Going further to measure improvements in health-care access and quality
Authors: Svetlana V Doubova, Ricardo Pérez-Cuevas
Journal: The Lancet (2018)

The use of comprehensive and meaningful summary metrics to track the performance of health systems worldwide in achieving universal health coverage, including access to high-quality health care, is ongoing.1Hogan DR Stevens GA Hosseinpoor AR Boerma T Monitoring universal health coverage within the Sustainable Development Goals: development and baseline data for an index of essential health services.Lancet Glob Health. 2018; 6: e152-e168Summary Full Text Full Text PDF PubMed Scopus (188) Google Scholar, 2Fullman N Lozano R Towards a meaningful measure of universal health coverage for the next billion.Lancet Glob Health. 2018; 6: e122-e123Summary Full Text Full Text PDF PubMed Scopus (12) Google Scholar, 3Kruk ME Kelley E Syed SB et al.Measuring quality of health-care services: what is known and where are the gaps?.Bull World Health Organ. 2017; 95: 389Crossref PubMed Scopus (42) Google Scholar At least two summary metrics are available: the service coverage index, which includes a set of 14 essential health services,1Hogan DR Stevens GA Hosseinpoor AR Boerma T Monitoring universal health coverage within the Sustainable Development Goals: development and baseline data for an index of essential health services.Lancet Glob Health. 2018; 6: e152-e168Summary Full Text Full Text PDF PubMed Scopus (188) Google Scholar and the Healthcare Access and Quality (HAQ) Index, which focuses on amenable premature mortality of 32 causes of death (ie, death from causes that should not be fatal in the presence of effective medical care).4Barber RM Fullman N Sorensen RJD et al.Healthcare Access and Quality Index based on mortality from causes amenable to personal health care in 195 countries and territories, 1990–2015: a novel analysis from the Global Burden of Disease Study 2015.Lancet. 2017; 390: 231-266Summary Full Text Full Text PDF PubMed Scopus (367) Google Scholar In The Lancet, Rafael Lozano and colleagues5GBD 2016 Healthcare Access and Quality CollaboratorsMeasuring performance on the Healthcare Access and Quality Index for 195 countries and territories and selected subnational locations: a systematic analysis from the Global Burden of Disease Study 2016.Lancet. 2018; (published online May 23.)http://dx.doi.org/10.1016/S0140-6736(18)30994-2Google Scholar have gone into greater depth on the topic of health-care access and quality than have previous studies of the HAQ Index. The authors used mortality-to-incidence ratios instead of risk-standardised death rates to provide a robust approximation of effective cancer diagnosis and treatment, transformed the score of the HAQ Index to percentiles to improve index stability, updated the cause of death and risk factor estimates from Global Burden of Disease 2016, applied the HAQ Index at subnational levels, and estimated the correlation of national HAQ Index levels with health financing and health system workforce and use. The global perspective of the study by Lozano and colleagues shows the magnitude of the gaps of health-care access and quality among 195 countries, and the relationship of the HAQ Index with overall development, as measured by the Socio-demographic Index (SDI). The results suggest that high-SDI countries are more able to deliver access to high-quality care than are low-to-middle-SDI countries. The foundations needed to reach universal health coverage goals include diverse arrangements of health systems within nations, prioritisation of health care in public policies, and capacity in low-to-middle-SDI countries to perform essential health system functions appropriately.6Pan American Health OrganizationStrategy for universal access to health and universal health coverage; 53rd Directing Council (CD53/5, Rev. 2). 66th Session of the Regional Committee of WHO for the Americas. Pan American Health Organization, Washington, DC2014Google Scholar Indeed, the results of this study prompt consideration of the need to rigorously investigate whether universal health coverage efforts at a local level are successful, although the adverse financial context of most low-to-middle-SDI countries must be taken into account, as well as the rapid epidemiological change that surpasses the speed of the health systems to adapt and respond. Accessible, high-quality, and efficient services should deliver improved health outcomes.7WHOHealth in 2015: from MDGs, Millennium Development Goals to SDGs, Sustainable Development Goals. World Health Organization, Geneva2015Google Scholar However, to fulfil these attributes, it should be considered that the supply and training of health-care providers of low-to-middle-SDI countries are not necessarily commensurate with increasing health-care demands and the complexity of the required services. In the past, the priorities of public health and health-care services focused on infectious diseases and maternal and child health; today, the unbridled growth of non-communicable diseases is an additional priority. Also, health systems in different countries (eg, Brazil and Colombia) show a tendency to introduce the health-care networks that integrate primary, secondary, and tertiary care, in which investments should aim at strengthening the continuum of care across the different health-care providers.8Montenegro H Holder R Ramagem C et al.Combating health care fragmentation through integrated health service delivery networks in the Americas: lessons learned.J Integr Care. 2011; 19: 5-16Crossref Scopus (49) Google Scholar The study by Lozano and colleagues provides a comprehensive measure of the progress and the magnitude of the gaps among and within countries to provide accessible, high-quality health care. The results underscore the importance of local monitoring and benchmarking, which is crucial to guide health policies in large and decentralised nations (eg, Mexico and Brazil), where different obstacles impair the bridging of disparities in health status and the provision of health care. Another noteworthy finding is that in high-SDI countries, HAQ Index results were more consistently related to total health spending per capita, whereas low-to-middle-SDI countries had a more varied performance. Therefore, a question remains to be answered: where and how could resources be allocated more efficiently? Although the health budgets of most countries have grown in past decades, their ability to use resources more efficiently have not improved, or are poorly documented. Besides the limitations that the authors recognise, it is clear that the HAQ Index faces methodological and practical challenges for its applicability and interpretation in the context of the diversity of health systems throughout the world. It would be worth learning whether the national health authorities use the results of the HAQ Index as a proxy to measure the performance of health systems and to guide health policies. The study by Lozano and colleagues confirms the notion that health systems must reinforce their capacity to strengthen governance of quality of care, facilitate innovative models of health care that provide continuous and coordinated care, and encourage training programmes for health professionals on evidence-based and patient-centred care. The worldwide view of this study is useful to guide the policy dialogue at an international level, and to better target the allocation of technical and financial resources at national and subnational levels to improve access and quality of care in the context of the universal health coverage efforts. We declare no competing interests. Measuring performance on the Healthcare Access and Quality Index for 195 countries and territories and selected subnational locations: a systematic analysis from the Global Burden of Disease Study 2016GBD 2016 provides a more detailed understanding of past success and current challenges in improving personal health-care access and quality worldwide. Despite substantial gains since 2000, many low-SDI and middle-SDI countries face considerable challenges unless heightened policy action and investments focus on advancing access to and quality of health care across key health services, especially non-communicable diseases. Stagnating or minimal improvements experienced by several low-middle to high-middle SDI countries could reflect the complexities of re-orienting both primary and secondary health-care services beyond the more limited foci of the Millennium Development Goals. Full-Text PDF Open Access