Recent gains against the burden of illness, injury, and disability and commitment to universal health coverage (UHC) are insufficient to close the enormous gaps that remain between what is achievable in human health and where global health stands today, says a new report from the National Academies of Sciences, Engineering, and Medicine. The report calls for urgent, comprehensive efforts led by ministries of health worldwide to transform the design of health care through systems thinking and principles of human factors, acknowledge and engage the informal care sector, focus on settings of extreme adversity, embrace digital technologies and emerging innovations, and address corruption.
In low- and middle-income countries, between 5.7 million and 8.4 million deaths occur each year from poor quality of care, which means that quality defects cause 10 percent to 15 percent of the total deaths in these countries, the report says. The resulting cost of lost productivity is approximately $1.5 trillion each year. The United Nations’ Sustainable Development Goals adopted in 2015 include a commitment to achieving UHC by 2030—so that all people and communities receive the quality services they need and are protected from health threats, without suffering financial hardship.
“Even if the current movement toward universal health coverage succeeds, billions of people will have access to care of such low quality that it will not help them, and often will harm them,” said Don Berwick, president emeritus and senior fellow, Institute for Healthcare Improvement, Boston, and co-chair of the committee that conducted the study and wrote the report. “In view of the immense dedication and effort of tens of millions of health care workers worldwide, often against massive obstacles such as limited resources, political and social fragmentation, and corruption, this assertion that the system too often fails to provide high-quality care is not made lightly or with disrespect. This report sets out an agenda for action on policy, management, and clinical care that, we believe, can deliver far better outcomes for the people who depend on us and far more satisfying and respectful conditions of work for those who try to help.”
The committee recommended a vision of health care that adopts systems thinking and fundamental principles of human-centered design and human factors. Specific design principles should include full transparency; co-design with patients, staff, and communities; care that is anticipatory and predictive, not merely reactive; care reflective of societal values; and care that bases decisions on clear evidence, continuous feedback, and learning. The path to quality improvement will be different for every country, but a strong and constant focus in any setting should be on integrating and coordinating care across the patient’s “journey” over time.
Adherence to these principles would lead to the emergence of a learning health care system—one that learns from both successes and failures and that encourages innovation, the report says. This culture of continuous learning demands strong leadership, commitment, cooperation, and a system for feedback to continually update policies, protocols, and systems.
Health systems should embrace emerging digital technologies, the report says. A shift in care delivered directly to people wherever they are—for example, in schools or homes—will require new skills, attitudes, and culture among health care providers. Specifically, the United Nations System should convene an international task force with multi-sectoral representation to provide guidance on governance mechanisms, standards, and regulatory oversight appropriate for these new technologies.
People in many parts of the world, more than 75 percent of the population in some countries, choose to seek care from informal providers—those who lack formal training but are often well-known in the community. This could be either because people lack access to formal providers or because they do not trust the formal system. However, little is known about the quality of this care. Governments should assess and integrate informal providers into national health strategies and quality monitoring and improvement plans, and undertake efforts to improve their care through education, training, and realigning incentives.
Even when care is available, quality problems are widespread. For instance, a study in Kenya, China, and India found that providers adhered to evidence-based treatment for conditions such as asthma, chest pain, and tuberculosis 25 percent to 50 percent of the time. High levels of excessive and inappropriate care are also pervasive, the report says. In the U.S., for example, 30 percent of estimated prescriptions for antibiotics are found to be unnecessary, posing risk to patients and contributing to antimicrobial resistance.
“For billions of people, universal health coverage will be an empty vessel unless quality improvement becomes as central an agenda as universal health coverage itself,” said co-chair Sania Nishtar, founder and president, Heartfile, Islamabad, Pakistan, and co-chair of the World Health Organization Independent High-Level Commission on Non-Communicable Diseases. “Increasing quality is not an endpoint, but an ongoing, all-hands-on-deck effort that will require investment, responsibility, and accountability on the part of health system leaders. Health systems need to embrace a vision of the patient journey that is anticipatory and preventive, and wholly centered on continually improving the experience of patients, families, and communities.”
In addition, the report says, settings of extreme adversity, such as conflict zones and refugee camps, pose severe quality challenges. About 2 billion people live in fragile states and conflict settings worldwide. Research on these areas should be an urgent priority for governments, nongovernmental organizations, and donors, to identify common quality problems, and to tailor and implement improvement strategies to reduce both preventable deaths and the waste of scarce resources.
Corruption is another large contributor to poor quality of care worldwide, leading to decreased trust among governments, health care systems, and citizens. Its effects are evident in longer wait times, poorer treatment by health care workers, absenteeism of providers, unnecessary charges for services, and general misuse and pilfering of funds. Ministries of health should include safeguards in their national health care quality strategies against corruption and collusion, as well as actions for improvements in integrity through prevention, detection, and enforcement.
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