Theme 1: Microsystem and individual health worker(s) motivation.

The willingness and commitment of individual health workers to make improvements, their ability and self-efficacy regarding change efforts, shared values, beliefs, and norms that affect teamwork, interpersonal communication and decision making, and the capacity of health workers and managers to lead QI can constrain or promote QI in PHC settings. Three multi-country studies in Sub-Saharan Africa [62, 79, 83], 19 single country studies in SSA (three apiece in Nigeria, South Africa and Uganda, two each in Benin, Ethiopia and Rwanda, and one study across Benin, Kenya, Mali, Tanzania and Zimbabwe reported various aspects of individual- and microsystem- level barriers to and enablers of QI along with the two studies [48, 56] from Latin America (Costa Rica and Haiti). Studies in Indonesia [70]; in Sri Lanka [76]; in India [49]; in Tajikistan [80]; and in Papua New Guinea [67] also discussed aspects of microsystems and individual health worker motivations for QI. All studies had good quality ratings using the mixed methods appraisal tool.

Health workers and other PHC stakeholders reported that job satisfaction arising from participating in QI activities was an important source of motivation, encouraging them to increase efforts and stirring up their desire to address the community’s health needs. Added to this, health workers felt extrinsically motivated by financial and non-financial incentives as was the case in Nigeria [46] where Odusola and colleagues found that such inputs bolstered efforts to expand hypertension preventive services and in Haiti where those health workers perceived an initiative to reduce absenteeism favourably because they thought it promoted openness in the performance-based financing scheme [56]. On the other hand, lack of recognition for putting in effort dimmed motivation levels. Other motivators included a strong desire to help one’s community and appreciation of the justification for a proposed QI project.

Motivation also arose out of observation of positive changes in the PHC setting due to QI and this was underscored by grateful clients or patients. Leadership by PHC facility and district QI mentors who remained committed and were able to showcase the use of context-specific data for QI was also found to enable QI. On the contrary, health workers did not like overlapping QI data streams because this, they perceived, stole time that they would otherwise spend caring for their patients.

Studies also reported the importance of buy-in by health workers and their managers into proposed QI interventions. This was signified by health workers embracing a spirit of personal sacrifice to receive public praise, including by PHC clients from the community. Further, research reports found that participants often embraced QI because they had grown dissatisfied with existing dismal quality of PHC services and felt an urgency to change [67, 74, 79, 81, 87].

Self-efficacy and capability to undertake QI was also highlighted in studies. A high level of technical and managerial proficiency acquired after implementing QI initiatives over time as reported from research in Kenya and Costa Rica [46, 48], promotes effective production, analysis, and use of PHC data for improvement. Moreover, participants in QI felt empowered and competent following training sessions which also served to help develop an understanding of their roles and responsibilities in QI [49] leading to increasing levels of comfort with QI approaches and methods [52]. Health workers reported that they could not spare time to attend QI meetings due to clinical engagements, a possible constraint. Other barriers reported in the literature included the sense of despair with which some easily gave up on QI initiatives when faced with multiple obstacles. An example of this came from a convergent mixed methods process evaluation of continuous quality improvement in South Africa [69] where health workers were discouraged by layers of managerial approval. In such cases across multiple PHC contexts, QI tasks were perceived to be time consuming—reducing health workers’ confidence in the QI initiative—and abandoned [45, 48, 49, 52, 54, 58, 59, 62, 67, 69, 71–75, 81, 83–85, 90].

Health workers developed personal skills through their participation in QI initiatives. Skills such as empathy and enhanced communication with PHC clients reportedly led to deeper connections with fellow health workers but also clients. This was seen to facilitate QI. Still, familiarity with patient-centered approaches to PHC, regular review meetings where gaps and root causes to poor service quality were discussed, and internal supervision where knowledge was shared, and additional skills acquired was reported in the literature as important enablers. On the other hand, health workers in PHC who felt inadequately skilled in technical and clinical aspects and in the use of technology reported difficulties engaging effectively in QI [71, 74, 83].

