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Abstract

The deﬁnition of quality of care from a population standpoint considers opportunity cost and prioritization of resources toward achieving particular health needs of an entire population. These deﬁnitions take into consideration three additional elements in addition to access and effectiveness discussed under quality of care from an individual standpoint. They include equity, efﬁciency, and cost. Equity is a subcomponent of access of care that is closely related to structure and processes of care, while cost is a subcomponent of effectiveness. Quality of care for a population can be deﬁned as the ability to access effective care on an efﬁcient basis for optimization of health beneﬁt/well-being of the whole population. The infrastructure of medical care in developing countries is often compromised. This bears the ethical question if medical care is doing more harm in not assuring a consistent system of care to sustain improved clinical outcomes. The hard discussion must be made to discern if QOC can solely be framed as a static quality improvement activity or as a more substantial engagement in an adaptive clinical system under resource-poor conditions.

Introduction

Quality of care (QOC) and ethical principles are intertwined. Health providers’ missions prominently advertise quality of care to every patient. To patients, QOC is an expected element of medical care. As a consumer of medical services, providing such care that meets or exceeds patients’ expectations is a mandate and not an option. Given the rising cost of health care, growing demand for health-care services, and variations in clinical practice in the midst of constrained resources, there is growing interest to provide quality health care. The highest healthcare-spending countries are not always those providing high-quality care. In fact, quality of care has become a crucial issue on the agenda of the World Health Organization and many other countries like the USA and the UK (World Health Organization 2006; Campbell et al. 2000). Fragmentation of health-care delivery system has been shown to be a major factor for low-quality health care in both developing and developed countries (World Health Organization 2006). Without deﬁning health care and quality of care separately, every effort to design and implement interventions to improve the quality of health would be impossible. Medical-care infrastructures are fragmented or nonexistent in resource-poor global contexts. The ethical quandary of overcoming systemic breakdowns presents its own set of complications. QOC is an afterthought in for policymakers in underdeveloped countries that lack even the basic level of consistent care.

Defining Quality Of Care Within A Population Context

Even though the deﬁnition of health care are many and contested, health care can be deﬁned as being composed of health-care system and actions taken within the health-care system to improve health and well-being (Campbell et al. 2000). Health care has three components: structure of the health-care system, process of proving such care, and the systemic outcome tied to receipt of care. The structure of health care is the organizational factors of the health system under which care is provided. It is made up of personnel (staff characteristics) and medical equipment/buildings. Structure is a channel through which actual care is delivered. Structural features may provide an opportunity to receive care. This unfortunately does not guarantee quality care. Structural features may have a direct/indirect effect on process of care and outcome. Unavailability of necessary technology, skilled health personnel for clinical examination, and preclinical investigations in a health-care facility may directly inﬂuence the manner in which care is delivered as well as the quality of care.

Processes of care refer to the actual care being delivered and received. It involves interactions between users and the health-care structure. Processes of care usually involve active participation of the patient and the health-care professional in deﬁning and communicating problems, diagnoses, management, and coordination of care. The clinician applies clinical medicine to the personal health problem communicated by the patient and discusses the diagnosis, management, and coordination of care with the patient.

Outcome, on the other hand, is the result of the interaction between individual service users/ communities and the health-care system (Campbell et al. 2000). Outcome of care has two main domains: health status and health-care consumer’s evaluation. From an ethical perspective, a patient should experience a symptomatic relief (health status) or having an improved functional status (health status). In qualifying QOL more generally, three elements are taken into account:

The patient’s interaction with health-care providers.
Expression of great satisfaction (user evaluation) with the health-care provider.
Achievement improved functional status.

When the health structure exists, a longer waiting time and delay in initiating treatment affect outcome (Campbell et al. 2000). Unfortunately, resource-poor countries do not share the same chance of having a reliable source of care, let alone a high QOC.

Quality of care as mentioned above is a crucial concern to both the developing and developed worlds. Different approaches can be used to deﬁne quality of care; this include the generic approach, disaggregated approach, and the whole-system approach (Institute of Medicine 2001; World Health Organization 2006). The generic deﬁnition of quality of care include care with zero defects, the degree to which health services for individuals and populations increase the likelihood of desired outcomes and are consistent with current professional knowledge, and clinically effective care. The generic approach may be applicable in one setting and not applicable in other settings and thus is not generalizable or operational sable. For example, it is difﬁcult to provide health care with zero defects or 100 % efﬁciency. While processes of care are under the control of the health-care provider, health outcomes (functional status/ symptomatic relief or patient satisfaction) may not; they are dependent on other factors outside the control of the health-care provider. Prescribing medications for hypertension does not necessarily mean the patient is going to adhere to the dosing frequency and duration of treatment. Also, a patient may well receive high-quality care from the attending health-care provider but considers the care (outcome/satisfaction) to be suboptimal.

