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

Delivering quality health services A global imperative for universal health coverage Delivering quality health services: a global imperative for universal health coverage ISBN 978-92-4-151390-6 WHO ISBN 978-92-64-30030-9 (PDF) OECD © World Health Organization, OECD, and International Bank for Reconstruction and Development/The World Bank, 2018 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial- ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO, OECD and The World Bank endorse any specific organization, products or services. The use of the WHO, OECD or The World Bank logo is not permitted. 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Printed in Switzerland Icons designed by Freepik, from www.flaticon.com 3DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE Contents Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Executive summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Chapter 1 Background: striving for quality in health care services . . . . . . . . . . . . . 15 1.1 Widespread evidence of poor quality in all countries . . . . . . . . . . . . . . . . . . . . . . . 16 1.2 The economic argument for good quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 1.3 Quality as a fundamental feature of universal health coverage . . . . . . . . . . . 17 1.4 Affordability of quality for all countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Chapter 2 About this document . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 2.1 Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 2.2 Scope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 2.3 Content . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Chapter 3 Global state of health care quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 3.1 The quality imperative for universal health coverage . . . . . . . . . . . . . . . . . . . . . . . 28 3.2 Defining quality of care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 3.3 Global picture of health care quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 3.4 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Chapter 4 Building quality into the foundations of health systems . . . . . . . . . . . 41 4.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 4.2 Foundations for high-quality care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 4.3 Quality of care as the foundation of people-centred health care . . . . . . . . . 49 4.4 The vision: health systems committed to people-centred care . . . . . . . . . . . . 52 4.5 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 Chapter 5 Understanding levers to improve quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 5.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 5.2 Driving improvement through national quality policy and strategy . . . . . . 58 5.3 Quality interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 5.4 Consideration and selection of quality interventions . . . . . . . . . . . . . . . . . . . . . . . . 65 5.5 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 Chapter 6 The quality call to action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 6.1 Sustainable development, quality and the way forward. . . . . . . . . . . . . . . . . . . . 74 6.2 Call to action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 Annex: Improvement interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 Contents 4 Figures Figure 3.1 Median under-5 mortality across dimensions of inequality, 2005–2012 . . . . . . . . . . . . . . .28 Figure 3.2 Elements of health care quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31 Figure 3.3 Number of clinical vignettes correctly diagnosed by Kenyan providers . . . . . . . . . . . . . . . .33 Figure 3.4 Burden of disease caused by adverse events, 2015 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34 Figure 3.5 Doctor providing easy-to-understand explanations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35 Figure 3.6 Trends in average waiting times for hip replacement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36 Figure 3.7 Structural and process quality of maternal services by county poverty level in Kenya . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36 Figure 4.1 Global density and distribution of skilled health professionals . . . . . . . . . . . . . . . . . . . . . . . . . .43 Figure 4.2 Variations in availability of basic equipment across health care facilities in sub-Saharan Africa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .45 Figure 4.3 Primary care as a hub of coordination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .53 Figure 4.4 Five strategies for people-centred services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .54 Tables Table 5.1 Illustrative quality interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .66 Table 5.2 Quality-related interventions: engaging key actors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .68 Boxes Box 3.1 Liberia: embedding quality in the post-Ebola health agenda . . . . . . . . . . . . . . . . . . . . . . . . . . .30 Box 4.1 Case study: training and retaining health care workers in underserved areas of the Philippines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44 Box 4.2 Case study: OECD Health Care Quality Indicators Project . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .47 Box 4.3 Case study: improving civil registration and vital statistics in Uganda . . . . . . . . . . . . . . . . . .48 Box 4.4 Case study: unmet needs for the care of chronic diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50 Box 4.5 Case study: primary care in Costa Rica . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51 Box 4.6 Case study: using Citizen Voice and Action to empower communities in Uganda . . .51 Box 4.7 Key actions: building quality into the foundations of health systems . . . . . . . . . . . . . . . . . .55 Box 5.1 Case study: Ethiopia – National Health Care Quality Strategy 2016–2020 . . . . . . . . . . . .59 Box 5.2 Case study: Sudan – National Health Care Quality Policy and Strategy . . . . . . . . . . . . . . . .60 Box 5.3 Case study: Mexico – National Strategy for Quality Consolidation in Health Care Facilities and Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .61 Box 5.4 Case study: Ontario, Canada – Excellent Care for All Act and Strategy . . . . . . . . . . . . . . . .64 Box 5.5 Key actions: understanding levers to improve quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .69 Box 6.1 High-level actions by key constituencies for quality in health care . . . . . . . . . . . . . . . . . . . . .75 5DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE The Sustainable Development Goals (SDGs) reaffirm a global commitment to achieve universal health coverage (UHC) by 2030. This means that all people and communities, everywhere in the world, should have access to the high-quality health services they need – promotive, preventive, curative, rehabilitative, or palliative – without facing financial hardship. The way we typically measure progress in UHC is through effective coverage of essential health services and financial protection (ensuring that no one becomes impoverished because of ill-health). But even if the world achieved essential health coverage and financial protection, health outcomes would still be poor if services were low-quality and unsafe. Delivering quality health services is essential to UHC. That is the focus of this report. Evidence suggests that substandard care wastes significant resources and harms the health of populations, destroying human capital and reducing productivity. Quality of care, especially patient safety, is essential to creating trust in health services. It is also key to global health security, which starts with local health security, and in turn depends on high-quality frontline health services. Quality health services not only prevent human suffering and ensure healthier societies, they also ensure better human capital and healthier economies. Too often, quality is perceived as a luxury that only rich countries can afford. This is a fallacy. Building quality health services requires a culture of transparency, engagement, and openness about results, which are possible in all societies – regardless of their income level. Around the world, lessons abound on what works and what does not, providing a rich foundation from which to rapidly scale up a quality revolution. Technological innovation plays a key role in offering new ways to expand high-quality health care services more rapidly, and at an affordable cost. A focus on people-centredness has to be the core of quality. People and communities must be engaged in the design, delivery, and ongoing assessment of health services to ensure they are built to meet local health needs – rather than those of donors, commercial or political interests, or because “it’s always been done that way”. Focusing on quality is critical, but leadership must also focus on celebrating excellence; communicating transparently; and fostering collaboration across clinical teams, as well as with patients, and civil society – including patient groups, nongovernmental organizations, and grassroots community groups. Universal health coverage is not a dream for the future. It is already a reality in many countries; however, without quality health services, it can remain an empty promise. This foundational report builds a strong technical and political case for investing in quality health services. The collective prize is a healthier, safer and fairer world. Preface Angel Gurría Secretary-General OECD Tedros Adhanom Ghebreyesus Director-General World Health Organization Jim Yong Kim President The World Bank Group

7DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE Acknowledgements This document was jointly prepared by the World Health Organization (WHO), the Organisation for Economic Co-operation and Development (OECD) and the World Bank under the overall guidance of Marie-Paule Kieny, former Assistant Director-General, Health Systems and Innovation Cluster, WHO; Timothy Evans, Senior Director, Health, Nutrition and Population Global Practice, World Bank Group; and Stefano Scarpetta, Director of Employment, Labour and Social Affairs, OECD. The writing team comprised Edward Kelley (WHO), Niek Klazinga (OECD), Ian Forde (OECD), Jeremy Veillard (World Bank), Sheila Leatherman (Gillings School of Global Public Health, University of North Carolina), Shamsuzzoha Syed (WHO), Sun Mean Kim (WHO), Sepideh Bagheri Nejad (WHO) and Sir Liam Donaldson (WHO Envoy for Patient Safety). Development of the document was coordinated by Sepideh Bagheri Nejad. The authors wish to thank colleagues from the Dutch National Institute for Public Health and the Environment (RIVM), Michael van den Berg and Wilco Graafmans for their input to the development of the overall conceptual framework and content of the document, Stefano Scarpetta, Mark Pearson, Francesca Colombo, Caroline Berchet and Luke Slawomirski from OECD for their contribution to the writing, and Sagar Dugani and Adanna Deborah Ugochi Chukwuma from the World Bank for their help with the revision of the text at the final stage. The document benefited from the rich inputs of the Advisory Committee, composed of the following members: Sir Liam Donaldson (Chair), Clifford Hughes, Tawfik Khoja, Jan Mainz, Rashad Massoud, Robin Osborn, Enrique Ruelas, Paul Shekelle, Anuwat Supachutikul and Nana Amma Twum-Danso. Country case studies were produced by the following people: Daniel Burssa and Eyub Gebretsadik for Ethiopia; Sebastian García Saiso, Paulina Pacheco Estrello and Enrique Ruelas for Mexico; Elmuez Eltayeb for Sudan; and Michelle Rossi, Joshua Tepper and Adalsteinn Brown for Ontario, Canada. The annex on improvement interventions was produced by Sheila Leatherman (Gillings School of Global Public Health, University of North Carolina), and Liana Rosenkrantz Woskie, Anthony Moccia, Ruma Rajbhandari and Kim Reimold (the Harvard Initiative on Global Health Quality at the Harvard Global Health Institute). We wish to thank Gheorghe Sorin Banica and Laura Pearson for administrative support and Gary Humphreys for writing the initial draft of the document. We would also like to thank the following peer reviewers: Donald Berwick, Helen Haskell, Margaret Kruk and Ephrem Lemango. Finally, we would like to express our appreciation to the many other staff members from the three partner organizations who contributed to this document. Without their dedication, support and expertise this work would not have been possible: Yetmgeta Abdella, Najeeb Al Shorbaji, Benedetta Allegranzi, Broog Alsadhan, Shannon Barkley, Marie-Charlotte Bouesseau, James Campbell, Meena Cherian, Mickey Chopra, Krycia Cowling, Jishnu Das, Neelam Dhingra-Kumar, Joan Dzenowagis, Peter Engelfriet, Linda Freiheit, Ruben Frescas, Michele Gragnolati, Michelle Karen Funk, Javier Gomez Batiste-Alentorn, Joyce Hightower, Maki Kajiwara, Rania Kawar, Michael George Kay, Acknowledgements 8 Claire Kilpatrick, Ramesh Krishnamurthy, Angela Lashoher, Agnès  Leotsakos, Manon  Lette, Akiko Maeda, Nicola Magrini, Elizabeth Mason, Kellie McGee, Nana Mensah Abrampah, Hernan Montenegro Von Mühlenbrock, Margaret Murphy, Jillian Oderkirk, Shanti Pal, Felicity Pocklington, Nittita Prasopa-Plaizier, Paul Peter Schneider, Emma Scholar, Maria Cecilia Sepulveda Bermedo, Maria Angelica Sousa, Julie Storr, Nuria Toro Polanco, Andreas Ullrich, Krisantha Weerasuriya, Erica Wheeler, Tana Wuliji, Mohammad Taghi Yasamy, Junping Yu, Hongwen Zhao and Hao Zheng. 9DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE Abbreviations CAIS centres for integrated health care (centros de atención integral en salud) CDS clinical decision support DALY disability-adjusted life-year EBAIS integrated health care basic teams (equipos básicos de atención integral de salud) EuroHOPE European Health Care Outcomes, Performance and Efficiency (project) HTA health technology assessment MDG Millennium Development Goal OECD Organisation for Economic Co-operation and Development P4P pay for performance SDG Sustainable Development Goal UNICEF United Nations Children’s Fund USAID United States Agency for International Development WHO World Health Organization Abbreviations 10 11DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE This document – 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 low- and 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, people- centredness, 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 Executive summary Executive summary 12 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. DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 13 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. Executive summary 14 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. DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 15 Chapter Background: striving for quality in health