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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The G20 Makes Early Childhood Development a Priority

World wide roughly 200 million children under the age of five, in low and middle income countries, will fail to meet basic developmental milestones. Such deficits affect health across the lifespan, the ability to contribute to the national economy, and the ability to stop the cycle of poverty. With this knowledge in mind the United Nations made a point of linking their sustainable development goals to children’s issues, specifically early childhood development (ECD). Recently the G20, with Argentina as the new chair, have placed an emphasis on ECD in the international community by adding it to their own sustainability goals. The G20 has recognized that ECD must be incorporated into all programs, not just within child centric programs and that an emphasis must be placed on children under five years of age.

Programmatic areas have remained siloed focusing on nutrition and ensuring school aged children receive an education. While these initiatives play a role in ECD they only focus on topical areas and do not formally integrate ECD, newborn to age five, into programmatic work. The G20 has created a case for cross collaboration within programmatic and policy level work, even laying out funding streams for such work. This puts the G20 in line with World Health Organization guidelines, including guidelines around integration of ECD in emergency situations. When you are already servicing families and their children, especially in low income programmatic settings, it is easy to add in basic ECD education. For example, when providing breastfeeding support to mothers this is a wonderful opportunity to briefly discuss the need to talk and sing to the child in order to develop language acquisition. Another example is to provide pamphlets, that match the health literacy level of the community, around positive parenting and age appropriate milestones at an immunization drive.  

ECD doesn’t just apply to children – it applies directly to the child’s environment: families, caregivers, and national leadership. ECD focuses a lot on positive parenting to encourage positive brain development and language acquisition. The World Health Organization just released a guideline that discusses nurturing care within ECD, highlighting strategies and policies focusing on the environment that impacts ECD. A really interesting piece that the G20 highlights is the need for better trained child care providers. The G20 ties it back to economics – if a family, mothers in particular, feels comfortable leaving their child in the care of someone else they are able to contribute to their local and national economy in a greater way. There is also the money saving aspect for countries who invest in programs that promote ECD in children under the age of five. As discussed in the literature, children’s brains are rapidly developing arguably from in the womb through the first 1,000 days of life, and programs that focus on this age group provide a larger cost saving than programs that focus on children over five. This is because potential developmental delays are prevented, thus not as much money is needed to get a child back on their developmental track. Also, at such a young age with the focus predominantly being on environmental factors the cost is solely around training and educating front line staff, not actual school aged interventions.

Again – it is great news to have a group like G20 make ECD a priority, especially for children under five. It brings the topic back to the front of the global health stage and proves that it can be easily incorporated into programmatic work.

Achieving health equity in global health through workforce diversity

This International Women’s Day we honor the achievements of women leaders working to advance the health and well-being of people all over the world. Their path to success was certainly not easy. It was fraught with numerous challenges; challenges that are not only experienced by those of us working in global health but by women across all industries.

We are considered either too soft and feminine or too bossy and pushy to be seen as competent leaders. Our work culture lacks family-oriented, work-life balance policies which enable us to contribute to our field in significant ways. We lack female mentors to encourage us to grow and push us to overcome any obstacles we encounter in our career. We work for organizations where the people who make the big decisions on what policies and programmatic areas to focus on are men. The struggles we face trying to advance in our careers are reflected in the lack of gender equality in the global health workforce. While women make up 70% of the global health workforce, only 25% of leadership positions in global health are held by women.

We have known for a long time that when women are given equal opportunities for leadership at all levels of decision-making in economic, political, and public life, everyone in society does better. Female leaders in health “promote access to contraceptives, empowerment programs for girls, women’s rights to family planning and maternity care, safe abortions, and protecting environmental assaults on children’s health.” In addition, women leaders at all levels of governance have shown to be the primary driver toward financing public goods such as health, education, hospitals, clean water, and sanitation. Women’s participation and leadership in economic, political, and public life is so critical to advancing societies that it is even written into one of the sustainable development goals. When women have a voice at all levels of decision-making, we are closer to eliminating the inequities that lead to disparities in health.

More global health organizations are recognizing the need for women leaders and organizations such as Women in Global Health are working toward achieving gender equality in global health leadership. Last year the World Health Organization’s newest Director-General, Dr Tedros Adhanom, appointed eight women to senior leadership, effectively outnumbering the men. In doing so, he took one big leap toward achieving gender equity at the WHO – a goal that was first set in 1997 and that took two decades to realize.

Gender equality is not the only type of diversity we need to strive toward in our global health leadership however. Diversity in global health leadership must also focus on inclusion of people from different ages, race and ethnicity, sexual orientation, social class, geography, religion, and other characteristics of personal identity.  As a woman and a first-generation Filipino-American working in global health in the United States, I often find myself at global health and public health conferences and meetings wondering why there are very few leaders that encompass the diversity that I represent on stage (and occasionally even in the audience). The people who make the decisions with the biggest impact in global health must reflect the diversity of the people we serve.  

Learning from, understanding, and seeing the world through another person’s point of view is at the heart of working in global health and a driving reason for why I chose to work in this field. In order to truly reflect the diversity of this field though, the definition of diversity itself needs to go far and beyond the characteristics of one’s personal identity. To fully be inclusive, we must also be open to learning from, understanding, and seeing the world through the perspectives of individuals in the global health workforce with diverse backgrounds, life experiences, and competencies. Our field could benefit from the ideas of diverse individuals in solving some of the world’s most pressing global health problems. These ideas cannot always come out of our own echo chambers. 

Achieving diversity in the global health workforce is everyone’s job. It requires each one of us to recognize and overcome the personal biases (whether they are subconscious or not) which prevent us from hiring and working with more diverse talent. For those of us responsible for making decisions, we must work to create policies at all levels which not only promote but require inclusion. It’s only then that we can achieve true diversity in our workforce and our leadership. It’s only then that we can progress further in achieving health equity.

