Surveys framing statements in a positive way and inviting patients to agree or disagree will lead to positive responses much more frequently than surveys with more neutral statements.
A10 More discussion on the utility of patient satisfaction as a measure of health system quality can be found in Section 4.
Other research has found that increased technical quality of health services, combined with responsive service delivery, fair treatment, better health outcomes, and financial risk protection, was associated with an increase in the probability of having trust in government. Similarly, a study in Haiti found that higher quality primary care facilities were associated with higher utilisation.
Perceived poor quality of care can also lead people to bypass certain facilities. Households might choose to travel further distances or pay more out of pocket to seek better quality care. Some people might also choose to bypass primary care facilities and seek care at hospitals or higher-level facilities for conditions that could be treated in primary care. Primary care is the cornerstone of a high-quality health system, serving as the main entry point for most concerns and playing a crucial role in coordinating care and ensuring continuity across health system platforms.
Nonetheless, primary care facilities often fail to fulfil their role. A crucial area for future research will be to estimate the demand response to higher quality of care, focusing on the role of information and perception of quality in influencing utilisation patterns. Proportion of households that report quality concerns as reason for bypassing public facilities in districts in India. A quality concern was defined as mentioning any of the following as a reason for bypassing government facilities: inadequate infrastructure, doctor not available, absent health workers, poor quality, drugs not available, inconvenient hours, long wait time, or distrust.
In darker coloured districts, a higher proportion of households cited quality concerns. Improving health system quality can be justified on ethical, epidemiological, and economic grounds. Little evidence exists on the link between levels of quality of care and economic outcomes. Here, we describe three types of economic consequences that could be averted by high-quality health systems: macroeconomic effects of premature mortality, health system waste, and catastrophic or impoverishing health expenditures faced by households.
A analysis 95 estimated the macroeconomic effect of mortality that could be prevented with access to high-quality care in LMICs.
The analysis was done by use of two distinct approaches to quantify economic losses from preventable mortality. The first approach projected gross domestic product GDP losses over 15 years due to the consequences of mortality on labour force and physical capital accumulation. This analysis shows that poor-quality care can result in a great macroeconomic burden that is inequitably distributed across countries.
Beyond the economic losses from premature mortality, poor-quality care can also lead to important waste and inefficiency. There have been few measurements of health-care waste attributable to poor-quality care in LMICs. However, evidence from high-income settings suggests that averting these costs could help LMICs make better use of scarce resources. High-quality primary care can prevent the need for hospital admissions for several health conditions called ambulatory care-sensitive.
Finally, people living in countries with poorly functioning health systems, without appropriate financing mechanisms and insurance, risk suffering from catastrophic or impoverishing expenditures when seeking care. Out-of-pocket payments ie, health spending made by patients themselves at the point of care as a share of household consumption have been increasing worldwide.
Nearly million people are pushed into extreme poverty each year because of out-of-pocket expenses. To help reduce impoverishing and catastrophic expenditures, prepaid health expenditures should replace out-of-pocket payments. A study published in , found that the proportion of the population covered by health insurance schemes or by national or subnational health services was not associated with financial protection. Conversely, increased shares of prepayment in total health expenditure, typically achieved through taxes and mandatory contributions, were important for protecting people against catastrophic spending.
The economic consequences we have described could be attenuated or averted in high-quality health systems. However, improving health system quality will require additional investments in many countries.
Analyses have suggested that these will be substantial but affordable in most settings, excepting the poorest countries. Further research is needed to measure the costs of specific quality improvement strategies, including those advanced by this Commission.
A health systems view must also be used to understand quality. This section addressed health care that is delivered at different levels of the health system, including through community outreach, primary care, and hospital care, and the linkages between them—referral systems and emergency medical services.
Figure 9 summarises evidence on quality across these key health system platforms. We have thus far reviewed the available evidence on quality of care at a national or multinational level. However, these estimates mask important variations within countries.
Equitable distribution of high-quality health care is essential to make the gains in health set out by the SDGs and ultimately contribute towards the realisation of the right to health. We now explore why some groups are more vulnerable to poor-quality care than others and who receives worse quality care.
This definition emphasises equitable health outcomes. The health-care system is one major determinant of health, and equitable access to the system is, therefore, important. But equitable access will not result in more equitable health outcomes unless all people—not just the privileged—are able to access high-quality services.
Equity in the quality of health care can be defined as the absence of disparities in the quality of health services between individuals and groups with different levels of underlying social disadvantage. For instance, tuberculosis has a strong socioeconomic gradient between countries, within countries, and within communities.
Similarly, a systematic review focused on diabetes showed that low individual socioeconomic status and deprivation in the residential area are associated with worse process indicators and intermediate outcomes, resulting in higher risks of microvascular and macrovascular complications.
The agenda for sustainable development is built on principles of universality and aims to ensure that no one is systematically left behind. Therefore, an effective implementation demands the defining and targeting of those most vulnerable. These factors are often fluid and have intersecting points, presenting serious obstacles to individuals in accessing high-quality health services.
