Crossing the Global Quality Chasm Improving Health Care Worldwide (2018) / Chapter Skim
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7 Embedding Quality Within Universal Health Coverage
7 Embedding Quality Within Universal Health Coverage
Pages 227-268
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From page 227... ...
In India, for example, OOP payments account for 70 percent of health care services and are responsible for the impoverish ment of 7 percent of the population. • Poor populations in several countries may receive care, but their inability to pay can lead to their detention in a hospital for weeks or even months afterwards, without continued care, food, or even a bed.
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The chapter first examines the necessary link between UHC and quality and explains why simply ensuring access and financial protection -- although important -- is insufficient to achieve effective UHC. It then examines UHC as an opportunity for quality improvement, providing examples of policy levers that can be used within UHC to institutionalize quality in health care systems and reviewing the available evidence on various levers.
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The sections below explore the interactions and interdependencies within UHC of access, financial protection, and quality -- the missing link for ensuring effective UHC. Expanding Access to Care As countries are reforming their health care systems, they are giving special attention to incorporating UHC into their objectives.
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. Moreover, relying on high OOP payments, regardless of income level, violates the spirit of UHC by driving people into poverty and can make the achievement of effective UHC impossible.
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One option is subsidizing fees based on income level so that OOP payments are not catastrophic for patients and their families, but the health care facility can continue operating. For example, committee members visited hospitals in Goma, DRC, and learned about a communitybased health insurance scheme initiated by the Church of Christ in the Congo Baptist Church in 2016.
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Even when such efforts to make medical care affordable are made, patient detention can still occur. For example, China recently rolled out an ambitious $130 billion package designed to ease the financial burden of health care.
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In Burundi following advocacy against patient detention, for example, user fees for young children and women in labor were eliminated. But with no plan in place to substitute for these lost resources, facilities experienced frequent drug shortages, reduced quality of services, and strain on health care providers (Nimpagaritse and Bertone, 2011)
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The end goals are impacted by what is being monitored and evaluated, and if the number of people accessing care and not encountering financial hardship is all that is being measured, many important elements within the dimensions of quality can be missed, leading to situations in which poor or ineffective care is provided for months or years unnoticed. In 2013, for example, Kenya abolished user fees in public health care facilities in hopes of increasing utilization rates, especially for maternal health care.
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. UNIVERSAL HEALTH COVERAGE AS AN OPPORTUNITY FOR QUALITY IMPROVEMENT The political will and momentum of UHC offer a number of opportunities that can be leveraged to embed quality safeguards within systems and programs.
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Public–Private Partnership Experts have long debated whether private or public health care is the better answer to the world's health problems. Some believe that private health care markets will fail because key preventive and public health services often are not valued in a market transaction, and patients' lack of knowledge and health literacy can leave them vulnerable to overprescription and excessive use of diagnostics (Hanson et al., 2008)
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However, the investor had negligible or uncertain financial returns, making the "business case" ambiguous. This was so in part because patients/consumers were unable to discern quality differences, and in part because quality improvement required using services that were not easily billable to any payer.
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The committee encountered several anecdotal examples of successful high-quality care delivery by private providers that could be replicated. For example, PurpleSource in Nigeria, a private integrated health care provider, set its own goal of improving access to quality primary health care services.
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. This approach can be taken a step further through pay-for-performance models that use financial incentives to foster additional quality improvements (Gottret and Schieber, 2006)
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2009. Reprinted from Public stewardship of private providers in mixed health systems: Synthesis report from The Rockefeller Foundation-sponsored initiative on the role of the private sector in health systems in developing countries.
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Additional research is needed on public reporting, examining, for example, its sustainability and its effect on prescription practices depending on patient or provider characteristics. Additional research also is needed on community engagement, such as how the composition of community groups can influence its impact.
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. Although the studies identified lend weak evidence for CDS as a tool for quality improvement, they do indicate that it can improve process efficiency and cost-effectiveness.
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. Collectively, the studies reviewed investigated the impact of accreditation on quality improvement, organizational and financial factors, process and health outcomes, hospital quality activities and measures, level of quality, and patient and provider satisfaction.
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HCAC currently holds accreditation by ISQua for its organization, surveyor training programs, and standards. HCAC works at the micro level by training hospital employees to become agents of change, and at the meso level by helping facilities establish quality management and patient safety systems.
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Teamwork culture, for example, is important for the willingness of staff to undertake improvement efforts, and if supplemented by leadership, can increase the likelihood that accreditation will advance quality improvement. Overall, the studies reviewed provide a growing base of evidence that accreditation can create a safety and quality culture in addition to yielding real improvements in health outcomes.
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However, some countries, even those of low-income status, elect to provide national health insurance instead of directly providing care, and can build in methods for ensuring that the insurance is used only where services meet quality standards. An example of a national health insurance fund is Rwanda's CBHI program, referred to previously with respect to its use of the "mutuelle," which is based on a partnership between the national and local governments (through their districts)
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. India Researchers in urban slums in India partnered with workers across 145 daycare facilities to reduce malnutrition scores among children enrolled in the facilities.
