(Illustration by Aurélia Durand)
For more than 25 years, the Institute for Healthcare Improvement (IHI) has used improvement science to advance quality and safety and to sustain better outcomes in health and health systems globally. In particular, IHI understands that quality healthcare is impossible without equity and that racism and white supremacy persist around the world. To illustrate our approach to these problems, we share lessons from IHI’s work with health systems in three settings—the United States, Brazil, and Ethiopia—to advance racial equity.
Pursuing Equity
In 2017, IHI launched Pursuing Equity with eight health system organizations in the United States to strengthen healthcare’s role in addressing equity. The initiative aimed to develop a more detailed blueprint of how healthcare can improve racial equity and to narrow clinical equity gaps. To do so, we have created, tested, and implemented a five-step framework for health systems to achieve health equity: make health equity a strategic priority; address the multiple determinants of health; build infrastructure to support health equity; partner with the community to improve health equity; and eliminate racism and other forms of oppression in healthcare.
To address racial equity with the participating teams, we began by defining racism and discussing examples and the history of racism in our health systems. Racism is how our systems, by design, perpetuate advantage and disadvantage by race, including differential access to resources, goods, and opportunities. Racism operates at multiple levels including the psychological, interpersonal, institutional, and structural, and includes discriminatory individual acts as well as policies and practices of institutions and interlocking systems. At in-person and virtual meetings throughout the two-year initiative, we discussed policies that disproportionately limit access to care and employment at the health system for communities of color, inequities that exist at the point of care for people of color resulting in inequitable outcomes, and cases of racial discrimination perpetuated by patients or employees. We also shared strategies to normalize conversations on racism, including naming it explicitly as a driver of inequities, as well as our personal challenges advancing this work in health systems.
To understand the impact of policies and proposals in the health system on communities of color and other marginalized groups, we used racial equity impact assessments, a set of focused questions to examine how a policy, action, or decision may affect different groups. We then used quality improvement methods and tools to determine how we would correct the problems we identified. These tools included driver diagrams to map the system and key levers we wanted to change, as well as the Model for Improvement, which asks three questions: What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in improvement? The Model for Improvement was used to set aims, establish measures, and identify changes. We then employed Plan-Do-Study-Act (PDSA) cycles for small tests of the changes we thought would lead to improvement.
We learned that knowledge about racism in the health system helps build a shared foundation for action and further learning. In addition, data that showed where inequities existed throughout the many departments in the health system built the determination for change and increased awareness of equity improvement efforts currently underway in the organization and opportunities for future equity improvement work.
Parto Adequado
Brazil has one of the highest rates of c-section births in the world. Since 2015, the Collaborative Parto Adequado (PPA) has sought to reduce these rates in the country’s public and private hospitals. In phase one, we increased vaginal births from 21.5 percent to 38 percent in the target population chosen by each hospital. In phase two, 114 hospitals are working to increase vaginal births in women classified as Robson 1-4, who are low-risk, reduce adverse events for the mother and babies, and improve the experience of care.
In phase one, we did not have a racial equity strategy. While we improved the rate of vaginal deliveries on average, we were not stratifying data to understand inequities and how our work affected women of color. Through one-on-one conversations and relationship building, we learned that the colorblind way we worked had excluded the contribution of black leaders—especially doctors and nurses—and perpetuated the status quo, undermining trust in our partnerships and preventing a focus on populations most burdened by the current system.
In phase two, this experience led us to commit to co-producing a strategy and a new way of working that centers women, especially the voices of black leaders and women’s activists, in every step of the process. Now, black mothers and activists from the community are members of the leadership committee and we share decision-making power. We also decided to provide a contextualized anti-racism training for 14 leaders of the collaborative, Faculty of IHI and IHI Staff to build a shared understanding of how racism operates at all levels, prepare leaders to build a multiracial coalition, and ensure white leaders work alongside people of color to advance equity.
PPA has just begun this anti-racist journey. Without everyone on the team understanding how racism manifests within our team structures, building a coalition with activists and mothers was nearly impossible. We needed to introspect as individuals and as a team to identify our own biases and white privilege, and understand how racism affects the health system. To improve the system overall and to narrow equity gaps, black mothers must be leaders and decision makers alongside white leaders in a multi-racial movement to improve care for all.
Ethiopia Health Care Quality Initiative
There is an unjustifiably high rate of death from the poor quality of care mothers and newborns receive in low- and middle-income countries (LMICs). This problem contributes to half of all preventable maternal deaths and 60 percent of all preventable neonatal deaths in LMICs (or 60,000 maternal and 660,000 neonatal deaths yearly). Improving healthcare quality, particularly as we strive to achieve universal health coverage, is imperative.
In Ethiopia, a low-income country of roughly 100 million people, great progress has been made to reduce maternal and child mortality. Since October 2013, IHI has worked in partnership with the Ethiopian Federal Ministry of Health (FMoH) to further improve quality and equity in the country’s health system. The Ethiopian Health Care Quality Initiative was designed to demonstrate how quality improvement can be used as a tool to advance social justice and equity in five ways:
1. We designed and prototyped the program to help populations with the worst maternal and newborn (MNH) health system experience and outcomes. We have developed and refined the approach in 26 rural districts across five regions, including six pastoral districts with some of the hardest to reach and underserved ethnic groups including the Afari and South Omo tribes.
2. We brought together key stakeholders across the health system, including patients, community health workers, midwives, clinical providers, data managers, and district leaders, to form improvement collaboratives to solve problems through flattening hierarchies, listening to patients and frontline health workers, and creating a learning environment.
3. We trained patients and providers to use data to advocate effectively for solutions beyond their immediate resources.
4. We worked on strengthening patient-provider communication.
5. We used quality-improvement projects to create safe and clean environments for mothers and newborns and to fill gaps in essential commodities.
IHI has prioritized building the capacity of an almost entirely Ethiopian staff and of our Ethiopia Federal Ministry of Health partners to galvanize a cadre of improvement leaders who will carry on this work far beyond its engagement. We have also supported local implementers to develop their research skills and publish in peer-reviewed journals, both to produce the best research and to continue their professional development.
Takeaways and Challenges
Around the world, systems have been built for the advantage of white populations and the disadvantage of communities of color. In our mission to improve health and healthcare worldwide, we have an opportunity to utilize our systems improvement toolkit to address systemic inequity and build a movement to support this effort.
At IHI, to continue clarifying our racial equity strategy, we frequently ask ourselves: As an organization, how does where we choose to work and with whom reflect our values and need to advance racial equity? How do we make sense of this concept around the globe where there are different histories and contexts? When and how do we push or meet people where they are? When do we insist on naming racism explicitly?
We are building a global movement that understands quality without equity is not improvement. This journey must be centered with patients and families that have been marginalized by healthcare. We must be ready to listen to them, identify racism, use our voice humbly, distribute power, and use methods of systems improvement to lead us through these complex challenges.
Support SSIR’s coverage of cross-sector solutions to global challenges.
Help us further the reach of innovative ideas. Donate today.
Read more stories by Santiago Nariño, Hema Magge, Angelina Sassi & Amy Reid.