abstract: 'Background: Access to safe surgical care represents a critical gap in

  healthcare delivery and development in many low-and middle-income

  countries, including Ethiopia. Quality improvement (QI) initiatives at

  hospital level may contribute to closing this gap. Many such quality

  improvement initiatives are carried out through international health

  partnerships. Better understanding of how to optimise quality

  improvement in low-income settings is needed, including through

  partnership-based approaches. Drawing on a process evaluation of an

  intervention to improve surgical services in an Ethiopian hospital, this

  paper offers lessons to help meet this need.

  Methods: We conducted a qualitative process evaluation of a quality

  improvement project which aimed to improve access to surgical services

  in an Ethiopian referral hospital through better management. Data was

  collected longitudinally and included: 66 in-depth interviews with

  surgical staff and project team members; observation (135 h) in the

  surgery department and of project meetings; project-related

  documentation. Thematic analysis, guided by theoretical constructs,

  focused on identifying obstacles to implementation.

  Results: The project largely failed to achieve its goals. Key barriers

  related to project design, partnership working and the implementation

  context, and included: confusion over project objectives and project and

  partner roles and responsibilities; logistical challenges concerning

  overseas visits; difficulties in communication; gaps between the time

  and authority team members had and that needed to implement and engage

  other staff; limited strategies for addressing adaptive-as opposed to

  technical-challenges; effects of hierarchy and resource scarcity on QI

  efforts. While many of the obstacles identified are common to diverse

  settings, our findings highlight ways in which some features of

  low-income country contexts amplify these common challenges.

  Conclusion: We identify lessons for optimising the design and planning

  of quality improvement interventions within such challenging healthcare

  contexts, with specific reference to international partnership-based

  approaches. These include: the need for a funded lead-in phase to

  clarify and agree goals, roles, mutual expectations and communication

  strategies; explicitly incorporating adaptive, as well as technical,

  solutions; transparent management of resources and opportunities;

  leadership which takes account of both formal and informal power

  structures; and articulating links between project goals and wider

  organisational interests.'
affiliation: 'Aveling, EL (Corresponding Author), Univ Cambridge, Inst Publ Hlth,
  Cambridge Ctr Hlth Serv Res, Forvie Site,Robinson Way, Cambridge CB2 0SR, England.

  Aveling, EL (Corresponding Author), Harvard TH Chan Sch Publ Hlth, Dept Hlth Policy
  \& Management, Boston, MA 02115 USA.

  Aveling, Emma-Louise, Univ Cambridge, Inst Publ Hlth, Cambridge Ctr Hlth Serv Res,
  Forvie Site,Robinson Way, Cambridge CB2 0SR, England.

  Aveling, Emma-Louise, Harvard TH Chan Sch Publ Hlth, Dept Hlth Policy \& Management,
  Boston, MA 02115 USA.

  Zegeye, Desalegn Tegabu, Fed Minist Hlth, POB 1234, Addis Ababa, Ethiopia.

  Silverman, Michael, Univ Leicester, Dept Infect Inflammat \& Immun, Univ Rd, Leicester
  LE1 7RH, Leics, England.'
article-number: '393'
author: Aveling, Emma-Louise and Zegeye, Desalegn Tegabu and Silverman, Michael
author-email: eaveling@hsph.harvard.edu
author_list:
- family: Aveling
  given: Emma-Louise
- family: Zegeye
  given: Desalegn Tegabu
- family: Silverman
  given: Michael
da: '2023-09-28'
doi: 10.1186/s12913-016-1639-4
files: []
issn: 1472-6963
journal: BMC HEALTH SERVICES RESEARCH
keywords: Quality improvement; Surgery; Patient safety; Partnership; Ethiopia
keywords-plus: PATIENT SAFETY; COMMUNITY-DEVELOPMENT; CARE; INFRASTRUCTURE; UNIVERSITY
language: English
month: AUG 17
number-of-cited-references: '36'
orcid-numbers: Zegeye, Desalegn Tegabu/0000-0002-5231-9967
papis_id: d878e9e2d53e8f84b031f111e7ddb672
ref: Aveling2016obstaclesimplementat
times-cited: '17'
title: 'Obstacles to implementation of an intervention to improve surgical services
  in an Ethiopian hospital: a qualitative study of an international health partnership
  project'
type: Article
unique-id: WOS:000381463200002
usage-count-last-180-days: '0'
usage-count-since-2013: '9'
volume: '16'
web-of-science-categories: Health Care Sciences \& Services
year: '2016'