
==== Front
Int J Prev Med
Int J Prev Med
IJPVM
Int J Prev Med
International Journal of Preventive Medicine
2008-7802
2008-8213
Wolters Kluwer - Medknow India

IJPVM-15-26
10.4103/ijpvm.ijpvm_397_22
Review Article
National Quality Policy and Strategy of the Health Services in Health Systems of Developing Countries: A Scoping Review
Fallah Razieh
Maleki Mohammadreza
Aryankhesal Aidin
Haghdoost Aliakbar 1
Department of Health Services Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
1 Department of Epidemiology and Biostatistics, Public Health School, Kerman University of Medical Sciences, Kerman, Iran
Address for correspondence: Prof. Mohammadreza Maleki, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran - 1996713883, Iran. E-mail: maleki.mr@iums.ac.ir
2024
05 8 2024
15 2618 12 2022
17 5 2023
Copyright: © 2024 International Journal of Preventive Medicine
2024
https://creativecommons.org/licenses/by-nc-sa/4.0/ This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.
It has always been argued that countries should not be inactive about the quality of health services. Therefore, a clear policy needs to be created regarding how quality of health services should be. The present scoping review was aimed to identify and map the available evidence regarding the National Quality Policy and Strategy (NQPS) of the health services in health systems of developing countries, graphically and tabularly. We followed the published methodological guidance of the Joanna Briggs Institute reviews. Also, we employed a narrative thematic synthesis integrated with the systematic analysis using the World Health Organization’s approach of NQPS, and the multiple-streams framework of Kingdon. We included 33 records that met the inclusion criteria; these records were published between 2010 and 2019. Meanwhile, government documents were the most frequent records (61%). Zimbabwe, Indonesia, and Sudan were the most frequent locations (each one 8%). The Ministry of Health was in charge of the ultimate responsibility for developing the NQPS in all identified countries. Besides, 82% of the countries were in the development phase of NQPS formulation, and convergence of three streams was observed in Indonesia, Sudan, and Tanzania. It seems that the African countries were informed about their quality issues, and the need for having NQPS have been more popular with them. We recommend that future research focuses on examining NQPS in terms of prioritizing in the agenda-setting phase of the policy-making cycle, and also, document analysis of all identified NQPS based on the core eight interdependent elements related to the NQPS approach.

Developing countries
government programs
policy
policy-making
quality improvement
quality of health care
==== Body
pmcIntroduction

A focus merely on health care coverage is unlikely to be sufficient to meet Sustainable Development Goals (SDG) on health to “ensure healthy lives and promote well-being for all at all ages.”[123] To reach this goal (SDG 3), we need to address the quality of health services, as a key to achieving Universal Health Coverage (UHC), which attempts to “ensure that all people and communities can use the promotive, preventive, curative, rehabilitative, and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship.”[45]

Although the chasm of health care quality is global,[6] among developing countries, poor health care quality has been increasingly and clearly failed to attain expected health care improvements in Low- and Middle-Income Countries (LMICs).[57] As recent estimates suggest that, globally, between 5.7 and 8.4 million people die every year due to poor quality care in LMICs.[6] Thus, to achieve better health outcomes at the societal level, it is important to emphasize quality across the spectrum of health systems from the sub-national to the national and across the levels of care.[8]

The handbook of National Quality Policy and Strategy (NQPS) published by the World Health Organization (WHO) is a practical and structured approach to help member states improve the quality of the point of care.[9] The NQPS will often be outlined in a document, providing an official and explicit statement of the approach, and actions required to enhance the quality of the entire pathway of care across all levels of the country’s health system.[9]

There are NQPS experiences in some countries; alongside, the development, refinement, and execution of an NQPS is a growing priority in countries that strive to systematically improve their health system performance;[910] however, this broad scope has not yet been comprehensively reviewed. Accordingly, the lack of published research papers was our impetus for the present Scoping Review (ScR). Thereby, we set out this study to identify and map the available evidence related to NQPS in the health system of developing countries graphically and tabularly regarding the types and chronological trend of identified evidence, their sources, frequent locations, the time frame of the NQPS, the ultimate responsibility for its development, the formation of the NQPS, and reasons for national efforts.

Methods

Study approach

The present review was conducted from December 2019 to August 2020, and updated in November 2021. We performed a ScR, following the published methodological guidance of the Joanna Briggs Institute (JBI) for the conduct of scoping reviews,[11] that is congruent with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist.[12] Also, we selected the narrative synthesis integrated with the systematic analysis as knowledge synthesis methods.[1314]

Inclusion criteria

Defining the PCC (Population, Concept. and Context) elements for scoping reviews was a substantial step in developing the inclusion and exclusion criteria[11] [Table 1].