Culture, comprised of shared norms, values, knowledge, artefacts, and practices, was found to play an important role in health workers’ efforts to improve the quality of PHC. For example, QI efforts appeared to thrive in PHC settings with strong culture of using data to orchestrate healthcare improvements, where health workers’ attitudes shift to focus more on the needs of patients (e.g., the desire to alleviate pain and reduce suffering), and where HCWs learn better and systematic approaches to solving problems [46, 47, 52, 55]. Additionally, culture of quality manifested in health workers being able to work across disciplinary boundaries, where QI initiatives stir up healthy competition, and where participants reported collective responsibility for cohesion, meritocracy, a strong sense of taking responsibility for failure and success, and high standards in the PHC setting or workplace [55, 63]. Microsystem culture such as working with unsupportive colleagues where workload is not shared and characterized by a rejection of quality checklists [79] was found to be unsupportive of QI. In Indonesia, Limato and others [70] conducted 28 in-depth interviews in West Java Province. This led them to conclude that health workers at government-owned PHC facilities had a general tendency to reject transparency and accountability, which led to the failure of a QI initiative built around performance-based financing. Evidence on workplace culture’s role in boosting or dooming QI interventions also came from other studies in multiple LMIC contexts [48, 54, 59, 60, 62, 64, 65, 68, 74, 81].

Theme 2: Attributes of quality improvement intervention.

Component attributes of a QI intervention discussed under this theme include its strength and the quality of evidence underpinning it, how and whether participants perceive it to be beneficial, its cost, potential to be scaled up, and perceived sustainability. Other characteristics of the QI intervention that can enable or constrain its implementation may include its trialability (being trialed in small measures where potential failure is not catastrophic), the ease with which it can be integrated into existing health worker roles and tasks, and whether clients were afforded opportunity to shape its design. Rounding up the key attributes of any QI intervention is the source of the intervention which may dictate its acceptability, its complexity i.e., ease with which implementers understand it, scope, and disruptiveness during roll out; and closely related to this, feasibility (the extent that implementers feel confident that they can adopt the QI intervention) [26, 39].

SSA studies contributing to this theme included five each from Tanzania and South Africa; four from Ethiopia; and two each from Rwanda and Nigeria. Five African countries (Benin, Kenya, Mali, Namibia and Zimbabwe) each had a single-country study while Tanzania, Rwanda, Kenya, Nigeria Malawi, Burkina Faso, Mozambique, and Ghana were each part of a multi-country study. In Asia, Indonesia, Tajikistan, Sri Lanka and Papua New Guinea each contributed a study with India contributing two. Studies from Haiti and Costa Rica round up the list of those that contribute an understanding of enablers and barriers related to QI intervention attributes in PHC in LMICs.

QI implementation is enabled when health workers and managers perceive an intervention to be effective e.g., by observing the desired outcomes for patients and successful acquisition of new skills [41, 44, 62, 67, 72, 74, 75, 81]. A relative advantage accrues when implementers view a new QI initiative as better than current practice and when the intervention is designed to foster collaboration among a diverse team of workers, and even PHC clients. In contrast, QI is constrained when a QI project does not lead to any tangible improvement or is seen to bear negative or unanticipated consequences like creating an administrative burden for already overstretched HCWs that may manifests in multiple reporting channels. Other barriers were reported in the literature: an intervention package that does not envisage nor address other contextual and health systems barriers to successful implementation such as when was QI focused on short term technical fixes but did not address nor consider structural bottlenecks to PHC quality.

Cost, scalability, and sustainability aspects of QI were closely related. As enablers, the design of a QI intervention needs to make provision for long-term work to sustain changes while ensuring that its costs do not overwhelm the PHC system’s capacity [48, 56, 62, 70]. At the same time, QI is scalable when QI interventions are perceived to be easily transferable to a new area of work within a PHC setting, to other health workers, or even to other health facilities by adopting small incremental changes rather than rapid disruptions [44, 52, 57, 72, 73]. Additionally, QI interventions are supported by health workers and health facilities when perceived to be sustainable, i.e., when participants feel confident of continued implementation beyond the planned intervention period [45, 48, 50, 56, 62, 69, 72, 75, 80].

