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S A F E C A R E P R O G R E S S R E P O R T 2 0 1 4
SafeCare
Preface
We believe that achieving inclusive healthcare begins by
creating trust between stakeholders through a common
language. SafeCare helps create this common language
by providing transparency on quality, scale and scope of
care. The methodology empowers healthcare providers
to improve the quality of care for their patients.
The SafeCare methodology is specifically designed for resource-restricted settings and focuses on opportunities rather than limitations. The program gives healthcare providers the tools and skills to move forward, and makes quality improvement tangible. Through the certificates, it creates a common language between all players of the health sector, increasing trust and facilitating transactions between providers, banks, insurers and patients. This drives improvements in quality of care and promotes investment in the healthcare market. So far, it has caught the interest of several African governments, who are institutionalizing SafeCare stand-ards and methodology into their healthcare systems.
In 2014, we introduced the concept of Centers of Excellence, where we reward clinics that show exceptional progress. Through peer-to-peer learning, they share their best practices to help clinics that are just starting their quality journey, demon-strating the benefits of the program from a financial and social perspective. Other developments include the upgrading of our AfriDB database and linking quality improvement to the PharmAccess Group’s new mobile health programs.
For the third year in a row, SafeCare has doubled in size. In 2014, more than 1,600 clinics were improving the quality of their services for over 1.5 million patients per month. So far, almost 450 people have participated in the SafeCare facilitator trainings and with our partners, we have conducted over 1,400 assessments. Learning and analysis is giving us better understanding on the impact - clinical, financial and social - of the program, which will bring a new round of innovation in 2015 that is aimed to help those facilities that are still struggling with the level of care they are providing.
The degree to which SafeCare is being embedded at national policy levels, as well as being embraced by many successful healthcare providers themselves, makes us proud of our achievements in the past year. We owe this success to the dedication and motivation of the teams within PharmAccess, but importantly also to our many international partner organizations that have made the system their own. We look forward to continue working together on the road to improving the quality of healthcare delivery in Africa.
Nicole Spieker Director SafeCare June 2015
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S A F E C A R E P R O G R E S S R E P O R T 2 0 1 4
In remembrance of Prof. Dr. Joep Lange and Jacqueline van Tongeren
While 2014 held many highlights, it was first and foremost the year in which we mourned the loss of our two beloved colleagues. On July 17th Joep Lange and Jacqueline van Tongeren lost their lives on board Malaysian Airlines flight MH17, en route to the International AIDS Conference in Melbourne.Joep was a world class scientist and a visionary leader, most known for his pio-neering work in HIV/AIDS care, treatment and research. As founder and chairman of PharmAccess, Joep helped expand this mission with new ways of financing healthcare, setting up impact evaluations and improving quality of care through SafeCare.
Mission, Vision and Objectives
Mission
SafeCare aims to improve the quality and safety of healthcare
services in resource-restricted settings using incremental standards-
based recognition and by building institutions that can objectively
measure and rate levels of quality and patient safety in healthcare
providers.
Vision
SafeCare’s vision is to become the world standard for benchmarking
and improving quality of healthcare providers in resource-restricted
settings through stepwise recognition of quality improvement.
Objectives
•
Improving quality of care of primary and secondary
health-care facilities in resource-restricted settings through an
external evaluation system based on standards and stepwise
quality improvement trajectories
•
Rating and benchmarking across healthcare facilities, provider
networks and resource-restricted countries
•
To provide information on healthcare provision, its scale, scope
and quality to international and national stakeholders
•
Establish a basis for performance-based payout and funding
systems for healthcare improvement
•
Work in a legal framework that is accepted by the local
authorities and may be extended to a national certification
and/or accreditation system for both public and private
healthcare providers.
3
A public-private approach
to quality improvement
In most African countries, there is a shortage of institutions and standards that ensure objective measurement and rating of the level of quality of basic healthcare facilities. Existing systems for licensing and accred-itation tend to fall short and are almost never customized for resource-restricted settings.
In 2011, PharmAccess, JCI and COHSASA founded SafeCare to help fill this gap in the African healthcare system. Through a set of internationally (ISQua) recognized quality standards and a step-by-step im-provement path, it offers positive incentives for healthcare providers to move upwards in clinical and business performance. So far, SafeCare has set up operations in Kenya, Tanzania, Nigeria, Ghana and Namibia, and has built capacity of more than 400 asses-sors to apply the methodology.
Building trust
Through the availability of data and bench-marking of quality and risk at the provider level, we reduce the risk and increase the trust needed to facilitate transactions between patients, healthcare providers, financers, and government. This public- private partnership approach is based on the following assumptions:
•
When quality levels in the health sector become transparent, patients are em-powered to “vote with their feet” and can choose those facilities that offer the highest quality healthcare services.•
Being able to differentiate betweendifferent quality levels provides the opportunity for pay-for-performance mechanisms, so that healthcare provid-ers can attract financial investments, qualify for (national) health insurance contracts and serve more patients.
•
Furnishing investors with reliable dataabout the risks in the healthcare market permits them to make more accurate long-term projections about financial investments.
•
Enabling governments to evaluate providers on the basis of quality and risk strengthens their ability to deliver effective regulation and enforcement through licensing, certification, and accreditation mechanisms.We strive to embed standards-based quality improvement methodology in the legislative framework of the countries where we work. We do this by building capacity within the government agencies responsible for inspection and quality assurance in the public and private sector. At the same time, our program builds capacity for self-regu-lation of the private sector. This enables access to better healthcare services for all.
SafeCare stimulates quality improvement throughout the health
system. In the private sector, we focus on introducing self-
regulation and benchmarking. Our activities in the public
sector are geared towards embedding SafeCare methodology
into the legislative framework.
‘SafeCare has served
as a benchmark for
the entire healthcare
system. Once the
quality of the private
clinics goes up,
government hospitals
cannot stay far behind.’
Dr. Charles Kandie, Head of Quality & Health Standards at the Kenyan Ministry of Health
5
The challenges and limitations that face healthcare delivery
in Africa disqualify most facilities from (inter)national
accreditation. Instead of applying a pass-or-fail system,
SafeCare measures, stimulates and recognizes incremental
achievements.
International standards,
local solutions
Many healthcare facilities in low and middle income countries lack very basic require-ments like running water, electricity or sani- tation. Often, they are faced with unreliable supply chains and chronic shortages of human and material resources.
