Management of Health Services
While countries often focus on increasing the quantity of health care—for instance, the number of immunizations or consultations or the rates of coverage—health care can be useless, wasteful, or even harmful if it is not appropriate for the particular condition and consistent with the best medical knowledge.2 Thus paying attention to the quality of health care is not a luxury that only high-income countries can afford, but another pillar of the health service system that has a profound impact on the cost-effectiveness and equity of interventions. Indeed, quality of care is a key element of the intangible technical progress that explains so many of the health improvements of the past 50 years. While more resources will support improvements in quality, such improvements are possible even with few resources.
". . . the quality of health care is not a luxury that only high-income countries can afford, but another pillar of the health service system that has a profound impact on the cost-effectiveness and equity of interventions."
Poor quality care is endemic in many health systems, whether in low-, middle-, or high-income countries. In a study of pediatric care in Papua New Guinea, only 24 percent of health center workers were able to indicate correct treatment for malaria, and clinical encounters observed by investigators met minimal examination criteria in only 1 percent of cases. In Pakistan, only 56 percent of providers demonstrated the ability to diagnose viral diarrhea and only 35 percent adhered to treatment standards. In Indonesia, one study attributed 60 percent of infant deaths to poor practices in health care services, compared with 37 percent attributed to economic constraints. In the United States, the Institute of Medicine has documented serious shortcomings in medical care that account for more than 40,000 deaths each year, including large numbers of mistaken diagnoses, cases of improper care, and harmful errors in health care provision.
"In Pakistan, only 56 percent of providers demonstrated the ability to diagnose viral diarrhea and only 35 percent adhered to treatment standards."
The problem of poor health care quality is not the fault of isolated health professionals or solely attributable to limited resources. Rather, quality problems are systemic and are consequences of gaps in knowledge and inadequate communication, training, supervision, and incentives. These problems persist when organizations providing healthcare are unable to monitor the quality of care and take corrective action. Sometimes these failures are related to incentives that encourage inappropriate care, as when dispensing drugs is an important source of income for health care providers. At other times, poor quality may be unrelated to incentives and merely reflect practices that do not draw upon modern evidence. Redressing this problem requires attention to measuring health outcomes and relating them to clinical practice so that problems can be identified and strategies for correction implemented. For low- and middle-income countries this is, in some ways, an optimistic finding. In general, quality can be improved much more quickly than other factors that promote good health such as income, education, new technology, or infrastructure.
". . . quality problems are systemic . . . consequences of gaps in knowledge and inadequate communication, training, supervision, and incentives."
To assess the quality of health care services, data are generally collected on the structural features of health care delivery, processes, and health outcomes. Structural features that are expected to improve quality include the amount and types of health infrastructure, equipment and supplies, and staffing. Such structural indicators can be relatively easy to collect, but they have also proven to be weak predictors of quality and health outcomes. Although good structural features may be necessary, they are not sufficient for good quality care.
". . . quality can be improved much more quickly than other factors that promote good health such as income, education, new technology, or infrastructure."
Processes, by contrast, are the ways in which personnel apply modern knowledge to the diagnosis, prevention, and treatment of diseases and disability. The quality of health care processes can be measured by observing staff to see whether they respond according to scientifically validated protocols when diagnosing and treating patients. The process of interaction between caregivers and patients can also influence whether patients follow prescribed medication and advice, and thus influences health outcomes. Although processes are often more difficult and costly to measure than structural features, they tend to be more closely related to health outcomes.
"Although processes are often more difficult and costly to measure than structural features, they tend to be more closely related to health outcomes."
The U.S. Institute of Medicine's definition of the concept of quality encompasses the following six elements:
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patient safety
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effectiveness (scientifically proven appropriate care)
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patient centeredness (respect and responsiveness)
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timeliness (minimal delays and barriers to getting access to care)
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efficiency (minimal waste of equipment, supplies, ideas, and energy)
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equity (care provided consistently across genders, ethnic groups, locations, and socioeconomic classes).
A range of policy interventions can affect these six dimensions of good quality care. These interventions include direct efforts to identify appropriate care and verify whether individual providers or groups of providers are following evidence-based standards of practice. Direct interventions have included training with feedback from peers who observe consultations and processes in a health care setting.
"Performance-based remuneration is one way that providers can be induced to provide better quality care. Relatively small incentives . . . appear to have significant effects on providers' behavior in Cambodia, Haiti, and Nicaragua, as well as in the United States."
Policies aimed at improving the quality of health care have also included indirect interventions to change providers' behavior by altering the structural conditions or financial incentives in the health care system or its organization. Performance-based remuneration is one way that providers can be induced to provide better quality care. Relatively small incentives (3 to 10 percent of a provider's total compensation) appear to have significant effects on providers' behavior in Cambodia, Haiti, and Nicaragua, as well as in the United States. Mexico and Uganda have successfully used performance-based professional recognition without remuneration to promote better processes.
Other indirect measures include setting legal standards for care. Accreditation, periodic recertification of knowledge and competency, and administrative regulations can establish minimum standards by controlling entry into practice and establishing conditions for license renewal. However, despite barring unqualified persons from practice, such measures have not generally had a significant impact on improving the quality of care among those who are permitted into practice. Malpractice litigation can induce better quality care, but uncertainties and perverse incentives in the judicial process make this a blunt and costly mechanism for public policy. Professional oversight, peer review, and inspections are better ways to get information about the quality of care but are more effective at providing information on processes than at improving providers' behavior and practice. Training in the use of evidence-based protocols and guidelines has shown promise in high-income countries. For example, in the Netherlands, implementing patient management guidelines improved health outcomes for people with asthma and chronic obstructive pulmonary disease.
". . . continuing medical education . . . appears to have little impact on health outcomes unless it is attached to strategies that encourage changes in practice based on the knowledge received."
Targeted education and professional training is the most direct way to affect the practice of medicine. Great hopes have been attached to continuing medical education, but it appears to have little impact on health outcomes unless it is attached to strategies that encourage changes in practice based on the knowledge received.
One of the biggest challenges for public policy is to improve the quality of care that private practitioners provide. This is critical in many countries in which private practitioners account for the bulk of primary health care. For example, in India, private health professionals are the first to see most patients with symptoms of TB, and unless the public sector can find ways to improve case identification, screening, and referral among private practitioners, TB control will remain out of reach.
Health sectors have used organizational changes to improve the quality of health care provision, including adopting such modern management techniques as total quality management, collaborative improvement models, and plan-do-study-act cycles from other sectors. When effective, these policies result in increased coverage rates, better prescribing patterns, and increased adherence to clinical guidelines (box 7.5).
[Box ]
" . . . the cost-effectiveness of improving adherence to good protocols for treating pneumonia is between US$132 and US$800 per life saved. For improvements in the correct treatment of diarrhea with ORT, the cost-effectiveness ranges from US$14 to US$500 per life saved."
Measures that improve the quality of care have costs: the direct costs of human and physical resources and the costs of implementing organizational changes. DCP2 assesses the cost-effectiveness of improving the quality of care for treating pneumonia and diarrhea. It finds that the cost-effectiveness of improving quality depends substantially on how far current practice is from the optimum and how prevalent the disease is. When current practices are poor and prevalence is high, the cost-effectiveness of improving adherence to good protocols for treating pneumonia is between US$132 and US$800 per life saved. For improvements in the correct treatment of diarrhea with ORT, the cost-effectiveness ranges from $14 to $500 per life saved. In other cases, interventions are cost saving, for example, reducing overprescription or avoiding unnecessary treatments (see, for example, box 6.4).
