Discussion on quality of care and the Universal Health Coverage agenda

ALISON MORGAN: Well, hi, everybody. In this discussion, we want to look at the interactions between universal health coverage and quality of care. And so Kris and I are going to draw on our own experiences, and draw on the literature, and discuss this important topic.

As we know, and as you’ve heard right through the course to date, there’s a real focus on the universal health coverage as a key priority for strengthening health systems in low and middle income countries. And so it’s worth thinking about, well, where does quality of care fit into the universal health coverage agenda? And Kris reminded me, by showing me the definition of universal health coverage, how key it is. And I just want to highlight that definition again for you. “Ensuring that all people have access to needed health services of sufficient quality to be effective while ensuring that the use of these services does not expose the user to financial hardship.” But I’d be interested to hear what you think.

Kris, do you think that quality has been lost in the universal health coverage push that is so current at the moment?

KRISHNA HORT: I wouldn’t say necessarily lost. But I think it’s possibly being neglected to some extent. I think the focus has been on the three dimensions of the quality cube that we’ve previously talked about. The extent of the service package in terms of breadth, the extent of financial protection in terms of height, and the extent of coverage of the population in terms of length. So I think much of the policy thinking and strategising has been around how to extend those three dimensions. And that may neglect quality of care. So Alison, what do you see as the way in which universal health coverage could impact on quality of care?

ALISON MORGAN: It’s almost like we need a fourth dimension that the graphic artist who did the universal health coverage cube did quality a major disservice by not having some other axis that could be drawn on. I think there’s a number of ways that the universal health coverage agenda might have an adverse impact on quality. And conversely, maybe we can look at where quality might improve the UHC agenda as well. There’s a very nice paper by Mate and colleagues that explores this.

And they highlight the fact that as you impro– increase the sort of service package and coverage, you might have less human resources– health workers are asked to do a lot more, or– and that might impact on a comprehensive and quality of the care provided. In the same way that you might get, you know, patients being quite dissatisfied. You know, they’ve walked to a health facility, they’ve then been asked to wait for four hours for a antenatal care that is two minutes long. And then they’ve got to get home again. And they sort of– patients will sort of know very quickly that, well, perhaps it’s not worth coming for that visit.

And so your– the coverage will be a lot lower, simply because the quality has been impaired by trying to increase it. Mate makes the point, too, that if you focus on quality– and I think it’s where people put their energies. If they’re putting their energies on extending services or in increasing the package of care within those services without looking at quality, we’ll see those detrimental effects. If we focus on quality, then that provision of care, the experience of care, will encourage greater utilisation. So it’s also I think where people put their focus.

KRISHNA HORT: Yes, I guess we could look at those things as around the element or the dimension of– we referred to previously as too little or too late care. But there’s another aspect of care that universal health coverage could also impact on. And that’s the too much, too soon element. So it’s possible that, particularly through universal health coverage, if patients have a readier access to referral level or secondary care level, they may receive treatment at that level with inappropriate or unnecessary investigations or treatment. And this can to expose them to adverse events, of course.

But it also impacts on the cost of the services being provided when patients receive secondary level care for conditions that could be managed at the primary care level. So Alison, where do we go from there?

ALISON MORGAN: Yeah, I think one of the priorities is to better measure or have better measures of quality of care. I think we’ve focused a lot on coverage and what actually happens whether certain elements are done. We don’t look so carefully, I don’t think, at the experience of care. We don’t look very well at adverse outcomes or patient safety. That those measures have been muted, I think, particularly in some low and middle income countries.

And I think that’s where we’ll be able to not just focus on the too little, too late, but to look at where there is too much too soon, and the risk that the universal health coverage might look like it’s providing a lot more, but it might actually be, you know, not improving the quality of the outcomes.

KRISHNA HORT: Well I guess one of the things that comes out of this discussion is that without attention to quality of care, we might well end up with our UHC cube looking like the Swiss cheese cube that we’ve discussed before. But conversely, we can also see that universal health coverage can, in fact, provide us with some mechanisms and strategies to assist in improving the quality of care. And we can identify three key mechanisms. The first one is that universal health coverage schemes can require measurement and reporting on quality of care and patient safety indicators, things like in-hospital mortality, post-operative complications, hospital-acquired infections.

Secondly, universal health coverage programs can provide incentives by providing higher levels of payment to facilities or providers that achieve better quality of care indicators. For example, higher reimbursement rates to hospitals that are– achieve accreditation standards. And thirdly, universal health coverage can also introduce some incentives to adhere to patient care guidelines by ensuring that payments are made only for procedures or investigations that are given according to guidelines. So this can act as an incentive to providers to ensure that they adhere to those guidelines. So overall, we can see that universal health coverage, while it introduces some risks to quality of care, is also a– introduces mechanisms and strategies that we can use to improve the quality of care.