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

by Yara Asi, posted in APHA IH Section, Health Systems, MDGs / SDGs, Policy and Advocacy, Research

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.

Global News Round Up

by ihsection, posted in APHA IH Section, News

Politics & Policies

According to a recent NPR-ProPublica investigation, we’re the only developed nation in the world where the rate of women dying of pregnancy-related complications is still rising, with more women dying from these causes here at home than in any comparably developed country.

The federal law protecting women from violence was set to expire at the end of the month, yet neither the House nor the Senate made renewing it a priority.

A pathbreaker in global health and a former CDC director, Bill Foege has some startling advice for young people interested in global health: Don’t have a life plan.  “Life plans are an illusion” he writes in his new book, “The Fears of the Rich, The Needs of the Poor.” Rather, he urges them to have a life philosophy that will guide them in the career and life decisions they make.

The United States’ commitment to global development does not look good compared with that of other wealthy countries – and it’s likely to get worse.

India has experienced a dramatic transition from a huge burden of infectious diseases to noncommunicable diseases, which now cause more than 69 percent of deaths in the country— almost 6 million each year.

Officials in Berkeley, Calif., have voted to require vegan-only food be served at city events and meetings that take place on Mondays.

Programs, Grants & Awards

The third UN High-Level Meeting on Non-Communicable Diseases (NCDs) on Sept 27, 2018, will review national and global progress towards the prevention and control of NCDs, and provide an opportunity to renew, reinforce, and enhance commitments to reduce their burden. NCD countdown 2030 is an independent collaboration to inform policies that aim to reduce the worldwide burden of NCDs, and to ensure accountability towards this aim.

The second phase of the “Science Management” course, aimed at researchers and managers from Portuguese-speaking countries in Sub-Saharan Africa and organised by the Calouste Gulbenkian and the “la Caixa” Foundations in collaboration with ISGlobal and the Manhiça Health Research Center (CISM), took place at the CaixaForum in Barcelona from September 10-14.

In the early 2000’s, three of Catherine Nalungwe’s children died one after another before the age of three. The cause of the children’s death became a source of pain and confusion for the family. Catherine later tested positive for HIV in 2002, but she had no access to treatment through nearby health facilities at that time.  With improvements in access to HIV/AIDS services in Zambia, she started treatment in 2004.

The opening session of the 2nd World Sepsis Congress, ‘Sepsis – still a Global Health Threat’ is now available on demand on YouTube and as a Podcast on Apple Podcasts.

A new global health institute aimed at tackling emerging health challenges was launched on Friday (Sep 21) at the SingHealth Duke-NUS Scientific Congress 2018.

Research

A new analysis has found that many of the products critically needed to fight some of the world’s most prevalent infectious are not likely to be developed based on current candidates in the research & development (R&D) pipeline, and reveals significant gaps in funding for health innovation.

Diseases & Disasters

A week after the storm made landfall at Wrightsville Beach, Florence continues to menace Southeastern North Carolina — both on and offshore.  After pummeling the region with wind and rain, the remnants of the storm haven’t dissipated and now have a slim chance to reform for a second go at the N.C. coast.

Water appears to have receded in some areas of the Carolinas, but more flooding from Hurricane Florence could arrive through the weekend, officials say.

North Carolina Governor Roy Cooper has urged residents to remain in shelters as the floodwaters from Storm Florence continue to rise across the state.

Active infections kill 4000 people a day worldwide, more than AIDS does. But the notion that a quarter of the global population harbors silent tuberculosis is “a fundamental misunderstanding.”

A novel study indicates promising avenues in an innovative approach for developing a vaccine against Plasmodium vivacious, the most prevalent human malaria parasite outside sub-Saharan Africa.

A WHO report estimates that more than a quarter of people worldwide – 1.4 billion – are not doing enough physical exercise, a figure that he barely improved since 2001.

The Democratic Republic of the Congo’s (DRC’s) 10th Ebola outbreak continued over the weekend, as officials reported three new deaths.

Technology

The government of Burkina Faso granted scientists permission to release genetically engineered mosquitos anytime this year or next,  researchers announced Wednesday. It’s a key step in the broader efforts to use bioengineering to eliminate malaria in the region.

Environmental Health

The impacts of climate change, from air pollution to extreme weather events, to disruptions to food and water systems will pose the greatest threats to global health in this century, and health leaders say it’s time for the sector to be a more active participant in the global climate debate.

