Expanding Access to Care

As countries are reforming their health care systems, they are giving special attention to incorporating UHC into their objectives. A number of LMICs in Africa, Asia, and Latin America have made substantial progress in their efforts to expand coverage to all population groups. Among the countries that have achieved what can be regarded as UHC systems are Mongolia, the Philippines, Sri Lanka, and Thailand in Asia; Gabon, Gambia, Ghana, and Rwanda in Africa; and Argentina, Chile, Costa Rica, and Cuba in Latin America. Varying levels of health care investment exist in these countries—from $56.66 annually per capita in Rwanda to $29.11 in Costa Rica in 2015 (World Bank, 2018).

Although access is a necessary condition for achieving high-quality care, however, in no way does it guarantee quality. Costa Rica's massive primary care reform of the 1990s, discussed in Chapter 3, helped reduce child and adult mortality by 13 percent and 4 percent, respectively, for every 5 years the reform was in place, compared with areas not yet covered (Starfield et al., 2005). Access was certainly part of the country's strategy, but Costa Rica went beyond access to realize these gains in health outcomes. This is not to minimize the importance of access, however, especially for those patients with complex chronic illnesses. For these patients, access to specialized care can have dramatic effects on their lives. For example, the Vajpayee Arogyashree Scheme (VAS), a social health insurance strategy in India for households below the poverty line, was rolled out in an area with more than 61 million people. Research found that VAS users had lower mortality rates thanks to increased care utilization, better-quality facilities, and earlier diagnosis (Sood and Wagner, 2018).

Reducing the Financial Burdens of Health Care

Since one of the goals of UHC is to reduce the financial hardship associated with health care, it is expected that, regardless of the quality of services in a system, high costs of care are being reduced. A key indicator to consider is the incidence of catastrophic spending.¹ Yet, even in the face of the global momentum of and political commitments to UHC, the incidence of catastrophic OOP spending globally has actually increased since 2000 at all household expenditure thresholds (WHO and World Bank, 2017; World Bank, 2016b).

Achieving effective UHC can help reduce this financial burden of health care. In the 1980s and 1990s, OOP payments became a more common method for paying for health care. Yet, of the $500 billion generated by user fees annually worldwide, the World Bank estimates that 40 percent is wasted (The Economist, 2018). A 2009 Rockefeller Foundation report notes that this type of spending is “the most inequitable and inefficient form of financing for health care, leaving patients” without access and further impoverished (Lagomarsino et al., 2009). Moreover, relying on high OOP payments, regardless of income level, violates the spirit of UHC by driving people into poverty and can make the achievement of effective UHC impossible. A high incidence of OOP payments in regions with low domestic funding for health care increases the fragility and instability of health systems and leaves many households vulnerable to financial catastrophe and impoverishment (Okungu, 2015). For millions, the financial burden can cause them to forego needed health care and potentially to become sicker (Xu et al., 2007). In India, for example, OOP payments account for 70 percent of health care services and are responsible for the impoverishment of 7 percent of the population (Ravi and Sood, 2018). One of the reasons why the VAS example described in the previous section was successful was that it reduced the financial hardship of tertiary care for those in the program, and at a reasonable cost to taxpayers: VAS-eligible households reported 60 percent fewer OOP expenditures for hospitalizations (Sood and Wagner, 2018).

For most people without access to such insurance schemes, high OOP expenses mean that families must provide a large sum of money (relative to their incomes), using multiple avenues, before accessing care. In some parts of the world, requirements for OOP payment deviate so completely from any type of functioning financial system that they lead to detention in the hospital of patients unable to pay, with an appallingly negative impact on the quality of care received. For example, in the Democratic Republic of the Congo (DRC), approximately 54 percent of mothers at one health care facility were detained after failing to pay medical fees for giving birth (Yates et al., 2017). Although they may receive care, these patients are detained for weeks or even months afterward, without continued care, food, or even a bed (Amon, 2015). Box 7-1 describes the example of a detained woman in Uganda. And while many are quick to condemn this practice, as it is certainly a human rights violation and clearly goes against the SDGs and the goals of UHC, the factors contributing to the practice are multifaceted, complex, and not easily resolved without dedicated resources and political leadership.

BOX 7-1

Case Study: Patient Detention.

