5 million people die because of poor quality of health care: goats and soft drinks: NPR

In the world of global health, giving people access to health care – even if they are only basic services – has long been a priority.

But if this approach is wrong?

A new report published in The lancet On Wednesday, in terms of health, quality – not quantity – seems to be more important.

The study estimates that 5 million people die each year due to the poor quality of health care in low- and middle-income countries. That's a lot more than the 3.6 million people in those countries who are dying of not having access to care.

This is also five times more than the annual deaths due to HIV / AIDS (1 million) and three times more than diabetes (1.4 million) in the same countries – although, of course, health care mediocre ones can also be fatal.

"For a very long time in the field of global health, we have really asked for and supported access to care, without really thinking about what happens when people arrive at the clinic," says Dr. Margaret Kruk, co Commissioner of this study. and professor at Harvard TH Chan School of Public Health.

These results come from The lancet World Health Commission on High Quality Health Systems, a two-year project to measure and improve the quality of health systems around the world.

The commission is made up of 30 experts – academics, policy makers, health advocates – in 18 countries. Their data come from a series of surveys, including household surveys in 47 countries, a quality of care survey, and 81,000 USAID-funded care assessments, which found medical visits to clinics and hospitals in 18 countries.

NPR spoke with Kruk about this study. This interview has been condensed and modified for clarity.

What was perhaps the biggest conclusion of the report?

There are 8.6 million deaths each year in low- and middle-income countries – the majority of the world, 134 countries – that could have been saved through quality health systems. These are deaths due to treatable diseases because people did not receive good care.

Of the $ 8.6 million, we found that 5 million people had received care but received only poor quality care. The remaining 3.6 million was due to lack of access, which was the traditional goal of global health.

What are the examples of mediocre health care?

On average, during health care visits, we find that providers typically follow less than half of the recommended clinical actions. For very sick children, the average length of the consultation can be 6, 7 or 8 minutes with a nurse. It's too little time to properly evaluate this child.

In a sample of five countries in sub-Saharan Africa, only 50% of providers can accurately diagnose pneumonia or diabetes – very common conditions.

The system as a whole is a failure for people. The delays are huge. If a person has cancer problems in a low-income country, there can be months of delay between this visit and the actual diagnosis – not to mention the treatment.

It's a crisis, especially when governments around the world are trying to extend health insurance. If your insurance services do not save lives, what is the real value of expanding insurance coverage and universal health coverage?

Can you talk about the context of this commission?

With my co-chair, Muhammad Pate, who was the former Minister of State for Health in Nigeria, we brought together a group of people who are studying health systems and how they work, as well as another group of people in the field. , struggling to improve health systems in the field.

The whole principle of the commission is to say: how do we do for quality on a global scale? We feared that the focus on access has overshadowed our understanding of what is really happening in health systems.

What is the message for health care systems?

If health systems are to improve health, they must do two things. They must promote the use of life-saving essential services – malaria treatment, HIV treatment, and so on. But they must also offer quality care and quality care.

As you mentioned, global health has long focused on access to care. Now, it seems that the focus is on fairness, fair access – for example, ensuring that women and children receive the same quality of care as men or women. that the poor receive the same level of care as their richer neighbors.

It is interesting that you use the word "equity". The other main goal [of the study was on] vulnerable groups. We looked at poor people, less educated, stigmatized people, pregnant teenagers. And even in a context of relatively poor overall care, the care is less good. Even simple treatments. For example, young adolescents are less likely to receive iron [supplements] during a prenatal care visit.

Equity is essential, but I would add the word "quality". It is about access to quality services.

What does quality health care look like?

For us, quality is about three things. One is effective care that can improve or maintain health. The second is about people's trust. The third is that systems must adapt and adapt. This means a quick adjustment in the event of an outbreak, but also the ability to change over time.

Basically, the big change we are proposing is that systems must be for and on people. We should judge them on what they do for people – not on the number of doctors they train.

About 1 in 3 patients have poor care experience. Disrespectful care, extremely short visits, poor communication, long delays. Many parents – 40 to 50% – leave the clinic without knowing the child's diagnosis. Is it because the supplier does not know or is it because the supplier does not communicate? It's hard to say in an investigation. But the fact remains that the parent does not know what is happening.

You mentioned the health of children in particular. Did your research relate to this? If yes, why?

The reason I mentioned children is that the strongest and most comprehensive data lies in these areas. The Millennium Development Goals have really involved children and women, in large part, and infectious diseases. So when you look at measurement systems, surveys, and ongoing research, they are more focused on women, children, HIV-positive people, and so on.

We wanted to talk broadly about various health priorities in low-income countries, including noncommunicable diseases, cardiovascular diseases, accidents, and so on. Mental health is another huge area. But we found extremely limited data. We call these blind spots complete now.

You mentioned a previous topic in global health on infectious diseases. According to this report, the total number of deaths due to poor health care is five times higher than that of HIV / AIDS.

These numbers are really important. We have identified about 5 million deaths due to the poor quality of people already using the health system. For deaths from cardiovascular disease worldwide, it is about 2.5 million. Then there are about 900,000 deaths from TB.

It's really a poor quality epidemic. Even though access to care is still incomplete – depressed people still can not get services, people with cancer often can not get care in low-income countries – even with this low level of care. Access, the greatest difficulty.

What are the potential solutions?

The biggest surprise for me is probably the question of improvement. Indeed, when we look at the evidence of commonly used improvement strategies – checklists, retraining, supervision – we were very disappointed with the effectiveness of these strategies and the inability of these things to evolve. Even if you have a result in a clinic, we do not have samples where it happens across the country.

So we looked at the improvement in a very different way. Much of the improvement has been concentrated at the point of service – at the point where the provider meets the patient. But in reality, given the scale of the problem, we need to return to a much more fundamental strategy.

We have identified four universal actions. The first is to focus on quality at the system level because there is no accountability today. There is no system to sound the alarm and there must be one.

Second, you need to rethink health systems. Many health systems are now organized to maximize access – many small clinics spread across a vast territory.

To give you an example, in the United States, Australia, and other rich countries, very few women give birth in hospitals that do not have caesareans – almost none.

But in a five-country study we conducted in sub-Saharan Africa, we found that almost one in three babies born in health facilities are very, very few [facilities] without cesareans, with poorly trained workers.

This is an example where a service like delivery should be transferred to the hospital where the surgery could be provided. Let's set up this service and help women get to the hospital, rather than wait for complications to develop in this remote clinic.

Third, the training of health personnel in many low- and middle-income countries is simply outdated. Clinicians are very good at identifying diseases on slides but have more difficulty in solving problems and establishing links with patients.

And then, the last area of ​​improvement for us was the public demand. In most service industries, customer pressure often improves the product or service. Yet in healthcare, we ignore patients as consumers. Many people anticipate poor quality and have low expectations. But people want good care.

So, how do these people get better services?

We really need to come together and think about what we can do to help low-income countries in the transformation we demand. One thing is to introduce new measures and new knowledge that will help one country learn from the other. We must stop flooding countries with quick fixes and brilliant solutions.

Quality health systems are fundamentally a political problem. It's a critical moment for leaders to see what people are looking for in the health system.

Melody Schreiber (@m_scribe on Twitter) is a freelance journalist in Washington, DC.