As a result, the experiences and needs of these populations are not integrated into national health strategies, further entrenching the discrimination and disadvantage that they face. In this Commission, we highlight three dimensions that might make people especially vulnerable to poor-quality care: settings of care, conditions, and demographic factors figure Within settings of care, vulnerability is greater for individuals on the margins of mainstream services or displaced from home, such as those who are in a humanitarian crisis or in refugee camps, internally displaced, living in informal settlements, prisoners, and migrant populations.
People with stigmatised conditions can face worse treatment in the health system than others; these conditions can include HIV and AIDS, mental health and substance abuse disorders, and some reproductive health services such as abortion. Finally, previously recognised social and demographic factors that indicate asymmetric power, such as gender, age, sexual orientation, ethnic group, disability, and insurance coverage, can predispose people to experiencing poor-quality care.
Reasons for poor-quality care in these three dimensions include the collapse of health services, insufficient financial and human resources, low patient empowerment, barriers to continuity of care, insufficient legislative controls, and breakdown in trust between patient and system.
These dimensions of vulnerability, along with an understanding of why these groups could receive poor-quality care and suffer worse health outcomes than others, can inform policies and programmes that target specific vulnerability factors. Women with perinatal depression can experience stigma associated with mental illness in some low-income and middle-income countries.
People with mental disorders are often victims of discrimination and denial of basic rights. A37 They can also internalise shame, anticipate rejection and discrimination, and accept diminished expectations from others. These two forms of stigma, enacted and felt, have the effect of exposing individuals with mental disorders to poor and inequitable quality of care. Therefore, in the context of perinatal depression, stigma would increase the likelihood that those suffering are denied access to the basic and often rudimentary services available.
A formative study done as part of the project Scaling up Care for Perinatal Depression for Improving Maternal and Infant Health in Nigeria, assessed the factors that might promote or hinder the delivery of quality services to women with perinatal depression appendix 1.
All 23 facilities sampled had the lowest level of institutional support for continuous care for depression. Of the patients who screened positive for perinatal depression by use of a validated tool, only three were identified by primary health-care workers. The treatment offered to these three patients was non-existent or grossly inadequate. None were provided with structured psychosocial interventions or offered specific follow-up to address their depression.
The low capacity of all the sampled facilities to provide quality care for depression, and the extremely low detection rates of depression by primary health-care workers recorded in the study showed important gaps in both the organisational structures and the manpower capacity of the front-line facilities to respond to common perinatal mental health conditions in a fully functional integrated chronic care model.
Despite the objectively rated poor quality of service being provided, the women using these facilities still rated them high regarding quality of care and personal satisfaction with the level of service provided. This paradox is an important indicator of the existing inequity in the system: people who have never experienced high-quality services set their expectations low and do not know how to demand higher-quality health care. Panel 4 and panel 5 illustrate how conditions eg, mental health and settings of care eg, humanitarian crisis or refugee camps can exacerbate poor-quality care and what might be done to address these inequalities.
The monitoring and tracking of equity in health intervention coverage has been the focus of major international efforts. However, there has been less work done on equity in the quality of care. As described earlier in this section, quality of care varies between and within countries. Quality of care can also vary between certain population groups and across conditions in the same area.
For example, a study in Kenya showed that the quality of labour and delivery care was generally low, but care available to the poor was substantially worse than that for wealthier people. Similarly, it was found that in Madhya Pradesh, India, poor people living in poor communities received especially poor-quality care.
We disaggregated several indicators of quality in maternal and child health presented earlier in this section by wealth, urban and rural residence, maternal age, gender, and education appendix 1 ; we also assessed variation in quality between the public and private sector. We found evidence that quality care is inequitably distributed across these stratifiers. Regarding evidence-based care, figure 11A shows the proportion of women and caregivers reporting different elements of antenatal and child health care by wealth quintiles.
We found evidence of a wealth gradient across most of these indicators. Among women attending antenatal care with a skilled provider, wealthier women were more likely to report receiving antenatal care assessments and appropriate preventive treatments and more likely to be retained in care until the fourth antenatal care visit. These inequities tended to be larger in low-income countries than in lower-middle-income and upper-middle-income countries.
Equity in maternal and child health-care quality and in user experience in low-income and middle-income countries LMICs. A Data are from Demographic and Health Surveys and Multiple Indicator Cluster Surveys done in 90 LMICs —16 ; wealth quintiles are pooled across countries and sampling weights are adjusted to weigh countries equally. Indicators are defined in appendix 1. During , there were 49 active armed conflicts with about million people affected, including 60 million refugees and internally displaced people throughout the world.
A38—A40 Additionally, an estimated million people are affected by natural disasters annually. A41 These crises cause excess morbidity and mortality through multiple pathways. A42 One of these is the disruption of what are often already weak public health systems. In most crises, the health system undergoes substantial degradation and fragmentation, with the void left by reduced government activities often filled by faith-based, private, and informal providers.
There are logistical, safety, and practical difficulties in undertaking research during times of conflict that have led to insufficient data on the quality of health services being provided in these situations.
