Delivering quality health services: a global imperative for universal health coverage

Delivering quality health services: a global imperative for universal health coverage – describes the essential role of quality in the delivery of health care services. As nations commit to achieving universal health coverage by 2030, there is a growing acknowledgement that optimal health care cannot be delivered by simply ensuring coexistence of infrastructure, medical supplies and health care providers. Improvement in health care delivery requires a deliberate focus on quality of health services, which involves providing effective, safe, people-centred care that is timely, equitable, integrated and efficient. Quality of care is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.
Data show that quality of care in most countries, particularly low- and middle-income countries, is suboptimal, as revealed by the following examples.

• Adherence to clinical practice guidelines in eight low- and middle-income countries was below 50% in several instances, resulting in low-quality antenatal and child care and deficient family planning.
• The Service Delivery Indicators initiative in seven low- and middle-income countries showed significant variation in provider absenteeism (14.3–44.3%), daily productivity (5.2–17.4 patients), diagnostic accuracy (34–72.2%), and, adherence to clinical guidelines (22–43.8%).
• A systematic review of 80 studies showed that suboptimal clinical practice is common in both private and public primary health care facilities in several lowand middle-income countries.
• Organisation for Economic Co-operation and Development (OECD) data from high- and middle-income countries show that 19–53% of women aged 50–69 years did not receive mammography screening, and that 27–73% of older adults (age 65 years and above) did not receive influenza vaccination.

BETTER HEALTH OUTCOMES THROUGH IMPROVEMENT IN QUALITY

High-quality health services involve the right care, at the right time, responding to the service users’ needs and preferences, while minimizing harm and resource waste. Quality health care increases the likelihood of desired health outcomes and is consistent with seven measurable characteristics: effectiveness, safety, peoplecentredness, timeliness, equity, integration of care and efficiency. For instance, in Pakistan, increasing first-contact accessibility to health care workers through the Lady Health Worker Programme improved management of pneumonia and lowered neonatal mortality.

BUILDING QUALITY MECHANISMS INTO THE FOUNDATIONS OF HEALTH CARE SYSTEMS

The five foundational elements critical to delivering quality health care services are health care workers; health care facilities; medicines, devices and other technologies; information systems; and financing. To ensure that quality is built into the foundations of systems, governments, policy-makers, health system leaders, patients and clinicians should work together to:

• ensure a high-quality health workforce;
• ensure excellence across all health care facilities;
• ensure safe and effective use of medicines, devices and other technologies;
• ensure effective use of health information systems;
• develop financing mechanisms that support continuous quality improvement.

INTERVENTIONS TO IMPROVE QUALITY OF CARE

Quality is a complex and multifaceted concept that requires the design and simultaneous deployment of combinations of discrete interventions. The development, refinement and execution of a national quality policy and strategy is a growing priority as countries strive to systematically improve health system performance. Most approaches to national quality strategy development involve one or more of the following processes:

• a quality policy and implementation strategy as part of the formal health sector national plan;
• a quality policy document developed as a stand-alone national document, usually within a multistakeholder process, led or supported by the ministry of health;
• a national quality implementation strategy – with a detailed action agenda – which also includes a section on essential policy areas;
• enabling legislation and regulatory statutes to support the policy and strategy.

Seven categories of interventions stand out and are routinely considered by health system stakeholders, including providers, managers and policy-makers, when trying to improve the quality of the health care system:

• changing clinical practice at the front line;
• setting standards;
• engaging and empowering patients, families and communities;
• information and education for health care workers, managers and policy-makers;
• use of continuous quality improvement programmes and methods;
• establishing performance-based incentives (financial and non-financial);
• legislation and regulation.

Selection by governments of a range and mix of quality interventions should be done by carefully examining the evidence-based quality improvement interventions in relation to the system environment; reducing harm; improvement in clinical care; and patient, family and community engagement and empowerment.

SHARING OF LESSONS LEARNED FOR SCALE-UP OF SUCCESSFUL INTERVENTIONS

Several nations are developing innovations to improve the different aspects of quality. As described in this document, many low- and middle-income countries have developed successful interventions, but require a global platform to share knowledge. This will allow nations to learn from successful interventions and adapt them to their local populations. It will also allow nations to avoid directing efforts towards unsuccessful interventions. Improving quality of care has proven challenging for all nations. However, providing quality care to people everywhere remains the most important shared responsibility and opportunity to improve the health of people globally. With a deliberate emphasis on quality, nations will be able to make significant progress towards achieving the Sustainable Development Goals and attaining universal health coverage.

CALL TO ACTION

This document, from the perspective of three global institutions concerned with health – OECD, the World Bank and the World Health Organization – proposes a way forward for health policy-makers seeking to achieve the goal of access to high-quality, people-centred health services for all. High-level actions are called for from each of the key constituencies that need to work together with a sense of urgency to enable the promise of the Sustainable Development Goals for better and safer health care to be realized.

All governments should:

• have a national quality policy and strategy;
• demonstrate accountability for delivering a safe high-quality service;
• ensure that reforms driven by the goal of universal health coverage build quality into the foundation of their care systems;
• ensure that health systems have an infrastructure of information and information technology capable of measuring and reporting the quality of care;
• close the gap between actual and achievable performance in quality;
• strengthen the partnerships between health providers and health users that drive quality in care;
• establish and sustain a health professional workforce with the capacity and capability to meet the demands and needs of the population for high-quality care;
• purchase, fund and commission based on the principle of value;
• finance quality improvement research.

All health systems should:

• implement evidence-based interventions that demonstrate improvement;
• benchmark against similar systems that are delivering best performance;
• ensure that all people with chronic disease are enabled to minimize its impact on the quality of their lives;
• promote the culture systems and practices that will reduce harm to patients;
• build resilience to enable prevention, detection and response to health security threats through focused attention on quality;
• put in place the infrastructure for learning;
• provide technical assistance and knowledge management for improvement.

All citizens and patients should:

• be empowered to actively engage in care to optimize their health status;
• play a leading role in the design of new models of care to meet the needs of the local community;
• be informed that it is their right to have access to care that meets achievable modern standards of quality;
• receive support, information and skills to manage their own long-term conditions.

All health care workers should:

• participate in quality measurement and improvement with their patients;
• embrace a practice philosophy of teamwork;
• see patients as partners in the delivery of care;
• commit themselves to providing and using data to demonstrate the effectiveness and safety of the care.

While no single actor will be able to effect all these changes, an integrated approach whereby different actors work together to achieve their part will have a demonstrable effect on the quality of health care services around the world.
World Health Organization, OECD & International Bank for Reconstruction and Development/The World Bank. (‎2018)‎. Delivering quality health services: a global imperative for universal health coverage. World Health Organization. 

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