The significance of designing QI interventions in a manner that ensures that health workers see alignment between the proposed QI package and their everyday work responsibilities (job expectations in the PHC practice setting) while complementing participants’ and health system’s values was addressed by Ulrike Baker and colleagues [41] in their qualitative process evaluation of QI in Southern Tanzania and Mary Kinney and her counterparts [65] who used multiple case studies to understand sustainability of MPDSR in South Africa. Good examples of facilitating factors regarding trialability pointed to QI interventions that had been adapted and pre-tested to suit local conditions [42, 43]. Barriers that may thwart assimilation included new interventions that are difficult to integrate into routine PHC practice or those that require substantial modifications to service delivery workflows and an array of new skills for practitioners, new initiatives perceived to be inflexible or rigid, in addition to those that do not explicitly build on existing initiatives [44, 45, 78, 81, 86, 88, 90].

Paying attention to the preferences of PHC clients when designing QI interventions that affect them was thought to enable QI in addition to health workers’ inputs to intervention design and was outlined by Mutambo and colleagues [77] who explored HCWs’ perspectives during the setting up of child-friendly spaces in PHC clinics in KwaZulu-Natal, South Africa. However, Umunyana and others [71] in Rwanda and Olaniran and colleagues [86] in Nigeria reported that QI interventions that do not allow implementers to make or suggest adaptations might lead to such initiatives being viewed as alien and imposed, potentially leading to their rejection and failure.

Less complex QI interventions focus on a specific problem, are not too general and do not try to address too many things instantly or concurrently. These were some of the enabling factors identified in the literature. Other facilitating factors included having streamlined management structures in their design. Barriers identified by participants in relation to intervention complexity included those that are considered hard to understand, not easily translatable into tangible action plans, and QI interventions perceived as not user-friendly [42, 52, 66, 67, 70, 75, 81, 85, 86, 90], and found that QI projects considered feasible, timely and aligned local priorities were widely embraced, contributing to successful implementation.

Theme 3: Organization and implementing team.

Buy-in (ownership), norms and culture, leadership, and decision-making at the organization level complement the tenure, prior experiences, cohesion, and skills of the implementing team to shape QI processes and outcomes. Also, maturity of the organization’s approach to QI, presence of subject matter specialists able and willing to guide health workers at PHC facilities, and the participation of physicians in QI initiatives received important considerations in research reports included in this review and are described under this theme.

Studies outlined the barriers to and enablers of PHC QI at the meso level in 15 different countries in SSA as reported in 36 different articles. The SSA countries include Uganda, Rwanda, Ethiopia, Burkina Faso, Mozambique, and Mali that are low-income settings; lower middle-income countries of Benin, Ghana, Kenya, Malawi, Nigeria, Tanzania, and Zimbabwe; and South Africa and Namibia being upper middle-income settings.

Ensuring that leaders, managers, health workers and other stakeholders buy in to QI initiatives in PHC emerged strongly from the literature. Baker and others [41] found that health care workers (HCWs) were more receptive to continuous quality improvement (CQI) and welcomed on-job-training meant to bolster their skills in Southern Tanzania. This was echoed by Coulibaly and colleagues [81] in Mali where positive reception of a performance-based financing scheme for improving PHC services was noted among the initiative’s strengths. Elsewhere, adequately preparing the team prior to introducing QI, having point persons to champion QI in the health facility and PHC network, managers and team members who do not mind taking up additional or new responsibilities and an enthusiastic team that readily and publicly commit to PHC quality improvements were also important enablers of QI [46, 47, 50, 52]. In areas where there was little buy in, such as in Papua New Guinea [67] where regional managers exercising their hidden powers opposed QI, and in Indonesia [70] where ‘ego programming’, the tendency by those that perceive themselves to be outside a QI programme to decline participation, QI initiatives faltered. Organizations also rejected QI outright, with some declaring proposed interventions to be unsuitable without due consideration e.g., in Uganda [68] while middle managers in decentralized PHC settings simply went missing and did not cooperate or support frontline HCWs with QI efforts e.g., in Rwanda and Malawi [73].