Stay tuned for part two of my series on Achieving health equity in global health through workforce diversity in which I will discuss different ideas for how we can achieve diversity in the global health workforce.

Australia, you’ve done us proud…

Between September 12th and November 7th this year, Australia distributed the Australian Marriage Law Postal Survey, a national survey that gauged support for legalizing same-sex marriage. Unlike electoral voting, which is compulsory in Australia, responding to the survey was voluntary. The survey was returned with 61.6% “Yes” responses and 38.4% “No” responses. Even though the measure was expected to be approved, the size of the win and the unusually large participation of 12.7 million Australians out of the 16 million eligible voters added political legitimacy to it. It’s funny to think three letter strung together in the right order can mean so much to millions of proud Aussies. Several hours after the results of the survey were released, theMarriage Amendment Bill 2017 was introduced into the Australian Senate. The amendment  is a Bill for an Act to legalize same-sex marriage in Australia, by amending the definition to allow marriage between two people. This is not only a time to celebrate a historic moment for the country, but to understand the vast positive impact for the LGBT community especially when it comes to health. Continue reading “Australia, you’ve done us proud…”

The Year of the Girl

The United Nations declared October 11th the International Day of the Girl Child.  Everywhere I looked for this post’s inspiration, I saw story after story of the daily violence perpetrated against girls worldwide. I had to ask myself, why just a day?  Aren’t girls – roughly half of the world’s population – deserving of much more consideration? I say that we declare 2017 the YEAR of the Girl and devote our efforts to address the following issues.

Female Genital Mutilation

Female genital mutilation, or FGM, is a global concern. Some 200 million girls and women in 30 countries have undergone FGM, usually between infancy and 15 years of age. In many countries, FGM is a deeply entrenched cultural practice that has seen little decrease in the decades since foreign aid workers have been campaigning for is abolition. The risks might be high – infection, infertility, and complications of childbirth – but the perceived social benefits outweigh the physical costs. Bettina Shell-Duncan, an anthropology professor working as part of a five-year research project by the Population Council, has witnessed this conflict firsthand among the Rendille people of Northern Kenya:

One of the things that is important to understand about it is that people see the costs and benefits. It is certainly a cost, but the benefits are immediate. For a Rendille woman, are you going to be able to give legitimate birth? Or elsewhere, are you going to be a proper Muslim? Are you going to have your sexual desire attenuated and be a virgin until marriage? These are huge considerations, and so when you tip the balance and think about that, the benefits outweigh the costs.

Despite cultural ties, FGM is decreasing in some African countries as evidenced by rates from the prior generation.  However, with prevalence as high as 81% (Egypt), 79% (Sierra Leone), and 62% (Ethiopia), there is still much work to be done.

prevalence

For example, with prevalence at 60-70%, FGM in Iraqi Kurdistan is a “hidden” epidemic.  Prevalence of this practice elsewhere in Iraq is 8%.  Outlawed in 2011 by the Kurdistan Regional Government under the Family Violence Law, FGM has continued largely unabated due to poor implementation and push-back from religious leaders.  You can read the Human Rights Watch harrowing report about FGM in Iraqi Kurdistan here.

Rape and Child Marriage

Last Friday, the BBC reported on a bill under consideration by the Turkish Parliament that would clear a man of statutory rape if he married his victim.  This bill is evidence of increasing violence against Turkish women.  Between 2003 and 2010, the murder rate of women increased by 1,400%.  Of course, the bill isn’t couched in terms of legalizing rape, but as a loophole for those offenders who know not the errors of their ways:

The aim, says the government, is not to excuse rape but to rehabilitate those who may not have realised their sexual relations were unlawful – or to prevent girls who have sex under the age of 18 from feeling ostracised by their community.

If passed, the bill would release 3,000 men from prison as well as legitimize child rape and marriage. Per Girls Not Brides, Turkey has one of the highest child marriage rates in Europe with 15% of girls married before the age of 18. Globally 34% of women are married before the age of 18 and every day 39,000 girls join their ranks. According to a study recently published in the International Journal of Epidemiology, child marriage comes with health and social consequences. Along with unintended pregnancies, infant and maternal mortality, and HIV, girls who are married suffer from social isolation, power imbalance, and experience higher lifetime rates of physical and sexual intimate partner violence.

Coming-of-age “Cleansing” Rituals

Practiced in parts of Africa, girls as young as 12 are forced to have sex as part of a sexual cleansing ritual.  The men, known as “hyenas,” are paid by parents to usher girls through the transition between girlhood and womanhood.  Girls are coerced into this practice through familial and societal pressure.  It is believed that great tragedy will befall the family and community should she not comply.  The use of a condom is prohibited.

A BBC radio broadcast found that communities believe the spread of HIV to be a minimal risk since they can pick men they know are not infected. One Malawian hyena, Eric Aniva, has been charged with exposing hundreds of girls and women to HIV. Aniva knew of his HIV status but did not disclose to his customers.

Forty percent of the global burden of HIV infections are in Southern Africa. Thirty percent of new infections in this area are in girls and women aged 15-24. Young women contract HIV at rates four times greater than male peers and 5-7 years earlier, linked to sexual debut or sexual cleansing rituals.

Let’s face it: Girls around the globe are being short-changed. Though progress has been made, there is still much work to be done. The Sustainable Development Goals have promised to “end all forms of discrimination against all women and girls everywhere” by 2030. Others attest that it will take at least another century for women to reach wage equity in the United States.  However it happens, rest assured it will take more than a day.