Quality first for effective universal health coverage in low-income and middle-income countries
Authors: Adolfo Rubinstein, Mariela Barani, Analía S Lopez
Journal: The Lancet Global Health (2018)

The UN has set universal health coverage (UHC) as a target for Sustainable Development Goal (SDG) 3.8, to be achieved by 2030.1UNAbout the Sustainable Development Goals.https://www.un.org/sustainabledevelopment/sustainable-development-goals/Date: 2015Date accessed: August 31, 2018Google Scholar The dimensions of UHC run along three axes: the population that is covered by pooled funds, the proportion of direct health costs covered by pooled funds, and the health services included. However, as use of health services increases and, at the same time, the burden of disease in low-income and middle-income countries (LMICs) shifts greatly to more complex conditions such as non-communicable diseases (NCDs), quality of health services rather than access alone appears as a key determinant for improving population health and reducing disease burden. In this regard, the report released by The Lancet Global Health Commission on high quality health systems in the SDGs era is relevant and timely. The Commission proposes that health systems be judged mainly on their population impact, equitable distribution of health gains, improvement of processes of care through the translation of scientific evidence into better patient care, reduction of waste and increased financial protection, and confidence and positive experiences of people and users, among others.2Kruk ME Gage AD Arsenault C et al.High-quality health systems in the Sustainable Development Goals era: time for a revolution.Lancet Glob Health. 2018; 6: e1196-e1252Summary Full Text Full Text PDF PubMed Scopus (1041) Google Scholar Argentina, an upper-middle-income country that has almost finished its demographic and epidemiological transition, has a well developed health system, particularly by LMIC standards. However, quality care is still a challenge that hinders the country's potential, given that Argentina is one of the leaders in the region regarding health-care spending per capita and human development.3Cetrángolo O Goldschmit A Organización y financiamiento de la provisión de salud por parte de la seguridad social en Argentina.http://bibliotecadigital.econ.uba.ar/?c=docin&a=d&d=docin_iiep_025Date: 2018Date accessed: August 31, 2018Google Scholar Moreover, although all inhabitants of Argentina are entitled to receive health care free of charge in public facilities, UHC is still nominal, implicit, and aspirational rather than actual and explicit. In this regard, we are facing many hurdles to achieve effective UHC and render UHC goals into outcome improvements to reduce health disparities on prioritised conditions.4Rubinstein A Zerbino MC Cejas C López A Making universal health care effective in Argentina: a blueprint for reform.Health Syst Reform. 2018; 4: 203-213Crossref Scopus (32) Google Scholar For example, infant mortality has a national average of 9·7 per 1000 and a two-times difference between poor and rich provinces, maternal mortality has a national average of 3·4 per 10 000 and an eight-times difference between poor and rich provinces,5Sistema Estadístico De SaludEstadísticas vitales información básica. Buenos Aires.http://www.deis.msal.gov.ar/index.php/estadisticas-vitales/Date: 2017Date accessed: October 1, 2018Google Scholar there is a longer time to reperfusion treatment in acute myocardial infarction—a strong predictor of mortality—in poor districts than in rich districts,5Sistema Estadístico De SaludEstadísticas vitales información básica. Buenos Aires.http://www.deis.msal.gov.ar/index.php/estadisticas-vitales/Date: 2017Date accessed: October 1, 2018Google Scholar, 6Charask AA Costa YBC D'Imperio H et al.Patients with ST-segment elevation acute myocardial infarction transferred to centers with percutaneous coronary intervention capabilities. National survey of ST-segment elevation acute myocardial infarction in Argentina (ARGEN-IAM-ST).Rev Argent Cardiol. 2017; 85: 90-102Google Scholar and there is an eight-times regional variation in cervical cancer mortality—which is strongly associated with poverty—and a three-times regional variation in colorectal cancer mortality.7Zapka J Taplin SH Anhang Price R Cranos C Yabroff R Factors in quality care—the case of follow-up to abnormal cancer screening tests—problems in the steps and interfaces of care.JNCI Monogr. 2010; 2010: 58-71Crossref Scopus (104) Google Scholar, 8Arrossi S Thouyaret L Laudi R et al.Implementation of HPV-testing for cervical cancer screening in programmatic contexts: the Jujuy demonstration project in Argentina.Int J Cancer. 2015; 137: 1709-1718Crossref PubMed Scopus (31) Google Scholar These differences are explained by regional variations in screening and time to diagnosis and treatment. Moreover, there are great variations by region in health coverage for cardiovascular risk factors and screening practices for cancer prevention. To reverse these gaps, we are working on a strategy centred on primary care to advance the integration of health-care coverage while enhancing quality of care. Quality care implies augmenting population-based and clinical-based coverage of effective health services; prioritising sensitive health conditions and enforcing the clinical pathways related to better care of these conditions; developing effective, accessible, and integrated health-care networks; and developing and achieving quality targets for these prioritised health-care problems. The first step on the quality challenge was to define the baseline scenario and the dashboard of key metrics we would use for monitoring performance for the UHC strategy (eg, health outcomes, health utilisation, people's confidence in the system, system competence, and user experience). Subsequently, we identified different existing panels of UHC indicators.9Primary Health Care Performance InitiativeSpurring improvements in primary health care.https://phcperformanceinitiative.org/Date accessed: August 31, 2018Google Scholar, 10WHOGlobal reference list of 100 core health indicators.http://apps.who.int/iris/bitstream/handle/10665/259951/WHO-HIS-IER-GPM-2018.1-eng.pdf;jsessionid=BF64F96F6DCE8253DBA1C89A91F3A6DE?sequence=1Date: 2018Date accessed: August 31, 2018Google Scholar, 11Organisation for Economic Co-operation and DevelopmentHealth at a glance 2017.https://read.oecd-ilibrary.org/social-issues-migration-health/health-at-a-glance-2017_health_glance-2017-en#page1Date: 2017Date accessed: August 31, 2018Google Scholar Finally, we built a panel of indicators that served as a basis to design the definite UHC quality scorecard. 