A cornerstone of UHC should be to end patient detention (Otremba et al., 2015), but doing so is not a simple task. Without a global budget from a national system or mechanisms for insurance and reimbursement, health care facilities naturally rely on user fees to stay open and provide care; otherwise, facilities would go bankrupt themselves, leaving the community without access to care. One option is subsidizing fees based on income level so that OOP payments are not catastrophic for patients and their families, but the health care facility can continue operating. For example, committee members visited hospitals in Goma, DRC, and learned about a community-based health insurance scheme initiated by the Church of Christ in the Congo Baptist Church in 2016. With little investment from the national level, hospital revenues rely on patient user fees to operate. Yet, because the population is very poor, these revenues are often not enough to cover even hospital overhead, such as employee salaries and general infrastructure maintenance. To stay afloat, hospital leaders are hoping to generate more revenue while offsetting the financial risk to patients through this contributory scheme, but doing so will require a concerted and long-term effort. As of December 2017, this effort had resulted in the enrollment of nearly 5,000 members from two districts, with the insurance covering 90 percent of a standard package of services and patients being responsible for the other 10 percent.² However, even a 10 percent copayment can be problematic for some families, and without additional funding to subsidize the pool of payments, making this effort sustainable will be an ongoing challenge.

Even when such efforts to make medical care affordable are made, patient detention can still occur. For example, China recently rolled out an ambitious $130 billion package designed to ease the financial burden of health care. Nonetheless, many hospitals still demand payment under threat of detention, reminiscent of corrupt practices described in Chapter 6. A common practice in China is for hospitals to place newborn babies in holding, preventing new mothers and parents from seeing them until payments are made. With fees totaling up to $19,000, these separations can be prolonged while families try to find the money, which can be especially dangerous with respect to breastfeeding of the babies (Wee, 2018).

Changing this practice of patient detention will require systematic thought, commitment to reform, and mobilization of resources. In Burundi following advocacy against patient detention, for example, user fees for young children and women in labor were eliminated. But with no plan in place to substitute for these lost resources, facilities experienced frequent drug shortages, reduced quality of services, and strain on health care providers (Nimpagaritse and Bertone, 2011). Worse still are the unintended consequences of hospitals refusing to provide care—even emergency care—until a patient can pay. This situation is tragically illustrated by a recent example in Cameroon, where a pregnant woman was turned away at a first hospital that claimed it could not offer the care she needed and then denied service at a second hospital upon arrival with insufficient funds. Following this denial of service, she died on the doorstep of the second hospital while her family member attempted to retrieve her unborn twins from her body (Berlinger, 2016).

Such examples highlight how crucial it is to design the system and financing of health care in a way that ensures quality of care and discourages such deadly practices. While providing care regardless of funding might be considered a step in the right direction, it is not justified if receiving that care sends patients further into poverty and compromises their human rights. Financial support of hospitals is imperative, but many countries will have to grapple with the reality that resources are finite, and thus will need to balance the priorities of funded health care, improved roads, investment in education, and other determinants that may in fact impact population health. These are important trade-offs that countries will need to consider, together with their citizens, clinicians, and other stakeholders, to design the right system. Regardless of the amount of funding directed at health, the focus needs to shift from reliance on OOP payments toward government and private-sector support, in partnership, to achieve UHC. Quality safeguards and assurances need to be incorporated into care offerings. For those populations living in the fragile contexts described in Chapter 5, more global and multipartner solutions will be necessary.

The Insufficiency of Access and Financial Protection to Ensure Quality

As detailed above, while both access to care and protection from financial catastrophe are critically important for keeping people healthy and out of poverty, they are not enough to truly meet the ambitious goals of UHC. Providing access to care that is of sufficient quality requires a focus on the specific dimensions of quality, as outlined in Chapter 1. The end goals are impacted by what is being monitored and evaluated, and if the number of people accessing care and not encountering financial hardship is all that is being measured, many important elements within the dimensions of quality can be missed, leading to situations in which poor or ineffective care is provided for months or years unnoticed. In 2013, for example, Kenya abolished user fees in public health care facilities in hopes of increasing utilization rates, especially for maternal health care. While this strategy was successful in increasing utilization, which rose significantly for 2 years, maternal and neonatal mortality rates remained unchanged (Gitobu et al., 2018)—this increased access to services did not come with a commensurate increase in human resources, medical supplies, and infrastructure (Otremba et al., 2015). Furthermore, the loss of revenue that results from eliminating user fees, unless replaced by public funding or a mechanism for reimbursement, can lead to worsening quality. All of these issues need to be considered for their quality implications before efforts are made to increase access and utilization (Hercot et al., 2011). This is a key example of the need to link access to quality and to undertake coverage and quality improvement efforts in parallel.