A44 However, methods that have been used to assess the quality of care showed low levels of competent care and user experience, issues with staff motivation, and less complicated conditions receiving better quality care than patients who were seriously ill. A45 During the past two decades, humanitarian actors have undertaken various, largely normative, initiatives to promote health-care quality. However, accountability and enforcement remains low, and few humanitarian agencies have implemented health governance systems.
Here, we discuss several challenges that need to be tackled to advance the quality agenda in the humanitarian health sector.
First, the pursuit of quality remains weak and needs to be incentivised. For example, donors of humanitarian activities should place greater emphasis and funding on strengthening the use and reporting of quality standards and performance metrics. Failure to collect and report these data should have consequences for agencies, such as removal of permission to operate and loss of funding.
Second, quality is impeded by insufficient capacity within the humanitarian health workforce. Efforts to professionalise the humanitarian health workforce need to be scaled up through training and updated technical standards and competency frameworks. Third, existing coordination mechanisms need to evolve into technical leadership arrangements, whereby, in exchange for the benefits of taking part in coordination eg, access to specific funding pools , actors agree to operate according to a standard package of care and specific service quality standards.
Fourth, governments need to explicitly consider crisis areas when implanting health interview and population surveys. The actors in these areas should collect data in a way that matches the quality indicators defined by the public health information systems, including assessment of confidence in the system. Lastly, health governance in the humanitarian systems remains weak. Robust governance arrangements, ideally interagency, need to be established to develop concrete accountability and liability in the humanitarian health sector.
We also found important urban—rural differences in several of these quality indicators, whereby women and caregivers in urban areas were significantly more likely to report better maternal and child health-care quality than those in rural settings figure 11B. These urban—rural differences were also largest in low-income countries. The largest gap was found in the rating of the overall quality of the last outpatient visit, for which people with primary education or less reported significantly lower quality than did those with more education.
These inequalities could be underestimated because studies have shown that less educated people tend to be more accepting of the care they receive. Additionally, adolescent women seeking maternal and child health care can also face particular stigma and poorer quality care appendix 2.
Among women attending antenatal care and delivering in health-care facilities, young adolescents were less likely to report receiving different elements of care than women aged 20—35 years. Younger mothers were less likely than others to receive post-partum checkups before discharge after giving birth in a health-care facility. The youngest adolescents year-olds appeared to be substantially less likely to receive all four recommended antenatal care visits, and their children were less likely to complete the diphtheria, tetanus, and pertussis vaccination series.
An analysis of data from the STEPS survey on receipt of lifestyle advice from health-care providers among adults diagnosed with diabetes, hypertension, or hypercholesterolaemia found that women were less likely to receive advice about tobacco use and physical activity than men, and overall, those with no formal schooling were more likely to receive advice about tobacco use and dietary change than those with primary or secondary schooling.
Individuals with secondary schooling were more likely to receive advice about physical activity, maintaining a healthy bodyweight, or losing weight than those with primary or no schooling. Additionally, evidence from the Prospective Urban Rural Epidemiology study found that the use of medication for secondary prevention of coronary heart disease was extremely low, with people in the poorest countries having the lowest rates of use.
Within countries, women and rural dwellers had lower use than men and urban dwellers; less educated patients were less likely to use antiplatelet drugs and statins than more educated patients. Quality can also differ between public and private facilities, but these differences vary across contexts. Such differences also depend on the types of provider included in the definition of private sector.
In terms of evidence-based care and competent systems in the Democratic Republic of the Congo, Kenya, Rwanda, and Uganda, adherence to WHO guidelines for sick child care was higher in private facilities than in public ones. Additionally, adherence to checklists was higher among private providers than among public ones in a standardised patient study 52 in India. However, an analysis of household surveys in 46 countries found that public and private sectors did similarly in terms of antenatal care quality.
By contrast, a systematic review in LMICs found that private sector providers including unlicensed and uncertified providers were less likely to follow medical standards of practice, had poorer patient outcomes, and reported lower efficiency than public sector providers, resulting partly from perverse incentives for unnecessary testing and treatment.
For user experience, public providers did worse in terms of timeliness and hospitality to patients than private providers. Additionally, country differences were found to be more influential than all other subnational factors combined in explaining variation in the quality of primary care services and labour and delivery care. The epidemic of poor-quality care described in this section casts doubt on the ability of legacy health systems to achieve the SDG health targets.
Poor-quality care in LMICs is reflected by inadequate adherence to evidence-based care, negative patient experiences, unequal treatment and access to health services, and by deficiencies in safety, prevention, continuity, and timeliness, leading to poor health, adverse economic outcomes, and loss of trust and confidence in health systems.
Additionally, poor and vulnerable groups appear to experience worse quality care. Despite the breadth of the evidence presented in this section, there were still many gaps in the availability of data on quality of care appendix 2. Poor-quality care has been attributed to the poor knowledge and competence of providers and to fatigued or unmotivated health workers.
