March 17, 2017 – Improving people’s access to health care around the world has been a major focus of global health experts in recent years. Now they are turning their attention to the quality of that care—especially in low- and middle-income countries that often bear the brunt of ill health.
Over the next year and a half, a group of 30 academics, policymakers, and health systems experts from 18 countries around the globe will conduct research and propose policy recommendations for improving health care quality as part of The Lancet Global Health Commission on High Quality Health Systems in the SDG Era (HQSS Commission).
Chaired by Margaret Kruk, associate professor of global health at Harvard T.H. Chan School of Public Health, and Muhammad Pate, former Minister of State for Health, Nigeria, the Commission was launched at a daylong conference held March 13, 2017 at Harvard Medical School’s Joseph B. Martin Center.
A wide range of factors can affect health care quality, according to Kruk. “While clinic equipment and medicines are important prerequisites for good care, it is the providers’ adherence to sound evidence, his or her effort during the visit, and respectful treatment of the patient that matter more for outcomes and patient satisfaction,” she said. “The Commission will attempt to refocus the world’s attention on the process of care and its outcomes, including the value that health care brings to patients, for example in terms of pain relief, feeling heard, and having confidence in the health system.”
Kruk said that policymakers and global health experts need to conduct research on key questions such as what drives variation in health care quality and why some clinics perform better than others. And countries need to rigorously test solutions for improving quality to make sure they work well.
At the conference, cosponsored by HQSS and the Harvard Global Health Institute (HGHI), HQSS Commissioners, policymakers, and leaders in global health and academia discussed the key challenges facing health systems in defining, measuring, and improving quality.
In opening the conference, Jha said, “The reason we care about quality is that it’s fundamental to improving lives and improving well-being. It’s as simple as that. We focus a lot on access and universal health coverage. We all agree that’s important. But that alone is not going to get us where we want to go.”
He added, “We know that health systems, whether they’re in Boston or Botswana, London or Lahore, fail us every single day. Not because the people in it are not good—they are—and not because they are not trained—they usually are—but for a variety of reasons that need to be explored and understood.”
Kruk said that people today demand good health care, and if they don’t get it “they will find somewhere else to go or they won’t use the health system at all.” Quality has been neglected because it is seen as too complicated or too expensive or both, she said, adding, “We’re here to change that.”
The importance of respect
Experts at a morning panel discussion said it’s important for clinicians to treat patients with respect and to communicate with them effectively.
Patients everywhere want the same thing, said Susan Edgman-Levitan, Executive Director of the Stoeckle Center for Primary Care Innovation at Massachusetts General Hospital. “People care about access to care. They care that when they show up for care that people greet them, that people treat them with respect and dignity. And they care about what kind of clinical information they get…. We need to do a much better job of giving people information about their own care.”
Jha agreed. “When people walk out of a health care encounter feeling neglected, dissatisfied, or not treated with dignity or respect, they don’t take the treatments you give them. They don’t come back when they have complications.” If the goal is to make people better, he said, it’s important to treat them respectfully.
Partnering with patients
Panelists also said that clinicians should work more in partnership with patients as opposed to simply dispensing information or treatments.
Edgman-Levitan quoted a colleague who said that “Clinicians have to come off their pedestals, and patients have to come off their knees.” There is still a lot of paternalism in health care, she said—the notion “that we know best, and that we don’t really need to talk to the people that we serve.” But more balanced doctor-patient relationships are critical, she said.
Ephrem Lemango, Director of the Maternal & Child Health Directorate for the Ministry of Health in Ethiopia, said that in his country, doctor-patient relationships in urban areas can be quite different than those in rural settings. In cities, some patients feel confident enough to negotiate with their physicians about their treatments. But people in rural areas, who may have less access to information about their medical choices, may feel that simply being listened to is their primary concern. It’s important for clinicians to be aware of these differences, he said. These differences also suggest the need to build demand for high-quality health care in some communities.
Other panels through the day focused on topics such as why it’s important for resource-constrained countries to focus on quality, and what minimum standard of quality low-income country health systems should guarantee.
Kruk said that the Lancet Commission’s work will culminate in the publishing of a report in fall 2018. The report will present new evidence on the state of health care quality in lower-income countries and will propose how countries might measure and improve it, keeping in mind that different contexts may require different solutions. Kruk hopes that the report will simplify the notion of health system quality and persuade Ministries of Health and providers that improving quality is achievable in every country.
She said the goal of the conference—a public forum that was day one of a three-day meeting—was “to stir up debate, to get conversation flowing about what we mean by quality, who deserves it, and how we can deliver it.”
photos: Sarah Sholes
Read a Lancet Global Health article about the new Commission, co-authored by Margaret Kruk: Introducing The Lancet Global Health Commission on High-Quality Health Systems in the SDG Era