Yet, they provide a wide range of services offered frequently by medical generalists (from outpatient care and phar- macy services, and often including inpatient care, laboratory testing, diagnostic imaging, and minor surgical procedures) that in high income countries would typically be provid-ed by specialists at secondary or tertiary hospitals. Given this setting, existing inter- national quality standards are often not
achievable within reasonable time frames, thus demotivating healthcare providers to embark on an improvement trajectory.
Governments of low and middle in-come countries face the problem of lack of enforcement options for quality standards. If implemented, such standards would require substantial investments for a vast number of both public and private providers. As a consequence, the required minimal quality scores are often lowered and asym- metries frequently exist in the enforcement of quality standards between the public and private sector. Innovative healthcare standards, a grading process, and stepwise quality improvement are particularly needed when licensing and accreditation systems cannot (yet) be adequately implemented.
Step-by-step
Many healthcare facilities do in fact have the capability and the motivation to improve, but the gaps between current practice and best practice cannot be bridged in a single step, and alternative ‘best of the rest’ solu-tions are often needed. SafeCare addresses this issue. Rather than applying a pass-or- fail system, SafeCare measures and recog-nizes incremental improvement. As facilities demonstrate continued improvement, their progress is rewarded with SafeCare Cer-tificates (Level 1-5) to recognize improved clinical and business performance.
‘SafeCare standards
generate a market
for healthcare quality
improvement and
improve access to care
for millions of people
in the informal sector
in Kenya.’
Khama Rogo, Head of the World Bank Group’s Health in Africa Initiative
SafeCare thus transforms quality assessment into a positive and encouraging experience. Facilities that demonstrate substantial leadership and improvement beyond that of their peers are recognized as “Centers of Excellence” and are held up as inspirational examples for other facilities to follow.
Local solutions
The basis of this methodology consists of internationally recognized, ISQua-accredited clinical standards that have been designed specifically to address the unique and complex challenges in these contexts. For example, as access to accredited training
is often limited, SafeCare has developed an alternative system of evaluating training needs in light of available resources. It also goes by the ‘best of the rest’ principle: if there is no central medical waste collection system, a cement pit for needle disposal will suffice. In many cases, meeting the SafeCare standards is not only a question of funding, but also a matter of coming up with creative solutions to common challenges.
Certificate definition
Level 1 The quality of the services provided is likely to fluctuate and there is a risk of unsafe situations.
Level 2 The facility is starting to put processes in place for high risk procedures however the quality of services provided is still likely to fluctuate and the risk of unsafe situations remains high. Level 3 The facility is starting to operate according to structured processes and procedures, however not all high risk procedures are controlled, thus the quality of services provided can still fluctuate. Level 4 The facility is accustomed to operate according to standardized procedures, and has started to monitor the implementation of their procedures and guidelines. Most of high risk procedures are monitored and controlled and the quality of services provided is less likely to fluctuate.
Level 5 The facility is regularly monitoring the implementation of treatment guidelines and standard operating procedures through internal audits, and is ready to begin the process of applying for accreditation from an international agency.
Accreditation Level The facility has a proven track record of continuous quality improvement, is in substantial compliance with the SafeCare standards and meets the decision rules for accreditation by independent organization COHSASA.
Low Quality High
L ev el 1 L ev el 2 L ev el 3 L ev el 4 L ev el 5 A ccr edit ation L ev el
SafeCare Certificate levels
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Management and Leadership
Management and leadership work collabo-ratively to develop the plans and policies needed to fulfill the mission of the facility and to coor-dinate and integrate the health service’s activities.
Patient and Family Rights and Access to Care
Health facilities work to establish trust and open communication with patients and to understand and protect each patient’s cultural, psychosocial and spiritual values.
Human Resource Management
A health facility needs an appropriate number of suitably qualified people to fulfill its mission and meet patient needs. Recruiting, evaluating and training personnel are best accomplished through a coordinated, efficient and uniform process.
Management of Information
Aggregated data from patient visits and treatment provided help the health facility understand its current performance and identify opportunities for improvement. By participating in external performance databases, a health facility can compare its performance to that of other similar health facilities.
Risk Management
Health facilities work to provide a safe, functional and supportive facility for patients, families, personnel, volunteers and visitors. To reach this goal, facilities, equipment and medication must be effectively managed.
Primary Healthcare Services
Planning and delivering care to each patient, monitoring the patient to understand the results of the care, modifying care when necessary and completing the follow-up.
Inpatient Care
Providing the most appropriate care in a setting that supports and responds to each patient’s unique needs requires a high level of planning and coordination. Delivery of the services is coordinated, integrated and monitored.
Operating Theater and Anesthetic Services
Services in the operating theater and anesthetic services carry high risk. It is essential that there is collaboration between the personnel in the theater, the infection control and health and safety personnel, and those responsible for supplying and maintaining equipment.
Laboratory Services
Laboratory investigations and rapid reporting systems are essential for patient assessment and the implementation of treatment plans. Laboratory services must be available when required by the organization.
Diagnostic Imaging Service
When a diagnostic imaging service is provided, there are radiation safety programs in place, and individuals with adequate training, skills, and ex-perience are available to undertake diagnostic imaging procedures and interpret the results.
Medication Management
The patient, physician and nurse work to-gether to monitor patients on medications. The purposes of monitoring are to evaluate the response to medication, to adjust the dosage or type of medica-tion and to evaluate adverse effects.
Facility Management Services
Buildings, grounds, plant and machinery are provided and maintained, and do not pose hazards to the occupants. Utility systems (such as electrical, water, oxygen, ventilation and vacuum - systems) are maintained, to minimize the risks of operating failures.
Support Services
Laundry, housekeeping and catering or support services work with other organiza-tional leaders and managers to improve the quality of service delivery throughout the organization to management, leadership, human resource development, infection control, environmental safety and quality improvement.
Service elements in healthcare delivery
SafeCare has defined 13 service elements in healthcare delivery. Each service element contains a number of criteria that are assessed in order to ascertain the level of compliance with the standards. Non-compliant criteria that represent a high risk in terms of safety, quality, or financial sustainability are identified as the highest priority for resolution.
9
‘Before, only a select number of larger
healthcare facilities could attain accreditation.
SafeCare has opened up a new avenue for
smaller facilities to work on improving their
quality. You can really see the joy on their faces.’
Elizabeth Kwamboka Nyambane, Relationship Manager Medical Sector, Chase Bank, Kenya
‘SafeCare has a well-tested system that gives
us standards by which to measure quality in our
facilities and a methodology which can empower
our healthcare workers to take ownership of the
process of rising up the quality ladder.’
