An “epidemic of poor quality”: New study finds that poor healthcare quality leads to millions of deaths globally

This is part 1 of a 4-part series on global healthcare quality.

The Sustainable Development Goals (SDGs), the global effort led by the United Nations to prioritize and standardize development goals in every country for the period 2015-2030, offer ambitious targets when it comes to the world’s health. SDG 3 is focused entirely on outcomes of health and well-being, such as reducing maternal mortality, ending diseases like AIDS and malaria, achieving universal health coverage (UHC), and ensuring universal access to reproductive health care. Other SDGs, such as Goal 2 which calls for zero hunger and Goal 6 that aims for universal and equitable access to safe drinking water as well as equal and adequate access to sanitation, have obvious implications for health. However, a recent Lancet Global Health Commission, chaired by Associate Professor of Global Health Dr. Margaret Kruk of the Harvard T.H. Chan School of Public Health, has come to some surprising conclusions about health systems in low- and middle-income countries (LMICs). Despite a push in humanitarian advocacy and research to focus on increasing healthcare access in LMIC, it is the quality of healthcare that is received by patients in these environments that may require more of our attention. The Commission estimates that as many as 5 million die each year because they are receiving poor-quality healthcare- more than a million more people than those who die due to no access to care at all (3.6 million). That means that annually, 8.6 million people living in LMIC are dying due to poor-quality healthcare systems. Poor quality care can be dangerous for patients, provides misleading data points about healthcare system improvements, and may support corrupt and fraudulent behavior by parties with power in the health sector. Is it possible to achieve the SDGs in this environment?

Health systems should be judged on “what they do for people- not how many doctors they train.”

Dr. Kruk describes quality healthcare systems as based on three factors: effective care, trust of the people, and a system that is able to adapt, both in cases of acute emergencies and with a longer-term vision. While many advancements in access can be supported by metrics, it is possible that we haven’t been measuring some of the factors that really matter. Dr. Kruk told NPR that health systems should be judged on “what they do for people- not how many doctors they train.” The Commission’s study, which was published by the Lancet earlier this month, found that the millions of deaths each year that can be attributed to poor health systems included many deaths due to factors the SDGs explicitly seek to reduce, such as neonatal conditions and traffic accidents. While one of the central tenets of SDG 3 is UHC, the Commission argues that the quality of care “is not yet sufficiently recognized in the global discourse on UHC” and that countries undertaking policies that bring them to UHC “must put better quality on par with expanded coverage” to improve health. The Commission identifies several individual initiatives in LMIC that are developing mechanisms for quality measurement and improvement. However, it is clear that improving the quality of care has not received the effort that expanding access to care has achieved, which will undoubtedly undermine efforts to achieve the SDGs, even if UHC is attained. While expanding access to care must remain a global priority, we cannot discount the need to ensure that care given is of high quality as well. Several studies from LMIC during the period of the Millennium Development Goals (2000-2015) suggested that in some instances, expanding access to care did not lead to more positive health outcomes because the quality of the care received was poor. However, we still do not even have highly rigorous and consistent tools with which to measure healthcare quality across global contexts in a way that would allow for standardized measures and generalizable conclusions.

Aside from the historical focus on access to care by humanitarian and governmental actors, there a few other reasons that quality of care has not received the appropriate amount of attention of donors and policymakers. Healthcare systems in LMIC are generally disintegrated, with pockets of government services, humanitarian agencies, and private facilities operating throughout the country. This complexity allows for the intrusion of many political and logistical barriers to providing high quality care consistently. In the public sector, corrupt bureaucrats may opt to control who is able to receive jobs at healthcare facilities rather than allow for a merit-based system where poorly qualified staff could be replaced by qualified employees, regardless of political factors. For-profit providers who have disparate financial interests may not properly follow treatment or diagnosis guidelines that are critical to quality care. However, entirely closing low quality facilities would leave some citizens with no access to care at all.

Dr. Tedros Adhanom Ghebreyesus, Director-General of the World Health Organization, published a response to the Lancet Commission, agreeing that “nothing less than a revolution” is needed to ensure that high quality care is delivered in every health system around the world, an essential component of SDG 3. He posits that poor data is one of the largest barriers to improving healthcare quality, arguing that we must “go beyond counting simply what services are delivered to measuring how they are delivered.” He calls for a “global learning laboratory for quality,” where local lessons based on the “messy realities of health services” are prioritized, but where these lessons are then disseminated and can be implemented, measured, and compared in contexts around the world. Policymakers and practitioners working in LMIC must consider these factors when designing and implementing health services or research studies. The Lancet Commission points to five distinct foundations where learning and improvement in the process of care leads to higher quality: the needs of the population, governance in the health and non-health sectors, platforms of care, the healthcare workforce, and the tools needed to provide quality care. To avoid the rising “epidemic of poor quality” that the Commission found and to put LMIC on a successful path to achieving the SDGs, we can no longer ignore the pressing need to address healthcare quality just as much as access.