However, the scale and range of the problem across countries, settings, and health conditions suggests that it is a manifestation of a broader systems failure. LMIC health facilities are underequipped, overcrowded, and frequently understaffed. Pre-service education and specialty trainings are inadequate.
Processes are inefficient or inexistent, including financial incentives and remuneration of providers, referral networks, and triage in emergency departments. These fragmented health-care systems are unable to support health workers in providing high-quality care. The core principle of this Commission is that health systems are for people. This section asks: are they for all people? We review the right to high-quality care and provide insights into steps that national governments and communities can take to address the issue of equity and build a strong high-quality health system that targets the poor and vulnerable groups.
The key findings of this section are shown in panel 6. The health and human rights agenda has been essential to motivating investments and actions to improve health in LMICs, as well as globally. This agenda historically emphasised inputs and access to care, but did not specify the quality of services provided.
In , 13 the UN Committee on Economic, Social, and Cultural Rights adopted general comment 14, which states that the right to the highest attainable standard of health includes availability, accessibility, acceptability, and quality.
In a review for this Commission of global health policy milestones since , we found that the global discourse has been focused on access to care and foundations of quality, but not enough appears on processes of care or quality-specific impacts, such as trust or satisfaction. However, with the implementation of the WHO framework for action on strengthening health systems to improve health outcomes and the WHO framework on integrated, people-centred health services, the trend is moving in the direction of patient-centred care and measures of quality focused on processes of care.
Health systems should communicate the right to health through a national health plan, initiatives to ensure that the public knows its entitlements and how to realise them, and data on health system quality.
One reason that quality has lagged behind access in global health discussions is the perceived trade-off between expanding coverage and improving quality. A trade-off is a compromise between two or more desirable, but competing considerations and, thus, involves a sacrifice made in one dimension to obtain benefits or ensure respect for rights in other dimensions.
This finding can be interpreted as the result of a trade-off made by decision makers: equitable access for all is better than access to high-quality services for some. Quality is essential to the equity agenda. We recognise that on the high end of care, such as expensive advanced technologies and medicines, provision of cheaper and somewhat less effective treatments can be an appropriate option in low-resource settings.
One example is the use of the visual inspection with acetic acid method for cervical cancer screening instead of the more expensive and time consuming Papanicolaou smear and human papillomavirus co-testing. There are two reasons for this: ethical achievement of health outcomes and efficient use of resources. First, increased access will not translate to better health outcomes for disadvantaged people unless all people have access to high-quality services. Second, spending scarce resources to expand access without quality is wasteful and inefficient.
Countries can build on their achievements in expanding coverage by improving the quality of services offered to meet the minimum quality level. They can then consider further expansion of quality services. As countries pursue UHC, approaches such as progressive universalism—a determination to include people who are poor from the beginning—have proven to be effective ways to target poor and vulnerable groups of society.
This Commission endorses this approach. Many countries recognise the need to be accountable for the health care of the population. Although these charters contain many of the same basic principles, such as legal and human rights guarantees, they vary substantially in length, scope, and detail. South Africa is attempting to make its promises actionable through its National Health Insurance Policy, which underpins the establishment of a unified health system based on the principles of social solidarity, progressive universalism, equity, and health as a public good and a social investment appendix 2.
This Commission recommends that countries adopt a national quality guarantee—ie, quality sufficient to consistently produce a health benefit. This would be concrete and operational for covered services.
What are the elements of such a guarantee? First, clearly poor-quality services, providing more harm or risks than benefits, fall below the thresholds of a guarantee.
Second, the quality of services must be sufficient to generate health benefits. For example, a rural clinic should specify to the patient the level of services that it is competent in providing.
Third, services must be provided in a respectful people-centred manner. An integral aspect of people-centred health systems is the relationship between provider and patient. Patient—provider relationships are shaped by societal norms and are susceptible to power imbalances. Pre-service and in-service training on respectful care is one way to improve the ethical competence of providers in low-income settings.
The quality guarantee should accompany any efforts to expand service coverage; in many countries, the movement to UHC is an excellent starting point. National standards for conditions covered by a UHC benefit package might include descriptions of adequate assessment and diagnosis, treatment and care, assurance of continuum of care, and referral.
This is a corrective to the current UHC discussion that revolves around the pooling of funds to expand the coverage of populations and services while decreasing the cost. Without building in quality, the increased coverage will not result in health gains for people. Although many countries can do more to provide quality health services with existing funds, others will require additional funds. Beyond these general considerations, countries need to undertake analyses and open discussions to specify their national standards.
National guarantees should start with the reality of social norms and health system functions and be context-specific. Current national standards are often defined and implemented through standard operating procedures or clinical practice guidelines.
Standards included in the national quality guarantee should be developed by health policymakers and professionals, in collaboration with users and national regulatory agencies, to ensure that upholding the guarantee does not fall solely on providers.
The guarantee is not intended to be punitive against individual providers; any redress mechanisms should be targeted to the appropriate level of the health system. Over the past three decades, the concept of accountability in provision of health care has gained increased attention.
However, accountability for quality in health care has been less explored. The three general categories of accountability are financial, performance, and political or democratic.