Olaokun Soyinka, Ogun State Commissioner for Health, Nigeria
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St. Patrick upgraded the lab two years ago, moving it to a larger room, installing separate sinks for staining and handwashing, and purchasing more equipment such as TB and HIV testing kits. “We used to have to outsource many tests, but now other facilities refer people to us and labs send us their samples,” says medical laboratory technologist Eric Okeyo.
“We closely monitor our ser-vices with performance reports and have installed an SOP for every test, a tracking chart for expiration dates and guidelines for the maintenance of our equipment. We also have a visible price list with the expected report time for results.” The number of lab tests have more than doubled, from 400 to about 850 per month. “The lab now generates a lot of
in-come and has bein-come the financial backbone of the hospital.”
49%
81%
Located on a bustling commercial road of Nairobi’s densely populated Kayole area, St. Patrick Health Care Centre is one of the go-to healthcare providers for the mainly poor and low-income population. Most pa-tients are self-employed in retail activities, handicrafts or personal services like bar-bers and taxi drivers. The privately-owned facility has 17 staff members and 26 beds, and is open 24 hours a day, 7 days a week. Ann Maina opened St. Patrick with her husband Patrick in 2002. Ann is a nurse by profession, with over 20 years of working experience in private practice. They joined SafeCare in early 2012. “It was difficult sometimes in the beginning because SafeCare requires a new way of thinking, both for us and for our staff,” Ann says. “It’s about accountability, transparency and establishing procedures – in all depart-ments, from the cleaners to the medical personnel. But now that our staff has seen
what the program can do, they are fully on board and committed to continue to improve our quality.”
Establish gaps
Shortly after joining SafeCare, St. Patrick obtained a loan as well as business training through the Medical Credit Fund (MCF). With the Ksh 500,000 (USD 5,000) loan, they purchased computers, installed a computerized management system, internal phone lines and a CCTV system. They also invested in financial accounts by an external auditor and minor infrastructural improve-ments.
SafeCare was an eye-opener for them. “We were not running the facility in the
right way,” Ann explains. “We had no ad-ministration office, no systems. We used to work from our pockets, writing on patient cards and counting the shillings at the end of the day. SafeCare helped us to establish our gaps and set in motion interventions to improve ourselves. Now, our record keeping is accurate, we have audited accounts and a digital client history that can be accessed at any time. The system has also helped minimize fraud and track the expiration dates of drugs in our pharmacy.”
The experience they gained in qual-ifying for their first loan through the MCF program was instrumental in building a financially sound organization. “Through the training and on-site support, we learned how to draft a business plan and what doc-uments to deliver to the bank. Our records
For Ann Maina, SafeCare was an eye-opener. It helped her establish
the gaps at St. Patrick and set in motion clear interventions to improve
her facility’s quality of care. ‘SafeCare makes you feel like a professional.’
Spotlight on
St. Patrick Health Care Centre
were neatly in place.” They repaid their first loan within six months. Their improved track record and financial management enabled them to secure a Ksh 5 million (USD 50,000) loan from a bank to invest in their laboratory and the further expansion of the facility.
Improvement path
“When the National Hospital Insurance Fund (NHIF) used to visit us for an evalua- tion, we never knew what they were looking for. There was no manual or checklist and we never received advice on how to improve. After we started SafeCare and the NHIF visited us again, it was a whole other story. We had standard operating procedures (SOPs) in place, we had an organized flow of clients, a well-stocked pharmacy, fire ex-tinguishers and many other improvements that impressed them.” So much so, that the NHIF brought their staff to St. Patrick to learn more about SafeCare and how it helped St. Patrick improve their quality of care.
St. Patrick then became NHIF- accredited for civil servants as well as for the general public, ensuring a bigger client and income flow. Patient visits have risen from almost 600 to more than 2000 a month, especially now that they have also managed to contract corporate clients and private medical insurance companies. “SafeCare has helped us to reposition our-
selves and increase our market value,” Maina says. “The program is even being pushed by the market now, there is demand for it from healthcare providers. In the end, we all want a system that cuts across the whole country. We could be treating your brother and you could be treating mine.”
‘SafeCare opened
our eyes as to how
patients perceive the
quality of care.’
Ann Maina
Service element
Laboratory
services
St. Patrick’s SafeCare assessment scores for laboratory services im-proved from:
High healthcare staff turnover is a challenge in Kenya, and St. Patrick’s situation is no different. On average, over one third of their personnel leaves every year, although staff retention has now improved. Ann and Patrick have completed and updated their personnel files, drafted job descriptions and now facilitate con-tinuous medical education every week.
Karen Anyango, one of the nurses who has been at St. Patrick for almost four years, praises Ann’s hands-on management style. “She can be tough, but we also call her ‘mom.’ She encourages us to ask
questions and improve in our work, and her door is always open.” Every Wednesday and Friday, the staff comes to work in specially designed St. Patrick uniforms. Ann: “We have grown to a full-fledged facility and all our staff is proud to be a part of it.”
44%
74%
Perception of care
“SafeCare opened our eyes as to how patients perceive the quality of care.” The changes that Ann and Patrick made may seem small, but they have had a huge impact on customer satisfaction. When St. Patrick admits new inpatients, they are given an orientation of the facility and are introduced to other patients so that they feel more comfortable. Maina even installed a mirror in the maternity ward, where they do about 40-50 deliveries a month. Smil-ing: “Once women deliver, many want to go back to normal life and put on lipstick.”
The waiting room was also adjusted. “Our facility is located on a busy street.
Before, we had the seats in our waiting room facing outside. Now, we have moved the TV to the opposite corner and turned the seats around to give people inside more privacy.” Where the walls of the facility used to be plain, they are now painted in bright colors and cartoon figures. “Children often don’t want to leave!” There is a clock and a sign with the visiting hours on the wall, as well as a plaque with St. Patrick’s vision for the facility. They also installed a sug-gestion box to gather patient feedback. “We never thought of these things before.
Everything we’re doing here now is SafeCare.”
Continuing the journey
In terms of risk management, Maina explains that her staff has learned about things like infection control and the importance of hand washing. “We used to throw away needles in the regular bin. Now we have a waste management system: we separate different types of waste in color-coded bins and we have an incinerator for clinical waste.” She has made a point of sharing knowledge with the community. Her facility now has health campaigns to educate people about hygiene and organizes events for pregnant women to share experiences and demystify child birth.
