Policy Transfer of Hospital Accreditation to Low-Middle Income Countries: Drawing Lessons from Eastern Mediterranean Countries

UoM administered thesis: Phd

  • Authors:
  • Wesam Mansour


Introduction: Hospital accreditation policy has transferred from high-income countries to many low-middle income countries (LMICs), with many national and international actors involved in the transfer process. Countries in the Eastern Mediterranean Region (EMR) had lagged behind but accreditation has now started to develop widely in the region, with many countries establishing their national accreditation programmes. This is despite the barriers to transferability and sustainability of the policy in these countries. Objectives: This research addressed the question of how national hospital accreditation programmes were developed using policy transfer theory. Our main objectives were to provide a deep understanding and extensive analysis of the process of accreditation policy transfer to LMICs, its related activities and outcomes, actors involved in this transfer process, how and why this transfer was successful in one place and not in another. In this way, the study aimed to draw contextually sensitive lessons for countries seeking to implement and sustain their national accreditation programmes as well as for international actors to help them exploit their role in supporting these countries. Methodology: This study employed multiple case study design based on Egypt, Lebanon, and Jordan in the EMR. In-depth semi-structured interviews were conducted with 27 key stakeholders in the 3 countries and experts in international organisations and accreditation agencies, e.g., The International Society for Quality in Health Care (ISQua), the Joint Commission International (JCI), the World Health Organisation (WHO) and the United States Agency for International Development (USAID). Relevant documents and organisations’ reports were also reviewed. In addition, we reviewed the literature on hospital accreditation and its development in LMICs in Medline OVID, Cochrane and HMIC databases and 78 articles in total were included in the analysis process. In-depth qualitative data analysis was conducted using the Dolowitz and Marsh policy transfer framework as an analytical framework to analyse the data emerged from reviewing the literature and the empirical data. Results: Accreditation was transferred to the EMR countries across international borders. Governments voluntarily chose accreditation as an improvement tool for poor hospital performance, but each country had a different reason to initiate the programme. International models such as JCI formed the basis, but tailored national standards were developed to fit the local contexts. The progress of accreditation in the three countries showed some differences with international actors playing the major role in this. They had a substantial influence on the development of accreditation, as sources of expertise, pump-priming funding, and through their networking and partnerships. The main components of accreditation (standards, accreditation body and surveyors) were transferred 14 successfully to Jordan supported with sustained donor funding, but only partially in Egypt and Lebanon, following the premature end of funding and political instability. Conclusion: Analysing accreditation policy processes and its determinants of growth or decline can provide contextually sensitive lessons for LMICs seeking to implement and sustain their national accreditation programmes as well as for international actors to help them support these countries. Sustainability of accreditation programmes in limited resource settings or volatile political settings is a major challenge. Sharing success stories such as the Jordanian one with other countries in the region might promote cross-country learning. Implementing and sustaining an accreditation system in a developing country requires continuous allocation of the needed fund, political and donor commitment, technical assistance to hospitals, and a functioning accreditation body. International actors might consider providing an on-going technical support at the institutional level to assist countries where the accreditation process is difficult to sustain. The results of this study can provide the basis for a comprehensive discussion of accreditation policy to underpin its successful implementation and sustainability.


Original languageEnglish
Awarding Institution
Award date1 Aug 2019