KA Afanvi^1,2*, SS Diarra³, LD Bawe⁴, Prof. YD Atakouma⁵, Prof. KKD Ekouévi¹, Prof. B Aguemon⁶, Prof. T Darré⁷, Prof. E-M Ouendo⁸, Prof. G Gresenguet⁹, Prof. IM Wateba¹⁰, Prof. M Mijiyawa¹¹

¹Département de Santé Publique, Faculté des Sciences de la Santé, Université de Lomé, Togo.

²Centre National d’Excellence en Qualité et Sécurité des Soins, Togo.

³Département de Santé Publique, Faculté de Médecine et d’Odontostomatologie, Université des Sciences des Techniques et des Technologies de Bamako, Mali.

⁴Service des Maladies Infectieuses et Tropicales du Centre Hospitalier Régional Lomé – Commune.

⁵Département de Pédiatrie, Faculté des Sciences de la Santé, Université de Lomé, Togo.

⁶Département de Santé Publique et d’Epidémiologie, Université d’Abomey-Calavi, Bénin.

⁷Décanat, Faculté des Sciences de la Santé, Université de Lomé, Togo.

⁸Institut Régional de Santé Publique Comlan Alfred Quenum (IRSP-CAQ), Université d’Abomey-Calavi, Bénin.

⁹Rectorat, Université de Bangui, République Centrafricaine.

¹⁰Ministère de l’Enseignement Supérieur et de la Recherche.

¹¹Ministère de la Santé et de l'Hygiène Publique, Togo.

*Corresponding Author: KA Afanvi, Département de Santé Publique, Faculté des Sciences de la Santé, Université de Lomé, and Centre National d’Excellence en Qualité et Sécurité des Soins, Togo; E-Mail id:

Citation: KA Afanvi, SS Diarra, LD Bawe, YD Atakouma, KKD Ekouévi, et al. (2024) Universal Health Coverage Era in Togo: The Golden Age to Professionalize Healthcare Quality. Medcina Intern 6: 226.

 Received: May 17, 2024; Accepted: May 21, 2024; Published: May 24, 2024.

Copyright: © 2024 KA Afanvi, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Quality is at the center of universal health coverage. The establishment of the universal health insurance in 2021 in Togo raises the question of its meaning for a quality professional. Our view is that it is the golden era to professionalize healthcare quality management. Quality mindset is missing in health systems because health professionals lack knowledge and skills in its discipline. Philosophically, the discipline of health qualitology is the technology for optimized and improved population health locally and globally. Mirroring the gold standard of professionalism in quality, the training of health qualitologists will take place in a national learning laboratory for health qualitology. The Centre National d’Excellence en Qualité et Sécurité des Soins is expected to be a clinical environment where students observe and follow experienced professionals and practitioners to develop their skills. Health qualitologists will be produced to protect and enhance the reputation of the health system, drive change, and improve profitability. The future is full of learning.

Universal health coverage, Professionalization, Healthcare quality, Health qualitologist, Qualitology, Togo.

The inclusion of universal health coverage (UHC) in the 2030 Agenda for Sustainable Development (SDGs) renewed its attention from researchers and policymakers [1]. Even if quality of care is not explicitly included in the World Health Organization (WHO)’s well-established UHC cube of three dimensions (population [who is covered]; services (services that are covered); direct costs [the proportion of the costs that are covered]) [2], it is critical to its achievement [1]. UHC should not be discussed and planned, let alone implemented, without a focus on quality [3]. Quality of medical care is, in modern reality, the most important predictor for achieving a sustainable competitive advantage [4]. Quality maximizes value by achieving the highest level of optimization in terms of customer satisfaction, cost, quality, process speed and invested capital [5]. Being at the center of UHC [6], what does it mean for a quality professional?

Overall, between 5.7 and 8.4 million deaths (up to 15 percent of overall deaths) are attributed to poor-quality care each year in low- and middle-income countries (LMICs) [7]. Overwhelming evidence now exists that significant numbers of patients are harmed from health care, resulting in permanent injury, hospital admissions, increased lengths of stay in hospital and even death [8]. Poor-quality care imposes costs of $1.4 to $1.6 trillion each year in lost productivity in LMICs [7]. The challenge of assuring and improving quality is not limited to LMICs. High-income countries have fallen short on the quality scale as well. In 2013, researchers estimated medical error to be the third leading cause of death in the United States of America (USA). These defects have high economic costs as well, with 15 percent of all hospital costs in Organisation for Economic Co-operation and Development (OECD) countries being due to patient harms resulting from adverse events [7].