QI interventions can flourish in organizations and teams with the right norms and where culture is supportive. A new way of solving intractable problems, regular team reviews that are focused on quality of care [52], finding ways to cope positively with scarcity when resources aren’t adequate and lack of control at lower levels in centralized PHC settings [55] were mentioned. A quality culture with shared values, attitudes, practices at the organization level includes regular data analysis that drives action and improvement cycles, with feedback loops built around effective communication where QI progress is shared with stakeholders who in turn are responsive. Some downsides to quality culture reported in the literature include unchallenged absenteeism by HCWs [56]; decreasing concern for and normalization of common adverse PHC outcomes [59]; adversarial relationships between managers and HCWs; and a perversive lack of accountability where no follow up is done to ascertain achievement of agreed QI work plan targets [62, 76, 79], which constrain the ability of PHC to meet patient and client needs.

The maturity of an organization in undertaking QI was reportedly facilitated by accreditation processes which inspire a virtuous cycle of QI. Organizations undergoing accreditation are expected to plan for QI, allocate budgets and subsequently avail resources needed to enhance the quality of PHC services over time [67]. But the presence of concurrent and similar QI programmes in the same organization might introduce fragmentation and bring about confusion regarding organizations’ priorities, a potential barrier [70]. Lack of institutional knowledge, where implementers do not fully understand organizational bureaucracies, can also hamper QI [80] where planned changes are complex and system wide. QI teams with short tenure due to high staff turnover appeared to reduce organizational maturity for QI implementation, e.g., in Benin where QI team members took up new jobs, and lack of community support and irregular monetary incentives affected teams’ longevity [58].

Using pre-post designs with interviews and focus groups, the role of leadership in facilitating QI was reported by Limato and colleagues [70] in Indonesia and Nahimana and colleagues [84] in Rwanda where leaders owned and steered interventions. In contrast, Hounsou and colleagues [89] using mixed methods reported that a lack of interest by managers constrained MPDSR in Benin. Senior leaders, especially, need to actively embrace and publicly show support for QI for it to succeed as health workers do not wish to second guess their bosses’ allegiances [43, 56, 64, 69, 77, 82]. While such champions can drive change within organizations and foster acceptance of QI initiatives, wearing too many hats can contribute to a lack of focus and become a distraction for QI. Weak leadership by governments in LMICs especially means that QI stewardship and monitoring was frequently left to donors and external partners, and this is in part because of lack of clarity in QI leadership arrangements and high turnover of leaders. In a sub-unit in Ethiopia, for example, leadership constantly changed hands [54]. Similarly, Eboreime and colleagues [45] linked weak leadership to organization culture unfavorable for QI, which proved detrimental to efforts to strengthen PHC quality in Kaduna state in Nigeria.

Physician involvement in QI also acted as an enabler and a barrier, depending on the context. Physicians assume leadership and help build other health workers’ skills. However, in Karnataka State in India [49] found QI constrained in situations where the physician over-asserted authority and ignored other team members’ contributions. Findings in Bihar [59], still in India, also highlighted the important gap left when doctors did not take up their roles as QI mentors in the context of management of birth complications for newborns, with fatal consequences.