While St. Patrick started with just a one story building, construction is underway to start offering services on the third floor. The second floor now houses the administration offices, a dental unit, in-patient wards and the kitchen for the inpatients. They have added a dentist’s office, an ultrasound and have upgraded their lab to include a broad range of tests, from cholesterol and liver function tests to thyroid tests and pap smears. They also progressed from being predominantly cash-based to accepting more modes of payment like ATM cards, Visa and M-Pesa.
The next step is installing an operating theater. “Our female clients want to give birth here because they feel at home, but they would feel more assured if we had a theater.” Maina is eager to continue im-proving quality of care and reach Level 5. “SafeCare needs a lot of commitment, but
you feel like you’re in another world. It makes you feel like a professional.”
595 2,078
# of patient visits increased from 595 to 2,078 per month
230,000 717,410
Revenues increased from Kshs 230,000 to Kshs 717,410 per month67% 81%
SafeCare score improved from 67% (Level 2) to 81% (Level 3)
356 1,406
# of female patients increased from 356 to 1,406 per month
65 128
# of malaria tests increased from 65 to 128 per month
10% 90%
% of medical staff trained in infection control in-creased from 10% to 90%.
Service element
Human resource
management
Improvements to the pharmacy include privacy, efficiency and inventory management. The dispensing window was moved so that clients can con-sult the pharmacist out of earshot of the waiting room and there is a sep-arate room for sensitive cases.
“With the automated hospital management system, I can open patient files and see what medication they’re already taking,” pharmacist Carol Bilha explains. “I don’t need to walk to the lab to collect test results, it’s all there. Also, the system mon-itors our stock so we don’t run out.” Medicines are now stored in a locked cabinet. Hazardous and flammable materials are stored separately. “We no longer leave medicines in the
direct light on the window sill. Some-times we let clients keep medication like insulin here if they don’t have a fridge at home.” The pharmacy now serves up to 200 people a day.
70%
79%
Service element
Medication
management
St. Patrick’s SafeCare assessment scores for medication management improved from:
St. Patrick’s SafeCare assessment scores for human resource manage-ment improved from:
Total number of health facilities in program
1,628
Clinics and results
521
Kenya
38
average overall assessment score SafeCare StandardsMost room for improvement
90
highest overall assessment score SafeCare Standards Top 2 service elements Diagnostic imaging service Risk ManagementPatient rights & access to care Management of Information 320
Tanzania
38
average overall assessment score SafeCare StandardsMost room for improvement
73
highest overall assessment score SafeCare Standards Top 2 service elements Diagnostic imaging service Risk Management Laboratory Services Support services 366Ghana
37
average overall assessment score SafeCare StandardsMost room for improvement
68
highest overall assessment score SafeCare Standards Top 2 service elements Diagnostic imaging service Risk Management Laboratory Services Human Resource Management 410Nigeria
42
average overall assessment score SafeCare StandardsMost room for improvement
90
highest overall assessment score SafeCare Standards Top 2 service elements Laboratory Services Risk ManagementPatient rights & access to care Support services CLINIC LEVEL
1,434
Number of assessments since start program Assessed using SafeCare Essentials Assessed using SafeCare Standards Basic or Advanced564
870
V 0 IV 0 III 14 II 44 I 251Total active certificates level 309 assessments A w ar ded S af eC ar e L e v el CLINIC TYPE
78%
Private26%
Rural12%
Public33%
Peri-urban9%
Faith Based41%
Urban Number of health facilities currently in the program1,628
PATIENTS & CARE
Total number of staff
T re atmen t indic at or s
38,587
17,790
Medical staff 98,147 Immunizations 71,641 Family planning7,755
Para-medical staff 391,175 Malaria1,583,684
Total number of patient visits to the facilities per month
13,042
Support staff 90,214 HIV IMPROVEMENT AREASRange of assessment score Diagnostic imaging Risk Management Laboratory Services Human Resource Management Patient rights & access to care Support services
14-90%
Top 3 service elements Most room for improvement
Number of facility trainings given CAPACITY BUILDING Technical Assistance PharmAccess Foundation KMET Kenya PSI Kenya APHFTA Tanzania Medical Credit Fund SFH Nigeria
Marie Stopes International FHI 360 Facility Trainings Clinical care 35 Lab 8 Pharmacy 7 Quality management 27 Admin 20
97
=
86
Number of facilitators trained444
Number of attendees SafeCare facilitator training49
Number surveyors trainedData until December 2014 Data until December 2014
11
Namibia
46
average overall assessment score SafeCare StandardsMost room for improvement
63
highest overall assessment score SafeCare Standards Top 2 service elements Primary Health CarePatient rights & access to care Operating Theatre & Anaesthetics Risk Management 17 S A F E C A R E P R O G R E S S R E P O R T 2 0 1 4
SafeCare staff
Georgine Mbeki
Senior Assessor Nairobi, Kenya
“Quality can be a very diffuse concept, with many possible different interpretations. When it comes to healthcare, many peo-ple perceive quality as having a lot of money and building very big structures. I believe quality is when you offer something that is acceptable and measurable, and leads to an outcome that has a positive impact on people’s lives. SafeCare gives quality a clear definition. It has also put a stop to this myth that to attain quality you need a lot of resources. Quality is not just for the rich. Although we work in resource- restricted settings, we help facilities address their gaps so that they can compete and even provide the same kind of quality that people only expect at bigger facilities. We identify the key priorities in their service delivery, and then they really don’t need a lot of money to scale up their facility. They just need to be awakened. The capacity building that we do doesn’t need a big budget, because many features are already in place. Often, it’s a matter of solidifying systems or helping facilities to understand government policies so that they
can apply for accreditation with health insurance companies. Capacity building of staff is key. We found that providers were often not aware of how patients perceived their facility. We work with them to help them structure consultations, to provide friendly treatment, to have the right drugs in stock or to ensure the facility is clean. All these things contribute to the patient’s ex-perience and the image of the facility. It takes time to embrace the change, but at the end of the day this holistic approach is con-tributing to great strides forward in healthcare delivery.
Empowering
SafeCare is causing a lot of rip-ples in the healthcare sector. All the providers that I have met in the field since 2012 see it as a God given program. Many of the private practitioners are either retired or nearly retired. They have a lot of clinical knowledge, but no business knowledge. They have invested their savings in structures but then are not able to manage the business side. So when we introduce them to Safe-Care, there is a feeling of growth,
a feeling of taking control of something they found unman-ageable before.