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Attacks on Healthcare are Beyond the Limits of War

In the spring of 2016, the 15 members of the United Nations Security Council adopted Resolution 2286, which had been cosponsored by more than 80 Member States. The issue behind the Resolution, which brought such overwhelming support from a sometimes fractious body, was the increase in attacks on medical staff and facilities in conflict zones. The Resolution was broad, covering attacks or threats against patients, personnel, transportation mechanisms, and medical facilities. It emphasized that such attacks are not only detrimental to those immediately affected, but for the long-term consequences on already fragile health outcomes and systems. Of course, these protections are not new, codified by the Geneva Conventions in 1949 and the Additional Protocols from 1977 and 2005. However, an unprecedented number of attacks on health, many of which were occurring in the same few countries, led to this new push to pressure antagonists to cease their attacks and provide medical and humanitarian personnel with their due protections under humanitarian and human rights law. “Even wars have rules,” said then-UN Secretary-General Ban Ki-moon.

Despite the strong words from the UN and organizations like Médecins Sans Frontières (MSF) and the International Committee of the Red Cross (ICRC), little action was prompted by the newfound interest in health-related attacks. As a result, attacks have only increased since the year before the resolution was passed; while there were 256 attacks in 2015, there were 302 recorded attacks in 2016, 322 in 2017, and 149 attacks in the first quarter of 2018 alone. Not surprisingly, attacks in Syria propel the bulk of these numbers, with the Central African Republic, Pakistan, Libya, and Nigeria rounding out the top five countries featuring attacks in 2017. Of course, with the imperfect methods of collecting data in these fragile countries, as well as fears of witnesses or survivors to speak out about perpetrators, it is likely that more threats and attacks exist than can be captured by these data. In fact, as attacks continue and even proliferate, medical workers who risk their lives documenting attacks and their outcomes have questioned whether their work is worthwhile.

In these fragile countries, where access to health care is vital in maintaining a civilian population’s ability to stay, fifty-six health programs were closed due to increased insecurity to the facilities and staff in 2017. Ambulances are destroyed or hijacked. Health workers are arrested or kidnapped. Some countries have attacks that are more specific to the nature of their conflict- for example, the occupied Palestinian Territories, where movement restrictions are common, reported the highest numbers for obstruction to the provision of healthcare. In countries affected by polio, such as Nigeria, vaccination efforts are common targets of attacks. Countries where terrorist groups such as the Islamic State reside see reports of fighters disguised as medical personnel to attack or occupy hospitals. While the mechanism of attack differs, the outcomes are the same: terrorized civilians, diminished health infrastructure, demoralized health workers, prolonged conflict, and a frustrated but ultimately immobilized international community.

Despite these grim reports, there are still actions that can be taken by stakeholders of all levels that can hope to at least minimize these attacks. A two-pronged approach is required: one focusing on investigation and the other on penalties. First, a robust investigation and data collection mechanism must be developed and, most importantly, implemented where needed. MSF president Joanne Liu urged the UN Security Council to conduct robust, independent, and impartial investigations of such attacks, noting that previous calls for such initiatives have been disregarded. In almost all cases where investigations are conducted, they are led and settled by the perpetrator themselves. Independent, well-funded, and rigorous investigations, coupled with new methods of surveying and interviewing witnesses and survivors, should be supported by the UN and civil society in such nations. Additionally, it is apparent that such attacks persist due to the lack of consequences on offenders. Perpetrators on or allied with members of the UN Security Council would be tasked with condemning or punishing themselves and each other, unlikely in the current environment of norms in the international order. While a strengthening of the commitment of states to international humanitarian law is long overdue, in the meantime, action is not necessarily limited to the walls of the UN. Some humanitarian organizations, such as Oxfam, are taking a more direct approach, petitioning states to stop selling arms to countries that have used these weapons to attack civilian infrastructure like hospitals.

Addressing the World Humanitarian Summit in 2015, ICRC President Peter Maurer said “Wars without limits are wars without end. Limiting wars is an intrinsic test of our civilization, and probably of all civilized worlds.” Public health advocates must insist that the international community draws a line on protecting those serving the world’s most vulnerable in the most challenging environments imaginable. While war may be inevitable, the erasure of the human rights of those involved is entirely preventable through collective advocacy and action. Much of the needed action lies at the institutional level, but individuals concerned with these issues can follow social media campaigns like #NotATarget, started by the UN and the theme of World Humanitarian Day 2017, or support NGOs tasked with delivering healthcare in conflict environments, either on the local level or with international organizations such as the ICRC and MSF. Lastly, organizations like Safeguarding Health in Conflict, Insecurity Insight, and Physicians for Human Rights produce data and reports about these issues that can be used to direct advocacy or propel research efforts.