Duke Energy said Thursday that three inactive coal ash basins in Goldsboro, North Carolina, are underwater after Hurricane Florence.  The electric utility said it’s monitoring the site and only a small amount of ash has leaked. But the heavy flooding has environmentalists worried about other sites and other hazards.

Climate change is the greatest health threat, and opportunity, of the 21st century and the health sector must lead the way to call on local, national and global policymakers to act now to significantly reduce climate pollution and build climate resilience,” said Dr. Maria Neira, the director of the Department of Public Health, Environment, and Social Determinants of Health of the World Health Organization, and the Public Health Institute is ready to meet the challenge head-on.

It’s no secret that California and the U.S. government are singing very different tunes when it comes to climate change.   The Golden State gathered a chorus of sorts at the Global Climate Action Summit, an international meeting of leaders and stakeholders in San Francisco Sept. 12-14.

Equity & Disparities

At the end of her mission to the country, Ikponwosa Ero, UN Independent Expert on the enjoyment of human rights by persons with albanism, issued a statement on Monday welcoming Kenya’s “unique achievements”, saying that the country was set to become a regional leader on the issue.

The philanthropist Bill Gates has thanked the UAE for its support in working to eliminate deadly diseases and reduce world poverty.

The HDI, compiled by the UN Development Program (UNDP), is used as a composite measure of global development, tracking national successes in health, income and education in 189 countries. Norway, Switzerland, Australia, Ireland and Germany top the rankings in the latest report, while Niger, the Central African Republic, South Sudan, Chad and Burundi have the lowest scores.

High poverty rates, low education and lack of insurance are all social determinants that are expected to lead to high mortality rates and negative health outcomes. Despite a 62 percent minority population with these characteristics in California, the state’s health profile was significantly better than the nation’s as a whole.

An estimated 5 million deaths per year in low and middle income countries (LMICs) are the result of poor quality care, with a further 3.6 million the result of insufficient access to care, according to the first study to quantify the burden of poor quality health systems worldwide.

In January, the United Nations Committee on the Rights of Persons with Disabilities will welcome Australia’s first female representative to the committee — Rosemary Kayess.

Women, Maternal, Neonatal & Children’s Health

Ending preventable maternal mortality and correcting unacceptable levels of disparity are essential to achieving Sustainable Development Goal (SDG) 3, which focuses on ensuring healthy lives for all.

Sexual and reproductive health and rights NGOs struggling to deliver services in the wake of the United States “global gag rule” have spent a year caught between donors, after the Swedish aid agency, a key funder of sexual and reproductive health and rights, said it could not support organizations that go along with the rule. This report builds on WHO’s long-standing work on young people’s health and rights, including the Strategy for Women’s, Children’s and Adolescents’ Health (2016–2030), the Global Accelerated Action for the Health of Adolescents (AA-HA!) guidance, and contribution to the new UN Youth Strategy.  It was developed as part of the roadmap towards the development of a WHO strategy for engaging young people and young professionals.

More than 60 years after the drug thalidomide caused birth defects in thousands of children whose mothers took the drug while pregnant, scientists have solved a mystery that has lingered ever since the dangers of the drug first became apparent: how did the drug produce such severe fetal harm?

Public Health and Migration

by Eighmey Zeeck, posted in APHA IH Section, Conflict and Health, Disaster Response, Human Rights, Maternal and Child Health, Policy and Advocacy, Refugee and Migrant Health

Throughout history humans have been on the move, migrating due to famine, war, persecution, and to find a better life. In a new age of “zero tolerance” policies and deeming humans “illegal” it is important to understand that how global policy defines someone matters.

There are many terms for populations that are fleeing disasters and we have to understand globally accepted terms for populations on the move.

    1. Asylum-seekers are people “whose request for sanctuary has yet to be processed”. Every nation has their own asylum system to determine who qualifies for protection and how they request this protection. If the petition for protection does not meet the host country’s criteria the individual may be deported to their home country.
    2. Internally displaced people have not crossed any borders to seek safety but have moved to another location within their home country seeking safety or shelter.
    3. Refugees are people who are forced to flee their home country in order to seek safety from conflict or persecution. This group of people are protected under international law and are not to be sent back to the situation where their safety is at risk.
    4. Migrants are people who choose to move for work, education, family unification, etc. These people can go back to their home country and continue to be protected by their home country government.
    5. Undocumented migrant is a person who has entered a country without proper documentation, or their immigration status expired while in the host country and they have not renewed their status, or they were denied legal entry/immigration into their host country but have remained in the host country.
    6. Statelessness is someone who does not have a nationality. Individuals can be born stateless or become stateless due to nationality laws which discriminate against certain genders, ethnicities, or religions, or the emergence or dissolving of countries.