I’m so proud to be a part of this program that is helping to in-crease transparency and build systems that work. To see small facilities in remote areas embracing the program and developing into a main referral point in their region. Often, they relocate because their patient numbers have increased so much that they need to expand their facility in order to meet the demand for their services. The most rewarding part of my job is seeing quality care being given to people at the bottom of the pyramid, care that is equal in the quality given to those who are better off.
‘The most rewarding part of
my job is seeing quality care
being given to people at the
bottom of the pyramid.’
19 S A F E C A R E P R O G R E S S R E P O R T 2 0 1 4
• AfriDB 2.0 allows multiple users to review and edit data simultaneously.
• AfriDB 2.0 has a more secure system for data submission and review with customized roles for assessors, reviewers, and administrators.
• Data-collection software is accessible with tablets and laptop computers, and is even available offline for use at facilities without internet access.
• Data is routinely backed-up using enterprise data storage facilities.
• Automated performance reports are available with one click.
• When entering assessment data, AFriDB 2.0 immediately notifies surveyors of potential conflicts in the data so that they can be addressed promptly. This improves data accuracy, consistency, and reliability.
• AfriDB 2.0 enables surveyors to refer to the SafeCare scoring guidelines on their tablet, even in areas without internet access.
• After each assessment, AfriDB 2.0 guides the facility managers and Safe-Care surveyors through the steps to create a detailed quality improvement plan that will help the facility progress to the next SafeCare level.
• Monitoring and evaluation are built into the quality improvement plan, allowing SafeCare to measure each facility's progress toward completion of their quality improvement plan.
Multiple users and responsibilities
Stable and secure data storage
Improved data accuracy
Customized quality improvement plans
SafeCare’s fourth year of operations included highlights such as
celebrating the 1000th clinic, developing a new training curriculum
and seeing our colleague recognized as an emerging leader at the
ISQua conference.
Highlights
In 2014, SafeCare welcomed the 1000th clinic into the program. This milestone was celebrated at the Ahadi Maternity Health-care Clinic in Kenya, one of the facilities that has made exceptional progress. “Pre- viously, we could not provide critical health- care management and patients had to be referred to hospitals which are 35 kilome-ters away,” said Grace Njuguna, proprietor of Ahadi. “We are now able to offer these services. In fact, we have seen a 20 percent increase in the number of patients.”
Centers of Excellence
Many facilities in the program have made significant achievements in improving quality, reducing risks and expanding their business. To recognize their progress and capitalize on their potential, SafeCare launched the Centers of Excellence program.
Facilities that are selected as a Center of Excellence are awarded a special certificate in a public ceremony in their
Software upgrade: AfriDB 2.0
Data collection and analysis are at the core of the SafeCare program. Our assessors and technical assistance partners are actively involved in every stage of the assessment, mon-itoring, and evaluation process through our web-based software platform AfriDB. It has also been installed at several partners’ offices, such as at the Tanzanian Ministry of Health and the Kenyan NHIF. In 2014, we launched an extensive software upgrade (AfriDB 2.0) to make it more transparent, secure, efficient, and user-friendly for our internal and external partners.
ISQua conference
In October 2014, over 1,000 delegates from 68 countries attended the ISQua conference in Rio de Janeiro, Brazil. SafeCare staff and partners presented our PPP approach at the international level, in panel discussions and presentations involving national health insurance agencies, quality improvement organizations, and accreditation bodies.
SafeCare chaired a session titled ‘Jumpstarting and sustaining quality in
de-veloping countries’ and was also involved in a WHO session where the SafeCare meth-odology was presented as a lead example of patient safety in primary healthcare in resource-restricted settings. We are very proud to announce that Emmanuel Aiyenigba,
‘Ahadi is a prime example
of what can be achieved if
all partners and especially
the staff create a mindset
geared towards continuously
improving services for their
patients.’
Nicole Spieker, Director SafeCare community or at a local, high profile confe- rence. This presents them as a leader in quality improvement and encourages them to use their influence to inspire other facil-ities in their region to improve. Our vision is that Centers of Excellence will become hubs of knowledge sharing, demonstrating the benefits of investing time and resources in quality improvement.
Healthy Business training
SafeCare and Medical Credit Fund developed a new training curriculum to build a tighter integration between the financial, managerial, and clinical aspects of quality. The Healthy Business training sessions focus on building business skills such as financial and human resource planning as well as clinical and technical skills such as health information management and standardized operating procedures. Trainings are provided in a group setting to enable healthcare facility man-agers to learn from each other’s approaches.
a senior surveyor on our team in Nigeria, was recognized as the first Emerging Leader of ISQua!
21
Over the years, SafeCare has attracted new donors and set up
many new partnerships in order to create a solid financial base
and leverage our impact on the ground.
Strategic partnerships & programs
The large number of long-term contracts with a broad spectrum of partners has helped to build SafeCare’s brand as an in-dependent quality improvement program. Existing partnerships with the AHME con-sortium led by Marie Stopes International (funded by the Bill & Melinda Gates Founda-tion and the UK Department for InternaFounda-tional Development (DFID)) and APHIAplusHCM (funded by USAID) have been instrumental in forging new connections in both the public and the private realm. Public contracts include the Ministry of Health & Social Welfare and the National Social Security Fund (NSSF) in Tanzania, the National Hospital Insurance Fund (NHIF) in Kenya and the National Primary Healthcare Devel-opment Agency (NPHCDA) in Nigeria.
Growing demand
In 2014, the demand for SafeCare method- ology and tools continued to grow. We have started consultancies with private hospitals in both Nigeria and Kenya, consisting of assessments, quality improvement plans
and facilitation visits. Acumen and KMPG contracted SafeCare to perform due dili- gence assessments for investment oppor- tunities. Through a new partnership with the Private Sector Health Alliance of Nigeria (PHN), SafeCare is conducting assessment and training interventions at 60 private healthcare facilities.
The past year also saw the start of the Business of Quality (BoQ) program in Tanzania, which we are rolling out under DFID’s Human Development Innovation Fund. The BoQ program provides training for 400 predominantly rural clinics at the lower end of the quality spectrum to help them improve their business performance as well as their clinical quality. The BoQ program was leveraged by ELMA Founda-tion to support addiFounda-tional intervenFounda-tions focusing on maternal, neonatal and child health.
mHealth
Africa’s expanding mobile communications sector offers huge opportunities in the field of healthcare. In Kenya, PharmAccess is rolling out innovative programs around mobile health wallets that contain funds earmarked for healthcare. In 2014, SafeCare conducted a quick scan to assess 50 facilities for possible inclusion in the mHealth program. SafeCare also partnered with Safaricom and AMREF to improve access to maternal and newborn care in Samburu.