With similar goals of prioritizing access, India created the Rashtriya Swasthya Bima Yojana (RSBY) program in 2008 to provide the rural poor with access to health care. To become empaneled RSBY providers, facilities—whether public or private—must meet certain requirements. Once people have their RSBY card and are enrolled, they can use their card at any empaneled facility, but only for inpatient costs (Upneja, 2015). In practice, however, barriers prevent this from being a successful high-quality program. Empaneled hospitals are located too far from villages to be effective; even if every inpatient hospital close to villages were empaneled, 63 percent of the rural population would still need to travel more than 5 kilometers to access inpatient care (Aitken et al., 2013). The goal of reducing the financial burdens of care for families has been shown to yield mixed benefits as well, with one analysis showing that RSBY provided no significant financial protection for poor households (Karan et al., 2017).

At the same time, however, a perhaps tertiary benefit of this program is that it collects large amounts of claims data with which to conduct evaluation and continual feedback for iterative quality improvement. Currently, the way the data are collected does not automatically make the program a good opportunity for this research, although the potential opportunities certainly exist (Morton et al., 2016). If the right efforts were undertaken using co-design approaches discussed earlier in this report, and if the metrics and indicators used were accurate reflections of quality care and health outcomes, the data collected could offer valuable insight into where resources should be targeted, and the program could be greatly strengthened. Researchers note that the absence of an accepted quality framework and national benchmarks in India remains a key constraint to adequate data capture and systematic quality measurement (Morton et al., 2016), although the recent introduction of a national patient safety framework suggests that changes may be on the horizon (Indian Ministry of Health and Family Welfare, 2017).

Public–Private Partnership

Experts have long debated whether private or public health care is the better answer to the world's health problems. Some believe that private health care markets will fail because key preventive and public health services often are not valued in a market transaction, and patients' lack of knowledge and health literacy can leave them vulnerable to overprescription and excessive use of diagnostics (Hanson et al., 2008). Some studies have found private care to be better than public care, while others have found the quality of care in private markets in LMICs to be very low as the result of a poor knowledge base and a lack of effort among doctors (Das et al., 2008). Studies have noted such shortcomings as private providers being less likely to prescribe oral rehydration therapy (ORT) and more likely to prescribe antibiotics (Wagner et al., 2015), newborns being less likely to receive Bacille Calmette-Guerin (BCG) vaccination in a private hospital (Sood and Wagner, 2013), and private patients less likely to be tested for HIV (Sood and Wagner, 2013).

Others have argued that no “public” system is entirely separate from the private sector when it comes to drugs, equipment, and innovation, even to the point of a blended workforce. Das and colleagues (2016) found that doctors who worked in both public and private settings in India (an arrangement that is fairly common in many countries) provided higher-quality care in the private than in the public clinics. On the whole, incentives in the public sector are no better aligned than those in the private sector to provide high-quality care. However, positive associations have been shown between government stewardship and the quality of clinics and hospitals—as demonstrated in Ghana and Kenya, where comprehensive government engagement with health care providers can be influential (Spreng et al., 2014). More research is needed to see which specific engagement strategies are most impactful. While this debate will surely continue, a much stronger evidence base on private-sector engagement is needed to enable better understanding and inform decision making for UHC schemes. It will be difficult for countries to achieve effective UHC without involving the numerous private-sector companies and providers that deliver care.

The committee was curious as to whether a business case can be made for investing in quality that would drive the private sector to improve quality for its own economic benefit. The evidence here is also mixed. Unfortunately, no peer-reviewed studies have directly evaluated the business case for quality among private providers in LMICs. Analyzing case studies on whether quality improvement costs or saves money, Leatherman and colleagues (2003) found an unclear mix. In most cases, the patient accrued a benefit, and stakeholders benefited from predictable cost savings in the long-term. However, the investor had negligible or uncertain financial returns, making the “business case” ambiguous. This was so in part because patients/consumers were unable to discern quality differences, and in part because quality improvement required using services that were not easily billable to any payer. If benefits to patients and other stakeholders apply at a larger scale, the uncertain “business case” calls for payment reforms and policies that “reward organizations that are willing to invest in quality” (Leatherman et al., 2003). The empirical evidence on this issue is supported by theory that says quality will be underprovided in markets with asymmetric information where sellers know more about quality compared with buyers (Lagomarsino et al., 2009).

Clearly, then, there is a need for systematic investments in improving the quality of care in both the public and private sectors, often in partnership. Both sectors bring strengths and weaknesses, and countries need to bring the two together to work within their own national contexts and address their own priorities to build the right UHC system.

Tapping the Private Sector

Studies have examined very few financing and incentivizing strategies for improving the quality of care provided by the private sector, whether supported by insurance or OOP payments. The authors of a 2017 working paper from the Center for Global Development did study the effectiveness of input and output incentives for private health care providers with different skill levels in India (Mohanan et al., 2017). Focusing on maternity care, the authors found that both input and output incentive contracts resulted in a more than 20 percent reduction in postpartum hemorrhage (PPH). Additionally, they noted that with output incentives, those providers with higher skills were able to achieve large reductions in PPH, but those with lower-level skills and training failed to do so. The rate for both groups was the same with input incentives, showing that pay-for-performance schemes could focus on input incentives regardless of skill levels.

