Crossing the Global Quality Chasm Improving Health Care Worldwide (2018) / Chapter Skim
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5 High-Quality Care for Everyone: Making Informal Care Visible and Addressing Care Under Extreme Adversity
5 High-Quality Care for Everyone: Making Informal Care Visible and Addressing Care Under Extreme Adversity
Pages 169-202
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From page 169... ...
• An estimated 22.7 percent of quality-related neonatal mortality deaths occur in fragile states annually, despite those states representing only 8.5 percent of the population of low- and middle-income countries. • In 2016, 1.8 billion people, or 24 percent of the world's population, lived in fragile contexts, a figure predicted to grow to 3.3 billion by 2050.
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From page 170... ...
INFORMAL HEALTH CARE PROVIDERS: OVERVIEW The size of the informal health care sector varies substantially by region -- for example, it accounts for 55 percent of all providers in India (Prasada Rao et al., 2017) , 77 percent in Uganda (Konde-Lule et al., 2010)
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From page 171... ...
They also found that the health sector globally has a significant number of IPs who operate in a variety of health areas. They may include community health workers (CHWs)
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From page 172... ...
The relevant evidence is difficult to parse, in part because IPs are such a highly variable group. Some IPs, for example, act as apprentices to formal doctors for several years, while others have almost no involvement in the formal health care sector before setting up shop.
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From page 173... ...
Countries need a national strategy for identifying these IPs and for measuring their work processes and outcomes. What Are the Benefits and Risks of Care Received from Informal Providers?
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From page 174... ...
Conversely, formal providers working in public clinics are often from outside the local community and are posted in those clinics for short periods of time. A study in India found that more than half of the IPs surveyed were born in the same block or district where they practiced, rendering them well-known and often trusted members of the community (Center for Health Market Innovations, 2010)
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From page 175... ...
Research suggests several plausible steps toward improvement, some of which are described below: acknowledging IPs, leveraging traditional healers, defining scopes of practice, and implementing various types of interventions. Acknowledging Informal Providers The notion of formalizing IPs is hotly contested, but evidence supports at the very least identifying them and incorporating them to supplement the health care workforce in many areas of the world, as well as leveraging their strengths within their trusting communities (discussed in the following section)
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From page 176... ...
As a start, the committee believes countries could include IPs in counting so that more knowledge can be generated about their practices and patients. In addition, countries could train IPs, where appropriate, to help buttress a formal health care sector that badly needs additional workforce capacity.
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From page 177... ...
Leveraging IPs' familiarity and access to community populations is one potential and feasible way to improve the quality of care in those communities. A Cochrane review on implementation strategies for health systems, for example, found that training traditional healers may improve their knowledge and patient management and referral practices for sexually transmitted diseases and HIV (Pantoja et al., 2017)
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From page 178... ...
Implementing Interventions The most common recommendations for improving informal care found in the systematic review of Sudhinaraset and colleagues (2013) are for educational interventions, such as capacity-building training, patient education programs, and continuing education requirements.
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From page 179... ...
2011. Figure in "Can interventions improve health services from informal private providers in low and middle-income countries?
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From page 180... ...
recommend that interventions not be reliant on individual-level behavior changes alone as they are extremely difficult to influence; rather, a combination of market-based and regulatory approaches with rigorous evaluations may prove to be successful for improving the quality of informal care. They identify quality improvement strategies that combine providing training with improving market conditions, such as provider incentives and accountability, as being most successful (Shah et al., 2011)
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From page 181... ...
HEALTH CARE QUALITY IN SETTINGS OF EXTREME ADVERSITY The challenges of assuring and improving the quality of care in lowresource settings are magnified in settings of extreme adversity, defined by Leatherman and colleagues (in press) as "comprising but not limited to fragile states, conflict-affected areas, and sustained humanitarian crises." The growth in connectivity in the past decade has increased awareness of the many instances of suffering, war, and conflict in the world, as well as of the growing numbers of people displaced from their homes.
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From page 182... ...
The committee has chosen to characterize these chaotic and uncertain environments as "settings of extreme adversity" so as to shine a light on
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From page 183... ...