Some of our partnerships and programs are highlighted on the next page.
Investor
Gabriele Beacco
CEO Ruaraka Uhai Neema Hospital Nairobi, Kenya
In July 2014, Ruaraka Uhai Neema Hospital contracted SafeCare for a quality improvement track consisting of a first assessment, a quality improvement plan facilitation visits and a second assessment at the end of the contract year.
“After five years of operations as a hospital, we felt it was important to arrange for an external party to evaluate us and ensure that we are working in the right direction and achieving the right milestones. We approached SafeCare as it of-fers an independent and objective assessment as well as solid follow- up with clear targets towards positive change and improvement. When you are involved in day to day activities, you think every-thing is fine but there is always a need for improvement. While we already had the goal of ensuring high quality services, but there was no concrete plan how to go about it. Also, our management team was not all speaking the same language. SafeCare engages personnel on all levels. Initially, some staff were hesitant, as they felt the program required them to confess their weaknesses. In time, they realized that the program was not there to find fault but to support them to do better.
SafeCare helped us see the need for guidelines across depart-ments, including administration. We thought we had protocols, but in fact most of those guidelines were just in our heads, not on paper where all staff could access it. We have now hired a human re-source manager to help develop manuals. We have also improved the waste management system and installed a second sink in the kitchen. During the building phase of our pediatric unit, SafeCare staff helped us to focus on specific structural aspects in the design of the new department. The
pedi-atric unit is now up and running smoothly.
We found the guidance for quality improvement extremely valuable. SafeCare is very detailed and practical. It not only identifies problems, but offers a way to take action to address that problem. This makes SafeCare unique, I have never come across anything like it.”
‘SafeCare offers an
independent and objective
assessment as well as
solid follow-up with clear
targets towards positive
change and improvement.’
23 S A F E C A R E P R O G R E S S R E P O R T 2 0 1 4
A closer look at some of our partnerships and programs:
Health Insurance Fund
SafeCare standards and stepwise improvement methodology were devel- oped and first implemented in the health insurance schemes funded by the Health Insurance Fund, providing insight into and improving the quality of the participating health-care providers. SafeCare standards and methodology continue to be a pivotal element in all interventions focused on bringing demand and supply for quality healthcare together, such as mHealth solutions.Medical Credit Fund
Medical Credit Fund facil-itates loans to private healthcare providers through African banks. The loans enable the clinics to improve the quality of their services and (further) develop their business po-tential, thereby increasing access to quality health-care. From the start of operations in 2010, Medical Credit Fund has contract-ed SafeCare to conduct quality assessments in participating clinics, iden-tifying most urgent needs and improvement priorities, as well as offering technical support.African Health Markets
for Equity
(AHME) AHME is a multi-stake-holder partnership led by Marie Stopes International and funded by the Bill & Melinda Gates Foundation and the UK’s Department for International Develop- ment (DfID). Other partners are Society for Family Health (Nigeria), Popula- tion Services Kenya and PharmAccess Group. AHME aims to improve health outcomes by en-hancing the quality of private healthcare for the poor in Ghana, Nigeria and Kenya. It does so by increasing the scale and scope of the partners’ franchise networks and linking the healthcare pro-viders in these networks to demand-side financing. Medical Credit Fund and SafeCare facilitate access to loans as well as support in business and quality improvement through SafeCare’s stepwise rec-ognition process.Human Development
Innovation Fund
(HDIF)/ ELMA
Foundation
In Tanzania, SafeCare has been granted funds from DfID’s Human Development Innovation Fund (HDIF) for the Business of Quality program. It builds on ex- isting PharmAccess pro-grams, combining use of the SafeCare standards and quality improvement methodology with access to credit and health in-surance. Implementing partners in this program are Association of Private Healthcare Facilities in Tanzania (APHFTA) and Christian Social Services Commission (CSSC). The program is specifically designed to improve both business performance and clinical quality in 400 clin-ics, benefitting Tanzania’s rural poor.
ELMA Foundation supports additional interventions in a selection of 100 fa-cilities, geared towards complementing the efforts of the Tanzanian MoHSW to improve maternal, neo-natal and child health. The aim is to increase scale and accessibility of these ser-vices in the private sector.
Ministry of Health &
Social Welfare
(MoHSW), Tanzania
SafeCare, supported by CDC Foundation, provides technical assistance to the MoHSW to work towards institutionalization of a national ‘stepwise certifi- cation towards accredita-tion’ system using the SafeCare standards. During the 5 year partnership, the SafeCare standards have been officially adopted and disseminated by MoHSW and the approach has been advocated to health facili-ties and other stakeholders.National Hospital
Insurance Fund
(NHIF)
, Kenya
SafeCare, in partnership with IFC, is implementing SafeCare standards and stepwise certification into the NHIF contracting sys-tem. NHIF staff has been trained and is currently independently performing SafeCare assessments, supported by PharmAccess.
25
Over the next few years, SafeCare will focus on a new round of
innovations and connect to the opportunities around mHealth.
We will also continue building the infrastructure to scale up
operations and expand into new markets.
Outlook 2015 and beyond
Basic assessment
Since SafeCare started operations, we have seen the needs for standards of partner or-ganizations expand. As the program scales up and is adopted by national programs such as the Tanzanian Ministry of Health for regulation purposes, but also by our mobile health program (in partnership with CarePay), there is a need for a rapid screening ap-proach, which will identify if basic safety measures are in place in a facility. This complementary program enables greater efficiency in rapid pre-qualification or screening assessments and will be a vital component of ensuring a minimum level of safety of facilities entering a program. To meet this need, we have adapted our
lighter ‘Basic assessment’ tool. Replacing the old Basic assessment, the new Basic requires fewer human resources to complete yet provides facilities and SafeCare quality managers with insights into the greatest quality improvement priorities. Facilities meeting these Basic requirements can qualify for the full SafeCare recognition process. This new tool will be introduced in a majority of facilities linked to CarePay in 2015.
Revised standards
Building on our experience in practice and in response to the valuable input from SafeCare surveyors, facilities and partner organizations, we are revising and updating the SafeCare standards. The improved standards will remove duplication of crite-ria and make the process easier to use for all stakeholders. With reduced time spent on collecting data, assessors will be able to provide more targeted and customized quality improvement support, helping to meet the overall objective of SafeCare.