Another key financing component that can improve the quality of services is strategic purchasing (Cashin et al., 2018). Strategic purchasing, as opposed to passive purchasing, makes use of information on performance and a payment mechanism that incentivizes certain behaviors and results, such as improvements in health system performance, improved efficiency in resource use, and improved quality (Cashin et al., 2018). Strategic purchasing involves decisions on what services to buy, what service providers to choose, and how and how much to pay providers (Figueras et al., 2005). These decisions would be optimally supported by such mechanisms as monitoring the performance of providers and knowing the different institutions that have purchasing functions. Goldfarb and colleagues (2003) identify six key means by which purchasing ensures quality of services:

• collecting accurate information on provider or health plan performance;
• contracting with providers that meet the quality threshold as defined;
• partnering with providers or health plans to improve quality;
• promoting “Six-Sigma” quality, an industry-based model for minimizing errors and waste;
• enhancing consumer awareness and understanding of quality services; and
• using incentives to reward or punish providers of poor-quality services.

The committee encountered several anecdotal examples of successful high-quality care delivery by private providers that could be replicated. For example, PurpleSource in Nigeria, a private integrated health care provider, set its own goal of improving access to quality primary health care services. It used partnerships to minimize the risk of counterfeit medications and used accreditation within its clinic network for quality assurance. With a deep customer development focus and using a hybrid strategy of improving efficiencies, leveraging economies of scale, centralizing management, and lowering costs without compromising quality, it applied lean execution methods with multiple pivots until it started seeing results (Sunmonu, 2017) (see also Box 2-2 in Chapter 2).

In another example, Narayana Health in India has been able to deliver high-quality services at affordable cost through such process innovations as configuring assets in a hub-and-spoke model facilitated by telemedicine and increasing the quantity of services provided (Govindarajan and Ramamurti, 2013). Narayana Health performs more open heart surgeries than anywhere else in the world, also increasing physician productivity; surgeons at Narayana perform 400–600 procedures per year, compared with 100–200 in the United States (Taylor et al., 2017). Similarly, providers in another system in India, Aravind Eye Care, perform high numbers of eye surgeries (McKinsey's Health Systems and Services Practice, 2011). This high volume of procedures makes it possible to develop and continually update protocols for patients of varying risk levels, enabling specific and evidence-based care for every type of patient. Both of these hospitals have also used task shifting to maximize efficiency and ensure that all providers perform only “tasks they are uniquely qualified to do” (i.e., working at the “top of their scope of practice”) (McKinsey's Health Systems and Services Practice, 2011; Taylor et al., 2017).

Policy and Financial Levers to Institutionalize Quality

A variety of mechanisms, especially for mixed health system stewardship, can be used to incentivize meeting quality-of-care goals among multiple players in the system (see Figure 7-1). These mechanisms have produced good outcomes in a variety of high- and middle-income countries, but have yet to be adopted in low-income countries. Pooled financing models influence health care quality in the private sector in many ways, but when they are paired with strategic purchasing, an insurer can develop a “network of preferred providers for insured patients to choose from” (Lagomarsino et al., 2009, p. 22). Through this model, insurers can assure quality by providing clinical protocols and training to approved providers and mandating that they meet basic quality standards (Lagomarsino et al., 2009). This approach can be taken a step further through pay-for-performance models that use financial incentives to foster additional quality improvements (Gottret and Schieber, 2006). If the levels of quality are not maintained by a provider, the insurer can remove that provider from the network or take other actions, such as withholding payments.

FIGURE 7-1

A conceptual model for mixed health system stewardship. SOURCE: Lagomarsino, G., S. Nachuk, and S. S. Kundra. 2009. Reprinted from Public stewardship of private providers in mixed health systems: Synthesis report from The Rockefeller Foundation-sponsored (more...)

In addition, these types of active, or strategic, purchasing measures can enable cost containment, align services with population needs, and balance provider payment. Thailand's UHC scheme, for example, practices active purchasing to control costs while also being responsible for achieving impressive health outcomes (Okungu, 2015). In fact, government health expenditures in Thailand total only 3 percent of its gross domestic product (GDP) (Limwattananon et al., 2013), and the country has met the WHO recommended threshold of less than 20 percent of total health expenditures as OOP spending (Xu et al., 2010).

