Better access to care is not enough to improve health, as an epidemic of poor quality care is revealed

While many low- and middle-income countries have made significant progress in improving access to care, a new reality is under consideration: poor quality care in the health system. total deaths due to poor quality care per year is five times higher than annual deaths from HIV / AIDS worldwide (1 million) and more than three times higher than deaths from diabetes (1.4 million) .

The results come from a new analysis published in The lancetas part of Lancet's Global Commission on High Quality Health Systems – a two-year project involving 30 academics, policy makers and health system experts from 18 countries who examined how to measure and improve the quality of health systems in the world.

"Quality care should not be the privilege of the elite, nor an aspiration for the distant future, it should be the DNA of all health systems," said the president of the Commission, Margaret E Kruk, Harvard TH Chan Public Health Faculty. Boston. "Human rights to health do not make sense without quality care Quality health systems give priority to people, they generate health, they trust the public and they can Adapt when health needs change., Responsible health systems when health workers and policy makers choose to receive health care in their own public institutions. "

The epidemic of poor quality care

The more than 8 million excess deaths from poor health care systems resulted in economic welfare losses of US $ 6 trillion in 2015 alone. The Commission found systematic deficits in quality of care in a number of countries in a range of health problems and in primary and hospital care. These included:

• About 1 million deaths from neonatal diseases and tuberculosis occurred in people who used the health care system, but received poor care.
• Poor quality is one of the leading health-related death factors in all LMIC conditions, including 84% of cardiovascular deaths, 81% of vaccine-preventable diseases, 61% of neonatal diseases and other deaths. by infectious diseases.
• Inadequate access to care contributed proportionally more to deaths from cancer (89%), mental and neurological disorders (85%) and chronic respiratory diseases (76%), highlighting the need to increase the number of deaths. access to care to improve quality. .
• Data from more than 81,000 consultations in 18 countries showed that on average, mothers and children receive less than half of the recommended clinical actions during a typical visit, including postpartum incorrect management of diarrhea or tuberculosis; and monitoring of blood pressure during labor (see Commission figures 2, 3 and 4).
• One-third (34%) of those in LMIC report a poor user experience, citing disrespect, long wait times, and short consultations. Similarly, confidence in health systems is weak. For example, in India, half of households report circumventing their nearby public institution, with 80% citing at least one quality problem (see Figure 8 in the Commission).
• Poor quality care is more common among vulnerable people in society. The richest women attending antenatal care are four times more likely to report blood pressure measurements and urine and blood tests than the poorest women. teenage mothers are less likely to receive evidence-based care; and children from wealthier families are more likely to receive antibiotics. People with stigmatized health problems, such as HIV / AIDS, mental disorders and addictions, as well as other vulnerable groups such as refugees, prisoners and migrants are less likely to receive quality care.

In India, an estimated 1.6 million deaths per year are due to poor quality of care (and 838,000 additional deaths due to poor access to care); in China, 630,000 deaths a year were due to poor quality care (and 653,000 deaths due to difficult access); in Brazil, 153,000 deaths a year were due to poor quality of care (and 51,000 due to lack of access). In Nigeria, 123,000 deaths per year were due to poor quality care and 253,000 to inadequate access [Country data provided in the Appendix]. These are cautious figures after subtracting sickness cases that should have been prevented by strong public health measures. "The impact of poor quality of care goes far beyond mortality, but can result in unnecessary suffering, persistent symptoms, loss of function and lack of confidence in the health system. Not surprisingly, only a quarter of people in low- and middle-income countries believe that their health care system is working well, "says Dr. Kruk.

The right to quality care

The Commission proposes several ways to address the quality of health systems, starting with public accountability and transparency of health system performance.

The Commission found that many current improvement approaches have limited effectiveness. In addition, commonly used health system parameters, such as the availability of drugs, equipment, or the proportion of births with skilled birth attendants, do not reflect quality of care and may lead to false complacency regarding progress. The Commission calls for fewer measures, but better measures of the quality of health systems, and proposes a scoreboard of measures that should be implemented by counties by 2021 to enable measurement and reporting transparent quality care.

"The vast epidemic of low-quality care suggests that there is no quick fix and policy makers must commit to reforming the foundations of health care systems. and appealing to the public to demand better care For too long, the global health discourse has focused on improving access to care, with little emphasis on the quality of care. and unethical, "says Dr. Muhammad Pate, Co-Chair of the Commission and CEO of Big Win Philantropy and former Minister of State for Health in Nigeria.

In a related comment, Dr. Tedros Adhanom Ghebreyesus, Director-General of WHO, adds, "Quality is not obvious, it requires vision, planning, investment, compassion, clinical The furthest away … The strength of a country's basic capabilities under the International Health Regulations depends on the quality of its health services: the same nurse vaccinating children and taking care of new mothers will also have to Identify an unusual communicable disease People and communities are at the heart of the quality of health services We can not talk about quality without placing them in the center When people are actively involved in their own health and care experience fewer complications and enjoy better health and well-being.

In support of the Commission's findings and recommendations, 19 leading global health organizations, including the Department of Health, Nutrition and Population, the Asian Development Bank, the Global Fund to Fight AIDS, Tuberculosis and Malaria, UNICEF and the Ministries of Health of Argentina, Japan, Malawi, Indonesia and South Africa signed the Bellagio Declaration on High Quality Health Systems Appealing to act: "High quality health systems are at the heart of global equity. a privilege for a lucky few, in some institutions, in a few countries: health systems must protect, treat and respect all individuals, especially the most vulnerable. for high quality health systems. "

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More information:
The lancet (2018). www.thelancet.com/journals/lan … article / PIIS0140-6736