Political and technical barriers to improving quality of health care
Authors: Mishal S Khan, Farah N Hashmani
Journal: The Lancet (2018)

With the currently renewed emphasis on universal health coverage, the study by Margaret Kruk and colleagues1Kruk ME Gage AD Joseph NT Danaei G García-Saisó S Salomon JA Mortality due to low quality health systems in the universal health coverage era: a systematic analysis of amenable deaths in 137 countries.Lancet. 2018; (published online Sept 5.)http://dx.doi.org/10.1016/S0140-6736(18)31668-4Scopus (334) Google Scholar in The Lancet is a timely reminder of the need to examine inadequacies in both access to and quality of health care.2Ghebreyesus TA All roads lead to universal health coverage.Lancet Glob Health. 2017; 5: e839-e840Summary Full Text Full Text PDF PubMed Scopus (68) Google Scholar Their key finding that poor quality of health care is a major driver of excess mortality in low-income and middle-income countries (LMIC) will not surprise those working in such settings.3Hanefeld J Powell-Jackson T Balabanova D Understanding and measuring quality of care: dealing with complexity.Bull World Health Organ. 2017; 95: 368-374Crossref PubMed Scopus (129) Google Scholar However, the authors' quantitative comparison indicating that improvements in the quality of health services would have a greater overall effect on mortality than expansion of service coverage (without attention to quality) provides new evidence to inform the resource allocation strategies of health policy makers and funding agencies. Indeed, excess mortality is only one of many adverse public health effects of low-quality health care. Other effects of low-quality health care include delays in diagnosis, which can result in transmission of communicable diseases or worse patient outcomes; inappropriate use of antimicrobials, which can cause drug resistance; and the incurrence of unnecessary costs by patients and health systems.4WHOWorld Bank GroupOrganisation for Economic Cooperation and DevelopmentDelivering quality health services: a global imperative for universal health coverage.http://documents.worldbank.org/curated/en/482771530290792652/Delivering-quality-health-services-a-global-imperative-for-universal-health-coverageDate: June 1, 2018Date accessed: August 17, 2018Google Scholar, 5Chuc NT Tomson G “Doi moi” and private pharmacies: a case study on dispensing and financial issues in Hanoi, Vietnam.Eur J Clin Pharmacol. 1999; 55: 325-332Crossref PubMed Scopus (61) Google Scholar There is clearly a strong case for taking steps to tackle provision of poor-quality health care. However, we believe that this issue does not receive the attention it deserves, largely because addressing quality of care is both technically and politically complex. Health-care systems in LMIC are usually fragmented, and there are often many different types of private-sector and public-sector health facilities operating.6Khan MS Salve S Porter JD Engaging for-profit providers in TB control: lessons learnt from initiatives in south Asia.Health Policy Plan. 2015; 30: 1289-1295Crossref PubMed Scopus (19) Google Scholar These facilities range from large, modern hospitals to rudimentary for-profit laboratories in the centre of busy cities to rural roadside stalls that sell drugs and petrol. There are two key technical challenges to assessing and addressing the quality of care. First, there are inadequate basic data on the numbers and locations of health-care facilities to be assessed because there are so many health-care facilities and because of their vast geographical distribution. This challenge in compiling data on the range of health-care facilities is compounded by the limited resources available to support information systems in LMICs. Second, there are methodological challenges in assessing quality of care; such assessments would include adherence of providers to relevant clinical protocols and provider-patient interactions. Research methods into innovative health systems that involve actors performing as patients and behavioural economics-based games are being applied, but the cost and logistical challenges of doing large-scale systematic studies, especially without access to a sampling frame of existing providers, should not be underestimated.7Das J Hammer J Leonard K The quality of medical advice in low-income countries.J Econ Perspect. 2008; 22: 93-114Crossref PubMed Scopus (201) Google Scholar, 8Codlin A Javaid M Qazi F Khan M Novel methodology to assess sputum smear microscopy quality in private laboratories.BMC Infect Dis. 2012; 12: 331Crossref PubMed Scopus (5) Google Scholar The substantial political challenges in acting against low-quality health-care providers are rarely acknowledged. Quality control issues occur in the public and private sectors, often with different factors driving resistance to change. In the public sector, for instance, replacing insufficiently qualified staff in primary health-care facilities can be met with opposition by powerful local policy makers, who want to have control over allocation of civil service jobs. The politics of controlling human resource management decisions was highlighted by our experience in Pakistan's People's Primary Healthcare Initiative (Sindh), which is a public–private partnership contracted to run almost 1200 basic health units on behalf of the Pakistani Government. In this context, we found that managers received threats to their personal safety for introducing a merit-based job application system. There is growing evidence from many LMIC settings that for-profit providers often do not follow essential guidelines when diagnosing or treating patients,7Das J Hammer J Leonard K The quality of medical advice in low-income countries.J Econ Perspect. 2008; 22: 93-114Crossref PubMed Scopus (201) Google Scholar, 8Codlin A Javaid M Qazi F Khan M Novel methodology to assess sputum smear microscopy quality in private laboratories.BMC Infect Dis. 2012; 12: 331Crossref PubMed Scopus (5) Google Scholar, 9McPake B Hanson K Managing the public–private mix to achieve universal health coverage.Lancet. 2016; 388: 622-630Summary Full Text Full Text PDF PubMed Scopus (69) Google Scholar and there is limited information on a way forward that addresses power dynamics and financial interests. Very often, public-sector staff (including senior doctors responsible for influencing policy) will additionally work in or own private health facilities to supplement low government salaries, which can result in a reluctance to shut down or limit the profit-generating services of such facilities.10Peters DH Tran NT Adam T for Alliance for Health Policy and Systems ResearchWHOImplementation research in health: a practical guide.http://www.who.int/alliance-hpsr/resources/implementationresearchguide/en/Date: 2013Date accessed: August 17, 2018Google Scholar Further, taking strong measures to shut down poor-quality health-care providers could result in some regions having a sudden gap in access to any health-care provider. Local politicians who are aiming to get re-elected will be concerned that such measures could be unpopular with local communities that are unaware of the quality issues of their local providers, and that steps to curtail activities of private health-care providers might result in pressure on the government to improve public-sector services. The analysis by Kruk and colleagues1Kruk ME Gage AD Joseph NT Danaei G García-Saisó S Salomon JA Mortality due to low quality health systems in the universal health coverage era: a systematic analysis of amenable deaths in 137 countries.Lancet. 2018; (published online Sept 5.)http://dx.doi.org/10.1016/S0140-6736(18)31668-4Scopus (334) Google Scholar is therefore an important initial step in providing evidence for the substantial public health benefits of improving the quality of health care in LMICs, but action on this evidence could be impeded by a vicious cycle: there are inadequate data at national and sub-national levels about providers that are operating and about variations in their quality. In parallel, there are political challenges to shutting down or limiting services offered by some low-quality providers, which allows this issue to be deprioritised in terms of evidence generation. FNH is Deputy Director of the People's Primary Healthcare Initiative. We declare no other competing interests. Mortality due to low-quality health systems in the universal health coverage era: a systematic analysis of amenable deaths in 137 countriesUniversal health coverage for SDG conditions could avert 8·6 million deaths per year but only if expansion of service coverage is accompanied by investments into high-quality health systems. Full-Text PDF Open Access