To identify the best options for policy and financial levers and their available evidence, the committee conducted a rapid review of current research on strategies for health care improvement being tested in countries (see Appendix B for the review protocol). More than 100 studies were analyzed for their impacts on health outcomes. The committee found that the evidence is mixed across many interventions and several countries and continents. Thus, there is clearly a need for additional research on potential interventions to show how they can be implemented sustainably at scale. (Note that the examples from various countries presented in boxes throughout this section are intended to provide additional context, but they were not included in the rapid review and should be considered separate examples of these types of incentives.)

Accreditation

Accreditation is a common mechanism for improving the quality of facilities, both within and outside the health sector around the world. The committee considered several studies, including a systematic review examining accreditation as an intervention for quality, in this review (Al Tehewy et al., 2009; Devkaran and O'Farrell, 2015; Halasa et al., 2015; Ng et al., 2013; Peabody et al., 2008; Saut et al., 2017). Collectively, the studies reviewed investigated the impact of accreditation on quality improvement, organizational and financial factors, process and health outcomes, hospital quality activities and measures, level of quality, and patient and provider satisfaction.

Saut and colleagues (2017) found that accreditation status in Brazil was significantly associated with patient safety and quality management activities. Similarly, Halasa and colleagues (2015) found that accredited hospitals compared with nonaccredited hospitals in Jordan had decreased rates of readmission to the intensive care unit (ICU) in 24 hours, reduced staff turnover, and improved completeness of medical records. Peabody and colleagues (2008), using clinical vignettes to calculate quality scores, found that accredited providers and institutions in the Philippines scored higher than nonaccredited facilities. Lastly, Al Tehewy and colleagues (2009) found that accredited health centers in Egypt had higher patient and provider satisfaction and performed better on patients' rights, information systems, compliance with care standards, and recording of patient visits in records. Although not included in this review, two nationwide accreditation programs, in Turkey and Jordan, are described in Box 7-2.

BOX 7-2

Examples of Nationwide Accreditation Programs Designed to Improve Quality.

These positive results, however, need to be qualified. Although Saut and colleagues (2017) found positive associations with accreditation, they did not find a correlation between accreditation and monitoring of safety goals, nor did they measure outcomes. Ng and colleagues (2013) found clinical impacts that included improved patient safety, reduced medical errors, and increased public reporting. However, some findings contradicted these results, which were not deemed to provide strong evidence for the use of accreditation. Devkaran and O'Farrell (2015) found perhaps the most mixed results. They analyzed the impact of accreditation on a set of quality measures that included patient assessment, laboratory safety, surgical procedures, medical errors, anesthesia and sedation use, use of and access to patient records, infection control, reporting of mortality and morbidity, and safety goals. While they found a significant improvement in quality leading up to accreditation, 26 percent of the measures had reduced scores postaccreditation, with only 2 percent showing improvement.

Ng and colleagues (2013) also report on a variety of factors that can affect the impact of accreditation on quality improvement. Teamwork culture, for example, is important for the willingness of staff to undertake improvement efforts, and if supplemented by leadership, can increase the likelihood that accreditation will advance quality improvement.

Overall, the studies reviewed provide a growing base of evidence that accreditation can create a safety and quality culture in addition to yielding real improvements in health outcomes. However, the study results are mixed. Peabody and colleagues (2008) attempted to investigate these mixed results, but their study's small sample size made it difficult to do so. Overall, the results do not support accreditation as a tool for quality improvement in all settings, nor do they support its use for quality improvement in isolation. The latter point is crucial. Although not always the case, third-party payers may contract exclusively with accredited institutions. Yet, the influence of accreditation standards is not fully explored in the literature. There is a chance that meeting these standards is merely done as a formality and not as a result of a quality improvement culture. Additional research is needed on how accreditation can create a quality improvement culture, on the linkage between accreditation and clinical indicators, on compliance with the standards, and on innovative ways to track improvements (beyond standards set by accreditation requirements).

Pay for Performance (P4P)

Whether the various financing strategies in use in health systems around the world have significant impacts on quality remains uncertain. Among these, P4P has been the subject of extensive research using a mix of methods and has been analyzed across several systematic reviews (Eichler et al., 2013; Suthar et al., 2017; Witter et al., 2012). While P4P has been shown to improve utilization of services, quality of care, and patient outcomes, the strength of the evidence is weak, and more studies with strong research designs are needed to understand the impact of P4P on quality of care. Furthermore, given that P4P is not a uniform strategy and can involve making several design choices, more studies are needed to document the implementation of P4P programs. Lastly, more studies are needed to understand the potential unintended consequences of P4P schemes. Box 7-3 describes examples of P4P schemes in different countries and their effects on quality (although these studies were not included in the committee's rapid review).

BOX 7-3

Pay-for-Performance Schemes.

