This study, published in BMJ Open Quality, aims to understand the influence of context on the choice of change concepts implemented by public primary and secondary level health facilities, as well as private health facilities in Lagos State, Nigeria.  

The study team used qualitative methods including reviewing meeting reports provided by health facilities, leading key informant interviews and collecting data through participant observation. Study findings reveal that some of the quality improvement (QI) priorities were common across facility types, often driven by health system and external stakeholders, including government or NGOs. Other priorities were shaped by the available time and capacity of the facility QI teams.  There was considerable variation between facilities, reflecting available finances, facility culture, magnitude of a problem illustrated by data, the level of care expected of a given facility type and the availability of QI and clinical subject experts. 

The secondary level public hospitals, and, to some extent, private facilities, focused on complication management to enhance better health outcomes. This focus was explained by the relatively high prevalence of maternal complication these institutions had to deal with on a regular basis. Primary health care facilities focused on changes related to tools and infrastructure, such as water and power supply to a larger extent. Private facilities were alone in considering economic dimensions of health care provision, for example more efficient payment systems.  

Government and non-governmental organisations played a critical role in influencing QI priorities at the facility level. The study authors caution that without coordination this can result in QI activities losing a data-driven focus.  Furthermore, findings suggest that the teams with least QI capacity may focus on easy tasks while failing to address problems that impact health outcomes. Government coordination and leadership together with mentorship, coaching and support are needed to ensure that facility QI teams and staff are well capacitated to make positive impacts.