Table 1 The PCC elements inclusion and exclusion criteria.

Inclusion criteria	Exclusion criteria	
Population: National quality policy and strategy	• The evidence was about subnational quality policy or strategy.	
	• The evidence was about national policy or strategy related to other than quality.	
	• The evidence was about quality-related policies or strategies that exist within the context of technical programs.	
Concept: Health services	• The evidence was about the national policy or strategy or both of them that targeted the quality of the only especial level of the health system, patients, disease, or type of care.	
	• The evidence was about the quality health system that did not target NQPS.	
Context: Health system of the developing countries	• The evidence was about quality-related policy or strategy or both of them that existed within the context of the health sector and addressed to quality-related social determinants of health, or merely health facilities, health services department/ward, services only supported by the individual provider, community engagement, and health insurer.	
	• The evidence was related to developed or transition countries based on the World Economic Situation and Prospects (WESP) classifications.[15]	
Types of sources of evidence	• The full text of evidence wasn’t available.	
 • To gain comprehensive resources and find all relevant records, the evidence was peer-reviewed articles or grey literature. (whether empirical or none-empirical) To gain comprehensive resources and find all relevant records, the evidence was peer-reviewed articles or grey literature. (whether empirical or none-empirical)	• The evidence wasn’t written in English	

Research questions

According to the guidance, the research questions were designed based on the PCC elements [Table 2]. These questions were answered according to available evidence wherever the answer had been exactly reported.

Table 2 Research questions sets and sub-sets

Questions sets and sub-set	Considerations	
Questions Related to the Nature of the Included Evidence
 1- Records chronological trend and Types: How are the chronological trends and categorizes of the available evidence about the NQPS of the health services in the developing countries’ health systems concerning their type, publication date?	In the absence of explicit research design in some of the records, the designs were determined by analyzing the circumstances of the information and the activities utilized. This question can be considered as a preliminary exercise before the conduct of a systematic review and can be provided a foundation to audiences for a future investigation of a systematic review.	
 2- Sources of the records: Which journal/organization contains the largest number of available evidence about the NQPS of the health services in the developing countries’ health systems? What is the most specialized source in the field?	The answer to this question helps researchers select the appropriate sources for similar topics and subjects.	
Context Research Questions
 1- Geographic coverage of evidence: What is the geographical map of the documents and which country has the most frequency among the geographical coverage of the included evidence?	The answer to this question underlines leading countries or regions related to the NQPS of the health services in the health system to international and national stakeholders.	
Population Research Questions
 1- Status of national efforts and formation of the NQPS: What is the status of efforts belonged to the identified developing countries for NQPS? How does the NQPS form?	The response to this question provides a general picture of the countries’ activities and commonalities for policy-makers involved in the NQPS process.	
 2- Ultimate responsibility for the development of the NQPS: Who/what organization is responsible for the development of an NQPS?	The answer to this question is determinant for the primary audiences, countries’ governments striving to have NQPS.	
 3- Policy map of the NQPSs by time frame: How many NQPSs of the developing countries are identified? And what are their time frame classifications?
 4- Reasons and rationales for national efforts on the NQPS: What are the issues, problems, or solutions that countries are motivated to address the issue of health care quality in the NQPS effort?	The response to this question provides a general picture of the countries’ activities and commonalities for policy-makers involved in the NQPS process. The answer to this question is determinant for the primary audiences, countries’ governments striving to have NQPS. This question guides policy-makers in decision-making about the horizon of the document. It was answered following the framework of Kingdon (16). According to John Kingdon’s approach (1984)–to move items onto the government’s formal agenda- suggests that the characteristics of issues combined with the features of political institutions and circumstances, together with the development of policy solutions, in a process that can lead to the opening and closing of windows of opportunity to shift an issue onto the agenda. This question shows policy-maker the gaps and opportunities for future work.	

Search strategy

The search was conducted in a three-step process according to the JBI guidance[11] and following the Peer Review of Electronic Search Strategies guideline.[17] Furthermore, due to the substantial role of librarians in developing a search strategy in the preliminary stages of a scoping review,[18] a librarian was consulted. PubMed and Embase using MeSH terms and Emtree, respectively, along with the other relevant sources such as Scopus, ISI Web of Science, Prospero, and Openthesis were searched. To find grey literature such as countries’ government documents, reports, conference papers, dissertations, and theses, and to attain manuscripts under the peer-reviewing process of journals, we also searched Proquest, some search engines, websites of the technical organizations, teams, and projects. In addition, we searched local databases to find evidence from Iran. Some unavailable evidence that was shared in the knowledge-sharing platform of the WHO (Global Learning Laboratory (GLL)), was accessed through the request of a membership account from WHO. Although the WHO approach for NQPS was published in 2018, according to the WHO meeting report, there are some national efforts that were initiated before 2018. So, all of the search processes were performed irrespective of any time frame limits. Samples of some search strategies covering search terms are presented in the Appendix Tables 1-4.