Positive team experiences from successful legacy QI projects also reportedly produced domino effects e.g., in Tanzania [90] cross-pollination of ideas occurred when successful initiatives were shared across institutions. Incidentally, in both South Africa [65] and Southern India [49] strong social networks among health workers enabled QI whereas less cohesive teams reported worse outcomes. Strong teams also reported better, inclusive decision-making from the start of a QI project and balanced top-down and bottom-up approaches in decision making. Here, diversity was a strength as everyone was involved. A good example came from Uganda [68] where Hutchinson and colleagues used qualitative methods to study collaborative improvement (CI) for malaria surveillance. They report that CI was undertaken by small, committed teams who willingly involved patients and volunteers. Conversely, barriers to QI arise when team leaders do not genuinely involve others like non-technical (auxiliary) staff, who begin to feel sidelined.

Elaborating on the importance of subject matter specialists for advancing QI initiatives, in Uganda [50] participants received excellent support from a mental health specialist who had good knowledge of clinical practice guidelines, joining champions to bolster QI. The development of skills and knowledge also increases when trained team members report back to fellow health care workers, enabling key QI concepts such as Pareto charts, root cause analysis, and PDSA cycles to percolate in the team for a shared understanding [71, 72], with regular on-job training [69]. One-off training that leaves QI team members without adequate knowledge and skills needed to implement QI were characterized as barriers [72].

Theme 4: Health systems support and capacity.

Availability, adequacy, and distribution of resources needed to deliver PHC services to communities were key contextual drivers for QI reported in studies. Studies found weaknesses in PHC systems pillars required for quality enhancements, signifying inadequate capacity for QI. These include gaps in staffing, supplies and commodities, equipment and devices, physical space and infrastructure, data infrastructure and reporting, learning and knowledge systems, management of patient referrals, and leadership and governance. Some enablers of and barriers to QI under this theme e.g., those relating to leadership and management and to staff training and development, inevitably affect and are affected by those discussed in the other themes in this review. Tellingly, no country among the LMICs studied reported adequate or excess levels of resourcing for QI. Consequently, most of this section describes barriers to QI rather than enablers.

Forty-two studies highlighting various aspects of health systems support and capacity came from 13 different SSA countries. There were also five studies conducted in four Asian countries (India, Indonesia, Sri Lanka and Tajikistan) and two studies from Latin America (Haiti and Costa Rica).

The first barrier to QI in LMICs concerns a dearth of health workers which pervades health systems and within these, PHC delivery structures do not appear exempt. Low numbers, frequent leave of absence, and rapid turnover of staff are each associated with high workload and were reported as important constraints to QI [43, 50, 62, 63, 66, 68, 73, 76, 83, 84, 88, 89]. Where staff are available, aligning job descriptions and incentives appeared in the literature as a potential enabler of QI.

Adequate, well designed physical space aids intuitive flow of clients, encourages health workers to undertake certain tasks that are important for quality of care such as handwashing or waste segregation, or even providing oversight to acute cases in the newborn unit from the nurses’ station. On the other hand, literature pointed to sub-optimal infrastructure (poorly designed) and or limited physical spaces as barring improvement actions [51, 77, 79, 81, 90]. This manifested as lack of much needed laboratories and pharmacy stores in Sri Lanka [76], for example.

Studies discussed the role of medical equipment and data infrastructure in relation to QI [69, 71, 75, 77, 81, 83, 85, 88]. Participatory and data-driven QI activities, revising data and tools to ensure harmonization of reporting systems were found to facilitate QI. Inadequate patient records at the PHC facility level as well as a lack of equipment, on the other hand, were mentioned as constraining attempts to enhance PHC service delivery and quality. As with equipment and staffing, stockouts of essential supplies and medicines was also reported as barrier to QI in PHC settings in LMICs including but not limited to Sri Lanka [76], India [78], Ethiopia [82], Nigeria and Tanzania [83, 86] and Rwanda [84].

Availability of resources to support QI was the focus of studies in Kenya [46], Uganda [52, 57], Democratic Republic of the Congo [51], Zimbabwe [53], Ethiopia [54, 72, 82], Malawi [55, 73], Haiti [56], India [59], Benin [58, 89], South Africa [60, 65, 69, 75], Tanzania [42, 61, 90], Zimbabwe [62], Rwanda [64], Namibia [66], Indonesia [70], Mozambique and Burkina Faso [79], Tajikistan [80], Mali [81], and Nigeria [44, 45, 86], underscoring its importance to impede QI and shared concerns across many LMIC contexts.