In this section, we use elements of financial and political or democratic accountability to discuss legal and social mechanisms. Performance accountability is discussed in the subsequent sections. For accountability to function, there must be actors responsible for activities, standards to define what actors should deliver, agents to hold actors to account, and tools or methods to do so.
A review done for this Commission on the accountability ecosystem and its relation to the delivery of quality care methods in appendix 1 supported the notion that accountability mechanisms can serve as a catalyst to initiate and sustain improvements in quality and advance the progressive realisation of the human right to health and quality health care.
The review found that multiple accountability tools have been used, and documented in the peer-reviewed literature, to improve access to essential and effective health care appendix 1. A key finding of the review was that single interventions do not have the power to induce large-scale change. Additionally, governance and coordination must be strengthened, resources must be planned and budgeted, and a performance monitoring system must make the information collected available.
Therefore, to improve quality, countries need to devise accountability strategies that encompass elements of legal and social accountability. National governments are the primary agents for accountability. Human rights conventions can provide the basis for legislation that recognises the right to health and health care, and can be an essential and minimum foundation for approaches to improve access and quality of care.
Meaningful legislation should not only recognise the right to health and health care, but also cater for the right to meaningful public participation, freedom of civil society, and freedom of information. Where such legislation exists, it can be used for accelerating action. Quasijudicial mechanisms exist in many LMICs, such as the ombudsman in South Africa tasked with addressing the system failures that led to the deaths of 94 mental health-care users.
Social accountability refers to approaches that involve communities, citizens, and service users directly; these approaches include attempts to increase community involvement, awareness, and demand generation for high-quality care. Multiple tools are available to foster social accountability. They include citizen report cards, community monitoring, social audits, participatory budgeting, citizen charters, and health committees.
Mechanisms for creating and acting on such tools exist in LMICs today. These social accountability mechanisms should be seen as complementary rather than substitutes to the legal approaches previously discussed.
A literature review done for this Commission aimed to present findings on the accountability—quality relationship and explore how accountability mechanisms contribute to improvements in quality of care. The review focused on legal and social accountability mechanisms pertaining to reproductive, maternal, and child health. The key findings were synthesised and the following actions were identified as important for effective and transparent accountability:.
Panel 7 synthesises the key findings from the review on legal and social accountability and proposes actions to support effective and transparent accountability at the national level. Health systems should give priority to poor and vulnerable groups of society to reduce inequities and expand the right to quality health care through progressive universalism. A movement towards UHC offers countries the opportunity to start on this path by expanding coverage tied to a national quality guarantee.
Legal and social accountability mechanisms can assist in upholding these quality standards. Enacting accountability is predicated on insight into current health system quality. In the next section, we assess the purpose, status, and promise of health system quality measurement. Valid and reliable information is a necessary input to a high-quality health system. Although some efforts, such as the Health Metrics Network, have included LMICs, country ownership of this agenda has been inconsistent, and progress on health system measurement remains incomplete.
Indeed, the findings described in Section 2 on healthcare quality in LMICs reveal crucial measurement gaps. Existing data on quality of care have largely been generated within vertical programmes, resulting in measures that have not been combined in ways that could illustrate quality of the health system as a whole, whether at local or national levels.
Moreover, research on health system quality—including the policy and implementation research urgently needed to bring effective interventions to scale—has not kept pace with the magnitude of the challenge, reflecting inadequacies in measurement approaches and data use.
A bibliometric search for quality-related research between , and , revealed that, although this type of research is increasing in LMICs, it remains overwhelmingly located in high-income countries appendix 2. The demands made of health systems are growing: the burden of disease is shifting towards non-communicable diseases and injuries, 6 health emergencies are rising, countries are actively moving towards UHC, 17 and people are demanding better services and outcomes. To meet these challenges, measurement approaches need to be responsive to new health system demands, relevant to people, and efficient.
At the heart of this reframing is the question: why measure and for whom? This Commission proposes two main purposes for the measurement of health system quality: accountability and action. Accountability requires the provision of information when questioned, whether for routine monitoring or detailed justification, paired with a mechanism for oversight.
For both performance and social accountability, data will typically need to be representative of the target population, comparable, and systematic. Measurement should further include elements that are of high value to people; for example, they should include not only health outcomes such as survival, but also function, pain, and processes such as respectful treatment panel 9.
Measures of health system quality have usually been organised into inputs eg, workforce, tools, facilities , processes of care eg, adherence to guidelines, communication , and outcomes eg, morbidity, mortality. In low-income and middle-income countries, many quality measurement and improvement efforts have emphasised inputs to health services.
Inputs are foundational to health-care provision and are easily measured, but they provide narrow insight into quality of care. Studies have found weak associations between input measures and care competence, A47 particularly when facility size is considered.
A25 The relation between input availability and the quality of care received can differ over the course of care delivery, A48 underscoring the need for motivated and competent providers and supportive systems for good care delivery. Similarly, multiple studies A49,A50 attest to the know—do gap: the deficit between provider knowledge and the clinical care provided.
