1. Investing in Health

A 2001 report from the Institute of Medicine of the U.S. National Academy of Sciences (Institute of Medicine 2001b) highlights great variation in the quality of clinical care in the United States. Its publication catalyzed reform efforts. In a recent evaluation, Leape and Berwick (2005) found that those reform efforts had a major effect on professional attitudes and organizational culture, although less effect, so far, on mortality. Chapter 70 on quality of care documents the similarly large variation in quality in low- and middle-income countries and the associated cost in lives and money. Improving quality of care amplifies the effect of investments in health. Promising approaches in improving the quality of care include the following:

• Invest in measuring quality and feeding that information back into the system. This approach has been shown to be possible (for example, clinical vignettes) and effective.

• Use evidence-based criteria to link quality of care to outcomes. This approach can be implemented by training and creating incentives for adapting clinical guidelines or by using the collaborative improvement model.

• Improve system-level and provider incentives. Minimally, do no harm with the structure of financial incentives facing providers, for example, by establishing a legal and ethical environment where care providers do not profit personally from sale of drugs, diagnostic procedures, or referrals to expensive specialized care.

• Emphasize high-volume care for selected surgical procedures and prevalent medical conditions. Such an approach can lead to higher quality and lower cost even while, in some cases (for example, cataract removal), allowing lower-level workers to substitute for more expensive and scarcer physicians.

Source: This box was prepared with input from John Peabody.