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A recent article in The Lancet analysed the barriers to reaching the Millennium Development Goals (MDGs) concerning maternal health, child health, tuberculosis, malaria and human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS). (1) Inappropriate provider behaviour, insufficient case management, limited management capacity, and referral and communication failures were identified at the service delivery level; at the policy and strategic management level, insufficient coordination between actors, weak links between programmes, and inappropriate use of information were mentioned. Looking at this evidence from a quality improvement angle is particularly interesting. The majority of the barriers described by the authors relate to the classic quality dimensions that define a quality service (in both delivery and management): to be effective, efficient, accessible, timely, acceptable, evidence-based, equitable, safe and client centred. For example, inappropriate provider behaviour often results from a lack of patient orientation, unacceptable and ineffective communication, and the non-application of evidence-based standards. If the majority of barriers to health-related MDGs can be seen as quality-related, quality improvement approaches may be able to tear down some of them. Quality improvement means any process or tool aimed at reducing the quality gap in systemic and organizational functions according to the dimensions of quality. The basic principles of quality improvement are common sense: customer focus, strong leadership, involvement of people, process approach, system approach to management, continual improvement, factual approach to decision-making, and mutually beneficial supplier relationships. (2) There is evidence that these basic principles can contribute to the improvement of health service delivery in developing countries: an article in this issue of the Bulletin describes how some of them have been used to improve the emergency care of children in several countries. (3) If we accept that quality improvement can make a difference in service delivery and management, we should look at how we can make this happen on a large scale and what the determinants are for the successful introduction of quality improvement approaches. Although quality improvement is already an aim of the vast majority of health sectors, there are still numerous problems linked to the introduction of approaches in developing countries. In many countries the choice of quality approaches is driven by the attraction of brands and by small lobby groups rather than by a rational decision-making process--consequently, they are often not adapted to the country's reality. As an example, the introduction of sophisticated hospital accreditation brands from competition-driven rich countries to poor district health systems rarely leads to the desired outcome, as rural inhabitants often have no alternative to district hospitals and market forces are limited. …

How quality improvement in health care can help to achieve the Millennium Development Goals