Other Mechanisms for Financing Health Care

The starting point for health care financing is understanding what is possible and what level and mix of funding are available, what the channels are for health care expenditures, and how sustainable they will be over time (Xu et al., 2018). The main sources of revenue for health care systems are currently tax revenue, mandatory social health insurance contributions, voluntary private insurance, or a mixed system (World Bank, 2016a). Public sources can include government revenue, social security contributions, and even external resources from international donor countries and organizations. However, some countries, even those of low-income status, elect to provide national health insurance instead of directly providing care, and can build in methods for ensuring that the insurance is used only where services meet quality standards. An example of a national health insurance fund is Rwanda's CBHI program, referred to previously with respect to its use of the “mutuelle,” which is based on a partnership between the national and local governments (through their districts) and the community (see Box 7-4).

BOX 7-4

Case Study: Rwanda's Community-Based Health Insurance Program (CBHI).

A Framework for Improvement in Health Care Quality

Clearly the path to effective UHC is not straightforward, and every country encounters challenges along the way, especially in covering its poorer populations, who often work in the informal sector and thus lack access to typical employer insurance. The committee understands that the pursuit of UHC is a difficult and multifaceted process, but again strongly emphasizes the need to include and evaluate quality along with the important issues of access, coverage, and financial protection. Much of the research conducted throughout various health systems is focused on the results of efforts addressing access, equity, and utilization rates. Very few studies have looked at health outcomes, patient or family well-being, or other quality indicators, making it difficult to understand which approaches result in higher-quality care and better health for populations, versus cost savings or improved efficiency.

Regardless, knowing that most countries will have a mix of insurance, government, and private-sector roles in health care, a framework is needed to understand how quality, coverage, and financial protection can be considered and accounted for as systems reform. Mate and colleagues (2013) developed a framework for improvement in health care quality that considers how insurers interact with other stakeholders to promote a cohesive national strategy within a country (see Figure 7-2). This framework can serve as a guide to policy makers as they think about quality improvement in the context of UHC. Depending on the country and employment demographics, the disease burdens, and the political leadership, the mix of options in the “ideas” and “execution” circles of Figure 7-2 will differ. But regardless, the stakeholders that need to contribute “will” to improvement efforts are likely the same, and within the same context of working to improve the quality of health care for their populations. Yet, political will for improving quality may occur slowly without adequate advocacy and public demand. The following are some of the questions policy makers need to ask in seeking to advance improvement:

FIGURE 7-2

Framework for improvement in health care quality. SOURCE: Mate et al., 2013.

• Do we have leadership and will to improve health care quality?
  • Is improving health care quality a national priority?
• What are we doing to motivate and equip health care professionals to improve quality?
  • Do providers have the technical skills to provide high-quality care?
  • Do providers have the right incentives? Are higher-quality providers rewarded in terms of prestige, reputation, or financial benefit?
  • Are providers working in learning health care organizations that have a mission to improve quality of care and empower providers to do so?
  • Do providers have access to decision support tools based on evidence-based guidelines?
• What are we doing to activate patient demand for quality?
  • Do patients have adequate health literacy?
  • Do patients understand what level of care is to be expected?
  • Do patients understand the consequences of poor-quality care?
  • Do they have the tools and resources to distinguish between high-quality and poor-quality providers?
  • Do they have the ability to choose high-quality rather than low-quality providers?
  • Is high-quality care affordable?
• Are payers focused on improving quality?
  • Does insurance cover high-quality care?
  • Are we using selective contracting and provider payment to improve quality?
  • Are payers monitoring quality and reducing the use of inappropriate or poor-quality care?
• Do we have a regulatory or legal framework for ensuring access to high-quality care?
  • Do we have a robust system for licensing and accreditation of providers?
  • Do we have a system for reducing counterfeit or substandard products?
• Do we have the leadership and organizational structure to provide quality health care?
  • Do different parts of the system coordinate care?
  • Is there accountability?

Leadership and Stewardship

Leadership for quality can manifest in different ways. In the case of Nigeria, the success of the National Quality Strategy (NQS) is attributable to the involvement of the leadership of the Federal Ministry of Health (FMOH) and its broad group of stakeholders in the strategy's implementation (Wickham et al., in press). Stakeholders represented regulatory agencies, implementing partners, the private sector, and patient groups. The many different workshops, meetings, interviews, and activities undertaken by the FMOH and nongovernmental organization (NGO) partners helped increase the demand for high-quality care. Stakeholders who were engaged from the beginning are now starting to carry out their own quality-of-care initiatives in line with the country's overall strategy, ranging from accreditation regulations, to patient empowerment through information access, to compulsory data reporting (Wickham et al., in press). Stakeholders reported a clear commitment at the state level and increases in demand, openness, and trust—all likely contributing to the success of the NQS implementation. However, it was national-level leadership and commitment from the Minister of State for Health that drove the success.