160 indicators were reviewed thoroughly by our team, considering the health priorities. Experts from Argentina were invited to participate in a Delphi panel to discuss indicators according to five criteria (importance, validity, reliability, acceptability, and feasibility). After a prioritisation process, 65 indicators were selected to compose the UHC quality scorecard to monitor UHC strategy. Performance indicators are organised in six domains: the system, focusing on primary-care-based metrics within the health-care system; inputs—ie, considering whether the system's resources, such as health professionals, facilities, and supplies are sufficient; service delivery, focusing on access, coordination, organisation, and management of care; results, looking for success of the system in providing adequate care; impact—ie, evaluating whether the services provided are efficient and equitable; and user experience, assessing patient-reported outcomes and people's confidence on the health system. Some examples of indicators by domain can be seen in the panel.PanelUniversal health care indicators by domainSystem•Proportion of people with exclusive public coverage that have access to basic health services•Proportion of people with exclusive public coverage assigned to a primary care facility•Proportion of primary care facilities with geographical responsibility defined•Proportion of primary care facilities that bill to social security•Current primary health-care expenditure per capitaInputs•Nurse density (per 10 000 population)•Primary care doctor density (per 10 000 population)•Health-care facility density (per 100 000 population)•Vaccine supply according to risk groups•Essential drugs availability according to target populationService delivery•Rate of scheduled appointments in primary care facilities•Barriers to access due to cost of treatment•Barriers to access due to distance•Diphtheria-tetanus-pertussis vaccine dropout rate•Tuberculosis treatment success rateResults•Rate of patients with diabetes with at least one prescription of statins•Rate of children aged 2–9 years with obesity diagnosis•Rate of women aged 25–64 years with cervical cancer screening•Women aged 25–64 years that have started treatment for high-grade squamous intraepithelial lesions or invasive cervical cancer•Rate of childhood vaccination for measlesImpact•Adult mortality from non-communicable diseases•Maternal mortality•Neonatal mortality•Mortality in children younger than 5 years•Rate of hospitalisation for primary-care-sensitive conditions System •Proportion of people with exclusive public coverage that have access to basic health services•Proportion of people with exclusive public coverage assigned to a primary care facility•Proportion of primary care facilities with geographical responsibility defined•Proportion of primary care facilities that bill to social security•Current primary health-care expenditure per capita Inputs •Nurse density (per 10 000 population)•Primary care doctor density (per 10 000 population)•Health-care facility density (per 100 000 population)•Vaccine supply according to risk groups•Essential drugs availability according to target population Service delivery •Rate of scheduled appointments in primary care facilities•Barriers to access due to cost of treatment•Barriers to access due to distance•Diphtheria-tetanus-pertussis vaccine dropout rate•Tuberculosis treatment success rate Results •Rate of patients with diabetes with at least one prescription of statins•Rate of children aged 2–9 years with obesity diagnosis•Rate of women aged 25–64 years with cervical cancer screening•Women aged 25–64 years that have started treatment for high-grade squamous intraepithelial lesions or invasive cervical cancer•Rate of childhood vaccination for measles Impact •Adult mortality from non-communicable diseases•Maternal mortality•Neonatal mortality•Mortality in children younger than 5 years•Rate of hospitalisation for primary-care-sensitive conditions In summary, although Argentina has achieved nominal UHC, it needs to work on reaching effective UHC. To accomplish this goal, it is necessary to include quality as a key dimension. Therefore, the Commission on High-Quality Health Systems2Kruk ME Gage AD Arsenault C et al.High-quality health systems in the Sustainable Development Goals era: time for a revolution.Lancet Glob Health. 2018; 6: e1196-e1252Summary Full Text Full Text PDF PubMed Scopus (1041) Google Scholar will surely serve as a roadmap for countries that, notwithstanding the achievement of nominal access as a starting point, still need to move forward to incorporate quality as a driving force to translate access into effectiveness. We declare no competing interests. AR is the current Minister of Health of Argentina. Adding quality to primary careThere is a word missing from the 1978 Declaration of Alma Ata: a close examination reveals that "quality", the adjective, does not appear in it. True, the stated definition of primary health care includes the notions of practicality, scientific soundness, and social acceptability, all elements of quality when referring to the provision of health care. But the omission of the actual term could almost be taken as a foretelling sign of what happened in the four decades following the Alma Ata conference—the attainment of Health for All through community-led and participative primary health care did not come as a natural evolution for most health systems, and most importantly, health-care delivery suffered from such deficiencies that poor-quality care ultimately became a more formidable obstacle to reducing mortality in low-income and middle-income countries than insufficient access to care. Full-Text PDF Open Access