Since 2017 in Togo, ensuring quality of health care and services for the entire population is a strategic choice [9]. A national policy [10] was enacted and strategic plans [11, 12] implemented at all levels of the health system. With the establishment of the universal health insurance in 2021 [13], our view is that it is the golden era to professionalize healthcare quality management.

Quality Mindset, The Missing Ingredient

In Togo, care provided by health facilities are of low quality [10] and most of these health facilities do not meet quality requirements [14]. Poor patient care, specifically, poor patient reception, poor provision of care, inadequate diagnostic instruments, use of expired reagents or of doubtful origin, non-compliant buildings, etc., are common quality of care issues [14]. Pharmaceutical products and medical equipment do not have certificates of conformity and are not regularly subject to quality control during their storage, conservation, and use [14]. After using the building blocks of health systems’ approach [15] and Pareto analysis to prioritize the sub-systems [16] on the weaknesses of the internal environment of our health system in 2023 as presented here [12], we found that 79% of the dysfunctions were from the building blocks “service delivery” and “leadership & governance” (figure 1).

Figure 1: Pareto chart prioritizing the most affected health system building blocks.

A quality mindset could have given professionals the skills to problem solve at a deeper level and continuously improve system’s performance [17]. This was the case in tuberculosis care and control as quality mindset was the missing ingredient for excellence [18]. Quality mindset is missing in health systems because health professionals lack knowledge and skills in its discipline [19-25].

Health Qualitology, The Technology of Optimized and Improved Population Health

Quality is the subject of a socio-economic approach (qualitisme in french) carried out with a technique (qualitique in french) that belongs to a science [26]. Qualitology is the branch of science which aims to study the quality of products, processes, and services [27-29]. In the USA, the term quality science and quality discipline is used [30]. Our position is for qualitology because the term is logical, monosemic and consistent with the terms in other branches of science [28]. Medical qualitology is an academic discipline that studies the essence, content, and management of the quality of medical care [4]. To avoid reductionism, health qualitology is used as the umbrella term of the discipline of quality practitioners in the field of health. Thus, health qualitology is the branch of health science that studies the quality of health and of its products, processes, care, and services.

The foundation of quality management is Shewhart’s work on operational definition based on the philosopher Lewis’s pragmatic conceptualism [31]. Philosophically, health qualitology is often classified as an applied science [32]. Because of the use of a broad technology [30] in addition to pragmatism and operationalism, health qualitology is, philosophically, a technology [33]. Technology is a science or knowledge applied to a definite purpose [34]. It is the use of resources (such as knowledge, skills, processes, techniques, tools, and raw materials) to solve a problem [35].

The goal of scientific research is truth for its own sake and that of technological research is useful truth to optimize and improve [33, 36]. Modern technology presupposes not only ordinary knowledge and artisanal skills but also scientific knowledge [33]. Knowledge to the technologist is an intermediate goal, something to be achieved to be used as a means for attaining a practical goal [33].Technological knowledge arises from, and is embedded in, human activity [37]. The ultimate task of technology is the fullest exploitation of natural and human resources at the lowest cost without regard for anything else [33]. Health qualitology is thus the technology for optimized and improved population health locally and globally.

National Learning Laboratory for Quality, Glocalization for A Triple-Function Reference Center

Quality is deployed through a management system made of quality planning, quality assurance, quality control and quality improvement [38]. Practicing in the field of health qualitology requires a deeper understanding of the realities of health services to understand local problems, find innovative solutions, learn from mistakes, scale up what works and share experiences [39]. Local learning must be a priority, but local lessons must also be shared with the world [39]. According to the Director General of the World Health Organisation, deploying quality needs a global learning laboratory for quality [39].

A learning laboratory (lab for short) is a physical, digital, and human space for observation, experimentation, and evaluation, to rethink and enrich learning and teaching attitudes and practices at the university [40]. In health systems, due to complex environments and organizational demands, learning labs require an interdisciplinary, inter-team ecosystem that incorporates systems engineering analysis and design methods into project work [41].