Screening and selection of the evidence

All records retrieved in the search were managed by EndNote version X8 to remove duplicates, and simplify the selection process [Figure 1]. Judgment about the fitness of records was made by all authors, and any disagreements were resolved via discussion with each other. The interdisciplinary essence of the retrieved records and the challenges of using quality criteria across the research paradigms meant that the appraisal of the included records classified in Table 3 was confined to considerations of relevance rather than research quality.

Figure 1 The flow diagram describing the selection process, reasons for exclusion, and final record number

Table 3 Contributions of evidence around the NQPS of the health services

Authors/responsible organization/country	Covered country/setting	Year	Type of evidence	
Ministry of health[19]	Eritrea	2010	Government document	
Ministry of Public Health[20]	Afghanistan	2015	Government document	
Zimbabwe ministry of health and child care[21]	Zimbabwe	2015	Government document	
Ministry of Health and Social Protection[22]	Colombia	2016	Government document	
Institute for Healthcare Improvement through the Bill and Melinda Gates Foundation[23]	Ghana	2016	Government document	
Ministry of Public Health[24]	Afghanistan	2016	Government document	
Uganda[25]	Uganda	2016	Country case study	
Ministry of health[26]	Uganda	2016	Government document	
Institute for Healthcare Improvement through the Bill and Melinda Gates Foundation[27]	Ethiopia	2016	Government document	
Ministry of health and child care[28]	Zimbabwe	2016	Government document	
Ministry of health[29]	Cambodia	2017	Government document	
Ministry of health and family welfare[30]	India	2017	Government document	
El-Jardali, F and Fadlallah, R[31]	Lebanon and Jordan	2017	Review article	
Ministry of Health Services[32]	Liberia	2017	Government document	
ministry of health and population[33]	Malawi	2017	Government document	
Federal Ministry of Health[34]	Sudan	2017	Government document	
Ministry of health, community development, gender, elderly and children[35]	Tanzania	2017		
Faculty of Medicine Universitas Gadjah Mada, in collaboration with Ministry of Health, Republic of Indonesia and supported by WHO Indonesia[36]	Indonesia	2017	Government executive Summary	
Ministry of health[37]	Palestine	2017	Government document	
García-Saisó S et al.[38]	Mexico	2018	Action brief	
WHO, Organisation for Economic Co-operation and Development, and The World Bank[10]	Mexico, Liberia, Sudan, Ethiopia	2018	Report	
Erdenee et al.[39]	Mongolia	2018	Review article	
Ministry of health[40]	Kenya	2018	Government document	
Awadalla H et al.[41]	Sudan	2019	Action brief	
Ministry of health[42]	Indonesia	2019	Government document	
Sierra Leone[43]	Sierra Leone	-	Snapshot	
Eswatini[44]	Eswatini	-	Snapshot	
Nigeria[45]	Nigeria	-	Snapshot	
Indonesia ministry of health, by Eka Viora[3646]	Indonesia	-	Government presentation	
Malaysia[47]	Malaysia	-	Snapshot	
Namibia[48]	Namibia	-	Snapshot	
Ministry of Health[49]	Bhutan	-	Government document	
Zimbabwe[50]	Zimbabwe	-	Snapshot	

Data Extraction, synthesis, and analysis

Adopting the narrative synthesis, we conducted data coding in three phases: Deduction, induction, and verification. In the first phase, we applied the framework method following Gale et al. model[51] to improve the organization of the review.[52] So, the data was retrieved according to the WHO handbook on NQPS[9] and Kingdon’s multiple-streams framework.[16] In the second phase, we dedicated the free codes to the messages extracted from the records, which allow new themes to emerge inductively. The coding schema was refined through continuous comparative analysis. Also, the coded concepts were certified, modified, unified, or added to through several iterations of analysis. During the coding schema, we had team works to minimize individual bias pertained to multiple analysts involved in coding and interpreting data. Hence, all authors committed to validating coding decisions and discussing emerging themes. Then, we synthesized the findings in quantitative (using frequencies) and qualitative (thematic analysis) formats through Excel.

