WHO, for example, suggests that quality assurance should make improvements in six areas or dimensions of quality where health care is effective adhering to an evidence base and results in improved health outcomes, efficient by maximizing resource use and avoids waste, accessible where delivering health care is not only timely but also geographically reasonable, acceptable and patient-centered taking into account the preferences and aspirations of individuals and communities, equitable with no variation in health care delivery among the components of the society, and finally safe minimizing risks and harm to service users.
Establishing a viable QA program in the Syrian health sector especially in the public health sector has been one of the objectives unsuccessfully targeted by the Syrian Ministry of Health. The modernization program of health care was initiated in Syria and included several QA initiatives some of which were initiated in partnership with international health organization such as the WHO and the health care international organization which assists public, private, and community organizations achieve their strategic objectives and improve its performance and outcomes. These programs stressed on the importance of establishing a health care quality assurance program and attempted to address some of the structural and organizational needs necessary to create such program.
Today, however, and despite these efforts, Syrian hospitals and physicians are still not governed by any practical or enforceable QA measure that mandate participation and reporting.
Why do we think the effort of the Syrian Ministry of Health did not achieve the objective of creating a reliable health care quality assurance program might be multifactorial. The uprising in Syria has certainly opened the door for a complete new set of governance rules in future Syria that should provide the needed environment for comprehensive reforms in the health sector. The transitional will need to set the record straight and provide the political will for the success of reforms in the health sector, including the implementation of a QA program.
The roles and responsibilities within the various parts of the QA system in Syria might not be well defined (policy and strategic development, health service providers, communities, and service users). A review process which should exist to monitor these roles and responsibilities of all the persons, committees, institutions and public structures involved in QA (policy/strategy development for quality, quality standard development, quality control etc.) is also lacking. Furthermore, the connection between these various parts might not be sufficient, and as an example decision-makers cannot hope to develop and implement new strategies for quality without properly engaging health-service providers, communities, and service users, by the same standards health-service providers need to operate within an appropriate policy environment for quality, and with a proper understanding of the needs and expectations of those they serve, in order to deliver the best results. Communities and service users in turn need to influence both quality policy and the way in which health services are provided to them, if they are to improve their own health outcomes.
Another obstacle in the Syrian health care QA program is that both hospitals and physicians today are still not subjected to any mandatory reporting requirement to government and private health insurance agencies.
It is also not known if Syria today has a National Quality Management Strategy defining realistic goals for QA and indicators for the achievement of goals, taking into account the available man power (managers, clinicians and other frontliners), financial resources and time (such plan if exists is not published). Training of the required man power, local staff and experts in the field of QA has not adequately taken place to make such a national strategy a viable entity if it existed. It is also not known if the Syrian Ministry of Health has formulated a legal and operational framework or work manual that can serve in a pilot quality assurance projects in certain medical institutions.
A design and development of standards, protocols and guidelines that govern both physicians and health care institutions and consistent with the goals of a national quality assurance program is still lacking as well.
One additional critical deficiency is the lack of a well-defined mandatory mechanism where both hospitals and individual physicians can accurately assess their own level of performance in relation to established standards and bench marks. This can be done via both self-assessment and external peer reviews.
A national team of experts in QA which is also necessary in the process of creating a QA program is not available in Syria today; such a team can be formed after adequate training and can serve as an expert resource panel. But more importantly there is no health information system that will collect the data, analyse it and provide it to policy makers for accurate quality assurance policies.
Finally, more developed and matured processes of utilization reviews, audits, peer reviews, mortality and morbidity reviews, reviews on the quality of nursing care and reviews on staff and patients' satisfaction by simple standardized tools are needed and can be necessary in the development process of a successful QA program.
In conclusion, like any institutional or governmental systems the health care system in any country including Syria cannot achieve its goals of delivering effective, efficient, accessible, safe, patient-oriented and equitable health care without a well-designed QA program; such a program should remain as a top priority of any health care reform in future Syria.
* Published in collaboration with Hivos