These issues do not mean that input measures are unimportant; indeed, timely and specific information on inputs, such as stock levels and equipment functionality, is crucial for health service planning and operation and should be collected by health systems. However, these measures should not be used as indicators that health systems are providing high-quality care. Process measures can play an important role in illuminating the quality of care provided.
These measures are immediate and relevant at the point of care, and they provide direct insight on care provision without risk adjustment, which makes them particularly valuable in assessing gaps or disparities in care for vulnerable subpopulations. A51 A judicious selection of process measures is essential, emphasising measures validated against the outcomes that matter to patients, A52,A53 whereas overmeasurement can divert provider time and weaken the quality and usefulness of data.
The proliferation of process measures in high-income countries, for example, has increased the burden of measurement and resulted in unintended consequences, including fixation on the measure rather than the intent, reallocation of efforts towards meeting measurement targets and away from other essential tasks, and gaming manipulation of the quality assessment system. Health outcome measures attest to the central goal of a health system—maintaining or improving health and wellbeing.
A56,A57 However, these measures can be challenging to attribute directly to health system performance because of the involvement of multiple factors. Baseline risk information is required for valid comparisons of health outcomes over time or between facilities. A58 Despite this complexity, there is global recognition of the crucial need for health-system-sensitive and patient-focused outcome measurements, even in very low-income settings.
A56 Health-system-sensitive outcomes include perioperative mortality, inpatient suicide, 5-year cancer survival, obstetric fistula, caesarean section, unsuppressed HIV viral load, uncontrolled blood pressure, lower extremity amputation in patients with diabetes, and hospitalisation due to ambulatory care-sensitive conditions.
High-income settings are increasingly turning to patient-reported outcomes PRO as a means of realigning health care with patient values. A59 PRO measures have been used to improve monitoring, decision making, and patient—provider communication, A60 with evidence suggesting that the use of these measures improved patient perceptions of care A61 and led to better health outcomes for some conditions, A62 although their usefulness in aggregate has yet to be fully demonstrated.
A63 Routine measurement and the use of health-system-sensitive outcome data and PRO are integral to achieving patient-centred health systems. Measurement for action is at the heart of learning health systems.
These measures should provide decision makers with answers to specific questions about the functioning of the health system and the quality of care delivered, help identify the targets and interventions for improvement, and monitor the results of the changes implemented. Quantitative data should be complemented by so-called soft intelligence, the insight on the context and processes of care delivery, to help inform action.
Fulfilling either purpose of measurement—ie, for accountability or action—requires valid and reliable measures, transparency in information exchange, and an entity with the power to demand a response.
Panel 10 outlines conditions required for measurement to induce change. To meet the SDG targets and improve health system quality by , countries will need to embark on a measurement agenda that will take time and investment to fulfil. This agenda starts by knowing what is currently being measured. Multiple strategies have been used to capture the range of information needed to assess health system quality, including measuring population health needs, health outcomes, and health system performance.
Table 2 describes the platforms in use and their best application; given the multiplicity of tools, central organisation and triangulation are needed to gain insight and act on these data. We, and others, have found that health system data collection is often costly, uncoordinated, and disconnected from decision making.
Commission framework is depicted in figure 1. Measurement alone will not ensure health system quality. Actionable information must reach agents capable and empowered to use it to effect change in the health system. Freedom of information—the right to access information held by public bodies—was enshrined in the Universal Declaration of Human Rights and has been adopted into law by more than 90 countries. A64,A65 Applied to health systems, freedom of information demands transparency of data within the system and to the public.
A66,A67 High-quality health systems are not automatically produced by governments. A regulatory system that engages an array of actors should hold the system to account for high-quality care. This system includes formal mechanisms such as audits, ombudsmen, and courts and informal actors such as patients, the press, professional organisations, and civil society.
A range of barriers can inhibit the flow of information about health systems. Power differentials can stymie communication, restricting the transmission of and responsiveness to local knowledge; A69—A71 hierarchical norms and fear of reprisal can inhibit incident reporting about health-care failures; A72 and, ironically, a surfeit of indicators in routine measurement systems can prevent the ready understanding and use of locally relevant information.
A69,A72—A74 Although governments often claim to want to reach users through open government initiatives, scant attention to how people understand and use information has led to an abundance of information but a minimal effect on care seeking and other outcomes.
Countries have the opportunity to take better advantage of increasing health system data by building trust in data, promoting learning cultures within the health system, and ensuring freedom of information. Obligatory reporting with data audit trails or data quality assurance institutions can bolster confidence in the indicators generated.
A74,A79 A culture of information and learning within and across health facilities can lead to greater transparency and action. A69,A80 For instance, facility audits and licensing exercises should include clear criteria for improvement and result in non-punitive responses, such as support for addressing deficiencies. A81,A82 To ensure freedom of information, formal protection for whistle-blowers is an important guarantee, although a culture of secrecy and professional protectionism should also be addressed.
