Challenges related to availability and access to good quality healthcare services contribute to about 15% of deaths in low and middle-income countries (LMICs). However, the attention to quality healthcare in many countries has not been adequate, albeit rising over the years. Several studies highlight challenges in healthcare quality, including the availability of health services, clinical care and patient experience.
Recently, a study from Uttar Pradesh (UP) in India analysed the reasons behind significantly higher mortality in newborn babies born in rural private health facilities compared to childbirths in public and private facilities in urban areas.2 In line with many other observations, the paper has highlighted several reasons relevant to the issue of suboptimal quality of healthcare in LMICs, indicating several systemic and policy challenges.3 The study brings up one common yet less talked about aspect affecting health services and patient experience: the risk-avoiding behaviour of healthcare providers. Owing to this fear, service providers in public facilities and small private setups offer only low-accountability care and refer patients needing specialised care or care for medical complications to the bigger centres such as large private hospitals or medical college-affiliated hospitals. On one hand, this fear is entirely valid because any risk to the patient may lead to conflict between the family and the service providers. Plus, reporting complications and deaths frequently from a health facility may lead to scrutiny and punitive action by higher officials. On the other hand, multiple referrals linked with such practice escalate treatment costs and agony to the patients in the process, can lead to lower confidence of the communities in the healthcare facilities, and can enhance the mistrust between the service providers and the communities. Unsurprisingly, the critical aspects of quality of care (as defined by the WHO)- safety, effectiveness, timeliness, equity, efficiency, and integration – are all threatened in such scenarios.
Despite such scenarios, most quality improvement efforts in healthcare in LMICs do not touch upon these issues and frequently rely on less impactful approaches such as facility accreditations or point-of-care quality improvement techniques. Many of these efforts remain confined to the technical training of service providers and altering some service delivery processes. Evidence suggests that some of these programs can positively impact specific care practices in some settings but are insufficient to improve population health outcomes, patient experience and community trust in health systems.
The current balance of quality improvement programs funded by the governments and international aid agencies is skewed towards the small scale, micro interventions at an opportunity cost of systemic changes, which are essential in LMICs for widescale healthcare quality improvement. The broader policy and systems-related issues such as a narrow range of primary health care services with even weaker access for vulnerable populations, non-handling of medical complications, lack of respectful care underpinned by asymmetries of power and information, weak accountability, multiple referrals, non-integrated systems of care, high travel times, undue high costs of care, demotivation and dissatisfaction of the service providers, punitive work culture and so on- some of these also understood as the ‘intangible aspects’ of the health system – are rarely addressed in a planned manner.
The governance systems in health, for example, do not measure the home-to-home experience of patients or communities while seeking healthcare services, their confidence and trust in the system, and the service providers’ satisfaction and motivation as routine elements of healthcare quality. This lack of engagement with deeper health system challenges– underpinned by health policies and architecture of the systems, including regulations, commercial-political interests of various actors, and fragmented public and private systems – keeps the quality-of-care programs at the surface.
While expert groups have suggested several health system-level quality improvement measures, these are yet to be adapted and tested in LMICs. Through our engagements in South Asian and African contexts on many systemic issues, we have put together four critical aspects to guide the larger scale healthcare quality improvement policy and action- 1. Developing a user/ patient perspective to quality-of-care efforts, rather than a provider-based perspective reflected in accreditation systems 2. Strengthen institutional mechanisms and capacity to examine the design and behaviour of the health systems, which shape the healthcare quality 3. Engage health service providers from all sectors to incentivise high quality and equity rather than the volume of services, which the current insurance models follow and 4. Routinely measure user experience from the point where the care-seeking starts to the end of completion of care (home-to-home experience of care-seeking rather than just facility-based experience). These aspects would require further grounding through research and action, which we intend to expand upon in future articles.
We do recognise that in LMIC contexts, embracing a systemic approach to healthcare quality improvement is challenging. Nevertheless, it is possible to improve upon the intangible, health system issues. We (re)emphasise that large-scale gains in healthcare quality can only be achieved by investing in policies and interventions that can pull the structural levers in health systems. Keeping the experience and expectations of the health service users at the centre of these efforts is imperative.
About authors: Dr Rakesh Parashar (https://orcid.org/0000-0002-2428-8622) is a physician and a specialist in global health systems and policy. He has worked on quality-of-care policies for over a decade, is a WHO health policy fellow and has a PhD in health systems management. Twitter: @Ra_Parashar
Dr Vikas Choudhry is a physician and holds a Ph.D. in public health. He leads the public health practice of Sambodhi Research and Communications (India) and has worked in health systems improvement programs for over a decade. Twitter: @choudhryvikas1
Competing interests: None
Handling Editor: Neha Faruqui