Results

The electronic databases and search engines identified 1,470 records. After the screening, 33 records were eligible for inclusion in the present review.

Nature of the included evidence

Records Chronological trend and types

Figure 2 demonstrates the chronological trend from 2010 to 2019 that peaked in 2017 (27%). The trend was detected regardless of the 24% of records with no publication date.[36434445474849505354] Most of these records (75%), which accounted for 18 percent of all documents, were snapshots of the latest status of countries’ NQPS that had been shared in GLL.[434445474850] The classifications of records according to their contributions [Table 3] show that only 6% of the records were articles.[3139] Besides, the government documents were the most frequent records (61%). In addition to the identified case studies of the countries, one report[10] also contained four case studies.

Figure 2 The chronological trend of records types per year

Sources of the records

Given the exclusion reasons of the identified evidence [Figure 1], most of the included records were related to gray literature. As shown in Figure 3, 58% of the records were taken from the GLL that contained the most diverse records compared to other sources; also, a notable proportion of the government documents (50%) was found from search engines.

Figure 3 Bubble plot of the type of evidence per source types

Context research questions

Geographic coverage of evidence

Given the included records, 37 frequent locations related to 26 countries were identified that are distributed in the geographical map [Figure 4]. Zimbabwe, Indonesia, and Sudan were the most frequent locations (each one 8%). Evidence from lower-middle-income developing countries and low-income countries accounted for 81% of the countries included. Furthermore, 50% of the countries found belonged to the WHO Regional Office for Africa (AFRO).

Figure 4 Geographical map of the contributed countries in the global context

Population research questions

Status of national efforts and formation of the NQPS

Unlike the countries that had the NQPS (81%), Jordan, Lebanon,[31] and Nigeria[45] declared the absence of NQPS as a substantial deficiency in their country. As shown in Table 4, 18% of the countries refined their existing quality initiatives. The formation details of the NQPS about countries that were preparing NQPS (Malaysia and Sierra Leone) were not available. Moreover, it was not possible to determine the approach of the countries’ documents that were not available.

Table 4 The classification of the population characteristics

Country	Title of the NQPS	Responsibility for the development	Time frame	Formulation	Integration	Process of process of policy and strategy development	Publication	Approach	
Afghanistan	National health policy 2015-2020	Minister of public health	5	Refinement*	Fully integrated†	Non- simultaneous	Complementary and co-dependent documents‡	A§	
	National health strategy 2016-2020		4	Refinement	Fully integrated	Non- simultaneous	Complementary and co-dependent documents	A	
Bhutan	National health policy	MOH	-	Development	Fully integrated	Non- simultaneous	Complementary and co-dependent documents	A	
Cambodia	National policy for quality and safety in health	MOH	-	Development	Aligned**	Simultaneous	Integrated	B††	
Colombia	National plan for quality-of-care improvement	MOH and social protection	5	Development	Aligned	Simultaneous	Integrated	B	
Eritrea	National health policy	MOH	-	Development	Fully integrated	Simultaneous	Integrated	A	
Eswatini	National health sector policy version 3	Indeterminate	-	Indeterminate	Fully integrated	Indeterminate	Indeterminate	Indeterminate	
	MOH strategic plan (2019-2023)		4	Indeterminate	Indeterminate	Indeterminate	Indeterminate	Indeterminate	
	Quality management strategic plan (2018 to 2022)		4	Indeterminate	Indeterminate	Indeterminate	Indeterminate	Indeterminate	
Ethiopia	National health care quality strategy	MOH and institute for healthcare improvement	4	Development	Aligned	Indeterminate	Complementary and co-dependent documents	B	
Ghana	National healthcare quality strategy	MOH	5	Development	Aligned	Indeterminate	Indeterminate	B	
India	National health policy 2017	MOH and family welfare	-	Development	Fully integrated	Simultaneous	Integrated	A	
Indonesia	National healthcare quality policy and strategy	MOH	5	Development	Aligned	Simultaneous	Integrated	B	
Kenya	Health sector strategic plan 2018-2023	MOH with the overall stewardship of cabinet secretary	5	Development	Aligned and fully integrated	Non- simultaneous	Complementary and co-dependent documents	C: Combination of A and B	
Liberia	National health quality strategy	MOH	4	Refinement	Aligned	Non- simultaneous	Complementary and co-dependent documents	B	
Malawi	Quality management policy for the health sector	MOH and population	-	Development	Aligned	Simultaneous	Integrated	B	
Malaysia	National quality of care policy and strategy	Indeterminate	Indeterminate	Indeterminate	Indeterminate	Indeterminate	Indeterminate	Indeterminate	
Mexico	National strategy for the consolidation of quality in health care facilities and services	MOH	-	Refinement	Indeterminate	Indeterminate	Indeterminate	Indeterminate	
Mongolia	Health sector policy for 2017 to 2026	Indeterminate	9	Development	Fully integrated	Simultaneous	Integrated	A	
Namibia	National health policy framework 2010 –2020	Indeterminate	10	Indeterminate	Fully integrated	Indeterminate	Indeterminate	A	
	National development plan 5		-	Indeterminate	Indeterminate	Indeterminate	Indeterminate	Indeterminate	
Palestine	National health strategy 2017-2022	MOH	6	Development	Aligned	Non- simultaneous	Integrated	B	
Sierra Leone	National QOC policy (broader) and strategy (RMNCAH-LALA)	Indeterminate	Indeterminate	Indeterminate	Indeterminate	Indeterminate	Indeterminate	Indeterminate	
Sudan	National health care quality policy and strategy	MOH	3	Development	Aligned	Simultaneous	Integrated	B	
Tanzania	National health policy 2017	MOH, community development, gender, elderly and children	-	Development	Aligned and fully integrated	Indeterminate	Complementary and co-dependent documents	C: Combination of A and B	
Uganda	Health sector quality improvement framework and strategic plan	MOH	4	Refinement	Aligned	Simultaneous	Integrated	B	
Zimbabwe	Quality assurance and quality improvement policy	MOH and child care	4	Development	Aligned	Non- simultaneous	Complementary and co-dependent documents	A	
	Quality assurance and quality improvement strategy		-	Development	Aligned	Non- simultaneous	Complementary and co-dependent documents	A	
*Refinement of existing quality initiatives. †Fully integrating the development and publication processes of NQPS. ‡Complementary and co-dependent policy and strategy documents developed as part of a system-wide effort to improve the quality of care. §A part of the formal long-term health sector national policies and plans. **Aligning the goals, priorities, and actions and cross-referencing documents. ††A national quality statement drawing on existing relevant policies and national health documents