A72 The free operation of traditional and social media can provide external accountability levers. A67,A69 Open government initiatives are an initial step, but their success should be judged on the basis of information use, not on quantity of data released. One path to fulfilling these opportunities is the development of a national body for monitoring health system quality, informing the public, and identifying and responding to failures, to serve as a locus for measurement, accountability, and action.
The proliferation of indicators burdens health-care workers and systems. Furthermore, fragmentation of these and other data sources prevents the coherent assessment of health system performance, to say nothing of actions in response to the data. Quality frameworks do not imply a need for equal measurement of each subdomain for all health services and conditions, but they do make apparent the multiple aspects of quality and highlight duplication and gaps.
Inputs, such as tools and workforce, were the most commonly assessed subdomains and formed the entirety or bulk of the Service Availability and Readiness Assessment SARA , Service Delivery Indicators, and Service Provision Assessments; our findings were consistent with existing research on the predominance of input measures in health system survey tools. Although global and national measurement sets included population health outcomes such as neonatal mortality rate, user experience and non-health effects were sparsely measured across all sets.
We mapped indicators against domains of the high-quality health systems framework figure 1 , identifying the single domain most relevant for each indicator.
We additionally classified indicators as patient-reported if the data were collected with individual self-reports. Full methods are detailed in appendix 1. Cells are coloured by greatest number of indicators per row source , with red indicating 0, orange and yellow the midrange, and green the maximum number observed for that measurement set.
The extensive collection of input measures is problematic. When collected through surveys, input data are quickly out of date and thus lose usefulness for supply planning.
Moreover, our analysis found that readiness metrics are only weakly connected to the content of care delivered. The remaining measures in global sets pertained to competent care and, to a lesser extent, systems.
Much of this measurement is focused on a subset of conditions, mainly maternal and child health and infectious diseases. Even in these areas, the validity of indicators collected raised concerns: for example, household surveys are not well suited for identifying children who truly have pneumonia to estimate appropriate treatment, and maternal morbidity and mortality in hospitals greatly exceeded the estimated rates based on documented administration of essential interventions.
In summary, the available measures do not promote accountability for high-quality health systems. Globally funded facility surveys overmeasure inputs that provide inadequate value for accountability.
At the national and global levels, health system measurement is insufficient to assess performance of the health system as a whole and inadequate for holding the system accountable to people for the user experience provided or the effect on impacts—health and non-health—that matter to patients.
Data must be of adequate quality to be used for accountability or action. Routine health information systems, whether individual-level electronic health records or aggregate reporting such as the District Health Information System DHIS 2, provide information on the use and content of care that, if the data are of adequate quality, should form a crucial element of health system measurement for accountability. Barriers to robust implementation and use of electronic health records and DHIS include restricted ownership by end users, scarce training on data skills, lack of motivation and engagement by overburdened health workers, large numbers of indicators required, and inadequate functionality of electronic platforms.
Countries should incorporate measures of quality within a broader health system assessment to appropriately track the value of the health system. The geographic availability of facilities overstates health system performance: reduced mortality due to acute abdominal conditions was associated with proximity to well resourced hospitals in India, but not with access to lower-quality hospitals.
Even basic process indicators provide greater insight into hospital capacity than the availability of a facility or equipment. Service coverage monitoring that does not explicitly include quality will similarly overestimate health system performance and will do so substantially in many cases because of quality deficits. Figure 13 lists the current coverage indicators for monitoring UHC specifically and the health-related SDGs more broadly.
Only one of these indicators effective treatment coverage for tuberculosis captures the health system effect on population outcomes. Calculating effective coverage requires defining the population in need, access to care, and receipt of quality care. Research is ongoing to identify standard indicators for many SDG conditions. Some indicators are available but need to be better implemented eg, HIV , others need to be refined by selecting the best indicators and determining efficient methods of collection eg, maternal health , and others still need to be developed de novo or validated for use at scale in low-resource contexts eg, substance use.
Illustrative indicators for advancing Sustainable Development Goal SDG monitoring from coverage towards effective coverage. Care cascades are an extension of the concept of effective coverage: instead of a single number, cascades break performance along the continuum of care to allow analysis of health system function. With each step conditional on the previous one, cascades illustrate health system failures in functions such as diagnosis, retention, and evidence-based care, while linking system performance to patient outcomes.
Although specific indicators can vary across conditions for example, disease control could be measured by viral load for HIV, blood pressure for hypertension, symptom-free days for major depressive disorder, and years without recurrence for breast cancer , the drop-offs in a disease-specific cascade can illustrate system-wide deficits: low rates of screening suggest failures in primary care as a first contact service, whereas poor outcomes among those on treatment implicate inadequate coordinated and continuous care.
We provide examples and discussion in appendix 2. For effective measurement of accountability and action, health system assessments must be reoriented away from measures that are poorly fit for purpose and towards people. A people-centred measurement means thinking about individuals across the life course and the total sum of their health system experiences rather than discrete services. The examples in this panel describe proof-of-principle testing of patient-reported indicators in low-income and middle-income countries.
Shared investment, innovation, and learning will be needed to validate and define the use at scale of patient-reported measures for action and accountability. The Quality of Care Network for maternal and newborn health is leading efforts to standardise measures of childbirth care experience.
