Improved access to care not sufficient to improve health, as epidemic of poor quality care revealed

An estimated 5 million deaths per year in low and middle income countries (LMICs) are the result of poor quality care, with a further 3.6 million the result of insufficient access to care, according to the first study to quantify the burden of poor quality health systems worldwide.

While many LMICs have made significant progress in improving access to care, a new reality is at hand: poor quality care in the health system is now responsible for a greater number of deaths than insufficient access to care. The total number of deaths from poor-quality care per year is estimated to be five times higher than annual global deaths from HIV/AIDS (1 million), and over three times more than deaths from diabetes (1.4 million).

The findings come from a new analysis published in The Lancet, as part of The Lancet Global Health Commission on High Quality Health Systems—a two-year project bringing together 30 academics, policy-makers and health systems experts from 18 countries who examined how to measure and improve health system quality worldwide.

“Quality care should not be the purview of the elite, or an aspiration for some distant future; it should be the DNA of all health systems,” said Commission Chair, Dr. Margaret E Kruk, of Harvard T. H. Chan School of Public Health, Boston. “The human right to health is meaningless without good quality care. High quality health systems put people first. They generate health, earn the public’s trust, and can adapt when health needs change. Countries will know they are on the way towards high-quality, accountable health systems when health workers and policymakers choose to receive health care in their own public institutions.”

The epidemic of poor-quality care

The over 8 million excess deaths due to poor quality health systems lead to economic welfare losses of US$ 6 trillion in 2015 alone. The Commission found systematic deficits in quality of care in multiple countries, across a range of health conditions and in both primary and hospital care. These include:

• Approximately 1 million deaths from neonatal conditions and tuberculosis occurred in people who used the health system, but received poor care.
• Poor-quality is a major driver of deaths amenable to health care across all conditions in LMICs, including 84% of cardiovascular deaths, 81% of vaccine preventable diseases, 61% of neonatal conditions and half of maternal, road injury, tuberculosis, HIV and other infectious disease deaths.
• Insufficient access to care was a proportionally greater contributor to deaths from cancer (89%), mental and neurological conditions (85%), and chronic respiratory conditions (76%), highlighting the need to increase access to care for these conditions alongside improving quality.
• Data from over 81000 consultations in 18 countries found that, on average, mothers and children receive less than half of the recommended clinical actions in a typical visit, including failures to do postpartum check-ups, incorrect management of diarrhoea or tuberculosis, and failures to monitor blood pressure during labour (see Commission figures 2, 3 & 4).
• A third (34%) of people in LMICs report poor user experience, citing lack of respect, long wait times, and short consultations. Similarly, confidence and trust in health systems are low. For instance, in India, half of households report bypassing their nearby public facility, with 80% citing at least one quality concern (see Commission figure 8).
• Poor-quality care is more common among the vulnerable in society. The wealthiest women attending antenatal care are four times more likely to report blood pressure measurements, and urine and blood tests compared to the poorest women; adolescent mothers are less likely to receive evidence-based care; and children from wealthier families are more likely to receive antibiotics. People with stigmatised health conditions, such as HIV/AIDS, mental health and substance abuse disorders, as well as other vulnerable groups such as refugees, prisoners and migrants are less likely to receive high quality care.

In India, an estimated 1.6 million deaths per year were due to poor quality care (and a further 838,000 deaths due to insufficient access to care); in China 630,000 deaths per year were due to poor quality care (and 653,000 deaths due to poor access); in Brazil, 153,000 deaths per year were due to poor quality care (and 51,000 due to insufficient access). In Nigeria 123,000 deaths per year were due to poor quality care, and 253,000 due to insufficient access [Country data provided in the Appendix]. These are conservative figures after subtracting cases of disease that should have been prevented by strong public health measures. “The impact of poor quality care goes well beyond mortality, but can lead to unnecessary suffering, persistent symptoms, loss of function, and a lack of trust in the health system. Other side effects are wasted resources and catastrophic health expenditures. Given our findings, it is not surprising that only one quarter of people in low and middle income countries believe that their health systems work well,” adds Dr. Kruk.

The right to high quality care

The Commission proposes several ways to address health system quality, starting with public accountability for and transparency on health system performance.

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

“The vast epidemic of low quality care suggests there is no quick fix, and policy makers must commit to reforming the foundations of health care systems. This includes adopting a clear quality strategy, organizing services to maximize outcomes not access alone, modernizing health worker education, and enlisting the public in demanding better quality care. For too long, the global health discourse has been focused on improving access to care, without sufficient emphasis on high quality care. Providing health services without guaranteeing a minimum level of quality is ineffective, wasteful and unethical,” says Dr. Muhammad Pate, co-Chair of the Commission and Chief Executive of Big Win Philantropy and former Minister of State for Health in Nigeria.

In a linked Comment, Dr. Tedros Adhanom Ghebreyesus, Director General of WHO, adds: “Quality is not a given. It takes vision, planning, investment, compassion, meticulous execution, and rigorous monitoring, from the national level to the smallest, remotest clinic…. The strength of a country’s core capacities under the International Health Regulations depends on the quality of its health services. The same nurse who vaccinates children and cares for new mothers will also need to detect an unusual communicable disease. Similarly, people and communities are at the heart of quality health service delivery. We cannot talk about quality without placing them at the centre. When people are actively engaged in their own health and care, they suffer fewer complications and enjoy better health and wellbeing.”

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