The disaggregated approach deﬁnes quality of care at an individual and population levels with distinct components. From an individual stand point, quality of care can be deﬁned as whether individuals access health-care structures and processes of care which they need and whether the care they received is effective. The main components of this individual-based deﬁnition include accessibility and effectiveness. Accessibility answers the question whether individuals can access health structures and processes of care which they need. Other subcomponents of accessibility include geographical accessibility, affordability, and availability. Geographical accessibility relates to physical barriers to getting to health-care facilities (living in a rural area) or barriers to the premises of health-care facilities as applied to the elderly and people with disability.

Availability on the other hand refers to the extent to which a health-care system provides facilities and services meeting the needs of individuals. For example, access to a general practitioner, a specialist clinic, counsellor, or physiotherapist. Another important subcomponent of availability is organizational access in which physical access to the health facility is inﬂuenced by other barriers such as the language barriers, length and availability of appointments, or the referral behavior of a primary-care physician to secondary care or other members of the care. As a component of accessibility, ﬁnancial accessibility or affordability at an individual level depends on who pays for health care and the health-care system concerned. In a situation where health care is not provided by the state or where services are not free at the point of delivery, the patient bears the ﬁnancial burden. Other important ﬁnancial barriers common in health systems in developing countries include transportation cost, prescription charges, and loss of earnings. Even though outcomes (health status and user evaluation, patient satisfaction) are not direct components of accessibility, they can inﬂuence access and/or quality of care. For example, if a client was poorly treated by a health-care professional (dissatisﬁed with care), it is but obvious that the client’s future decisions to accessing formal care may be affected.

The second part of the deﬁnition of quality of care at an individual level is effectiveness. Effectiveness is the extent to which care is delivered in response to the need to improve the health outcomes of individuals. There are two main elements of effectiveness: clinical care and interpersonal effectiveness. Effectiveness of clinical care can be evidenced based or designated as legitimate. Evidenced based is when there is a good scientiﬁc evidence demonstrating a link between processes of care and outcome. Legitimate care is the extent to which a treatment meets a patient’s expectation and traditional professional norms without necessarily having scientiﬁc evidence of effectiveness. Effectiveness of interpersonal care is care that is planned for and with the patient through negotiation between the patient and the physician. It is also called patient-centered care. Patient-centered care considers the patient’s personal experience during the delivery of healthcare services. It is care that is respectful of and responsive to individual patient preferences , needs, and values and ensures that patient values guide all clinical decisions (Institute of Medicine 2001).

An important concept to also consider with regard to effectiveness of care as a component of care is coordination of care. This is actually a subcomponent of both clinical and interpersonal care. It refers to the effectiveness with which health professionals involved in the care of the patient interact with each other within the same organization or from other organization that may inﬂuence the health or quality of life of the patient. This involves the role played by professionals in social care, counseling, education, and housing.

A Whole-System Perspective On Quality Of Care

The whole-system perspective on quality of care takes into account six domains of quality of care. The six domains of quality of care according to this approach include effectiveness, efﬁciency, accessibility, acceptability/patient-centered care, equity, and safety (World Health Organization 2006). This approach suggests that a health system should strive to make improvements in these six areas if its goal is to improve the quality of care it delivers to individuals and the community it serves. The whole-system approach deﬁnes quality of care as care that is safe, effective, patient centered, timely, efﬁcient, and equitable (Institute of Medicine 2001). This deﬁnition encompasses clinical care (safe and effective), interpersonal care (patient-centered care), and contextual care (timely, efﬁcient, and equitable). Effective clinical care is delivering health care that is based on scientiﬁc evidence and results in improved health outcomes for individuals and communities, based on need.

Health care is considered safe when it minimizes risks and harm to service users. Acceptable/ patient-centered care on the other hand is health care that takes care of the aspirations, preferences of individual services, and cultures of the communities concerned.

