Academic journal article Bulletin of the World Health Organization

Quality of Care: Measuring a Neglected Driver of Improved health/Qualite Des Soins: Mesure D'un Facteur Neglige D'amelioration De la sante/Calidad De la Asistencia: Medicion De Un Impulsor Ignorado De la Mejora De la Salud

Academic journal article Bulletin of the World Health Organization

Quality of Care: Measuring a Neglected Driver of Improved health/Qualite Des Soins: Mesure D'un Facteur Neglige D'amelioration De la sante/Calidad De la Asistencia: Medicion De Un Impulsor Ignorado De la Mejora De la Salud

Article excerpt

Introduction

High quality of health care is an important component of efforts to reach sustainable development goal (SDG) 3: to ensure healthy lives and promote well-being for all at all ages. (1) The United States National Academy of Medicine defines quality as the extent to which health-care services provided to individuals and patient populations improve desired health outcomes. (2) The key tasks for quality measurement are to assess the performance of services and to quantify the gap between reality and expectations in reference to certain standards and guidelines. However, a lack of consensus exists on the role of quality of care in achieving SDG 3, (3) which is reflected in the absence of measures of quality that are appropriate to lower-income settings. This paper addresses the rationale for elevating the issue of quality in the global health discourse. We outline the current status of quality measurement in low-and middle-income countries and the gaps in measuring quality of care. We conclude with policy recommendations.

Why now?

For the following reasons we propose that now is the time to focus on quality of care in low-resource settings and, specifically, to tackle the challenges of measurement.

Responding to complexity

The millennium development goals (MDGs) on health focused on combating maternal and child mortality and a relatively small number of diseases. (4) These efforts boosted disease-specific (vertical) funding for health services and in some cases were accompanied by strong accountability mechanisms including measurement of outcomes and service quality. (5) SDG 3 and its targets encompass more conditions, and, by including noncommunicable diseases, are also more complex to attain than the MDGs. As we move into the SDG era, the funding and delivery streams are being interconnected and integrated into broader health systems to promote more rational and patient-centred health care across a wide range of health needs. This is observed at both global (6) and country levels. The logistics of integration, including ensuring technical efficiency, will be challenging, but may also provide an opportunity for adoption of best practices in quality management in areas ranging from stand-alone vertical programmes to the broader health system. (7)

Acting on evidence

The impact of health-service quality on health outcomes has been well documented in high-income countries, (8-11) and poor quality is increasingly being linked to failure to attain expected health-care improvements in low- and middle-income countries. Studies from India, Malawi and Rwanda have shown that greater access to institutional deliveries and antenatal care was not accompanied by reductions in maternal and newborn mortality; a finding attributed to poor quality of care. (12-15) Higher than predicted maternal mortality has been found in hospitals in high-mortality lower-income countries, despite good availability of essential medicines, suggesting clinical management gaps or treatment delays for women who develop obstetric complications. (12) In the area of infectious disease control, nearly one third of all outpatients (n = 2019) in publicly-funded health facilities in Malawi received incorrect malaria treatment. (16) Providers in India frequently gave inaccurate care to tuberculosis patients; (17) in one study only 11 of 201 private practitioners followed diagnostic standards for tuberculosis management. (18) Worldwide, low-quality facilities have been implicated in higher mortality after surgery. (19) The effects of low quality of health services will be magnified in efforts to achieve the more complex SDG health goals. (3)

Ensuring policy success

Quality of care is also central to the success of several health policy instruments recently introduced in low- and middle-income countries, such as universal health coverage and results-based financing. The universal health coverage target of SDG 3 (target 3. …

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