These international definitions are important, because it determines if, how, and when the international community can respond to crisis situations. A large caveat is that due to national sovereignty under international law a nation must request that international organizations like UNHCR provide international assistance to these particular communities. If nations do not request assistance or reject assistance then these populations are left without any sort of protection leaving them vulnerable and isolated, as seen with Syrian refugees in Lebanon. The international community has also seen the inhumane treatment of people seeking protection to include isolated detention on islands such as is currently used in Australia.

No matter how the international community defines these populations, they face poor health outcomes due to disease, economic stress, and trauma. Examples include:

  • An increase in child brides among Syrian and Rohingya refugee populations. This in turn affects infant and maternal mortality rates as well as the woman’s future economic prospects.
  • Malnutrition of both mother and child leading to increased death rates for children under five and stunting of growth in children that survive. This is currently being seen in Yemen.
  • Decreased breastfeeding rates due to maternal stress, disease, and separation from familial groups/support systems. An increase in breastmilk substitutes in refugee or displaced persons camps is also an issue that goes against international humanitarian policies.
  • During the Mediterranean refugee crisis the international community witnessed large groups of people risking their lives on overfilled boats that often sank, causing large scale loss of life. These refugees then faced xenophobia, closed borders, and detention upon their arrival.
  • Currently in the United States there has been an increase in detaining families and child migrants from Latin American countries for an indeterminate amount of time. Organizations like American Academy of Pediatrics have begun to discuss long term effects this type of detention has on child and adolescent health outcomes such as: high risk of psychological stress that may lead to anxiety and depression due to separation and forced detention, suicidal ideations, victims of assault by other children in these detention centers, or sexual assaults from other detainees or employees at these facilities.
  • In South America sovereign nations have closed their borders or placed restrictive regulations on Venezuelan migrants seeking food, shelter, and basic medical care for their families amid a massive economic crisis. Not only do these migrants face arduous journeys, but they also face poor health outcomes like malnutrition due to starvation, and the potential for contracting diseases due to poor sanitary conditions, and consuming non-potable water.
  • Migrants are a vulnerable population who can succumb to human trafficking and the modern slave trade along their migration routes. Migrants that are caught up in human trafficking often face abuse (mental and physical), serious injury from due to extreme work conditions, and exposure to communicable diseases from overcrowded and unsanitary living environments.   

Humans take immense risks to seek safety and new opportunities that they did not have in their home country. As an international public health community, whether we work in crisis situations or not, we must make it a priority to treat all humans in a humane manner. Health is a human right, and should be guaranteed for all.  

 

Moving in the right direction: India court legalizes gay sex in landmark ruling

by kimberly levitt, posted in APHA IH Section

There currently are no official demographics for the LGBT population in India. However according to unofficial estimates submitted by the government of India to the Supreme Court, there were about 2.5 million gay people in 2012. Lesbian, gay, bisexual, transgender (LGBT) people in India face many difficulties, both social and legal. Reports of killings, attacks, torture, and beatings are not uncommon. LGBT people in India also face discrimination in the community and rejection from their families. Continue reading “Moving in the right direction: India court legalizes gay sex in landmark ruling” →

United Nations High-Level Meeting on Tuberculosis: Importance of drug quality

by pragmaticsolidarity, posted in APHA IH Section, Health Systems, Infectious Disease, Pharmaceuticals

At the end of next month, the inaugural United Nations (UN) High-Level meeting on Tuberculosis (TB) will take place in New York to discuss the future of the bout against the devastating yet elusive disease. As TB remains the largest infectious disease torturer in today’s society taking the lives of 4500 humans each day, the theme of this occurrence is “United to end Tuberculosis: an urgent global response to a global panic”. This unparalleled step undertaken by governments throughout the world along with those allies engaged in ending Tuberculosis will address an assortment of issues at this meeting. Although the exact agenda has yet to be revealed, the resolution to host this single day meeting mentioned the following items could be discussed:

  • Adequate funding for novel diagnostic testing, medications, and vaccinations
  • Multi-Drug Resistant Tuberculosis (MDR-TB)
  • Responsibility for multisectoral collaboration within nation states, regions, and the globe
  • Universal health care coverage and ensuring tuberculosis coverage is included

Each of these items – ranging from the use of prophylactic low dose isoniazid therapy to equal distribution of the recently designed TB diagnostic test Xpert MTB/RIF – are crucial in accomplishing the END TB strategy laid out by the World Health Organization. However, after looking over these action items for the meeting, Tuberculosis drug quality seems to absent.