Efﬁcient care is health care that is delivered in a manner which maximizes resource use and avoids waste, while accessible care is care that is delivered timely, is geographically reasonable, and is provided in a setting where skills and resources are appropriate to medical need.

Equity is delivering health care which does not vary in quality because of personal characteristics such as gender, race, ethnicity, geographical location, or socioeconomic status.

There is the assumption that quality clinical care must be done adhering to set standards or guidelines for it to be safe and effective. Quality clinical care also assumes that interpersonal care (patient-centered care) and patient values guide all clinical decisions. This does not always happen. Owing to the subjective nature of patient values, needs, and preference, indicators and metrics to measure quality of patient-centered care are currently being developed (Institute of Medicine 2001). Lastly, efﬁcient, timely, and equitable care assumes that there is no waste of equipment, supplies, ideas, or energy; no waiting time or harmful delays for service users; and no variation in delivering health care as a result of demographic characteristics (age, gender, ethnicity, geographic location, and socioeconomic status). Reerick and Sauerborn (1996) offer three reasons why QOC is a low priority in serving underdeveloped countries:

Priority setting of “coverage” over quality
“The view that quality is difﬁcult to assess in the absence of reliable documentation and health information systems”
“The perception that improving quality is tantamount to increasing inputs, thus costly and not affordable for many countries”

Quality Of Care In The Maternal And Newborn Health Context

The conceptual framework of health care and medical care has seen tremendous development over the last 40 years. It was ﬁrst developed in 1970 and reviewed in the 1980s. In the 1990s, three models were described: the perspective model (focusing on quality of care from the perspective of health-care providers, patients, and health-care managers), the characteristics model which lists elements and features of care, and the systems model that considers quality of care as function of the structure of health-care services and processes of health-care delivery.

The quality of care model for maternal and newborn health must balance several ethical considerations. The health-service users’ experience must account for the autonomy of the patients which affects the health of the unborn fetus. As a recipient of pregnancy-based medical services, the clinician must then recalibrate care in a number of ways. First, while unlikely, the patient has the right to accept or turn down care. Second, there are cultural and religious issues that vary even with a country that may affect the approach that must be taken to prenatal/postnatal care. In doing so, clinicians appropriate intervention pathways that overcome delays during delivery and inputs and outcomes. While clinicians in resource-poor countries may not know the particularities of every cultural practice, communication with the patient becomes more vital to ascertain cultural issues. This model is an extension of the Donabedian quality of health model consisting of structure, clinical care processes, and outcomes (Austin et al. 2014). The key components of this model in relation to maternal and newborn health include structure, processes of care, and outcomes. Structure in this case refers to the context in which maternal and newborn health care is provided. This may be at the community, district, and facility levels. Process of care refers to whether evidence-based practices of maternal and newborn care are followed and whether quality of care as deﬁned by the Institute of Medicine is delivered. Outcomes include maternal/neonatal mortality antenatal consultations uptake, immunization rates, and maternal satisfaction of health services and timely utilization of health services. In the modiﬁed Donabedian framework, the three components of quality of care are interconnected; good structure should produce quality maternal/newborn care and quality maternal/newborn care in turn should promote good outcomes. The public health expectations could be a reduction in infant mortality/ maternal mortality and an increase in vaccination uptake rates.

Interventions To Improve Quality Of Care

While it is important to develop strategies to improve quality of care, decision makers, health service providers, and the communities must be actively involved to make it work. The decision makers develop the strategies, create an environment to facilitate quality improvement, and thus remove barriers that may impede quality development. Health-care providers on the other hand must provide high-standard care that meets the need of health-service users, their families, and the community. A simple but great approach to developing strategies for quality improvement seeks to understand the problem, plan, take action, study results, and plan new actions in response following an evaluation of the quality improvement plan.

Stakeholder Involvement

The key stakeholders include political and community leaders, health-service users, health-care delivery organizations, health advocacy groups, health workers’ representative, and regulatory bodies. The key stakeholders can designate a core group that works in close collaboration with the ministry of health to ensure quality. Also drawn from the stakeholder group, is a steering group. The steering group is involved in all stages of quality improvements, advice decision makers and reviews the progress of quality improvement strategies. There is a need for clear-cut terms of reference as what each member is expected to do.