On a broader scale, in addition to commitment from leadership and a clear vision for improvement, country experiences have shown that structures at the national, regional, and hospital levels are needed to coordinate and lead the implementation of activities related to a national strategy (Wickham et al., in press). During Ethiopia's journey toward an NQS, for example, the federal government established a new Health Service Quality Directorate. A Steering Committee for National Quality was also created to convene multiple stakeholders and agencies on a regular basis to review progress in implementing the NQS. Furthermore, the country is developing a Quality Technical Working Group to bring together a broader set of partners supporting quality-related work. This example is being duplicated at the subnational level, with quality units being formed within regions; focal persons being assigned to coordinate implementation at the zonal level; and hospitals and health centers, respectively, being expected to have quality units and committees (Wickham et al., in press). Further supporting these newly established structures will be well-trained experts in quality who are able to operationalize the strategy and continue to iterate in a continual improvement process. This expertise, if not found in house, can be sought through linkages with academia and other health partners. Government structures and dedicated personnel, however, will have limited effectiveness if there is high administrative turnover or loss of institutional memory.

Beyond commitment and the establishment and maintenance of government structures, the success of UHC designs and payment systems will depend on the political acceptability and sustainability of the financing system. In fact, it has been found that UHC is less likely in societies with low social solidarity (e.g., political or economic divisions) (Stuckler et al., 2010). The institutional universalism described by Okungu and colleagues (2018) as making a noncontributory financing approach successful requires a high level of collective responsibility among the population, which in some countries, regardless of income level, is difficult to imagine.

National Quality Policy and Strategy Development

With so many countries at various stages of quality control and improvement and a clear need for many systems to deliver better care, WHO recently developed a handbook with country-level input to support those countries interested in improving their health care systems (WHO, 2018a). While improvement is traditionally viewed as a linear process, the handbook makes an argument for moving toward a more triangular or circular process whereby “implementation experience drives policy and strategy development [and] can build a sense of ownership among those implementing to ensure products are grounded in realities” (WHO, 2018a, p. 11). This argument aligns with the committee's call for systems thinking, integrated co-design, and meaningful engagement with stakeholders in evaluating and improving any health care process, as outlined in the design principles presented in Chapter 2 of this report. Ongoing relationship building and engagement with the entire health care team, including patients and families and blending top-down and bottom-up approaches, are needed to ensure that interventions tested in the real world are being incorporated into policies and strategies.

The WHO team reviewed more than 20 existing quality strategies across LMIC settings in developing the handbook, which is intended to guide countries in the development and implementation of their National Quality Policy and Strategy (NQPS). The process is organized into three stages: policy development, strategy development, and tools and resources. Eight key elements are identified as requirements in the policy and strategy development stages: (1) national health priorities, (2) local definition of quality, (3) stakeholder mapping and engagement, (4) situational analysis, (5) governance and organizational structure, (6) improvement methods and interventions, (7) health management information systems and data systems, and (8) quality indicators and core measures (see Figure 7-3). This committee endorses that list.

FIGURE 7-3

The eight elements of a National Quality Policy and Strategy. NOTE: NQPS = National Quality Policy and Strategy. SOURCE: WHO, 2018b.

Because the handbook is intended for use by authorities, stakeholders, and external partners involved in the development of an NQPS, the guidelines account for the fact that countries are in different stages in the development and implementation of national initiatives. The handbook provides guidance on how to develop a national quality policy, either as a stand-alone document or incorporated into the overall national health policy.

The policy development stage of the process aims to acknowledge the existing systems and factors that will contribute to the national quality policy. The handbook states that the national policy should be based on agreed ambitions that should intentionally become the agreed course of action (WHO, 2018a). The strategy development stage entails the process by which the policy is enacted. It should include a time frame for the various activities to be launched and consider and plan for the various practical concerns that may arise when translating the policy into action. The same eight elements included in the policy development stage should also be applied in this stage, and even simultaneously when appropriate. WHO acknowledges that advocacy efforts may be required to incorporate goals and priorities related to quality successfully across the health care system and ensure that they are present in national health planning and budgeting in addition to the NQPS. This, again, will require commitment and political will from the highest levels of leadership—whether at the level of a health care facility, care delivery network, or national government entity (WHO, 2018a). The “Tools and Resources” section of the handbook describes how to access and select the tools needed to implement and sustain successful NQPS strategies.

