Open Access Highly Accessed Research article

Understanding the barriers to setting up a healthcare quality improvement process in resource-limited settings: a situational analysis at the Medical Department of Kamuzu Central Hospital in Lilongwe, Malawi

Josephine Nana Afrakoma Agyeman-Duah1*, Antje Theurer23, Charles Munthali3, Noor Alide4 and Florian Neuhann5

Author Affiliations

1 Project Officer, Project Fives Alive! Health Directorate, National Catholic Secretariat, P. O. Box KA 9712, Accra, Ghana

2 Medical Department, Kamuzu Central Hospital, Lilongwe, Malawi

3 Department of Internal Medicine, St. Katharinen Hospital, Seckbacher Landstrasse 65, 60389, Frankfurt, Germany

4 Kamuzu Central Hospital, PMB, Lilongwe, Malawi

5 Institute of Public Health, Ruprecht-Karls University of Heidelberg, INF 324, 69120, Heidelberg, Germany

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BMC Health Services Research 2014, 14:1  doi:10.1186/1472-6963-14-1

Published: 2 January 2014



Knowledge regarding the best approaches to improving the quality of healthcare and their implementation is lacking in many resource-limited settings. The Medical Department of Kamuzu Central Hospital in Malawi set out to improve the quality of care provided to its patients and establish itself as a recognized centre in teaching, operations research and supervision of district hospitals. Efforts in the past to achieve these objectives were short-lived, and largely unsuccessful. Against this background, a situational analysis was performed to aid the Medical Department to define and prioritize its quality improvement activities.


A mix of quantitative and qualitative methods was applied using checklists for observed practice, review of registers, key informant interviews and structured patient interviews. The mixed methods comprised triangulation by including the perspectives of the clients, healthcare providers from within and outside the department, and the field researcher’s perspectives by means of document review and participatory observation.


Human resource shortages, staff attitudes and shortage of equipment were identified as major constraints to patient care, and the running of the Medical Department. Processes, including documentation in registers and files and communication within and across cadres of staff were also found to be insufficient and thus undermining the effort of staff and management in establishing a sustained high quality culture. Depending on their past experience and knowledge, the stakeholder interviewees revealed different perspectives and expectations of quality healthcare and the intended quality improvement process.


Establishing a quality improvement process in resource-limited settings is an enormous task, considering the host of challenges that these facilities face. The steps towards changing the status quo for improved quality care require critical self-assessment, the willingness to change as well as determined commitment and contributions from clients, staff and management.

Healthcare quality improvement; Patient care; Barriers to quality improvement; Healthcare in resource-limited settings