Incubators of innovation and learning [40], learning labs are selected local sites where contextually tailored and evidence-based interventions are implemented and monitored with the aim of enhancing local sites’ capacity to deliver quality health services which leaves no one behind [42].

Adapting the global learning laboratory for quality concept to the national health system, glocalization [43-46] leads to a national learning laboratory for quality. This national reference center is a clinical environment for practice, training, and research in health qualitology. In Togo, the creation of the “Centre National d’Excellence en Qualité et Sécurité des Soins (CNEQSS)” will satisfy the requirements in table I and bridge local health facility labs of quality and the global learning lab.

Health Qualitologists, Mirroring the Gold Standard in Quality

The importance of the quality management discipline has been recognized in UK by its professionalization through the award of chartered status [47]. The Chartered Quality Institute is the only chartered body in the world that’s dedicated to quality management [48] and the only organization in the world that can award chartered status to quality professionals [49]. The quality field is also recognized in the USA but there, the profession is fragmented with a variety of certifications [30]. Chartered status far exceeds certifications and is the gold standard for professionalism [50-55].

Table I: Critical to quality requirements for the CNEQSS.

The universal health insurance is a golden opportunity to professionalize health qualitology. Gold standard for professionalism in quality, Chartered Quality Professional (CQP) title places the holder at the same professional level as other chartered professionals [56-58]. The CQP’s work is quality management, and he can adapt and apply his skills in most situations [59]. To put quality at the heart of their organizations, quality professionals focus on three specific areas, or competencies [57]:

• Strong governance. This starts with top management expressing a commitment to quality. Effective governance means making sure that the aims of management are crystal clear, that they reflect the requirements of stakeholders, and that the right people, policies, and processes are in place to turn them into action.
• Proper assurance. This ensures that the policies and priorities that have been decided on are being carried out properly, and that whatever is being produced – whether it's a product, service, or project – is meeting stakeholders' needs.
• A culture of improvement. This means continually evaluating the organization’s performance to improve efficiency, eliminate waste, reduce risk, respond to changes and create new opportunities.

Chartered titles have traditionally been linked to academic qualifications and most modern Chartered bodies that intend individual chartered status as a robust professional qualification set the entry level at master’s degree level (or equivalent in skills and experience) [60]. CQPs require a level of knowledge of quality management principles, methods, and tools at university degree level [56]. Because the new quality profession needs more degree-level training [47], to reflect the CQP, a health quality professional, called a health qualitologist, needs to hold a master’s degree in health qualitology. After four years of specialist training, a medical doctor earns a specialist qualification in health qualitology and is called a medical qualitologist.

If a person actively practices quality management as part of his job role or specializes in specific areas of quality management system such as inspection, assurance, and improvement, he is a quality practitioner [59]. In quality glossary [61], a person who functions as a quality practitioner is a technician and is called a qualitician. Thus, someone who functions as a health quality practitioner is called health qualitician. Traditionally in health sciences, to be a technician, a person must hold a bachelor degree. Thus, a health qualitician must hold a bachelor’s degree in health qualitology.

Training health professionals takes place in a clinical environment where students observe and follow experienced professionals and practitioners to develop their skills [62]. Our view is that the CNEQSS is such an environment for health qualitology.

Health systems can expect, as measures of quality professionals' success, reputation protection (avoiding the potentially catastrophic risks of getting things wrong) and enhancement (value maximization for patients, population and stakeholders), profitability improvement (unnecessary cost and waste elimination, and revenue growth), and change driving (contribution to the ongoing improvement of the organization) [63].

Quality is at the center of universal health coverage. To answer the question of the meaning of the establishment of the universal health insurance in 2021 in Togo for a quality professional, our view is that it is the golden era to professionalize healthcare quality management.

A national learning laboratory for quality, the “Centre National d’Excellence en Qualité et Sécurité des Soins”, is created. As the national reference center, CNEQSS is a clinical environment for practice, training, and research in health qualitology.

Mirroring the gold standard for professionalism in quality, health qualitologists will be produced to protect and enhance the reputation of the health system, drive change, and improve profitability.

The future is full of learning.

Conflict of Interest

None

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