Ultimate responsibility for the development of the NQPS

As can be seen in Table 4, 69% of the identified countries mentioned the responsibility for development of the NQPS; among which.,56% of national documents held only the MOH responsible.

Policy map of the NQPSs by time frame

As Table 4 presents, 7% of the identified national documents were being developed. Consequently, their time frame was indeterminate. Furthermore, among documents that had time frames (57%), most of them (87%) had medium-term horizons.

Reasons and rationales for national efforts on the NQPS

The reasons and rationales were mentioned about 77% of the countries’ efforts [Table 5]. Furthermore, three-streams convergent whereas observed in Indonesia, Sudan, and Tanzania.

Table 5 The frequency of reasons

Heme	Category	Code	Afghanistan	Bhutan	Cambodia	Colombia	Eritrea	Ethiopia	Ghana	India	
Reasons	Politics stream	Legislation insists				(22)					
		Significant priority of the government			(29)						
		Change of the government political regime									
		New demands for drafting processes, format, and contents of national sector policies									
		Responding to increased awareness of the population toward patient rights									
	Problem stream	Inadequate provision of quality care along with weaknesses of the health sector	(20)						(23)		
		Weaknesses of the regulation and accountability structures	(20)						(23)		
		Absence of a comprehensive NQPS and need to synergize all efforts in QI									
		Emerging increasing challenges					(19)				
		Contextual changes after the last national health policy								(30)	
		Most pressing health issues									
		Reduction of financial resource									
		Un-even distribution of health cadres among different levels									
		Weak links persist between clinical care and public health at the district level							(23)		
		Working independently without any coordination							(23)		
		Little expectation of accountability teaching hospitals							(23)		
	Policy stream	The mission of the Ministry of Health	(20)		(29)						
		The vision of the Ministry of Health	(20)								
		Achieving the goals/objectives of the national broader (long-term or medium-term) plan or NQPS			(29)	(22)		(19)	(23)		
		Harmonization and coordination of existing quality initiatives and institutionalizing quality at all levels							(23)		
		Improving care private sector involvement	(20)						(23)		
		Constitution of the country		(49)							
		Low of the country			(29)						
		Achieving the goals/objectives of the WHO regional documents regarding quality									
		Quality UHC									
		Global quality-related initiatives such as SDGs, UHC	(20)								
		Total number	6	1	4	2	1	1	8	1	
	