Studies in Rwanda [64, 71], in Namibia [66], in India [78], and in Mali [81] described the need for strong patient referral systems because continuity of care is integral to PHC. Inadequate patient referral systems, they reported, affected QI where the initiative aimed to enhance linkage and networking within a care network. Other enablers uncovered took the form of continuing (medical/health/nursing) education [47] and knowledge exchange platforms [48, 50, 54, 80]. Knowledge exchange platforms, it was reported, could enhance chances of successful QI by breaking down silos and fostering the integration of care packages.

As previously reported under microsystems and QI team and organization support, facilitative and regular follow up and mentorship enabled QI to happen in LMICs. Facilitating aspects such as feedback from the district health management team and mentorship for frontline HCWs supported skills-building and enabled implementers to brainstorm challenges. Unsurprisingly, QI implementing health workers found unpredictable follow up and punitive supervision geared towards fault-finding undesirable for efforts to improve the quality of PHC.

Quoting program and policy stakeholders in South Africa, Joan Mantell and colleagues [75] cite fragmentation in PHC as a key systems constraint for QI. Also, policies that limit access to PHC budgets as part of larger health systems configuration can also bar QI in LMICs. Conversely, Manisha Yapa and colleagues [69] report that availability of key guidelines and tools, and according to Werner et al. [80], national policies e.g., those that give a high visibility to PHC can indeed foster a supporting environment for PHC-focused QI.

Elsewhere, sub-optimal government policies and guidelines e.g., failure to integrate clinical decision support systems (CDSS) across the entire health system rather than in one or few vertical programmes was a key constraint contributing to non-use by trained health workers [74]. Mutambo and others [77] also observed that a government policy forbidding the clattering of walls had the unanticipated consequence of limiting the ability of QI implementers to decorate a children’s clinic. The QI team had hoped to encourage play and boost service uptake by making the HIV clinic child friendly. Both studies were conducted in South Africa.

Theme 5: External environment and structural factors.

The external environment forms the larger context in which QI interventions are implemented. It transcends the social, economic, political, legal, and other normative aspects that shape societal and national health systems priorities and may indirectly or directly affect execution of QI projects or initiatives [26, 39]. In the present review, external incentives and societal pressures that drive change, macro-level allocation of resources and other externalities, and community characteristics such as social norms affect QI implementation in varied ways. Such structural factors are not enacted or imposed by social actors intending to shape QI interventions (although they may end up doing just that) but to address other intractable systemic or societal concerns. Thus, it is important for QI implementers, researchers, and policy makers to be aware of these and to make necessary adjustments to their QI programmes, where possible.

Evidence on external environment and structural barriers and enablers that affect QI implementation came from 19 countries reported in 31 studies. SSA contributed 26 studies from 14 countries while Asia had five countries’ experiences reported in three studies. Six studies were conducted in Rwanda, five in Tanzania, four in South Africa, three in Ethiopia and two each in Malawi and Nigeria. Kenya, Burkina Faso, Mozambique, Namibia, Mali, Benin, Ghana, and Uganda in SSA and Papua New Guinea, Tajikistan, India, Indonesia, and Sri Lanka in Asia each had one research report included in this review.

Increased visibility of PHC business plans for donors, high level politicians and citizens in Tajikistan, and its high-level prioritization by the central government, was reported as an important enabler [80]. On the other hand, studies in Kaduna state in Nigeria [44, 45] reported that the government at state and national level had not prioritized PHC improvements and largely left the implementation of interventions geared towards PHC systems strengthening to donors, placing constraints on the relevant PHC Development Agency. Interestingly, weak coordination between the central government and semi-autonomous peripheral governments in Tajikistan thwarted the scale up of QI plans due to insufficient intergovernmental engagement [80].

