by Shams B. Syed, MD, MPH
In the last 6 years I have had the privilege of shaping and leading the implementation of a WHO program focused on improving patient safety in Africa through the use of hospital partnerships. African Partnerships for Patient Safety (APPS) has been implemented through a phased approach aimed at continuous refinement.(1) In this article, I summarize the journey and reflect on key implications on the use of institutional health care partnerships for global patient safety improvement.
The magnitude of harm resulting from unsafe care is known to be large in African health systems.(2,3) While exact data remain elusive, a steadily growing knowledge base indicates that the need to improve patient safety is great in low- and middle-income countries.(4) Recognizing the need for urgent action, in September 2008 WHO presented a technical report on patient safety issues and solutions in African health systems to all 46 countries in the WHO African Region.(5) Twelve patient safety action areas were highlighted (Table). The report was endorsed by all 46 countries.
As I stood in the vast hall in Yaoundé, Cameroon, listening to the proceedings—admittedly a little nervous just weeks into my new position as the lead for APPS at WHO—I wondered how we would shape our response to this clarion call for action from health leaders across Africa. Now, 6 years later, we can look back at this response and appreciate some of the lessons that have emerged.
Phase 1: Co-development and program design (2009–2011)
Unlike other patient safety initiatives to date, APPS sought to catalyze change through establishment of mutually beneficial hospital partnerships.(6) In keeping with emerging thinking in global health, we decided that co-development was absolutely essential.(7) Following a rapid consultation, APPS applied a "learn and do" approach in six hospital partnerships involving six African countries (Cameroon, Ethiopia, Malawi, Mali, Senegal, and Uganda) and partner hospitals in England and Switzerland. This phase involved co-development of a first batch of tools and resources and early components of a six-step APPS Improvement Framework. The foundation of the program was thus co-developed by frontline health workers in Africa and Europe. These groups came to agree that APPS should embrace three simple objectives.
First, build strong patient safety partnerships. Significant effort went into examining the meaning of partnership by utilizing sociological constructs.(8) This resulted in the co-development of both an APPS working definition of an effective partnership and a novel approach to measurement of partnership strength: "A collaborative relationship between two or more parties based on trust, equality, and mutual understanding for the achievement of a specified goal. Partnerships involve risks as well as benefits, making shared accountability critical."(9)
Second, focus on tangible patient safety improvements in each partnership hospital. The entire effort was framed around the 12 action areas, thus translating regional African policy into local implementation. The initial focus was development and utilization of a patient safety situational analysis tool, to build all improvement efforts on a clear understanding of local context.(10) While different groups of partners choose different projects based on local needs and interests, all of the groups worked to implement a series of hand hygiene interventions.(11)
Third, facilitate spread of the patient safety efforts, allowing partnership implementation experiences to catalyze wider change. This spread work had both national and local dimensions. APPS focused on influencing national patient safety initiatives by highlighting what had been learned through each partnership.(12) Moreover, local spread was also emphasized, with a focus on community engagement.(13)
Phase 2: Managed partnership expansion (2011–2013)
The lessons from phase 1 of APPS were then applied to a further batch of hospital partnerships, which included five countries in the African Region (Ghana, Mozambique, Rwanda, Tanzania and Zambia) and five hospitals in England. These new partnerships applied a more refined APPS Improvement Framework.(14) Two-year partnership plans focused on patient safety improvement were implemented; final evaluation findings emerged in mid-2014. During this phase, France also began to support APPS hospital partnerships involving five additional African countries and five hospitals in France.
Our experience in implementation taught us that patient safety learning was not unidirectional within partnerships. The "how to" of improvement in African hospitals had clear relevance to improving capacity in partner hospitals in Europe. We collated global thinking on the benefits that can flow from health systems in so-called developing countries to so-called developed countries.(15) At the same time we quickly learned that approaches from health systems in high-income countries needed clear adaptation for adoption to improve safety in African partner hospitals. We also began to emphasize learning between African countries (sometimes referred to as "South-South learning" in the global health community). We were pleased when partnership hospitals in Africa increasingly saw how local innovations could be shared across Africa. Further, partnership implementation experience was utilized for patient safety policy development across African countries, thus moving toward implementation-informed policymaking.(16)
Phase 3: Outward partnership expansion (2013–onward)
Following requests from Member States from both the African Region and across the world, the partnership model developed by APPS was opened to all African countries through an open Web-based registration mechanism launched during the World Health Assembly in May 2013.(17) Indeed, the strategic role of APPS was explicitly mentioned in a formal statement by African Member States at the Assembly as part of the discussion on patient safety. Momentum for the partnership-based approach as an alternative model for improvement continued to grow.(18) Today, any hospital partnership that is focused on patient safety improvement in an African hospital can join a steadily growing network of global improvers. The first such partnerships involving hospitals in the United States such as Rush in Chicago and Johns Hopkins in Baltimore has recently begun work with four African countries (Liberia, South Sudan, Tanzania, and Uganda). Other institutions in the United States are set to join the effort. At the same time, a WHO Collaborating Centre in Brazil has announced its focus on utilizing the APPS model for patient safety partnerships for improvement across the five Portuguese-speaking countries in Africa.
