ABSTRACT
Quality Improvement (QI) has become a central strategy for strengthening primary healthcare systems, particularly in low- and middle-income countries where gaps between clinical guidelines and routine practice persist. This study examined the Quality Improvement initiatives implemented in three primary healthcare facilities in Sunyani, Ghana Seventh Day Adventist Hospital, Rafchik Health Centre, and Nkrankrom Community-Based Health Planning and Services compound and explored how these initiatives influence healthcare providers’ adherence to quality guidelines and protocols. A qualitative case study design was employed, guided by an interpretivist paradigm. Semi-structured interviews were conducted with twenty-one healthcare providers purposively selected for their involvement in clinical care and Quality Improvement activities. Data were analysed thematically to identify recurring patterns and meanings. The findings show that Quality Improvement activities across the facilities were organised around four main initiatives: peer review, community engagement, participation in the SafeCare programme, and the routine use of patient satisfaction surveys and clinical protocols. These initiatives focused on improving patient care, infection prevention and control, preventive health services, and operational efficiency. Healthcare providers reported that Quality Improvement initiatives contributed to better patient outcomes, smoother workflows, increased staff motivation, and improved performance in external assessments. Providers demonstrated a high level of familiarity with quality guidelines and generally strong adherence to protocols. However, full compliance was sometimes constrained by resource shortages, emergency care pressures, and the technical complexity of certain procedures. Internal supervision, peer review processes, and external inspections were identified as critical mechanisms for monitoring practice and reinforcing accountability.

ABSTRACT
Objective: This article argues for a reorganization of health systems in Africa, and Cameroon in particular, that brings together biomedical and local knowledge rather than treating them as opposites. Introduction: African health systems remain built on an imported biomedical model grounded in Western positivism and determinism, which prioritizes investment in so-called dominant pathologies. Documentation on the profile of patients currently underserved by the health system reveals conditions such as mystical illnesses, cardiovascular diseases, psychological disorders, home births, HIV/AIDS, epilepsy, tuberculosis, and non-communicable chronic diseases across five major zones of Cameroon. Most patients appear to navigate a system that, in practice, has made no provision for their health problems beyond symptomatic care. Stroke, mystical illnesses arising from failure to honour the last wishes of the deceased, and epilepsy fall within a witchcraft-related register, whereas HIV/AIDS, tuberculosis, and chronic diseases reveal more material system failures. Methodology: A descriptive and analytical study using a qualitative approach was conducted from January to August 2024 in eighteen health areas spread across the six health districts of the Noun Subdivision (West Region). Data collection combined semi-structured interviews, focus group discussions, and participant observation with patients, caregivers, health personnel, traditional healers, and health authorities, supplemented by a literature review and a comparison across five major socio-cultural and health zones of Cameroon. Results: Therapeutic pluralism emerges as a structural fact: patients follow multiple therapeutic pathways combining traditional healers, exorcists, religion, and biomedicine. A tripartite typology of causes (natural, individual mystical, and ancestral), identified through the case of Yiémum (or hemiplegia) in the Noun Subdivision recurs in varying forms for epilepsy, malaria, infant malnutrit