Aceso Global CEO Maureen Lewis and André Medici, World Bank, co-authored a recent article, “Health Policy and Finance Challenges in Latin America and the Caribbean: An Economic Perspective,” published in the Oxford Research Encyclopedia of Economics and Finance. The article outlines trends and challenges in health financing across the region, and provides an overview of the health economics literature and research to date. It then offers directions for reform that move the conversation beyond issues of funding and equity to new ideas around efficiency, quality, and payment and delivery models.
Aceso Global has been working with the Inter-American Development Bank (IDB) on the Salud Mesoamérica Initiative (SMI). SMI is a pioneering public-private partnership between the Bill & Melinda Gates Foundation, the Carlos Slim Foundation, the Government of Spain, the IDB, the countries of Central America, and the state of Chiapas, Mexico. It is one of the most successful and thoughtfully designed results-based aid (RBA) models and we are excited to join and contribute to their effort, while also learning from their work.
SMI aims to reduce maternal and child health inequalities through an RBA model that is in alignment with the priorities established by the governments of the region. The SMI model is based on four basic concepts:
1. Countries have to work within the poorest 20% of their populations, selected based on Poverty Incidence Data;
2. SMI funds can only finance evidence-based, cost-effective and promissory interventions for maternal and child health;
3. All projects are co-financed by SMI and countries (50% average cost-sharing) and must be executed using the SMI results based aid model; and
4. All results are externally verified by an independent third party through both household and health facility surveys. If countries meet 80% of their goals, they receive 50% of their original investment to use freely within the health sector.
Specifically, Aceso Global is tasked with designing an innovative learning program for middle managers to support Quality Improvement (QI) efforts in the eight SMI countries. The program breaks from more traditional training styles that use didactic lecturing and aims to reach behavior change and competency development with interactive and experiential learning techniques. The curriculum focuses not only on the “hard skills” of measuring and improving quality of care, but also on “soft skills” like leadership, team building, communication, coaching and continuous learning that are essential ingredients for any change process. It is firmly grounded in the local realities of the SMI countries and uses case studies, experiential learning and peer-to-peer exchanges to convey contents over the course of the ten-month training.
The competency development program equips middle managers with the necessary skills to coach frontline primary healthcare providers on QI. It also contributes to the larger transformation agenda that SMI and country leaders are pursuing to fundamentally shift the way that care is delivered, to put quality at the center of organizational culture, and to move towards a true learning system that accepts failure and is relentless in the pursuit of innovation and improved performance.
Aceso Global is also developing a unique evaluation strategy for the learning program that examines changes in leadership, organizational culture and skill development, deploying customized evaluation instruments that will gauge the extent to which hard and soft skills have been mastered. The purpose is to yield standardized, comparable data on leadership behaviors and organizational contexts that influence the successful implementation of QI initiatives and ultimately lead to improvements in maternal and child health.
This project falls under Aceso Global’s quality portfolio, which addresses quality of care across the health system by: (1) collaborating with country leaders to put quality of care culture, measurement, improvement and innovation at the center of national healthcare agendas; (2) working closely with providers and stakeholders on the frontlines to shift the culture around quality of care and improve the use of quality data; and (3) integrating quality data with national health information systems, including supporting or developing quality dashboards. Our portfolio approach echoes some of the key takeaways from last year’s wave of reporting on global quality of care, including the Lancet Commission’s High-quality health systems in the Sustainable Development Goals era: time for a revolution, the OECD, World Bank and WHO report, Delivering Quality Health Services: A Global Imperative for Universal Health Coverage, and finally the Institute of Medicine’s Crossing the Global Quality Chasm, for which Aceso Global CEO and Founding Director Maureen Lewis was an expert reviewer.