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Rwanda adopted a performance-based financing approach to improve quality of care by rewarding health care facilities for good performance, and health care providers receive bonuses on top of their salaries. After this approach was scaled nationwide, along with a rigorous evaluation program, significant positive impacts on quality with respect to targeted maternal and child health outcomes were seen (Kalisa et al., 2015)
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Yet, political will for improving quality may occur slowly without adequate advocacy and public demand. The following are some of the questions policy makers need to ask in seeking to advance improvement: FIGURE 7-2 7-2 Framework for improvement in health care quality.
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-- Are providers working in learning health care organizations that have a mission to improve quality of care and empower providers to do so? -- Do providers have access to decision support tools based on evidence-based guidelines?
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As countries transition from severely underfinanced health systems to those that have sustainable and equitable funding sources, leaders will be key in ensuring that UHC policies help improve quality. Leadership and Stewardship Leadership for quality can manifest in different ways.
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as making a noncontributory financing approach successful requires a high level of collective responsibility among the population, which in some countries, regardless of income level, is difficult to imagine. National Quality Policy and Strategy Development With so many countries at various stages of quality control and improvement and a clear need for many systems to deliver better care, WHO recently developed a handbook with country-level input to support those countries interested in improving their health care systems (WHO, 2018a)
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The policy development stage of the process aims to acknowledge the existing systems and factors that will contribute to the national quality policy. The handbook states that the national policy should be based on agreed ambitions that should intentionally become the agreed course of action (WHO, 2018a)
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Included are measures of improvement in health outcomes, strengthening of systems, and patient-centeredness. The guiding principle of the strategy is to improve health care coordination, so it incorporates the public and private health care sectors, emphasizes partnership with patients and providers, and establishes feedback loops to guide quality improvement at all levels (Ghana Ministry of Health, 2016)
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During his testimony to the committee in Nairobi, Maina Boucar, from University Research Company's Regional Office for Francophone Africa, highlighted several instances of low-resource countries implementing quality improvement efforts with corresponding success. He noted that tangible improvement is possible where leadership is strong, but that these types of interventions cannot be seen as an external effort, and need to be owned by and implemented within organizations.
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While achieving this level of health literacy may require robust community outreach and education efforts, it will offer some balance to the asymmetry that exists around the world between the patient and the physician. In most places, when people seek care from a health care facility, they are reliant on the provider for all knowledge about their condition, and they are unable to actively choose to avoid underperforming providers (Miller and Babiarz, 2013)
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. Embracing the technological advances and shifts to consumer ownership of health data and health care decision making described in Chapter 3 will require that the health care industry transform its business models to incentivize providers to enhance the care experience, reduce waste, and improve quality (Hudson and Rikard, 2018)
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India saw success with its VAS social health insurance program, in which patients experienced lower mortality rates thanks to increased care utilization, etter quality facilities, and earlier diagnosis, as well as 60 percent fewer b OOP expenditures for hospitalizations. Costa Rica undertook massive primary care reform, helping to reduce child mortality by 13 percent for every 5 years the program was in place.
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• Demand creation at the community level was a successful strategy for improving the uptake of antenatal services, but it was most ef fective in reducing rates of stillbirth when coupled with supply-side efforts to improve the quality of care and system strength. Overall, the studies reviewed on accreditation also provide a growing base of evidence that this strategy can create a safety and quality culture, in addition to yielding real improvements in health outcomes: • Accreditation status in Brazil was significantly associated with patient safety and quality management activities.
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The committee en dorses the recent Global Quality report and recommendations of the World Health Organization, the World Bank, and the Organisation for Economic Co-operation and Development, and further recommends the following steps: • Every ministry of health should develop a national health care quality strategy, together with supporting policies, and should agree to be held accountable for progress. • Every ministry of health should adopt goals for achieving high quality care, adapted to their national context, but considering all the dimensions of quality highlighted in this report.
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Recommendation 7-2: Use Universal Health Coverage (UHC) as a Lever to Improve the Quality of Care As ministries of health and health care leaders implement UHC, they should work with payers and providers to improve quality by institu tionalizing evidence-based policy levers and systematically assessing their effects on quality.
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2014. Effects of a performance and quality improvement intervention on the work environment in HIV-related care: A quasi-experimental evaluation in Zambia.
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2016. Ghana National Healthcare Quality Strategy (2017–2021)
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2013. Improving health system quality in low- and middle-income countries that are expanding health coverage: A framework for insurance.
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2015. Towards universal health coverage: Exploring healthcare-related financial risk protection for the informal sector in Kenya.
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2016. Public reporting as a prescriptions quality improvement measure in primary care settings in China: Variations in effects associated with diagnoses.
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2018. New perspectives on global health spending for universal health coverage.
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