A health clinic with a bed and privacy screen is shown.
Note the privacy screen and buckets for infection control, addressing both the experience of care (privacy of patients) and provision of care (standards for clinical practice).

Where does quality of care fit with health systems strengthening?

2018 was the year of reports on quality of care with the publication of three very comprehensive documents:

They each provide the stark data around what is called the quality of care chasm (the global inequities and mortality and morbidity that results from poor quality care). They then talk about the importance of health system strengthening if this chasm is to be bridged. We encourage you to have a look at each of the reports in full, as they are rich in case studies and insights into why this aspect of health service delivery has been so challenging.

The definition of quality in all the reports adheres to the 2001 Institute of Medicine domains of equity, timeliness, people-centredness, safety, effectiveness and efficiency. Within these domains, what appears to matter most is competent care, the experience of care, and user confidence in the systems and health outcomes. To date, we have gaps in our understanding of the user experience, system competence and confidence in the system, as they are areas that have been difficult to monitor. Of course this argues that the things we measure often end up being where quality-improvement actions happen, and we need to be more intentional in examining some of these blind spots.

We believe there are also two myths we need to dispel

Myth 1. Quality comes once coverage is addressed

Consider the following statement made at a recent high level discussion on quality of care:

“Quality is something you work on once you have the basics in place. Much like Maslow’s hierarchy of needs, quality is something you consider once you have a health system in place.” (personal communication to author).

What do you think when you read this statement?

For too long, this has been a common attitude of health planners; that quality improvement is the final step in developing a health system. In settings with limited resources, and limited coverage, this often means quality improvement is a step that is never addressed.

Yet what these three seminal reports are arguing is that this sort of linear thinking – that a focus on improving quality comes after high coverage is established, is entrenching the inequities in quality that are evident the world over. We need to flip our thinking and instead, ensure that high quality care is the starting point – that you don’t offer any service without it being a quality service. This idea implies that the long term consequences of poor quality health services (lack of trust, poor health outcomes, demotivated health staff) outweigh any advantages of any sort of service being available. Put simply: it is better to have no clinic than a bad clinic. Do you agree with this?

As Kruk et al (2018) state in their overview of the Lancet Commission,

“Quality should not be the purview of the elite or an aspiration for some distant future; it should be the DNA of all health systems” (page 1).

Myth 2. Health workers are responsible for the quality of care

As health workers are the frontline of the health system, they are often held responsible for the quality of care, and blamed when quality is poor. What is not so well understood is that, as part of a complex system, health workers are also subject to systemic disadvantages of poor training, inadequate remuneration, insecure employment conditions, limited decision making power and unreliable supply chains. Many are working in unsafe conditions and are fearful of retribution. Even the best of us would struggle to provide high quality care in these circumstances. We need to stop blaming health workers and instead, look for ways to support them; in providing good information flows, clear guidance and referral pathways, supportive peers and clear protections from abuse, many of the ideas that have been presented in week five of this course.

Spend some time reading at least the executive summaries of the three reports listed above and then respond to the scenario presented in the next step.


Is it better to have substandard care if the alternative is no care at all? When would that not be the case?

Share your thoughts in the comments section below before moving on to the next step.


References
Kruk, ME, Gage, AD, Arsenault, C, Jordan, K, Leslie, HH, Roder-DeWan, S, Adeyi, O, Barker, P, Daelmans, B, Doubova, SV and English, M, 2018, ‘High-quality health systems in the Sustainable Development Goals era: time for a revolution’, The Lancet Global Health, vol. 6, no. 11, pp. e1196-e1252.
National Academies of Sciences, Engineering, and Medicine, 2018, Crossing the global quality chasm: Improving health care worldwide, National Academies Press.
World Health Organization, 2018. Delivering quality health services: a global imperative for universal health coverage.

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Health Systems Strengthening

The University of Melbourne

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