Heme	Indonesia	Kenya	Liberia	Malawi	Mexico	Mongolia	Nigeria	Palestine	Sudan	Tanzania	Uganda	Zimbabwe	Total number	Proportion	
Reasons	(22)												2	4%	
					(29)	(45)	(37)	(41)	(35)				6	11%	
									(35)				1	2%	
									(35)				1	2%	
									(34)				1	2%	
								(37)		(35)			4	7%	
													2	4%	
	(36)												1	2%	
										(35)			2	4%	
													1	2%	
					(38)								1	2%	
									(34)				1	2%	
									(34)				1	2%	
													1	2%	
													1	2%	
													1	2%	
												(28)	3	5%	
													1	2%	
	(42) (36)	(40)	(10)	(33)				(37)					9	16%	
			(10)	(33)									3	5%	
													2	4%	
				(33)									2	4%	
													1	2%	
	(42)												1	2%	
									(34)				1	2%	
	(42)			(33)				(37)	(34)	(35)	(26)		6	11%	
	3	1	2	4	1	1	1	4	6	6	1	1	56	100%	

Discussion

Bibliometric research questions

Records chronological trend and types

The peak observed in 2017 seems unrealistic because, if the access to publication date of the abovementioned records was possible, the results definitely would change. The majority of these records (18%) are snapshots of the latest NQPS status of countries shared on the GLL. Since the GLL is a recent product that coincides with the release of the NQPS handbook,[9] as well as three global reports on the global health care quality gap along with the identified approaches to closing the gap in 2018,[55] the possibility of an exponential trend of the document generation related to NQPS can be considered a strong hypothesis.

The small number of NQPS-related articles in contrast to the significant amount of gray literature available from the valuable experiences of countries indicates a gap in the production of scientific products. With this in mind, our study can be considered as a feasibility study that confirms the lack of sufficient pioneering studies to conduct a systematic review of the evidence from developing countries. Paying attention to this could be an important research priority in the future.

Sources of the records

The GLL for quality UHC strives to create a safe space to share knowledge, experiences, ideas, and innovations across the world, and its focus is on accelerating global learning that is informed by local action in the area of quality service delivery.[56] Syed et al. confirmed the need to collect and share experience on national quality efforts through GLL, as well as to promote innovative and context-specific solutions that underpin all these endeavors.[57]

However, the documents extracted by search engines were not available in the GLL. Some countries only had a snapshot of their national quality efforts[434550] in the GLL, while their original documents[28] or their related broader programs[5358] were accessible with search engines. Sharing a diverse range of NQPS documents of countries in the GLL may indicate their conscious participation. However, results of the present review on the source of the majority of government documents show that some countries do not yet seem willing to participate in the GLL, or are not aware of the GLL benefits. Another point is that, sharing documents in GLL with the original language of the country of origin, such as Mexico, reduces the possibility of accelerating global learning. It seems that some kind of filtering regarding the uploading of documents by the GLL team is required.

Context research questions

The frequent countries

According to the results, it seems that the AFRO countries were informed about their quality issues; in addition, the need for having NQPS have been more popular with them, which have been strongly motivated in publishing their documents and extending their national efforts into the GLL for quality UHC in order to strengthen the WHO learning agenda on NQPS. Accordingly, Itam and Anthonia[59] also argued for the need for a national policy on quality in health care as one of the three strategies for advancing quality in health systems and health security in African health systems that face many quality issues.

Population research questions

Policy map of the NQPSs by time frame

National quality effort makes no difference either with or without a timeframe; however, the results showed that most NQPS without any timeframe (34%) were national policies (70%) that seemed to be permanently defined for the health system, regardless of time.[192930334449] We have to mention tow issues. First, countries should not conform to inconsistent timeframes when releasing documents, as was the case with Sudan’s national documents.[1041] Second, it can be claimed that the identified documents generally considered the time interval between two years; however, in case of Palestine[37] and Ghana,[23] the last year of the time horizon is considered as a separate year. Furthermore, the uncertainty of the publication date between the national multi-documents of Namibia[48] and Eswatini[44] limits the learning of other developing countries.