Implications for the future
The use of institutional health care partnerships for global patient safety improvement has the potential to revolutionize the global patient safety arena.(19) Exchange between frontline health workers utilizing a structured framework can keep improvement efforts grounded in the realities of health service delivery. Problem solving in challenging environments can sharpen the edge of patient safety improvers; potential mutuality of benefits abound. Indeed, the capacity for hospital partnerships to be a channel for reverse innovations—essentially innovations developed in developing countries and applied in developed countries—in global patient safety is an area ripe for exploration.(20)
APPS is now a part of the new WHO Department of Service Delivery and Safety. The partnership model co-developed by APPS will need to be further refined to ensure a clear blending of improvement science and sociological methods. These efforts promise to develop patient safety capacity in parts of the world where it is most needed, as is clearly evident from the current global Ebola-related emergency. Borderless capacity building for patient safety improvement involving frontline health workers can contribute to the flattening of the global health architecture by emphasizing the unifying concept of patient safety in health systems across the world that are moving toward universal health coverage for their populations.
Shams B. Syed, MD, MPH
Lead, African Partnerships for Patient Safety (APPS)
WHO Service Delivery & Safety
World Health Organization
Lead, African Partnerships for Patient Safety (APPS)
WHO Service Delivery & Safety
World Health Organization
1. WHO African Partnerships for Patient Safety. Geneva, Switzerland: WHO Patient Safety, World Health Organization. [Available at]
2. Wilson RM, Michel P, Olsen S, et al; WHO Patient Safety EMRO/AFRO Working Group. Patient safety in developing countries: retrospective estimation of scale and nature of harm to patients in hospital. BMJ. 2012;344:e832. [go to PubMed]
3. Bagheri Nejad S, Allegranzi B, Syed SB, Ellis B, Pittet D. Health-care-associated infection in Africa: a systematic review. Bull World Health Organ. 2011;89:757-765. [go to PubMed]
4. Jha AK, Larizgoitia I, Audera-Lopez C, Prasopa-Plaizier N, Waters H, Bates DW. The global burden of unsafe medical care: analytic modelling of observational studies. BMJ Qual Saf. 2013;22:809-815. [go to PubMed]
5. Patient Safety in African Health Services: Issues and Solutions: Report of the Regional Director. Geneva, Switzerland: World Health Organization; Regional Office for Africa. Report AFR/RC58/8. June 24, 2008.[Available at]
6. Syed SB, Gooden R, Storr J, et al. African partnerships for patient safety: a vehicle for enhancing patient safety across two continents. World Hosp Health Serv. 2009;45:24-27. [go to PubMed]
7. Crisp N. Global health capacity and workforce development: turning the world upside down. Infect Dis Clin North Am. 2011;25:359-367. [go to PubMed]
8. Principles of partnership. Geneva, Switzerland: WHO African Partnerships for Patient Safety, WHO Patient Safety, World Health Organization. [Available at]
9. Rutter P, Syed SB, Storr J, et al. Development of an evaluation framework for African–European hospital patient safety partnerships. BMJ Qual Saf. 2014;23:332-337. [go to PubMed]
10. APPS: Patient Safety Situational Analysis (Long Form). Geneva, Switzerland: World Health Organization, African Partnerships for Patient Safety; April 2012. [Available at]
11. A Guide to the Implementation of the WHO Multimodal Hand Hygiene Improvement Strategy. Geneva, Switzerland: World Health Organization. [Available at]
12. Syed SB, Dadwal V, Storr J, et al. Strengthening the evidence–policy interface for patient safety: enhancing global health through hospital partnerships. Global Health. 2013;9:47. [go to PubMed]
13. Gooden R, Syed SB, Rutter P, Hightower JD, Kelley E. Building a community engagement approach for patient safety improvement. Community Dev J. 2013 Dec 8; [Epub ahead of print]. [Available at]
14. APPS: Improving Patient Safety—Partnership Preparation Package. Geneva, Switzerland: World Health Organization, African Partnerships for Patient Safety; November 2012. [go to PubMed]
15. Syed SB, Dadwal V, Rutter P, et al. Developed–developing country partnerships: benefits to developed countries? Global Health. 2012;8:17. [go to PubMed]
16. APPS: National Patient Safety Policy and Strategic Planning Workshop. World Health Organization, African Partnerships for Patient Safety. September 9–13 2013; Harare, Zimbabwe. [Available at]
17. APPS Registration. Geneva, Switzerland: World Health Organization, African Partnerships for Patient Safety. [Available at]
18. APPS: Building Momentum for Safer Health Care. Geneva, Switzerland: World Health Organization, African Partnerships for Patient Safety; 2012. [Available at]
19. Global Catalyst Group for Institutional Health Partnerships. Position Statement. World Hospitals and Health Services. May 2014;50(10-13). [Available at]
20. Syed SB, Dadwal V, Martin G. Reverse innovation in global health systems: towards global innovation flow. Global Health. 2013;9:36. [go to PubMed]
Table. Twelve Patient Safety Action Areas in the WHO African Region
|1. National patient safety policy|
|2. Knowledge and learning in patient safety|
|3. Patient safety awareness|
|4. Health services for patient safety|
|5. Health care–associated infections|
|6. Health care worker protection|
|7. Health care waste management|
|8. Safe surgical care|
|9. Medication safety|
|10. Partnerships (patients, family, health professionals, and policymakers)|
|11. Patient safety funding|
|12. Research and surveillance|