Crossing the Global Quality Chasm Improving Health Care Worldwide (2018) / Chapter Skim
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1 Introduction
1 Introduction
Pages 23-52
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. The pursuit of equity is at the heart of the SDGs, and Target 3.8 specifically addresses the achievement of universal health coverage (UHC)
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. Quality, Universal Health Coverage, and Global Health Security While the quality of care is not always linked to UHC, some argue that both should be linked more closely with global health security, which WHO defines as the reduced vulnerability of populations to acute threats to health (WHO, 2007)
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In short, health systems of the future, while becoming more predictive and holistic, also represent an important opportunity for a better merging of quality, UHC, and global health security to achieve positive, synergistic effects. What Is Universal Health Coverage Without Quality?
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. Finally, if care delivery does not treat patients with respect and dignity, trust in the system and providers can erode, and people therefore may not seek care that could help them in the future.
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This section outlines some of the challenges faced by low-resource settings in the areas of fragmentation of care delivery and poor health system building blocks. These challenges can result in a fragmented and complex patient journey (described later in the chapter)
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Providers and facilities fail to communicate with each other or coordinate their work, causing important health information to fall through the cracks and impairing patient experiences. While users in high-income countries may have an electronic health record (EHR)
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. Service readiness depends on the presence of basic amenities, such as reliable power, improved water, and sanitation; standard infection precautions; and medical equipment (WHO, 2010)
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WHO emphasizes the importance of health worker density,3 but that concept may implicitly assume that these workers are adequately trained and consistently deliver care that meets clinical standards. Yet, even when health workers are present, several studies indicate a lack of adherence to clinical guidelines and implementation of evidence-based practice (Puchalski Ritchie et al., 2016)
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. In low-resource settings, accountability can be lacking because of weak regulations and the limited capacity of organizations to hold health workers to professional, discipline-based standards, which may explain why the performance of health workers, even those who are trained, is low and highly variable in LMICs (Das, 2011)
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. A BMC Health Services Research study explored the sustainability of electronic health information systems (EHISs)
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Furthermore, without a sustainable source of revenue, health care facilities can experience stockouts; fail to deliver care that meets clinical guidelines; or engage in aberrant behavior, such as patient detention, in an effort to garner revenue. These problems related to the financing of UHC are discussed in more detail in Chapter 7.
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In fact, leadership and governance of a country too often are tainted by corruption and collusion, as discussed further in Chapter 6. A POOR PATIENT JOURNEY Given the fragmented nature of health care delivery in LMICs and the weaknesses in health system building blocks discussed above, it is crucial to view health care quality not just as a point estimate that applies during one clinical encounter.
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Doing so will in turn require understanding the challenges that occur when patients transition among care settings and in between clinical visits. One crucial challenge is the issue of "health literacy," or "the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions" (IOM, 1990, p.
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36 FIGURE 1-1 The patient journey from a life-course perspective.
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framework offers a valuable perspective that poor-quality care is often a consequence of upstream factors. Influence of the Well-Being of Providers The committee unequivocally embraces the centrality of the patient experience in defining and pursuing quality, but it also recognizes that the experience of health care providers is equally important to high-quality health care.
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work environments are linked to poor patient experiences and health outcomes (Bodenheimer and Sinsky, 2014)
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; to unique health care innovators, such as Narayana Health Care and PurpleSource (discussed in Chapter 7) ; to high-tech health facilities serving as hubs for medical tourism (Medical Tourism Magazine, 2018)
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, as well as from innovators from East and West Africa. At the third meeting, hosted by the Institute of Global Health Innovation at Imperial College London, United Kingdom, in March 2018, the public session explored the future of health care quality.
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• The committee should also consider nonhealth features of low-quality care, e.g., the question of financial protection, particularly as it relates to the implementation of universal health coverage elements. • Define the opportunity -- The committee should review the evidence on the potential to systematically improve quality of effective and safe care and offer recommendations about when and where quality im provement methods (defined broadly to include policies, processes, behavior change, and system modifications)
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The 2001 report also does not address issues of accountability and transparency and their fundamental relationship to achieving high-quality care delivery. Furthermore, understanding of the nature of "patient-centered care" has evolved in the intervening years.
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This can cause health care resources to be depleted by vested economic interests of the powerful elite. Thus, this report uses the updated six dimensions to guide quality measurements: • Safety: Avoiding harm to patients from the care that is intended to help them.
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As health care continues to advance, and patients receive care transnationally or from multinational companies, the committee believes that purely national lines will fail to capture quality of care adequately. For instance, just as deleterious effects from poor quality can occur in high-income countries, such as the United States (Jewett and Alesia, 2018)
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A Note on the Committee's Recommendations The committee recognizes that the recommendations offered in Chapters 2 through 8 of this report are aspirational, requiring in many cases transformative efforts that will necessitate combined and sustained action on the part of the full range of governments, leaders, and organizations worldwide involved at every level of the health care enterprise. However, the committee believes that the evidence reviewed in this report clearly demonstrates the need to think big while also identifying specific actions that, collectively, can advance global health care toward a quality system that meets the needs of all the world's citizens, including those in the most resource-poor regions.
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Chapter 5 calls attention to the billions across the world who fall outside of formal health care systems, including those whose care comes from informal providers and those in settings of extreme adversity where health care is scarce and infrastructures absent. Chapter 6 highlights the negative health impacts of corruption in the health sector and how tools outside the health sector can be used to address this important problem.
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2016. Barriers and facilitators to health information exchange in low- and middle-income country settings: A systematic review.
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BMJ Global Health 2(2)
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2017. Redefining universal health coverage in the age of global health security.
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2014. Effective coverage: A metric for monitoring universal health coverage.
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2016. Health workforce requirements for universal health coverage and the sustainable development goals.
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52 CROSSING THE GLOBAL QUALITY CHASM World Bank.
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