In many low-resource settings, however, the foundations of the health care system can be variable throughout a country. In settings of extreme adversity, the quality of the inputs to the system and general service readiness is even lower, and may vary widely on a daily basis depending on the status of the power grid, existential threats (such as bombs)
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From page 184... ...
The team that conducted the analyses for quality dimensions in Chapter 4 also performed analyses on a subset of countries that are classified as fragile states to gain a better understanding of the quality of health care delivered in these adverse contexts, although the lack of available data limits these findings in ways similar to those discussed in Chapter 4, and these numbers thus represent the committee's best estimates. In the case of quality-related neonatal mortality (unnecessary mortality among those with access to care)
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From page 185... ...
Simply providing access to lifesaving care has historically been the priority, but as the numbers of people in extreme adverse circumstances worldwide rise and as the crises responsible for these circumstances shift to protracted status rather than being just acute emergencies, the need for health care services across the continuum from preventive to palliative care is increasingly being acknowledged. Given the amount of violence and trauma to which both adults and children bear witness, mental and emotional health care is a top priority
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From page 186... ...
FIGURE 5-4 Experience of disrespect in fragile states compared with all low- and middleFIGURE 5-4 income countries (LMICs)
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From page 187... ...
Humanitarian responders recognize, as with refugees from Syria, the need for increased accessibility of specialized mental health services and greater capacity for these services within the primary care workforce. But given the breadth and depth of the problem, services must go beyond meeting basic needs and leverage community-based health care systems (Marquez, 2016)
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From page 188... ...
Sexual violence is common in these settings of extreme adversity, and it is exacerbated by separation from traditional communities and a breakdown in law and order. At the 2016 World Humanitarian Summit, WHO called attention to sexual and reproductive health needs, particularly among women and girls.
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From page 189... ...
. Evidence Available to Guide Health Care Leaders Both country-specific information and a general understanding of the evidence base are needed to address quality issues in contexts of extreme adversity systematically.
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From page 190... ...
For example, health care quality fared the best in Afghanistan when both patient and provider were female (Hansen et al., 2008) , likely because of the many cultural and religious challenges that surround interactions between men and women who are unmarried.
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From page 191... ...
However, research has shown that this is not always the case. In the previously described Afghanistan study looking at the quality of primary care services, for example, researchers found that neither remoteness, facility type, in-service training, nor timely salaries were associated with a change in quality (Hansen et al., 2008)
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From page 192... ...
Established in Japan for decades, a simple tool such as a maternal and child health (MCH) handbook can be used in settings of extreme adversity, with important implications for improving care.
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From page 193... ...
. Critical Nature of Validation Given the clear lack of evidence for quality status and improvement interventions in low-resource settings, let alone within settings of extreme adversity, the argument for more research can easily be made.
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From page 194... ...
This is a health care challenge, but one that also represents an opportunity. Researchers have identified promising interventions for addressing the quality concerns within the informal health care sector while also relieving pressure on the formal system.
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From page 195... ...
To this end, they should acknowledge that these informal providers exist and undertake efforts to assess and improve the care they provide, such as through education, training, and incentives, to the full extent possible. Health Care in Settings of Extreme Adversity About 2 billion people live in fragile states and conflict settings worldwide.
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From page 196... ...
and other research funders should support primary and implementation research aimed at identifying what interventions work and in what contexts to im prove health outcomes in fragile states and austere environments. • Multilateral organizations and the United Nations System should create multistakeholder collaborations for the purposes of review ing and vetting the available evidence; developing consensus on promising interventions for improvement; and identifying issues of leadership and accountability for quality of care in particular circumstances, such as conflict zones, humanitarian crises, and fragile states.
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From page 197... ...
2011. Making health markets work better for poor people: The case of informal providers.
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From page 198... ...
2012. Assessing community health workers' per formance motivation: A mixed-methods approach on India's Accredited Social Health Activists (ASHA)
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Health care quality in settings of extreme adversity: A review of the literature.
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2006. Informal health workers -- to be encouraged or condemned?
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2013. What is the role of informal healthcare providers in developing countries?
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