Strong societal norms seep into the health system, through to individual health workers and managers, and shape contexts of health systems where QI is implemented. As an example, Hounsou and colleagues [89] used a retrospective mixed methods approach to explore implementation of the MPDSR mechanism in Benin and found that a culture of blame had a chilling effect in the reporting and audit of maternal deaths; a similar finding to Ayele et al. [63] in Ethiopia who also used mixed methods with administrative MPDSR data and in-depth interviews to report that health workers feared litigation and blame by relatives of deceased PHC clients. In this context, broad community dissatisfaction with explanations of causes of death and an overly litigatory society. However, in Mali, Coulibaly and colleagues [81] documented positive collaboration among health workers due to strong societal norms that encourage competitiveness, irrespective of place of employment. The inherent competitiveness inspired health workers to put in their best effort in QI implementation.

External pressures and incentives sometimes combined synergistically with socioeconomic policies to enable QI in PHC. This was the case in Tajikistan where the government introduced, rather serendipitously, a new health financing policy providing for per capita payments for PHC. The policy reduced financial barriers in the provision of PHC services. However, the QI research literature also reported areas where new policies had negative unintended consequences like the introduction of user fees in Rwanda which led to financial difficulties for women seeking ante-natal care, a component of a newly introduced QI package [84]. Expectedly, Wedernberg et al. [88] also reported socio economic challenges for patients that hindered access to PHC services in Rwanda.

Other external issues are more intractable. Impassable or unmotorable roads impede access to PHC clinics for communities and make it difficult for QI supervisors to undertake regular visits. Shaky internet constrains health workers’ from downloading learning materials. And extended power outages make life difficult for both managers and health workers alike. Good telephone connectivity may enable QI by making it easier for mentors to check in with frontline implementers without the necessity of a long, costly road travel. At the same time, good roads make travel within PHC networks easier for both communities and QI teams and supervisors. While responsibility for none of these structural issues lies within the health system, their inadequacies have the effect of introducing bottlenecks in QI efforts, especially in LMICs, where resources are scarce. Added to these, poor weather conditions, unsafe work environments, conflict, and security threats, further complicated matters, and may even see an exodus of skilled health workers besides diverting resources away from life-saving quality PHC. Expanding the list of challenges to QI that was found in the literature is the onset of COVID-19 pandemic which disrupted PHC in Sri Lanka, as was possibly the case globally in early 2020. Multiple research [44, 63, 67, 69, 76, 78, 79, 82, 83] reported these macro level barriers in one form or the other. Nahimana and colleagues [84] add to this long list of protracted constraints detailing how a prolonged drought and famine and the resulting refugee crisis, as happened in in eastern Burundi, rolled back progress in improving PHC in Kirehe district in Rwanda.

Theme 6: Execution of quality improvement intervention.

No QI intervention is going to attain the desired objective unless implemented. Although this theme is being presented last, it is perhaps the most insightful, following this comprehensive synthesis of the evidence on barriers to and enablers of QI in PHC in LMICs. Execution includes elements of dosage and reach, and how the QI intervention is executed (with scope, quality, time, and cost) to achieve the intended results.

The twenty-two studies that underly this theme came from 17 countries. Eighteen of those studies originated from thirteen countries in SSA whereas four studies from Asia were derived from four different country contexts. Of the 17 countries in total, six are low-income countries, nine are lower middle-income countries and two are upper middle-income countries. South Africa and Rwanda each had four studies; Ethiopia, Benin, Malawi, and Tanzania each had two studies included and the rest (Mali, Namibia, Papua New Guinea, India, Malawi, Kenya, Mozambique, Burkina Faso, Sri Lanka, Tajikistan, Ghana, and Nigeria) were covered by a single research report.