Situational Analysis

In as much as the situational analysis is concerned, important items to consider include an initial assessment of the current health policies and policies across other sectors, current health goals and priorities, current state of the health structures and leadership, current performance of the health system especially with respect to the domains of quality deﬁned above (effective, safe, accessible, acceptable, equitable, and safe), and ongoing quality improvement interventions. The situation analysis tries to make connections between the health sector and other sectors because quality of health care may well be inﬂuenced by other sectors like agriculture, ﬁnance, and information/communication sectors of a given country. This is usually spearheaded by the steer or core group of stakeholders for quality improvement.

Confirmation Of Health Goals

Conﬁrmation of health goals is important for any quality improvement intervention to be successful and sustainable. A good situational analysis usually provides the basis from which policy makers and stakeholders decide on which quality improvement strategy to implement. Once the health goals of the health system have been identiﬁed and agreed upon by decision makers/ stakeholders through a political process, decision-making on how to improve them can then be feasible. Important health goals for a health system include reducing mortality or morbidity and making health care more safe by reducing the incidence of hospital-acquired infections.

Development Of Quality Goals

After having clearly deﬁned the health goals, the next step is developing quality improvement goals, the choice of which is driven by the agreed-upon health goals. Usually, the evidence or justiﬁcation of the quality improvement goals can be found in the situation analysis. The quality improvement goals must relate to the different dimensions of quality. Some important questions to consider when developing quality improvement goals include what are the deﬁciencies in efﬁciency, effectiveness, or accessibility of the current health-care system. A thorough situation analysis should be able to inform judgements about the signiﬁcance of general evidence of a particular health issue in order to develop a quality improvement goal. For example, if the health goal following a situational analysis is to improve the outcome of people with cancer, the quality improvement goals will be to improve access to diagnosis and early treatment, improve effectiveness through evidence-based care, and ensure continuity of care. Further, if the health goal is to improve the health outcomes of a rural population, improving local access and acceptability of health services will be a quality improvement goal to consider. From a practical standpoint, these goals need to be explicit, time bounded, and measurable.

Choosing Interventions For Quality

Improving quality of care actually involves choosing the right interventions as well as where to make these interventions. Quality improvement interventions can be addressed at six interrelated strategic levels (World Health Organization 2006). The six strategic levels of quality improvement include leadership, information system, patient and population engagement, regulation and standards, organizational capacity, and models of care. Leadership is the heart (core) of this model because the success of most quality improvement initiative success depends on a strong and consistent leadership support especially from national and community leaders and health-care organization leaders (key stakeholders in quality of care). Information is also an important domain to consider because it is crucial to measure changes in processes of care and outcomes following a quality improvement initiative. A quality improvement in information systems needs to be consistently applied across the entire health system. This will enable comparability between different parts of the system. Apart from being transparent, information system supporting quality assurance must provide stakeholders access to information on processes of care and outcomes. The quality improvement to consider in this domain include improving the availability of information about best practices to health workers, providing individuals and communities information to manage their own health, and improving the manner in which health providers give information.

Patient and population engagement is at the heart of all strategies and policies for quality improvement. Strategies to improve patient and community engagement include improving health literacy, self-care, and patient experience with the health system. Involving patients and the community is an important step because they usually want to share the responsibility for their own health as well as in the governance of the health system.

Regulation and setting standards is one of the domains most policymakers focus on to bring changes or improve quality of health care. It involves setting standards and monitoring adherence to these standards. This facilitates compliance with scientiﬁc evidence-based care. The role of regulatory agencies and professional bodies play a crucial role in partnership with the government. The organizational capacity of the health system is also important to consider. Quality improvement here applies to all levels: national level, community level, and health-care provider organizations. Quality improvement strategies at the national level ensure that the government has a capacity to lead/develop quality improvement policies, drive its implementation, and keep the performance of the health system under review. At the community level, the community should be able to identify needs and preferences . Healthcare provider organizations on the other hand need to develop systems with the capacity to support quality improvement by providing an organizational culture that values quality, rewards, and incentives to promote quality and providing their workers with the necessary skills to deliver quality.

Developing new models of care should aimed at addressing all the dimensions of quality and improve health outcomes through an integrated approach. Models of care are a means of delivering health care to a particular population group deﬁned by common need (people with chronic conditions) or common characteristics (disability, elderly and children). Developing models of care as a strategy of quality improvement ensures that all aspects of health are taken care of, including health promotion and protection with contributions from primary care, specialized care, and social care organizations.

