results of this study will create a list of the most relevant patient safety interventions, based on the consensus reached among a range of experts including frontline clinicians and administrators, non-governmental organisations, policymakers and researchers. The study aims to increase awareness of the issues in this area, and identify priority interventions as well as areas for further evaluation and research.

This article in the Journal of Global Health aimed to consider which patient safety interventions are the most effective and appropriate in fragile, conflict-affected, and vulnerable (FCV) settings. The authors examined available literature published between 2003 and 2020, using an evidence-scanning approach. They found that the existing literature is dominated by infection prevention and control interventions for multiple reasons, including strength of evidence, acceptability, feasibility and impact on patient and healthcare worker wellbeing. They identified an urgent need to further develop the evidence base, specialist knowledge and field guidance on a range of other patient safety interventions such as education and training, patient identification, subject specific safety actions and risk management.

The article in the Journal of Global Health examines the unique patient safety risks that can arise in fragile, conflict-affected and vulnerable settings (FCV), including humanitarian crises, conflict, extreme adversity, services disruption and immediate or protracted emergencies. Recent estimates suggest a large proportion of the total number of preventable deaths take place in FCV settings, including 60% of preventable maternal deaths, 53% of deaths in children under five years, and 45% of neonatal deaths. The authors highlight a gap in knowledge and research about healthcare in FCV settings, which prevents researchers from being able to effectively assess interventions for quality, safety and sustainability. They suggest that more academic research is urgently needed in order to make policy and practice more effective in improving patient safety in these settings.

This report by Save the Children's Global Medical Team (GMT) shares the results of independent audits conducted in 2021. The audits aimed to assess the safety and quality of clinical and pharmacy services delivered by the organisation across seven countries. The team strategically focused on higher-risk programmes where Save the Children staff deliver services directly, with an aim to ensure that services remain safe and fully assured. This report highlights some key findings. Clinical services 100% of direct medical services were conducting the Clinical Standards Scorecards to ensure the safety of their service provision. However, use of the monthly and quarterly checklists was not as high or as regular. Direct service delivery in a majority of countries audited (5 out of 7) were fully compliant with the Clinical Standards. The average patient satisfaction score was 88%, outlining that in general, the 105 patients surveyed were satisfied with all aspects of service provision within our direct medical services. The report also makes recommendations for improvement related to: Infection prevention and control Morbidity and mortality reviews Clinical referrals Medical standard treatment compliance Clinical triage Infrastructure Human resources for health Pharmacy services Overall compliance to pharmacy standards varies significantly across countries, ranging from 57 to 100%. Compliance with waste management and Medical Incident Reporting (MIR) is generally high (above 80%) across all seven countries. Countries that were able to attend GMT Pharmacy Reference Group meetings on a regular basis had higher compliance scores. The report also makes recommendations for improvement related to: Sourcing medications In-country staff engagement Stock management Medication storage Ensuring pharmacy support at a local level

Nigeria is projected to become one of the most populous countries in the world, and is rightly taking its place on the world stage. The Lancet Nigeria Commission tells the story of the country through a health lens, and details recommendations that will enable the country and its people to fulfil their potential, and seize the opportunity ahead. It has been led by Nigerians for Nigerians. The Commissioners call for the creation of a new social contract that redefines the relationship between citizen and state. They argue that health has, to date, been neglected by successive governments and consequently the citizens of Nigeria, and must be recentred as a vital investment in the population – one that will reap political and economic benefits. Nigeria is poised to define the future of West Africa, the African continent, and the whole world. This Commission lays out how best to realise that ambition.

Despite global consensus that access to pharmaceuticals as a lifesaving commodity is a fundamental human right, 2 billion people globally still lack access to medicines. In this blog, Karrar Karrar, Access to Medicines Adviser at Save the Children, looks at why weak regulatory systems are a major patient safety issue in low- and middle-income countries. He highlights that lack of regulatory capacity results in falsified, substandard and fake medicines making their way into local pharmacies and hospitals. It also delays patient access to new medicines due to lengthy processing times. Karrar argues that governments must prioritise investments in strengthening national regulatory systems and increase cross-country collaboration to strengthen regional and global regulatory networks and systems.