Quality improvement and the hierarchy of needs in low resource settings: perspective of a district health officer.

District services in developing countries are afflicted with frequent system breakdowns, caused by a combination of resource constraints, limitations of the health workforce, and poorly developed management systems. Narrowly focused, outcome-oriented quality improvement initiatives and sporadic accreditation visits fail to address the most pressing need of district health services- to improve manageability. To improve quality at the district level, attention should be directed first toward this need- by building widely focused systems for ongoing, operational monitoring and response.