Ultimate responsibility for the development of the NQPS

Given the results, we can confirm the undeniable role of the MOH in all of these countries. However, in Kenya[40] and Ethiopia[27] which have NQPS for the health sector, the Cabinet secretary and Institute for healthcare improvement respectively were held responsible along with the MOH. In this regard, the results of a study regarding the African health systems confirmed the cooperation of national MOH in African countries with the WHO to establish the national health quality program.[59] In addition, Chan et al. and also Sajadi et al. defined the steward in the context of quality as a national-level public organization, and typically MOH.[606162]

Status of national efforts and formation of the NQPS

Based on the findings, the formation can be addressed here from three aspects:

Formulation: Although Afghanistan[6364] and Tanzania[656667] had separate NQPS; their desire to have a quality policy integrated with the macro-health sector policy[2035] to improve the health of the community in recent years can be encouraging for other countries. Another point is that merely drafting a document will not solve the problem, but, as stated in Bhutan document,[49] a national strategic plan is needed for the implementation of an NQPS. In this regard, the results of two studies on the long-term policy related to the quality of health services for Iran’s health system also confirmed that this policy should be implemented in five-year plans.[6869]

Moreover, the NQPS that has been formulated to provide services to the Ministry of Health can have the potential to be applied to other ministries, private sector, donors, patients, and their families engaged in providing health services as is the case with Cambodia[29] and Zimbabwe.[2128]

Publication: We observed two inconsistencies between the title and the nature of the documents. First, although the Cambodia and Malawi documents[2933] seem just policy at the first glance because of their titles, some strategies confirm the policy and strategy integration. Second, the Palestine[37] document seems to be merely a strategy because of its title at the first time, some policies also confirm the strategy and policy integration.

Approaches: Some ambiguities discuss as follows: The Eswatini and Namibian documents[4448] were snapshots that included multiple national quality initiatives, but no data were available on the differences between these initiatives. Furthermore, Zimbabwe, despite having a separate quality policy and strategy,[2128] has developed a national strategy for equity and quality in health.[70] In the same period (2016–2020), which has not been explained their relationship in any of these documents.

The document analysis of all the identified NQPS based on the core eight interdependent elements related to the NQPS framework to learning lessons are recommended for future research.

Reasons and rationales for national efforts on the NQPS

Given that we found the data related to the policy stream in 70% of the countries that had NQPS, and its remarkable proportion among the other streams (52%), it could be concluded explicitly that there was a proposal for NQPS. Furthermore, in the 35% of the countries with NQPS, the problem stream was observed along with policy stream. Thus, quality idea proposed problem-informed in these countries. In this regard, Umeh reported the perceived poor quality of care in Tanzania and Ghana.[71] Alongside, results of Leatherman et al.[72] indicated a lack of visibility of the issue as one of the four major barriers in developing countries.

Due to realizing NQPS through the convergence of three streams in some countries of this review,[343542] Leatherman et al.[71] also concluded that improving the quality of health care in developing countries requires extensive social and governmental interest. Overall, it seems that the creation of NQPS was certainly through political trade-offs of the policy entrepreneurs, and then the opening of the opportunity window. Examining these NQPS in future research will be a major step toward filling the knowledge gaps.

Conclusions

How the NQPS is developed should be decided by each country following their respective governmental structures, as well as taking into consideration their unique context and population needs. This is a fact that there are not enough articles to perform a systematic review of the developing countries’ evidence in the context of the NQPS. We think that the establishment of some mechanisms to promote the informed participation of countries in sharing their documents in the GLL is crucial. We recommend that future research focuses on: examining NQPS in terms of prioritizing in the agenda-setting phase of the policy-making cycle, and also document analysis of all identified NQPS based on the core eight interdependent elements related to the NQPS approach.

Conflict of interests

The authors declare that they have no competing interests.

Acknowledgment

This study was part of a Ph.D. dissertation supported by the Iran University of Medical Science (Grant no: IR.IUMS.REC.1397.895).

Appendix

Table 1 Some search strategies and search terms of PubMed.

Search	Actions	Details	Query	Results	
#6			Search: (((#2) OR (#3)) OR (#4)) OR (#5)	525	
#5			("National Policy"[Title/Abstract] OR "National Strategy"[Title/Abstract] OR "national strategic framework"[Title/Abstract] OR "national directions"[Title/Abstract] OR "national direction"[Title/Abstract] OR "national plans"[Title/Abstract] OR "national plan"[Title/Abstract] OR "national framework"[Title/Abstract]) AND ("Quality universal health coverage"[Title/Abstract] OR "health services quality"[Title/Abstract] OR "quality health services"[Title/Abstract])	1	
#4			Search: ((((((((“National Quality Policy and Strategy”[tiab])) OR NQPS[tiab]) OR “National Quality Policy”[tiab]) OR “National Quality Strategy”[tiab]) OR “Quality management strategy”[tiab]) OR “Quality management policy”[tiab])) AND (((((“health systems”[tiab]) OR “health system”[tiab]) OR “health care”[tiab]) OR “healthcare”[tiab]) OR “health services”[tiab])	41	
#3			Search: (((((((“national health quality strategy”[tiab]) OR “national health quality policy”[tiab]) OR “National Healthcare Quality Strategy”[tiab]) OR “National Healthcare Quality policy”[tiab]) OR “National Health care Quality Strategy”[tiab]) OR “National Health care Quality policy”[tiab]) OR NHQS[tiab]) OR NHQP[tiab]	3	
#2			Search: ((“quality of health care”[MeSH Terms]) AND “delivery of health care, integrated”[MeSH Terms]) AND “policy”[MeSH Terms]	480	

