Since 2017, Margaret Kruk, MPH ’00, Associate Professor of Global Health at the Harvard Chan School, has been chair of The Lancet Global Health Commission on High Quality Health Systems in the SDG [Sustainable Development Goals] Era. In that role, she has led an effort to review current knowledge, conduct new empirical studies, and offer policy recommendations for improving health care quality in low- and middle-income countries [LMIC]. The commission will be publishing its findings later this year.
Kruk’s quest to improve health care quality has taken her to Ethiopia, India, Liberia, Tanzania, and other countries. She began her public health career as a family medicine physician, running a regional hospital in Geraldton, an old mining town in northern Ontario. “It was Canada, so we had good funding, a good base, and good training. But we were very remote—three hours from the nearest surgical hospital, with the road ending 50 kilometers outside the community. Yet we were able to give good care, routinely and consistently. It was not just because of resources. It was a collective investment in the idea of a high-quality system.”
Kruk spoke recently with Madeline Drexler editor of Harvard Public Health.
Q: Formal explanations aside, what motivated you to chair the Lancet commission?
A: On the one hand, we have been celebrating the accomplishments of health systems. We’ve reduced child mortality and infectious diseases, including HIV. At the same time, it’s a known fact that in most low-income countries, policymakers, health leaders, expats, and people who have any financial means would never use a country’s clinic when they themselves get really sick. They would find the first plane out.
And in my work in Tanzania and other countries, very poor women in remote areas would tell me, “Sure, distance is a barrier for us to get care. But is it actually worth it to even go to a clinic?”
These observations added up to a picture that health systems are not providing the care that people want or that will help them get better. We have talked about improving access as a marker of success. But if you stop at access, then once people enter the clinic door, our job is done. We never really looked under the hood.
Poor-quality care costs about 7 million lives a year in low- and middle-income countries. Those are very often lives of people who are young and in their most productive years, who could have been saved if the system had been able to respond.
Q: What are the main reasons for poor quality?
A: First, it has never been in the interest of either policymakers in-country or their global funders to dig into this. It feels far too difficult and too complicated. As a result, they haven’t been asking clinics to clear a particularly high bar.
Second, people don’t demand enough from their systems. In surveys, people rate objectively poor quality as pretty good. It’s because they’ve encountered such bad care for a majority of their health needs that they don’t feel entitled to good care. And they don’t know what good care looks like.
Q: How so?
A: For an antenatal care visit, a family planning visit, or a parent who brings in a sick child, people might not be asked their symptoms. They might not be examined. They might not be told when to return. They’re basically getting half the care that they should be getting, according to best practices globally. Even for diseases that are well known in these countries, such as diarrhea or TB, people get the correct treatment only about 50 percent of the time.
“We cannot judge health systems on inputs: number of doctors, number of clinics, number of antibiotics. Stethoscopes themselves don’t produce good care. We need to be judging systems on performance.”
The situation is worse with newer, less-familiar conditions. One study showed that only 5 percent of people with depression in a range of low- and middle-income countries received what psychiatrists would call minimally adequate treatment—globally, there’s a huge amount of unnecessary suffering from depression. There is also vast undertreatment of severe pain; people with chronic, debilitating conditions, such as cancer, are often dying in excruciating pain, because less than 0.1 percent of all the global morphine and morphine-related medications are dispensed in low-income countries.
Today, we know almost nothing about the quality of cancer care in LMICs. We know almost nothing about the quality of treatment for injuries and emergencies, hypertension, and diabetes. Yet those conditions are rising rapidly in LMICs.
Q: What is a takeaway message from the commission’s work so far?
A: Going forward, we cannot judge health systems on inputs: number of doctors, number of clinics, number of antibiotics. Stethoscopes themselves don’t produce good care. We need to be judging systems on performance: the competence of care, the respect that patients get when in treatment, their health and trust in the system.
Q: Checklists are a popular approach now to improving health care quality in LMICs. What are the strengths and weaknesses of checklists?
A: Checklists are a powerful and elegant idea, and they have been shown to work in some high-income countries. I think of a checklist as a way of reminding people of the things they already should be competent at and doing. Checklists are like the capstone or final step in a quality production process—they cannot replace the foundation of good training, good systems, good oversight.
Q: What would it take to start a movement around improving health systems in resource-poor nations?
A: This kind of movement cannot happen until there’s been a political decision in the country that health care quality matters. We think that having activated patients and activated communities is an asset to the government, because they would hold clinics accountable, reducing pressure for government oversight. But the government has to be willing to take the first step and open up the door to complaints and legitimate grievances and expectations. One of our strong findings is that when people trust their health systems, they tend to trust their governments—so leaders reap a political benefit from demonstrating good services.
People are more connected than ever. They’re on their phones, they’re watching TV, they’re seeing what kind of care the wealthy in their community are getting. Over time, even if we do nothing, expectations are going to rise.
For more information on The Lancet Global Health Commission on High Quality Health Systems in the SDG Era, go to hqsscommission.org.
Photo: Kent Dayton/ Harvard Chan