As health care professionals across the globe continue to treat TB on a patient specific basis, certain untreated cases occur that puzzle even those who have treated the disease for years. The reasoning behind treatment failure? Adherence to medication or drug resistance are often the first assumed thoughts those sharing their patient’s fate may have. Yet, the actual medicine with its various active and inactive ingredients is often not called into question.

Towards the end of last year, the World Health Organization released an alarming figure concerning drug quality in low to middle income countries. In the report released to the public, WHO stated that approximately 10% of medications are counterfeit in these areas of the world – which happen to be the areas where Tuberculosis and other infectious diseases take their largest toll. In addition, WHO added that this percentage is most likely only a small part of the number of humans truly affected by counterfeit medications. To provide clarification, WHO considers counterfeit medications to be unapproved by regulators, unable to meet quality standards, or purposefully misrepresented active or inactive ingredients in the medication. In addition to this report by WHO, the National Institutes of Health (NIH) published a report outlining in 2015 that 9% to 41% of anti-tuberculosis and other infectious disease medications failed to meet the standards sought in specific studies.

It is vital for the global health community to obtain an effective vaccine to prevent pulmonary tuberculosis, to have a rapid yet specific TB diagnostic test, to create a strategy for various sectors of a nation state to work together in ending TB, and novel agents to treat the most severe cases of MDR-TB. Individuals in rural Kampot, Cambodia, inmates in the Russian prison system, or those residing in the slums of Bangalore, India often can be restored to health through the means that have been available for the last half a century. The RIPE (rifampin, isoniazid, pyrazinamide, and ethambutol) regime has proven its success in treating non-resistant tuberculosis – so long as each of the medications are of appropriate quality. However, The Lancet released a report in January 2017 that found that 8.9% of Indian rifampicin products were of inadequate quality in a country that is burdened with the highest prevalence of tuberculosis across the globe. Moreover, WHO revealed that 28.3% of rifampicin containing medications found in the Russian Federation in 2011 failed to meet predetermined specifications for proper quality – a country known to have one of the highest MDR-TB burdens in the world. With the aforementioned statistics released by the WHO, The Lancet, and NIH, a renewed emphasis needs to be placed on ensuring the quality of each and every tuberculosis medication that reaches a human being. The possibility of one in ten (or more) TB medications being counterfeit will continue to lead to failed treatment regimes, inappropriate use of resources, and spread of MDR-TB even if innovative technology is developed.

In order to combat counterfeit medications on a global level, the World Health Organization developed a reporting system for the interconnectedness of the medication market. The Global Surveillance and Reporting System (GSRS), that all WHO members are eligible to contribute to, aims at collecting data on falsified medications, vaccines and other medical equipment to address real-time situations and prevent further harm. With this reporting arrangement in place, the WHO has reacted and thwarted mortality and morbidity associated with counterfeit medications – including the contaminated cough medication supply that led to 60 deaths in Pakistan and a number of individuals treated with an antidote in Paraguay in 2013. On top of the GSRS, WHO has implemented Good Manufacturing Practices (GMP) that each manufacturer should achieve in order to be certified by WHO; thus, providing a reliable source of medications that nation states can purchase from. Although these initiatives have brought about encouraging results along with halting global medication emergencies, there are still barriers that accompany these programs. The technical training, technology, and adequate staffing to properly identify and report through the GSRS is often difficult to obtain in the developing world while GMPs are often misapplied and have inadequate supervision. The root cause is the long-term development of countries’ public health systems – of which continuing problems with counterfeit medications remains deficiently addressed. A county’s public health care system is the vital organ to ensuring quality medications through these mechanisms that WHO has created and employed. An underutilized and under resourced public health care system leads a budding yet unregulated private market – unable to ensure proper treatment for those seeking it.

Since the United Nations declared this a high-level meeting, meaning all heads of member states are encouraged to participate in the highest level possible, this venue provides the ideal opportunity to recommit to guaranteeing TB drug quality. The sustained empowerment of the public health care systems for those countries tirelessly battling tuberculosis will be a step forward into truly ending this devastating disease. Each health care professional spanning the globe has a responsibility to accompany these governments, colleagues, and fellow humans by investing their time, resources, and talents to develop procedures and systems to ensure effective drug quality.