Providing high quality healthcare is an imperative of UHC
High quality healthcare involves the right care, at the right time, in the right place, and by the right care provider, while minimizing harm and resource waste and leaving no one behind. Unfortunately, many countries around the world fail to meet these requirements and struggle to provide healthcare services that deliver clinical value to patients, are safe, and meet the needs and preferences of patients.
Poor quality healthcare prevails in countries at all levels of economic development, manifesting every day in inaccurate diagnosis, medication errors, inappropriate or unnecessary treatment, and inadequate or unsafe clinical facilities or practices. The implications are devastating for patients and their families. In low and middle-income countries, for example, 10 percent of hospitalized patients can expect to acquire an infection during their stay, compared with seven percent in high income countries [1]. According to the World Bank Service Delivery Indicators initiative, healthcare workers in seven low- and middle-income African countries were only able to make accurate diagnoses one third to three quarters of the time, and clinical guidelines for common conditions were followed less than 45 percent of the time on average [2]. A recent study found that even if access to care is improving around the world, the clinical benefits for patients and populations remain limited: in eight high-mortality countries in Africa and the Caribbean, effective coverage averaged 28% for antenatal care, 26% for family planning, and 21% for paediatric care [3].
Poor quality healthcare also has significant costs on people’s lives, health systems, and societies. In high income countries alone, harmful medical errors and preventable complications account for 15% of hospital costs, according to OECD analyses [4]. Globally, misuse and inappropriate use of antimicrobials is fueling the rise of antimicrobial resistance, leading to significant additional health spending, affecting labor supply and productivity.
Improving access to care, especially for the poor, through Universal Health Coverage is not enough to achieve better health outcomes. This is a simple and powerful reminder from a new report co-authored by the World Health Organization (WHO), the World Bank Group and the Organization for Economic Cooperation and Development (OECD) and available here. The report, Delivering Quality Health Services: An Imperative for Universal Health Coverage, is the first global report co-authored by the three multilateral organizations.
The report calls for urgent action from governments, clinicians, patients, civil society, and the private sector to help rapidly scale up quality healthcare services for Universal Health Coverage. To start with, governments should develop national quality policies and strategies that address the foundations of quality health systems. Building quality health services requires a culture of transparency, engagement, and openness about results, that should be promoted in all societies. National quality policies and strategies should ensure that healthcare workers are motivated and supported to provide quality care; that healthcare services are accessible and well-equipped; that action is taken to ensure that medicines, devices, and technologies are safe in design and use; that information systems continuously measure, monitor, report and drive better quality care; and finally, that the way healthcare providers are paid for encourages and enables quality of care.
While high quality healthcare for all may seem ambitious, it can be achieved in all settings with good leadership, robust planning, and intelligent investment. For example, in Uganda a model involving citizens and communities in the design of healthcare services has improved a range of indicators, including a 33% reduction in child mortality [5]. Costa Rica has also achieved remarkable improvements in primary care quality through a carefully planned, implemented, and resourced improvement strategy focused on quality [6].
Around the world, lessons abound on what works and what does not, providing a rich foundation from which to rapidly scale up a quality revolution. For the first time, the report reviews evidence available for 23 distinct interventions that governments, managers, and clinicians can take to improve quality of care. Among those, seven categories of interventions stand as priority interventions: changing clinical practice at the front line; setting standards; engaging and empowering patients, families and communities; information and education for healthcare workers, managers and policy-makers; use of continuous quality improvement programs and methods; establishing performance-based incentives (financial and non-financial); and legislation and regulation.
Each country requires different sets of interventions to improve quality of care—depending on its quality baseline, resources available, capacities and capabilities, and needs and expectations from the populations served. The report describes how four countries with vastly different contexts—Canada, Ethiopia, Mexico, and Sudan—are doing so systematically.
Of course, quality care requires some investment, but it is affordable, especially when the costs and consequences of poor quality are considered. Many of the interventions to improve quality—think of checklists or basic hygiene, for example—are inexpensive and within reach for all countries. The returns are plentiful—better individual and population health, more productive workers, and pupils that perform better in school and will contribute better to the economy. In other words, investment in quality health care contributes to growth in human capital and economic development. So striving for universal quality health coverage is not just an investment in better health—it is a commitment to building a healthier and more productive society.
Jeremy Veillard is a program manager in global engagement at the World Bank Health, Nutrition and Population Global Practice where he focuses on service delivery redesign and quality of care. Jeremy is also an assistant professor at the Institute of Health Policy, Management and Evaluation at the University of Toronto, Canada.
Edward Kelley is Director of the Department of Service Delivery and Safety at the World Health Organization. In this role, he leads WHO’s efforts to strengthen the safety, quality, integration and people-centredness of health services globally and is the lead for WHO’s work on strengthening health systems and security.
Sepideh Bagheri Nejad is a technical officer responsible for knowledge management at the Department of Service Delivery and Safety at the World Health Organization. She coordinated the development of the joint WHO-OECD-World Bank report “Delivering quality health services: a global imperative for universal health coverage.”
Francesca Colombo is Head of the OECD Health Division. OECD work on health provides internationally comparable data on health systems and economic analysis of health policies, advising policy makers, stakeholders and citizens on how to respond to demands for more and better care.
Tim Evans is the senior director for Health, Nutrition and Population at the World Bank Group. Dr. Evans has been active in the international health arena for more than 20 years. Dr. Evans earned his DPhil in agricultural economics at Oxford, and pursued medical and postgraduate studies at McMaster and Harvard Universities.
Niek Klazinga is senior health-economist/policy analyst at the OECD, working on the measurement and improvement of health care quality and outcomes. He is also professor of Social Medicine at the Amsterdam University Medical Centre, The Netherlands.
The opinions expressed and arguments employed herein are solely those of the author and do not necessarily reflect the official views of the OECD or of its member countries.
Competing interests: None declared.
References:
[1] Health at a glance 2017: OECD indicators. Paris: Organisation for Economic Cooperation and Development; 2017 (http://dx.doi.org/10.1787/health_glance-2017-en, accessed 29 June 2018).
[2] DataBank: Service Delivery Indicators. Washington (DC): World Bank (http://databank.worldbank.org/data/source/service-delivery-indicators, accessed 29 June 2018).
[3] Leslie HH, Ndiaye Y, Kruk ME. Effective coverage of primary care services in eight high-mortality countries. BMJ Global Health. 2017; e000424.
[4] OECD (2017), “The economics of patient safety: Strengthening a value-based approach to reducing patient harm at national level”, OECD Health Working Papers, No. 96, OECD Publishing, Paris, https://doi.org/10.1787/5a9858cd-en
[5] Citizen Voice and Action: civic demand for better health and education services. World Vision International; 2012 (https://www.wvi.org/local-advocacy/publication/citizen-voice-and-action-project-model, accessed 29 June 2018)
[6] OECD reviews of health systems: Costa Rica 2017. Paris: Organisation for Economic Cooperation and Development; 2017. (http://www.oecd.org/countries/costarica/oecd-reviews-of-health-systems-costa-rica-2017-9789264281653-en.htm, accessed 29 June 2018).