The idea that universal coverage without quality of care is empty rhetoric is no longer in doubt. Yet, we still see a glaring mismatch between the urgent need for better, safer care and the version of care reaching patients.
In low- and middle-income countries, poor quality is contributing to 10 to 15 percent of deaths. Up to a third of patients experience disrespectful care, short consultations, poor communication, or long wait times. The World Health Organization (WHO) estimates that 20 to 40 percent of all health sector resources are wasted through inappropriate medicine use, suboptimal human resources mix, overuse or oversupply of equipment, corruption, and underuse of infrastructure. Finally, despite performing 6.2 million unnecessary caesarian sections at a cost of US$2.32 billion, the world faced an unmet need for 3.2 million caesarian sections, costing US$432 million. In contrast, better health care quality could save over 8 million lives each year.
What’s next? The hard work begins or continues.
The global health community seems to be rising to the challenge. My interactions with some health systems in Africa and the Middle East as well as foundations attest to this. The Lancet Global Commission on High Quality Health Systems made four recommendations last year: governance for quality, redesign of service delivery, workforce transformation, and increase demand for quality through active patient engagement.
Permit me to reflect on governance. After all, as we say in Africa, when a fish rots, it starts from its head.
What are the opportunities and challenges in the quest to govern for quality through creation of a shared vision and establishment of quality management systems?
Balance Policy and Strategy
At the very top is the seeming conundrum in certain places about the divide between quality policy and quality strategy. At times, countries spend an inordinate amount of time crafting high-level policy intentions that are devoid of practical implementation guidance. This would not necessarily be an issue, except that the effort to write such a document tends to be so time-consuming, and endless debates about what to include or exclude sometime lead to paralysis that precludes meaningful action.
To tackle this divide, I recommend referring to the WHO’s resources for combining quality policy and strategy or IHI’s soon-to-be-published practical guidance for national quality strategies implementation. These resources help shed further light on finding the balance between planning policy and guiding implementation.
Combine Quality and Safety
Though we aim for “100 percent quality and 0 percent harm,” quality and safety are sometimes seen as rivals instead of being leveraged as different sides of the same coin. In some countries, consequently, leaders wonder whether they should write separate policies for quality and patient safety. The implications of this are not trivial. Fearing that one or the other will not receive enough attention without its own structure, countries with limited resources may attempt to create parallel systems to govern quality and safety rather than combining them.
Develop Learning Systems to Drive Improvement
Increasingly, countries are gravitating towards a structure for the governance of quality at multiple levels of the health system. Some countries continue to struggle with developing and leveraging true learning systems that study their own best and worst performances to take corrective action informed by real-time response to local data.
Various models have emerged to improve integration. For example, National Quality Technical Committees (NQTCs) or Steering Committees include broad membership drawn from a variety of stakeholders, including patients and communities; directorates within Ministries of Health; those who lead licensing and accreditation, health insurance, clinical guidelines and protocols development; regulatory bodies, and other agencies. Meeting every quarter, these NQTCs are mandated to use whole system quality and safety metrics to identify gaps, prioritize, commission regional quality management teams, analyze data, harvest best practices, and mitigate challenges, while promoting multi-directional feedback loops across the health system. In between these quarterly meetings, day-to-day activities are driven forward by quality management units or departments headed by National Quality Managers or Directors, respectively.
It is important that we not allow innovations to rest in silos within the health system or to sit in data sets pending publication. Further, carefully documented best practices with cost implications ought to feed into national health budgets for sustainability. By working together across policy and strategy, safety and quality, countries can build unified improvement to achieve better health for all.