Rethinking healthcare quality: An interview with Margaret Kruk, co-chair of the Lancet Commission on High Quality Health Systems

A recently published report by The Lancet found that 5 million people die each year because of poor-quality healthcare in low- and middle- income countries (LMICs) and 3.6 million deaths occur due to the lack of use of healthcare altogether.

Co-chairs Margaret Kruk, Associate Professor of Global Health at the Harvard T.H. Chan School of Public Health and Rabin Martin International Advisory Council member, and Muhammad Pate, CEO of BigWin Philanthropy, formed the Global Health Commission on High-Quality Health Systems in the SDG Era (HQSS) by bringing together thought leaders and practitioners from academic institutions, government and the health sector. The Commission took on the task of defining high quality health systems and proposed new ways to measure and improve performance by first examining the quality of care available to people in LMICs across a range of health areas included in the Sustainable Development Goals (SDGs), exploring ethical dimensions of care and reviewing existing quality measures and quality improvement approaches.

Here are highlights from our conversation with Dr. Kruk, which have been edited and condensed.

What do you think is most surprising about the findings of the Commission?
We found that the science on existing quality improvement mechanisms (i.e. checklists, supervision) is weak and limited. In many LMICs, quality improvement is focused on the point of care and quick fixes. The Commission took a different path in thinking about quality to identify what we mean by a high-quality health system because we think good outcomes will take more than a doctor or a nurse, and include a whole system.

Stepping back from the traditional definition of quality health care, the Commission defined a quality health system as having three core components:

  1. Health systems need to deliver care that improves or maintains health consistently, not just on Friday morning at 9AM, but consistently for the population as a whole, at all times.
  2. Health systems must be valued and trusted by people and include the essential nature of trust as a quality measure.
  3. Health systems should be able to adapt and chance either way when a health shock comes, like an outbreak, or a population’s health changes over time, such as we’re seeing with the rise of non-communicable diseases in so many countries.

        
What is the value proposition of strengthening health quality?
If countries are to achieve their national health goals, as well as targets set out within the Sustainable Development Goals (SDGs), it is critical to rethink how we define a quality health system. Moreover, unlike in the era of the Millennium Development Goals (MDGs), more countries are now facing multiple diseases and co-morbidities where single, one-off interventions are no longer sufficient.

The Commission recommended actions to think beyond the point of care, including:

Governing for quality. The focus of health system governance should be on good performance. Responsibility for quality should be taken at the highest level, cascading down the system from the national level to the provincial or district level so that everyone is in sync and good quality exists across the board.

Redesigning health service. Many health systems are originally arranged to maximize outreach in a population, which is great for basic, non-specialized services, but does not work for positions that require more competence and skilled providers. Units of health systems, i.e. at the district or provincial levels, should be redesigned to provide services at the level at which quality and good outcomes can be guaranteed, rather than just thinking about distance. Distance is a problem that can be solved outside the health system.

Transforming health workforce education. Based on analyzing clinical observations of care that is being provided to people, it became evident that many providers don’t follow basic clinical practice and a lot of shortcuts are being taken. The health workforce must be more competency oriented and do a better job of critical thinking and critical diagnosis.

Igniting demand for good quality care. Improvement of health systems must include feedback from patients as well as educating the population on what good quality care looks like.

The private sector, for example, knows very, very well how to use consumer feedback and consumer demand to improve products and services. And the health system, on the contrary, is quite deaf to user input. Health systems are very top down and there is a lot of wisdom and input and feedback left on the table that could actually put pressure on health systems and provide very good ideas to improve them, if only we listen to the patient and change the system.

Healthcare companies have a vested interest in growing markets for their products and services. How should they think about the role of quality in driving demand for healthcare?
When we think of quality, it’s not just too few services, but also too many services or the wrong kinds of services. And if I were a global company with a medication portfolio, for example, I would really be thinking about getting on the right side of the equation by ensuring that overuse of medications and diagnostics is not promoted. The problem with [overuse] is that it leads to sub-optimal care where governments see huge amounts of spending that actually doesn’t improve outcomes. The question companies should be asking themselves is “how they can create ethical partnerships with government and the local private sector in a way that promotes the right amount of care for people that need it?”

One huge challenge is antimicrobial resistance, which results from poor quality decision-making around antibiotics. Health systems are here for the long run, so companies should align themselves with getting the right medicines, the right diagnostics and the right tools into the hands of trained providers, in a public-private partnership. That, I think, is the way to go.

The growing burden of non-communicable diseases also provides a challenge in how we think about quality as a driver of health. For companies thinking about this issue, one key need in NCDs is continuity. How do we work with health systems to help ease the strain of people who have to [re-enter] the health system numerous times? Can we take our medicines less often, can they be simpler, can we be in touch with patients electronically, can we track progression of disease or maintenance at a distance to reduce the load on the health system?
       

Health workers meeting in Zimbabwe. Photo credit: WRA Zimbabwe

How would you respond to someone who feels there might be better impact for the cost by investing in vertical programs that have been successful in the past, even while circumventing the health system — such as vaccine campaigns or setting up of dedicated supply chains for ARVs, rather than improving health systems more broadly?
They [vertical interventions] have been extremely meaningful, but the point is there is a time and a place for those. And in many countries, that job is not done.