Streamlining operations
By further streamlining our client-centered approach, we aim to achieve efficiencies in terms of time, scale and costs in the PharmAccess programs offered to the clinics aimed to help meet standards adherance. Clinics contracted by PharmAccess are assigned a single relationship manager to whom they can address all their questions, after which specialized services by clinical quality or business advisors can be allo-cated based on need. Also, facilitation and
training services will be offered to clinics at different capacity levels: beginner, inter-mediate and advanced.
New markets
In 2014, PharmAccess Group, through SafeCare and Medical Credit Fund began exploring opportunities in Uganda. In partnership with IFC (Health in Africa Initiative), Bank of Uganda and the Ugan-dan government, we are in discussions to provide loans and business and quality technical assistance to small and medium healthcare facilities that provide services for the lowest quintiles of the community. Unique to this approach is the endorsement and strong support from the Ugandan government to strengthen the private sector. This includes a co-investment in the loan fund by the public sector, which makes it the first loan fund of its kind in Africa. Besides exploring these new markets, we will continue to develop our programs in Kenya, Tanzania, Ghana and Nigeria.
mHealth
Since rolling out the first pilot programs in 2013, mobile health (mHealth) has be-come an integral part of the PharmAccess approach. In Kenya, the mobile payment platform M-Pesa offers unprecedented opportunities to increase efficiencies in healthcare delivery and connect more people to quality healthcare, by lowering the transaction costs and significantly increasing access to demand side finance mechanisms especially for the poor and the informal sector.
SafeCare will be engaged in the mHealth program by pre-qualifying facilities with quality assessments and quality im-provement plans when they enroll in the mHealth program. After quality benchmarks and ratings are established, it will be pos-sible to incentivize quality improvement with pay-for-performance reimbursement mechanisms.
‘The impact of SafeCare
on the ground is huge.
The issues it addresses
can seem simple, but
the program is opening
doctors’ eyes to what
needs to be done. And the
patient always recognizes
small things.’
Peter Mbithi Matolo Head of SME/Retail / K-REP Bank
27
'We have seen that quality
improvement through the
stepwise SafeCare approach
is feasible even in resource
constrained public facilities.
Enrolment of other facilities
into the SafeCare program
would well save our people.'
Dr Aloyce Andronicus Rwelamira
Mlandizi Health Center, Pwani Region, Tanzania
29
The three founding organizations PharmAccess, Joint
Commission International (JCI) and Council for Health Service
Accreditation of Southern Africa (COHSASA) established
SafeCare in 2011 to address the shortage of institutions and
standards that can ensure objective measurement and rating
of quality basic healthcare facilities in Africa.
Based in Amsterdam, the Netherlands, PharmAccess stimulates both the demand and supply side of the healthcare sector through quality improvements and clinical standards, loans for healthcare providers, health insurance, health infrastructure consultancy, HIV/AIDS corporate programs, mHealth and impact research with a wide range of public and private partners. By mobilizing public and private funds to lower risk and build trust, PharmAccess has been able to leverage large amounts of international and local capital for Africa’s underfunded health systems, making the healthcare market more attractive for investors. As healthcare delivery and affordability continue to improve, patients, doctors, insurance companies, banks and governments gain access to the tools they need for social and economic development.
Based in Cape Town, South Africa, COHSASA is accredited by the International Society for Quality in Health Care (ISQua) as a competent healthcare evaluation body, and its standards are recognized as meeting the principles set out by ISQua. COHSASA has been working in the field of quality improvement and accreditation for over 15 years.
Based in Chicago, U.S.A. JCI works to improve patient safety and quality of healthcare in the international community by offering education, publications, advisory services, and international accreditation and certification. In more than 100 countries, JCI partners with hospitals, clinics, and academic medical centers; health systems and agencies; government ministries; academia; and international advocates to promote rigorous standards of care and to provide solutions for achieving peak performance.
SafeCare Founders
Team SafeCareThe Netherlands
Nicole Spieker Director Quality
Elsemiek Snijders-Storm Deputy Director
Hanneke Peeters Operations Manager
John Dekker Manager Laboratory Services and Procurement
Aletta Kliphuis Quality Chief Surveyor
Annedien Plantenga Quality Manager
Nienke Meijland Quality Program Support
Toon Luttikhuis Financial Consultant
Mike Johnson Research Officer Kenya
Millicent Olulo Program Director Kenya
Kasmil Masheti Operations Manager
Jacinta Mburu Senior Assessor
Margaret Mwakiridia Senior Assessor
Mary Njoki Wachira Senior Assessor
John Nziu Senior Assessor
Elly Wandago Senior Assessor
Emmanuel Milimo Senior Assessor
Petronilla Wesango Senior Assessor
Georgine Mbeki Senior Assessor
Irene Kasyoki Senior Assessor
Catherine Nyawira Assessor Nigeria
Dupe Oludipe Program Director Nigeria
Emmanuel Aiyenigba Senior Assessor
Jimi Odetola Senior Assessor
Anire Asumah Senior Assessor
Peggy Imoniovu Senior Assessor
Joshua Kolawole Assessor
Funsho Egbedeyi Assessor
Ojo Olukayode Assessor
Azuka Okeke Assessor
Ugo Anaeto-Okeke Assessor
South Africa (COHSASA)
Jacqui Stewart Deputy CEO; Chief Operations Manager
Giel van Schalkwyk Chief Surveyor
Grace Labadorios GP Accreditation Standards Coordinator
Riël le Roux Surveyor
Edith Palmer-Harrington Surveyor
United States (Joint Commission International)
Paula Wilson President and CEO
Paul van Ostenberg Vice President International Accreditation, Standards and Measurement
Cecily Pew Director Board and Committee Activities
Tanzania
Peter Risha Program Director Tanzania
Nicodemus Butamanya Senior Assessor
Johnson Yokoyana Senior Assessor
Edith Ngirwamungu Senior Assessor
Anunsiatha Mrema Senior Assessor
Liberatha Shija Senior Assessor
Elizabeth Amuli Senior Assessor
Bayoum Awadhi Senior Assessor
Piensia Nguruwe Senior Assessor
Lemali Mbise Senior Assessor
Venna Lyimo Senior Assessor
Emmanuel Tluway Assessor Ghana
Maxwell Akwasi Antwi Program Director Ghana
Bonifacia Benefo Agyei Senior Assessor
Gabriel Fiadorme Senior Assessor
Joseph Asumang Peasah Assessor
Mary Asantewaa Assessor
Theresa Boakye-Poku Assessor Namibia
Wilet Pothas Senior Assessor
Sylvia Ashikoto Assessor
31 S A F E C A R E P R O G R E S S R E P O R T 2 0 1 4
Introducing
the PharmAccess Group
The PharmAccess Group is dedicated to making health markets
work for people in Africa.