After careful review of the six strategic levels of quality improvement, policymakers need to revisit their situational analysis to select the appropriate level for quality improvement to deliver the desired outcomes/improvements. For example, if there is poorly aligned or conﬂicting health policies identiﬁed during the situational analysis, there will be a great need to make improvement on the leadership. Also, if there are deﬁciencies in the information system that could undermine the health outcomes of patients and communities, then an information system intervention is needed.

Implementation And Monitoring Progress

With the quality improvement strategy identiﬁed (leadership intervention, patient/population engagement intervention), it is implemented. The steer group of stakeholders usually decide on the leadership and accountability, timescales and milestones, and how to monitor progress before implementing the intervention. A desire to modify activities and make changes in response to feedback, sustained interest, and commitment are crucial to the success and sustainability of quality improvement interventions. The last element of quality improvement is monitoring the progress of implementation. It helps to make adjustments when expected results (improved outcomes) have not been met. Monitoring progress involves the three cycles of analysis, strategy development, and implementation.

Case Study For Your Consideration

The following case study was presented by Maru et al. (2012) to highlight the gap between best practices and actual implementation encountered in resource-poor countries. A young school-age boy with severe respiratory distress presents to a remote hospital. Previously, the boy had been seen by untrained private clinicians in the community three times over 4 days. At presentation to the hospital, the child is evaluated by a midlevel practitioner who provides an initial course of antibiotics. Despite the child’s ill appearance, supportive treatment including intravenous ﬂuids and supplemental oxygen were not provided until discussion with the Medical Director 3 h later. Later that evening, the electric nebulizer and oxygen concentrator became unusable after the hospital lost power owing to a blackout of the public electric grid and malfunctioning of the hospital’s backup generator. The regulator for the backup oxygen canister could not be found. At this juncture, without the ability to provide oxygen, the medical team recommended transfer. The family refused to be transferred due to the high costs of other regional health facilities. That evening, after not being examined for over 2 h by on-call staff, the child was found unresponsive with a rapid and scarcely perceptible pulse. The midwife managing the ward that day did not initiate cardiopulmonary resuscitation for over 10 min because she did not know the procedure and the bag valve mask was not at the bedside. Following 15 min of unsuccessful resuscitation, the child died.

In order to the respond to the above clinical scenario, it is worthwhile to identify the problems and propose a health system quality improvement approach. The Donabedian framework of health care would help guide the identiﬁcation of the problems with this case. The problems in this case study can be grouped into those related to health-care structure and process of care. With regard to the outcome of this case scenario, it is obvious (death of the school-age boy and may be parental dissatisfaction with the health facility by logical reasoning).

The problems related to structure according to the Donabedian model of health care include untrained private clinician in the community who attended to the child for 3 days and could not make an appropriate diagnosis and treat the boy with appropriate antibiotics. Other problems related to structure include poor logistics, unstable public power supply, malfunctioning of hospital’s backup generator, unavailability of backup oxygen canister or back valve mask to assist in ventilation, and probably no ambulance to transport the boy to the regional hospital for specialized care. The unstable power supply which to some extent was the primary factor responsible for the child’s worsening condition could also be a leadership problem.

Problems related to process of care include the untrained private clinician in the community and lack of continuity of care between the midlevel practitioner and the medical director. This actually led to a delay in the initiation of supportive therapy (it was started 3 h later following discussion with the medical director) and poor clinical follow-up of a child in distress by the health staff on call. They did not examine the child for over 2 h until he was unresponsive and the attention of an incompetent midwife managing the ward was called who could not perform a cardiorespiratory resuscitation.

The outcome of all the deﬁciencies led to the death of the school-age boy and ultimately parental dissatisfaction with the health facility. The fate of this young school-age boy would have been different if there was an existing quality improvement initiative in this health facility. Below is what would have happened if things were done differently. One day after his parents reported a cough and fever, the boy was visited by a community health worker and referred to a health post where he received an initial course of antibiotics. On the second day, when follow-up revealed a higher fever and respiratory distress, the child was referred to the hospital. After initial consultation, a midlevel provider admitted the patient and spoke directly with the Medical Director to ensure proper management. Oxygen was administered via a generator-powered nebulizer, and on the third hospital day, after signiﬁcant decline, the child was transferred via an oxygen-equipped ambulance to a regional hospital. After 8 days on the inpatient unit at the regional hospital, the child followed up as an outpatient and was visited at home regularly by a community health worker. The following week, the family attended a community health worker class on respiratory illness and prevention in the community.