Dosage (frequency and intensity) and reach (coverage) of QI interventions largely determine whether a QI change package is successful or not. Thus, reaching adequate numbers of implementers with knowledge and skills, whether by offering training sessions repeatedly or targeting and delivering them when most participants are available, were deemed important enablers [41, 69, 70]. Developing results oriented QI work plans and executing these in a participatory manner, ensuring periodic verification of whether a QI intervention is being implemented as planned, using feedback data from PHC facilities, and rolling out a QI package incrementally—where subsequent sessions build on earlier ones in a responsive manner—also facilitated QI [42, 71, 76, 77, 80, 81, 85, 87]. Contrary to these, keeping a limited focus of QI throughout its implementation, not unfurling all planned aspect of an intervention, and late roll of only a few aspects posed major hindrances, signaling a lack of fidelity to the specific QI’s design and intent [45, 79, 89], and its potential failure. This could be attributed to the lack of clear implementation plans, overly ambitious QI work plans, and skewing QI implementation from original plans under pressure from funders, which exacerbate the challenges of QI implementation.

Already described earlier, supervision and mentorship were identified by the health workers among the biggest enablers of QI during the execution stage, according to Umunyana et al. [71]. Baker and colleagues [41] also reported positive impressions of health workers from being visited at their host health facility by mentors and supervisors. However, such visits needed to be reflexive (questioning own stance, habits, values, attitudes) and reflective (learning from everyday experiences) to enable QI. In the case of tech-driven QI such as electronic integrated management of childhood illnesses (eIMCI), promptness with which implementation challenges were addressed also counted as an enabler for improved practice. Non-implementation of supportive supervision and limited training for implementers was identified as a constraint to QI [74]. When health workers do not practice new skills gained from QI for extended periods, they potentially forget QI techniques, underscoring the importance of ongoing support and mentorship [69, 76, 81]. Being humble and non-judgmental as a mentor-supervisor, Manzi and colleagues [87] reported, was preferred by PHC health workers following interviews and focus group discussion in Rwanda. Such mentors or supervisors assumed a wide range of roles such as facilitators, trainers, coaches, and role models [90] which enabled QI implementation. They could also act as champions, identifying blockers at various levels of the organization early enough and converting them to supporters thereby bolstering QI implementation [63, 66, 78, 88].

Engaging communities and targeting multiple stakeholders was further identified in research reports as key enablers, e.g., in Rwanda [64, 84, 88], Tanzania [42], Ethiopia [72, 82], India [78] and Nigeria [44] besides Burkina Faso, Malawi, Mozambique and Kenya [79], where QI implementers needed to work collaboratively with community resource persons and opinion leaders and make use of local knowledge to tailor their communication. As an enabler, engaging with a diverse array of QI stakeholders during implementation was specifically outlined by Kinney et al. [65] in South Africa, Basenero et al. [66] in Namibia, and Coulibaly et al. [81] in Mali. A boycott of QI by community catchments of PHC facilities happened in some instances where their local leaders had not been involved in QI implementation, constraining implementation. Also, QI activities geared towards improving access and quality of PHC services were hampered because clients kept off due to previous negative experience when seeking care, and because of limited risk communication by service providers. Nevertheless, reminders in home-based records for patients, where applicable, facilitated good communication between health workers and their clients [62, 63, 65, 66, 78, 81, 88, 90].

Another enabler during QI implementation entailed the redesign of work/patient flows, as described from stakeholders’ experiences in South Africa, Rwanda, Uganda, Ethiopia, and Tanzania. Because sub-optimal physical infrastructure was identified as a key barrier to the provision of quality PHC, QI interventions that sought to re-design the clinic workflow, as needed, in a patient-centered manner, likely made it easier for health workers to adhere to care protocols.

Among others, [63, 86] found that QI implementation is more successful if it includes enhancements in documentation of care processes, and when stocks of key commodities are tracked and reported regularly. Conversely, failure by implementers to keep track of the availability of drugs and other stocks, aside from the actual stockout, constrains implementation. Further, QI roll out should pay due attention to limited staff time and competing tasks as described earlier, which can present significant challenges to participation by HCWs. Failure to consider this may mean that some staff miss numerous QI meetings and training sessions and place avoidable constraints on QI implementation [69].