Are we ready for a quality revolution?

Abstract

What is the point of a health system? To provide services aimed at improving or maintaining the health of a given population? Seems obvious enough. But is it? Should these services by default reflect the current population's needs and can they adapt to further changes or shocks? Who is the population anyway? Does it inevitably include older, disabled, informally housed, migrant, low-caste, and illiterate people? How (and by whom) should the effectiveness of these services be measured in terms of whether they actually improve health? Is there a minimum standard for these services? Can individuals expect “good customer service” or is that a bonus? These questions were at the forefront of discussion at the second meeting of the 30 academics, policy makers, and health systems experts working on The Lancet Global Health's Commission on High-Quality Health Systems in the SDG Era in Johannesburg in December. Co-hosted by the South African Department of Health, the meeting was a chance to bring in stakeholders from around the world to discuss health systems challenges and opportunities as well as to refine an initial draft of the Commission report, the final version of which will be published in early September. Taking place simultaneously with the Commission meeting was the Universal Health Coverage (UHC) Forum in Tokyo, at which participants declared their commitment to “achieving health for all people, whoever they are, wherever they live, by 2030”. The focus in Tokyo was naturally on the dual elements of service coverage and affordability, drawing on the monitoring work (on coverage, catastrophic health spending, and impoverishing health spending) published in the journal this month. Yet the element of quality was not explicitly mentioned. How is a health system to achieve health for all people if the services provided, even if accessible and affordable, are not fit for purpose or are delivered in such an off-putting way that patients actively avoid attending? The missing dimension of quality, and the barriers thereto, were discussed in Johannesburg by individuals involved in national commissions—parallel work to the global Commission led by stakeholders from nine low-income and middle-income countries. Representatives from Ethiopia and Mexico agreed that a degree of “coverage mania” still prevailed in health systems thinking, but that the tide was beginning to turn in terms of working out what returns were being made on investments, shedding light on where quality stands. Education and in-service training of health-care workers was also a recurring theme. In Senegal there was a perception that quality is seen as a national government issue, with providers themselves receiving little sense of accountability from their training. In Argentina, a pervasive lack of urgency was thought to perpetuate the country's poor regulation, auditing, and incentive structure. In Mexico, medical curricula were felt to be stuck in the 1970s. “We don't teach community practice”, said the Mexican representative. “We teach hospital practice that health-care workers use in the community”. We should empower these communities to hold health-care providers and their services to account, added the Ethiopian delegate. Encouragingly, research on service-level quality has seen a real surge in recent years. Among the many studies we have published in the past year is a carefully designed validation study out this month. In this paper, Charles Opondo and colleagues demonstrate that a scoring system developed to assess the quality of admission care for children attending hospitals in Kenya correlates with mortality and thus could be used as a quality indicator in similar settings. However, as Carina King and Eric McCollum write in their associated Comment, if such measures are to have any effect, there must be a concomitant systems-level improvement in data collection and remediation processes. And this is the key to the Commission's approach. We are not talking about tinkering at the edges of individual services here. We are talking about a whole-health-system quality revolution. A quick fix it is not, and a harmonised approach from international agencies, governments, donors, health-systems experts, educators, practitioners, and—yes—patients will be needed. The Commission will not have all the answers, but it will provide evidence of what can work, a framework on which to base structural change, and mechanisms for ensuring equity; in other words, fertile ground for what will hopefully bring about a revolution. Are you ready?