A Health System’s Quality Response

The above case study shows a great need to have global health quality improvement initiatives in health facilities. A six-step system quality improvement response can be discussed in relation to this case scenario. First, there is a need for a paradigm shift. Global health ﬁnancial schemes need to emphasize on quality metrics when planning and ﬁnancing health services. Volume-based ﬁnancing of health facilities should strongly be discouraged; health facilities should be ﬁnanced based on predetermined health quality metrics. In this case scenario, the central funding mechanism (leadership/accountability mechanism) should provide funds to the hospital based on whether predetermined health quality metrics were met.

The second strategy is to develop quality improvement curricula with continuing medical education programs and regular competence evaluation/self-assessments (regulation and setting standards) especially in rural settings where health personnel have little interaction with academia. In this case, quality improvement-related continuing medical education of the hospital staff with regular staff competence review in the hospital may have identiﬁed and solve the many problems that led to this child’s death. Speciﬁcally, if performance evaluations of the nurse midwife were done, it would have identiﬁed insufﬁcient knowledge of resuscitation protocols to enable targeted education.

Thirdly, there is a need to scale up data capacity (information) for this health system. Real-time data collection and evaluation should be encouraged by global health quality improvement initiatives. Scaling up data capacity is of great importance because it can provide health-care providers with information about their performance in comparison to other health-care facilities with suggested areas of improvement. In this case study, data on treatment for pneumonia based upon scientiﬁc established protocols and rates of appropriate antibiotics prescription would have informed clinical practice especially with the improvement they need to make in their practice.

The fourth in the stepwise approach encourages active engagement of patients and community in taking responsibility of their health. This can be achieved by ensuring public meetings about available health services, making performance data publicly available, publishing healthcare facility report cards, and establishing a community accountability checklist. In the case of this school-age boy, knowledge of the performance of metrics/proﬁle of untrained private care providers, the parents would have acted differently by taking their child directly to the regional hospital, even though there was a ﬁnancial barrier. Implementing evidence-based quality improvement programs (models of care) such as the Plan-Do-Study-Act, checklists, morbidity and mortality case conferences with ongoing clinical education and regular team-based process evaluation and a multidisciplinary care team for chronic diseases (Chronic care model) are crucial to ensure high quality healthcare in resource limited settings. Many errors would have been detected if a low-tech quality improvement tool such as pneumonia management checklist was used. Checklists are designed to ensure standardized high-quality care/team communication.

The last approach proposed for this case study is to develop an implementation science research agenda. There is a great need to promote quality improvement research on the implementation of quality improvement programs focusing on clinical care but most especially to logistics, managerial, and communication systems of health-care systems. Through research, logistics, managerial, and communication pitfalls that led to the death of this school-age child would have been prevented.

Conclusion

In conclusion, global health quality improvement initiatives need to have a paradigm shift from ﬁnancing and scaling up volume-based global health initiatives to quality global health initiatives in health-care systems. Deﬁning medical systems using paradigms appropriate for resource-rich countries is ill-advised and may hamper any movement toward sustainable health improvements in those countries. Access to care from a population perspective is the extent to which local and national factors (Societal factors) inﬂuence the availability of health services that is often outside the control of health professionals (Campbell et al. 2000). Effectiveness of care at the population level has four main subcomponents. These include cost, efﬁciency, equity, and affordability. Efﬁciency is the most efﬁcient use of care to maximize outcome. It is also the ratio between cost and beneﬁt. It takes into consideration how procedures can be used to produce maximum beneﬁt (allocative efﬁciency) or how procedures can be used in the most technically competent manner (technical efﬁciency). The difference between quality of care at an individual level and population level lies on cost-effectiveness. Quality of care at an individual level focuses on achieving maximum desired outcomes for individuals. Quality of care at population level takes into account inputs and outputs and ensures that resources are distributed efﬁciently where there is great potential for greater gain. Efﬁcient care must be affordable. In terms of assuring the most ethical care possible in resource-poor countries, ethics must be at the foundation of its medical care. While there are systemic factors which complicated the realization of perfectly ethical care, there must be an acceptance that ethics and QOC are synergistic. Ethical quality care is a requirement, not an optional goal.

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