Labour companion of choice is one of the quality measures for emotional support and is recommended in four WHO guidelines to date. A86,A87 Evidence shows that women who received continuous labour support might be more likely to give birth vaginally, be satisfied with their birth experience, and be less likely to have caesarean birth or use pain medication.
A88 Labour companions can also play a role in the prevention of mistreatment of the woman during childbirth by serving as an advocate, witness, and safeguard. A process indicator would be the proportion of women who wanted and had a companion supporting them during labour, childbirth, and immediate post-partum period in a health facility, based on observation or facility or population survey.
Currently, nine countries in the network are in the process of including and testing different mechanisms for three common experience of care indicators including labour companion as part of large-scale quality improvement efforts for maternal and newborn health.
In the wake of the COVID pandemic, it has become even more imperative for lawmakers to find an affordable solution for Americans. To address these high costs, policymakers have discussed finding a way to lower prices without compromising the quality of the services and care provided.
Some solutions include significantly reducing prescription drug prices or allowing policymakers to regulate healthcare prices. And competing with the public option could pressure private insurers to lower their costs. This includes access to healthy food, affordable housing, transportation, childcare services, education, and more.
A healthy population leads to better outcomes and more affordable care for all. Healthcare policy analysts play a huge role in making effective changes to our healthcare systems. They are responsible for evaluating current policies and suggesting improvements that can impact patient care.
These analysts use critical thinking skills to compile and evaluate relevant data and research, suggest changes to current policies, and create new policy proposals. Most healthcare policy analysts start by earning an undergraduate degree in public health, public policy, political science, government, or a related field. Nurse practitioners NPs can also play an important role in healthcare policy. NPs and other nurses can help identify problems within the current healthcare system, come up with solutions, and suggest new policies that can positively impact the well-being and safety of their patients.
You can also earn a role specialty as a family nurse practitioner. Healthcare policy is important on a macro and micro level. It affects our whole society, as well as each community and facility where care is administered. The University of St. The MSN has several options to accelerate your time to degree completion.
Earn your advanced nursing degree while keeping your work and life in balance. USAHS offers a Master of Health Administration MHA program designed for working healthcare professionals who want to improve systems of finance, informatics, operations, policy, and other key functions of healthcare organizations.
The program is taught online, with optional on-campus immersion weekends scheduled to resume in and an optional internship. Whether you choose the traditional or accelerated track you will gain real-life experience and expand your professional network.
During your capstone project, you will work with an industry mentor. Designed for working clinicians and healthcare educators, the program has two required residencies and optional on-campus immersions resuming in Spring Design a customized plan of study that takes advantage of our acceleration options and wide array of electives—and prepare to educate the next generation of healthcare professionals.
Nurse practitioners and physician assistants are advanced healthcare practitioners with similar responsibilities, such as diagnosing illnesses and prescribing medications. However, their training and paths toward certification differ in significant. As an occupational therapist OT , you will have the opportunity to specialize in one or more areas over the course of your career.
Adding a specialty demonstrates your knowledge of. In January , when the COVID pandemic was weighing heavy on society, students were learning at home, and the Black Lives Matter movement was inspiring demonstrations for equality around the.
Physical therapy and occupational therapy are both rehabilitative disciplines that require hands-on work—leading many people to believe they are interchangeable. However, these professions vary greatly. When deciding which healthcare career.
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|Bcbs carefirst formulary drug||Some people healthcaree also choose to bypass primary care facilities and seek care at hospitals or higher-level facilities for conditions that could be treated in primary care. The site is secure. We are also aware of other major efforts on quality of care at the time of the writing of this Commission. However, this focus also signifies that people are not just beneficiaries of health services, but have a right to health care and have agency over their health and health-care decisions. For people with life-threatening emergencies, such as labour complications, trauma, and stroke, treatment healthcare focus on policy change 2018 substantially increase mortality risk. For example, after giving birth, women should be assessed for abnormal bleeding, perineal tears, signs of infections, and ca jobs kaiser permanente blood pressure. In low-income and middle-income countries, many quality measurement and improvement efforts have emphasised inputs to health services.|
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|Legacy humane society||Policy impacts issues as fundamental as healthcare access, cost, delivery methods, and privacy. Nonetheless, patient satisfaction should be interpreted with caution cocus a go here of quality panel 3. A42 One of these is the disruption of what are often already weak public health systems. These considerations guided our analysis. Although some efforts, such as the Health Metrics Network, have included LMICs, country ownership of this agenda has been inconsistent, and progress on health system measurement remains incomplete.|
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Mar 22, · 1. Healthcare Consolidation Between Insurers and Providers. What it is: Over the past few years, the healthcare industry has seen a trend of consolidations due to declining . Nov 14, · Policy development is one of the core functions of public health 49; however, public health professionals have cited policy development as one of the areas in which training . Dec 26, · Healthcare organizations turned to unexpected partners in Dealmaking stayed hot in , with a focus on physician practices Greater flexibility, new alliances define .