When Prof. Joep Lange (1954-2014) founded PharmAccess in 2001, the objective was to turn groundbreaking scientific research on triple-combination drug therapy into action by bringing HIV/AIDS treatment to the people who needed it most. PharmAccess joined forces with private companies like Heineken to set up workplace programs for their employees and dependents. These schemes proved that treatment in Africa was feasible and that the delay in delivering it was a political choice. This helped lay the foundation for large-scale international action: today, more than 10 million people living with AIDS have access to life-saving drugs.
PharmAccess continues to be widely recognized as a pioneer in increasing access to improved healthcare. Building on our work on the front lines of HIV/AIDS treatment, our focus has broadened to making healthcare systems more effective and more inclusive. Reversing the vicious cycle that stifles progress requires innovations that explore new directions, challenge the status quo and provide real world solutions.
PharmAccess builds trust on both the supply and the demand side of the healthcare market and leverages donor contributions to reduce risks and increase investments in health. We address market inefficiencies through an integrated approach: improving quality of care through clinical and business standards, intro-ducing mHealth applications, providing access to loans for healthcare providers, facilitating access to health insurance and other health financing options, and conducting impact research for evidence-based innovation.
On a solid base of local and international public-private partnerships, and with the support of many international development stakeholders including the Netherlands Ministry of Foreign Affairs, we help improve healthcare delivery and affordability for patients and increase market transparency for investors.
PharmAccess employs a multidisciplinary team of almost 200 professionals. While our headquarters are in Amsterdam, we are firmly rooted in Africa with over 60% of our staff based in Kenya, Tanzania, Ghana, Nigeria and Namibia.
Our partners
Public donors and investors
African Development Bank, Asian Development Bank, Department for International Development (DfID), Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ), Dutch Ministry of Foreign Affairs, Entrepreneurial Development Bank (FMO), German Development Bank (KfW), International Finance Corporation (IFC), International Labour Organization (ILO), Life Sciences & Health for Development (LS&H4D), Netherlands Organization for Scientific Research (NWO), Overseas Private Investment Corporation (OPIC), Rijksdienst voor Ondernemend Nederland (RVO), Saving Lives at Birth (USAID, Bill & Melinda Gates Foundation, UKaid, NORAD, Grand Challenges Canada), United States Agency for International Development (USAID)
Private investors and donors
Achmea Foundation, Algemene Pensioen Groep (APG), Bill & Melinda Gates Foundation, Calvert Foundation, Centers for Disease Control and Prevention (CDC) Foundation, Clinton Foundation, Deutsche Bank Americas Foundation, Dutch Postcode Lottery, ELMA Philanthropies, Goldman Sachs, M-PESA Foundation, Pfizer, President’s Emergency Plan For AIDS Relief (PEPFAR), Rockefeller Foundation, Safaricom Foundation, Soros Economic Development Fund, Stichting AmsterdamDiner Foundation
Strategic partners
Government and parastatal organizations
Ghana: National Health Insurance Authority (NHIA),
National Health Insurance Scheme (NHIS)
Kenya: Ministry of Health, National Hospital
Insurance Fund (NHIF)
Nigeria: Cross River State, Kwara State Govern-
ment, Lagos State Government, National Primary Health Care Development Agency (NPHCDA), Ogun State Government
Tanzania: Ministry of Health and Social Welfare,
National Health Insurance Fund (NHIF), National Social Security Fund (NSSF),
Uganda: Government of Uganda
Multilateral organizations and agencies
African Health Markets for Equity (AHME), Agence Française de Développement (AFD), Belgian Development Agency (BTC), Global Fund to Fight AIDS, Tuberculosis and Malaria, Global Partnership for Effective Development Cooperation, Inter-national Federation of Health Plans (iFHP), The International Society for Quality in Health Care (ISQua), Joint Learning Network, World Bank Group, World Economic Forum
Foundations and associations
Aids Fonds, Amref Health Africa, Association of Private Health Facilities in Tanzania (APHTA), Christian Social Services Commission (CSSC),
East Africa Healthcare Federation, Kisumu Medical and Education Trust (K-MET), Nigerian Healthcare Federation, Stop AIDS Now!
Research institutions
African Population and Health Research Centre (APHRC), Lagos University Teaching Hospital, Strathmore Business School (SBS), University of Ilorin Teaching Hospital
Multinational corporations
Achmea, Aegon, Heineken, KPMG, OLAM Group, Pfizer, Philips, Safaricom, Shell, SNS Reaal, Unilever, Vodafone
Social franchise networks
Marie Stopes International, Population Services International (PSI), Society for Family Health (SFH)
Partner banks
BancABC (Tanzania), Bank of Africa Tanzania, Chase Bank (Kenya), Diamond Bank (Nigeria), First City Monument Bank (Nigeria), HFC Bank (Ghana), K-Rep Bank (Kenya), National Micro- finance Bank (Tanzania), uniBank (Ghana)
Insurance companies and administrators
AAR, Africa Medilink Ltd, Hygeia
Health accreditation organizations
Council for Health Services Accreditation for Southern Africa (COHSASA), Joint Commission International (JCI)
The Netherlands Trinity Building C Pietersbergweg 17 1105 BM Amsterdam +31 (0)20 566 7158
Kenya New Rehema House, 3rd Floor Rhapta Road, Westlands Nairobi +254 (0)20 444 2120
Tanzania Skyways Building 2nd Floor Ohio/Sokoine Drive Plot No. 149/32 Dar es Salaam +255 (0)222 124 888
Nigeria 10A Ademola Close off Remi Fani Kayode Street GRA Ikeja, Lagos +234 (0)134 22 800
Ghana 29 La Tebu Crescent P. O. Box CT 10245 East Cantonments, Accra +233 (0)302 73 5261/2
Namibia 1-3 Fouche Street Windhoek West Windhoek + 264 (0)61 419000 www.safe-care.org [email protected] follow us on Twitter @PharmAccessOrg