A strength of the WHO handbook is the adaptability of strategies to countries regardless of their stage in the design and implementation of an NQPS (WHO, 2018a). For example, Ghana developed an NQPS for 2017–2021 through a collaborative approach, led by a steering committee, managed by a Ministry of Health team, and evaluated by patients and providers (Ghana Ministry of Health, 2016). This collaborative effort is intended to encompass the entire health care system, categorized by country priorities: maternal health, child health, malaria, epidemic-prone diseases, NCDs, mental health, and geriatric care. Included are measures of improvement in health outcomes, strengthening of systems, and patient-centeredness. The guiding principle of the strategy is to improve health care coordination, so it incorporates the public and private health care sectors, emphasizes partnership with patients and providers, and establishes feedback loops to guide quality improvement at all levels (Ghana Ministry of Health, 2016).

Not every country's policy and strategy will be the same. Depending on the emphasis placed on certain areas—based on national priorities—plans will manifest differently to address certain gaps. The selection of goals may also be related to recent outbreaks or events that are fresh in a country's collective mind. For example, Ethiopia's ultimate aim is to “consistently ensure and improve the outcomes of clinical care, patient safety, and patient-centredness, while increasing access and equity for all segments of the Ethiopian population, by 2020” (WHO, 2018a, p. 35). Namibia's strategy, on the other hand, is aimed instead at providing a framework for the implementation of quality management initiatives at all levels using four key objectives as a guide: (1) improve quality management systems and accountability, (2) ensure client-centered care and empowerment of consumers, (3) improve patient and health worker safety, and (4) improve clinical practice (WHO, 2018a). Different still, is the strategy of Sudan, where quality is defined as “providing the best possible patient-centred care using available resources and evidence-based practice” (WHO, 2018a, p. 36).

Accountability

These processes of quality improvement are thoughtful methods of care management. During his testimony to the committee in Nairobi, Maina Boucar, from University Research Company's Regional Office for Francophone Africa, highlighted several instances of low-resource countries implementing quality improvement efforts with corresponding success. He noted that tangible improvement is possible where leadership is strong, but that these types of interventions cannot be seen as an external effort, and need to be owned by and implemented within organizations. He stressed that accountability for this improvement and assurance of quality is crucial. One of his final reflections was on how to gain buy-in from local leaders and managers, as well as solicit the voices of consumers, to achieve the long-term sustainability of these quality efforts, which otherwise would certainly be in question.

The authors of a 2009 report on public stewardship of private providers in mixed systems also support the notion of accountability, and highlight the importance of “educating and incentivizing patients to demand the most beneficial services,” increasing the “supply of high-quality services,” and reducing “inappropriate provider behavior” (Lagomarsino et al., 2009, p. 6). Examples of such educating and incentivizing interventions include social marketing; conditional cash transfer; rural cooperatives; and trusted sources of knowledge within the community, such as consumer associations or citizen complaint lines. At the core of these efforts, however, is the aim to build health literacy.

Use of Coverage to Develop Learning Health Systems

Aside from OOP payment schemes, the majority of health systems are backed by some type of insurance coverage or government or donor investment. Health system leaders need to think about how this funding for health care facilities and providers, often as reimbursements for services, can be leveraged for improved quality. As discussed in this chapter, there are contractual and other mechanisms that can be used to build quality assurance and improvement into coverage systems, but they need to be supported by strong political commitment and leadership, as well as accurate metrics and measurement to demonstrate effects on quality and health outcomes. To be most effective, these metrics should be tracked over time, not just at a single point in time, to show rates of improvement. Those measuring and tracking also need to be sensitive to how the results are being used, ensuring that they are being used to drive continual improvement, incentives, and feedback, not for punishment and reprisal.

Using the previous example of PurpleSource in Nigeria, its leaders realized that achieving their goal of access to high-quality primary care services for mostly poor and informal workers in their network would be a long-term effort. As part of that process, they employed the principles of co-design and human-centered design discussed in Chapters 2 and 3 to include their employees in the design and implementation of any new experiments or changes in care delivery. They also spent time learning about their patients and where bottlenecks existed in the patient journey and the health care delivery process that were costing money and leading to poorer health outcomes. From these efforts, they were able to define a small set of traction metrics and focus on the right product–market fit for primary care in their densely urban context. As they learned, they incorporated those lessons back into their model and pivoted where necessary to continue to improve. The result has been up to 80 percent of primary care hospital visits costing 40 percent less and taking less than one-fourth of the time (Sunmonu, 2017).

Similarly, Thailand's experience attests to the potential impact of continual research, monitoring, and updating of a universal coverage program (Missoni, 2010). Chapter 8 explores this concept of a learning health care system in greater detail, with specific examples of how it can be operationalized in various contexts.