Table 2 Some search strategies and search terms of Embase

No.	Query	Results	
#3	#1 AND #2	36	
#2	‘health systems’:ab, ti OR ‘health system’:ab, ti OR ‘health care’:ab, ti OR ‘healthcare’:ab, ti OR ‘health services’:ab, ti OR ‘health care system’:ab, ti	781988	
#1	‘national quality policy’:ab, ti AND strategy: ab, ti OR ‘nqps’:ab, ti OR ‘national quality policy’: ab, ti OR ‘national quality strategy’:ab, ti OR ‘quality management strategy’:ab, ti OR ‘quality management policy’:ab, ti	111	

Table 3 Some search strategies and search terms of Scopus

ID	Name	Query	Documents	
result#6	THESIS	( TITLE-ABS-KEY ( “national health quality strategy” OR “national health quality policy” OR “National Healthcare Quality Strategy” OR “National Healthcare Quality policy” OR “National Health care Quality Strategy” OR “National Health care Quality policy” OR “NHQS” OR “NHQP” ) ) OR ( TITLE-ABS-KEY ( ( “National Quality Policy and Strategy” OR “NQPS” OR “National Quality Policy” OR “National Quality	126	
		Strategy” OR “Quality management strategy” OR “Quality management policy” ) AND ( “health systems” OR “health system” OR “health care” OR “healthcare” OR “health services” ) ) ) OR ( TITLE-ABS-KEY ( ( “National Policy and Strategy” OR “National		
		Policy” OR “National Strategy” OR “national strategic framework” OR “national directions” OR “national direction” OR “national plans” OR “national plan” OR “national framework” ) AND ( “Quality universal health coverage” OR “Quality UHC” OR “health services quality” OR “quality health services” ) ) )		
		View Less		
		Edit query		
result#5	thesis-SCOPUS3	TITLE-ABS-KEY ( ( “National Policy and Strategy” OR “National Policy” OR “National Strategy” OR “national strategic framework” OR “national directions” OR “national direction” OR “national plans” OR “national plan” OR “national framework” ) AND ( “Quality universal health coverage” OR “Quality UHC” OR “health services quality” OR “quality health services” ) ) . View More	5	
result#4	thesis-SCOPUS2	TITLE-ABS-KEY ( ( “National Quality Policy and Strategy” OR “NQPS” OR “National Quality Policy” OR “National Quality Strategy” OR “Quality management strategy” OR “Quality management policy” ) AND ( “health systems” OR “health system” OR “health care” OR “healthcare” OR “health services” ) ) . View More	97	
result#3	thesis-SCOPUS1	TITLE-ABS-KEY ( “national health quality strategy” OR “national health quality policy” OR “National Healthcare Quality Strategy” OR “National Healthcare Quality policy” OR “National Health care Quality Strategy” OR “National Health care Quality policy” OR “NHQS” OR “NHQP” ) … View More	6	

Table 4 Some sources that were searched

Sources	
Organizations	• WHO	
	• World Bank	
	• United Nations	
	• European Union	
	• HealthQual	
	• Institute for healthcare improvement (IHI)	
	• International Society for Quality in Health Care (ISQua)	
	• Agency for Healthcare Research and Quality (AHRQ)	
	• Institute of Health Metrics and Evaluation (IHME)	
	• Harvard Initiative on Global Health Quality (HIGHQ)	
	• Karolinska Institute	
	• Joint Commission International (JCI)	
	• National Academies of Sciences, Engineering, and Medicine	
	• Organisation for Economic Co-operation and Development (OECD)	
Teams	• European Collaboration for Healthcare Optimization (ECHO team)	
	• Ireland National Quality Improvement Team	
Project	• United States Agency for International Development (USAID) ASSIST	
	• (Applying Science to Strengthen and Improve Systems) Project	
Local sources	• Irandoc	
	• SID	
	• Noormags	
	• Magiran	
	• Iranmedex
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