For more information, please contact: Sarah Mintz, firstname.lastname@example.org
 Salud Mesoamerica Initiative Program Description, Progress and Results, May 2016
This presentation explores the challenges facing the Brazilian healthcare sector in terms of quality, efficiency and outcomes. It draws from the US experience with value-based care to highlight possible directions for innovation in Brazil, with a focus on integrated care, alternative payment mechanisms and new roles for information technology. Aceso Global CEO Maureen Lewis delivered this presentation at the seminary Dasa/Valor Econômico in São Paulo, Brazil, in November 2018.
The recent WHO/OECD/World Bank report on Delivering Quality Health Services fills a much needed gap in defining and explaining the importance of quality of care in the attainment of Universal Health Care (UHC). Essentially, the message is: without quality, what is the point of health care investments? Along with access, quality is the sine qua non of health services.
The report’s careful explanation of quality of care and requirements for achieving progress in this area lay out imperatives for countries choosing to take on the challenge of raising quality of care in health care delivery. And while the list of actions is long, it reflects both gaps in data and evidence, and the hard road ahead in closing the gap. Unfortunately, the summary of available evidence and data is thin and limited largely to South Asia, specifically India, and a handful of African countries, complemented by OECD examples on the quality front. Finally, while not mentioned in the report, quality improvement initiatives have often been partial, focusing on one part of the system, such as maternal and child health, while ignoring the need for a culture of quality, a set of core indicators and, critically, some means of ensuring sustainability of initiatives.
As articulated by the OECD (Francesca Colombo remarks), while quality is complicated, some initiatives can be simple and straightforward. Building blocks, such as checklists for surgery or tracking selected adverse events in hospitals, offer a path toward quality improvement that are straightforwardly simple and worth adopting. Others, such as a quality culture and robust data systems, entail greater investments and longer time frames. But all of the requirements and suggestions entail a shift in the way that health care is delivered, and a greater reliance on data. More importantly, and absent in the report, are the roles of incentives and accountability in health care.
The importance of incentives, both financial and non-financial, cannot be underestimated in driving toward a quality culture. Similarly, without accountability, change is unlikely and, where it occurs, unsustainable. Multiple experiences suggest as much. The seminal Institute of Medicine report, To Err is Human, outlined the abysmal state of US health care quality, despite virtually universal hospital accreditation, highly trained staff and significant resource investments. Quality isn’t automatic. In response to the report findings, the weight of public payers, mainly Medicare, forced change through setting clear incentives, and ensuring accountability, e.g., defining performance, rewarding good results and following through on consequences for not meeting data, process improvements and outcome targets. Much progress has been achieved as a result.
Similarly, Atul Gwande’s project on a surgical checklist for “essential birth practices” in India implemented a 28-item checklist accompanied by hands-on collaboration with providers over an eight-month period to test the benefits of using a simple tool for reducing medical errors associated with childbirth. Despite valiant efforts, the checklist system showed no impact. However, there was no incentive for providers to consistently use the method and, more importantly, they were not being held accountable for outcomes.
The quality agenda remains imposing, but as the WHO/OECD/World Bank report makes clear, embracing quality at the national level offers the only serious route to achieving UHC. And while the report reflects a tour de force on a policy and technical level, implementation issues raise the stakes further. Many of the report’s recommendations offer a menu of options, and countries will need to determine what to prioritize. However, the importance of structuring quality initiatives to ensure adoption and sustainability on a national scale calls for specific actions to drive shifts towards quality, specifically:
- defining, collecting and using data to capture progress in improving quality in service delivery at all levels of the system;
- establishing incentives to encourage collection of (correct) data, analysis of performance and use of the data at all levels to monitor performance and measure quality improvements;
- financial and non-financial incentives aimed at providers to encourage adoption and mainstreaming measures to raise quality in service delivery; and
- harnessing the data to allow supervisors across the system to hold providers and staff accountable for the quality of services.
While simple to describe, these shifts translate into dramatic changes in how health care is delivered, financed and monitored. That part of the quality agenda remains far from simple and straightforward, but captures the essence of quality improvement in context of low- and middle-income countries.