Countries are benefiting from the pooled procurement of vaccines and that should continue to try to reduce the cost for those countries of something that will always be a health need. I think countries have benefited from the simplification of HIV regimens, from the simplification of malaria medication, and diagnostic testing as well. [Those gains] were really essential at a point in time when HIV, malaria and child diseases were the main killers.

But when we look ahead to the next decade, those are not going to be what’s killing people. What worked in the past is no prediction of future effectiveness.  I’d like to see a high-income country that operates its health system through a vertical program. [Vertical programs] are just not the example of success out there.

What are some examples of national or donor investments that have had little impact due to inadequate attention to quality?
HIV programs have spent a lot of money to retrain providers, to provide the tools for the care of people with HIV, and yet they are still struggling to optimize the system as a whole in a way that can provide care for a lifetime. As we are getting quality right on so many levels (i.e. having medication match people’s needs and having earlier diagnoses), what’s still lacking is that systems have not been set up to think longitudinally about how the health clinics and communities work together to keep those people in care and keep them on medications. That is what determines survival.

The HIV programs provide lessons for NCD care, both of which involve a lifetime of care. HIV and NCD programs should join hands and think about the joint need for clinics that provide high-quality, routine care. Systems that can maintain loyalty to the clinic and system for HIV care should certainly be able to do that for diabetes or high blood pressure.

Another example is malaria.

We really thought rapid diagnostic tests and combination medicines would have led to elimination. Despite great successes, there is still a large excess of deaths from malaria. However, technology can’t fix competency gaps, particularly in situations such as complex child cases. The kids who die are kids who develop severe malaria, which is often underdiagnosed by providers. The system is not set up to provide high-quality care to the very sick child.

Another challenge is related to investment in workforce development. Short courses and supervision offer marginal gains in performance. With the existing workforce, we want to get the very best out of them, but it won’t be through isolated training alone. As we think about system redesign and getting people to work in teams and getting the best performers to be the team leaders, we need to be thinking through the environment that promotes excellent care. And frankly, some healthcare workers are not trained well enough to provide the care they are asked to provide. So they should be doing different types of tasks, such as healthcare promotion or prevention. It’s not about ensuring each [health worker] can be a crack diagnostician, but rather a good fit between their ability and the type of care we want to guarantee people.

However, in the Commission we have said that a big part of the answer to this relies on pre-service training. We need to get the right people in the first place and ensure competency-based training vs. memorizing pathologies. Many are very good at identifying abnormalities on slides but don’t how to do differential diagnosis. In today’s day and age, its critical to know when someone is very sick and needs care immediately, and to have the support of the clinic and the system to be able to deliver that care.

Why is quality important for countries to consider as they move toward Universal Health Coverage?
We’ve had these conversations with colleagues at the WHO that are pushing countries to take on universal health coverage as a health goal.

If it is simply about expanding access through better insurance or more insurance, what we’re going to do is improve access to poor care in many countries. And two things will happen from that: [Governments] will have just spent a lot of money to subsidize insurance and what we will have gained from that is more people using healthcare. But we will again see paltry returns on health.  Second, what we see in countries is that, even when people have insurance services, if the services don’t meet their expectations of quality, they won’t use them. They will go out of their way to find better services and pay out of pocket when they feel they need quality. You lose the people’s confidence. There is major danger in pursuing universal health coverage without quality. UHC without quality is an insurance scheme. What you want is a health scheme that includes quality as a key dimension.

For health Ministries working within tight budgets, there is sometimes a tension between providing the broadest possible access to care and ensuring quality care. What are your thoughts on how governments can address this tension, while keeping quality paramount?
What we talked about on the commission is this notion of a national quality guarantee. Most people would agree that we don’t want services that won’t improve our health. The idea that we would be reaching out to populations and saying there are services available, near your home, [providing] these three things because we know that they really make a difference and that they can improve your baby’s outcome. That’s an honest assessment. Then saying, for other services, we want to help you in accessing that because everyone should be able to access high-quality care. But that access isn’t going to be by putting them in the clinic next door. That access may be through helping you find your way to the town, where we have the larger clinic. People are happy to travel further, to make the effort, when they know it’s going to be worthwhile. They are already traveling many, many kilometers to reach a clinic they feel is better.

No one is going to a clinic to sit and wait to see a provider who has no idea what’s going on with you, with none of the right medications to give, who doesn’t have the right tools to do the job. Healthcare is about getting better. The idea that you would have a service in name only that isn’t able to turn that visit into better health is a lie to the population. It is unethical to extend services that cannot guarantee people better health.

Big thanks to Margaret for sitting down with us and chatting all things quality. What are your thoughts regarding quality within the context of national healthcare systems? Challenges in implementing or maintaining quality measures? The role of the private sector? Ensuring quality across a mix of public and private providers? We’d love to hear from you. Write to us at info@rabinmartin.com.