Improved access to care not sufficient to improve health, as epidemic of poor quality care revealed

Insufficient access to care could hinder dividends of improved quality care in resource-poor societies, new findings from a new analysis published in The Lancet, as part of The Lancet Global Health Commission on High-Quality Health Systems – a two-year project reveals.

For example, according to the analysis, over 123,000 people die every year in Nigeria due to poor quality care, as opposed to 253,000 due to insufficient access, according to bringing together 30 academics, policy-makers and health systems experts from 18 countries who examined how to measure and improve health system quality worldwide.

Globally, an estimated 5 million deaths per year in low- and middle-income countries (LMICs) are the result of poor quality care, with a further 3.6 million the result of insufficient access to care, according to the first study to quantify the burden of poor quality health systems worldwide.

“Quality care should not be the purview of the elite or an aspiration for some distant future; it should be the DNA of all health systems,” said Commission Chair, Dr. Margaret E Kruk, of Harvard T. H. Chan School of Public Health, Boston (USA). “The human right to health is meaningless without good quality care. High-quality health systems put people first. They generate health, earn the public’s trust, and can adapt when health needs change. Countries will know they are on the way towards high-quality, accountable health systems when health workers and policymakers choose to receive health care in their own public institutions.”

While many LMICs have made significant progress in improving access to care, a new reality is at hand: poor quality care in the health system is now responsible for a greater number of deaths than insufficient access to care. The total number of deaths from poor-quality care per year is estimated to be five times higher than annual global deaths from HIV/AIDS (1 million), and over three times more than deaths from diabetes (1.4 million).

The over 8 million excess deaths due to poor quality health systems lead to economic welfare losses of US$ 6 trillion in 2015 alone. The Commission found systematic deficits in quality of care in multiple countries, across a range of health conditions and in both primary and hospital care.

Poor-quality is a major driver of deaths amenable to health care across all conditions in LMICs, including 84% of cardiovascular deaths, 81% of vaccine-preventable diseases, 61% of neonatal conditions and half of maternal, road injury, tuberculosis, HIV and other infectious disease deaths.

In a linked Comment, Dr. Tedros Adhanom Ghebreyesus, Director-General of WHO, adds: “Quality is not a given. It takes vision, planning, investment, compassion, meticulous execution, and rigorous monitoring, from the national level to the smallest, remotest clinic…. The strength of a country’s core capacities under the International Health Regulations depends on the quality of its health services. The same nurse who vaccinates children and cares for new mothers will also need to detect an unusual communicable disease. Similarly, people and communities are at the heart of quality health service delivery. We cannot talk about quality without placing them at the centre. When people are actively engaged in their own health and care, they suffer fewer complications and enjoy better health and wellbeing.”

Insufficient access to care was a proportionally greater contributor to deaths from cancer (89%), mental and neurological conditions (85%), and chronic respiratory conditions (76%), highlighting the need to increase access to care for these conditions alongside improving quality.

Poor-quality care is more common among the vulnerable in society. The wealthiest women attending antenatal care are four times more likely to report blood pressure measurements, and urine and blood tests compared to the poorest women; adolescent mothers are less likely to receive evidence-based care, and children from wealthier families are more likely to receive antibiotics. People with stigmatised health conditions, such as HIV/AIDS, mental health and substance abuse disorders, as well as other vulnerable groups such as refugees, prisoners and migrants are less likely to receive

“The impact of poor quality care goes well beyond mortality but can lead to unnecessary suffering, persistent symptoms, loss of function, and a lack of trust in the health system. Other side effects are wasted resources and catastrophic health expenditures. Given our findings, it is not surprising that only one-quarter of people in low and middle-income countries believe that their health systems work well,” adds Dr Kruk.

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