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.