care services 1 Chapter 1 Background: striving for quality in health care services 16 Universal health coverage is an important and noble objective. Enshrined in the Sustainable Development Goals (SDGs), universal health coverage aims to provide health security and universal access to essential care services without financial hardship to individuals, families and communities, thus enabling a transition to more productive and equitable societies and economies. But universal health coverage should not be discussed and planned, let alone implemented, without a focus on quality. It is essential to ensure that care is effective, safe, and in keeping with the preference and needs of the people and communities being served. Further, provision of care should be timely and equitable across populations, coordinated across the continuum of care and throughout the life course, while minimizing resource waste. Quality of care therefore underpins and is fundamental to universal health coverage. For if quality of care is not ensured, what is the point of expanding access to care? Access without quality can be considered an empty universal health coverage promise. Quality is not a prerogative of high-income countries. If countries can afford to provide any health care – and even the poorest can and should do so – they must provide care of good quality. The alternative – poor-quality care – is not only harmful but also wastes precious resources that can be invested in other important drivers of social and economic development to improve the lives of citizens. Billions of dollars are spent on the consequences of poor-quality care – money that can fund schools, social services and infrastructure. And poor quality can also undermine the trust of the population in the benefits of modern medicine. Seen this way, universal health coverage without quality of care is a job half done. 1.1 WIDESPREAD EVIDENCE OF POOR QUALITY IN ALL COUNTRIES Much progress has been made in improving some aspects of quality of health care across the world, for example with regard to cancer survival rates and mortality from cardiovascular diseases (1, 2). But in other areas, progress has been slow and uneven. The numbers speak for themselves. • In high-income countries, one in 10 patients is adversely affected during treatment (3). • In high-income countries, seven in 100 hospitalized patients can expect to acquire a health care-associated infection (in developing countries this figure is one in 10), infections that can be easily avoided through better hygiene and intelligent use of antimicrobials (4). • Unwarranted variations in health care provision and delivery persist, and a considerable proportion of patients do not receive appropriate, evidence-based care (5, 6). • Influenza vaccination rates vary across high-income countries from 1% to over 78%, despite a goal of 75% by 2010 set by the World Health Assembly in 2003 (7). • Antimicrobial resistance has become a major global public health issue, partly due to the misuse and overuse of antimicrobials in health care (8). • Globally, the cost associated with medication errors has been estimated at US$ 42 billion annually, not counting lost wages, foregone productivity or health care costs (9). DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 17 • While the rate of skilled birth attendance increased from 58% in 1990 to 73% in 2013, mainly due to increases in facility-based births, there are still many women and babies who, even after reaching a health facility, die or develop lifelong disabilities due to poor quality of care. The World Health Organization (WHO) estimates that 303 000 mothers and 2.7 million newborn infants die annually around the time of childbirth, and that many more are affected by preventable illness. Further, some 2.6 million babies are stillborn each year (10, 11). • Nearly 40% of health care facilities in low- and middle-income countries lack improved water and nearly 20% lack sanitation – the implications for quality of care are clearly evident (12). • Cross-country estimates of the distribution of diagnosis and control of raised blood pressure in selected countries outside the OECD highlights the importance of quality preventive services. In most, at least half of the adults with raised blood pressure have not been diagnosed with hypertension. Hypertension treatment coverage is therefore low, ranging from 7% to 61% among people who have presented with raised blood pressure in the household surveys. However, effective coverage is considerably lower than coverage, ranging from 1% to 31%, indicating a quality issue (13). 1.2 THE ECONOMIC ARGUMENT FOR GOOD QUALITY Beyond the effects on people’s lives, poor-quality care wastes time and money. Making quality an integral part of universal health coverage is both a matter of striving for longer and better lives and an economic necessity. Building quality in health systems is affordable for countries at all levels of economic development. In fact, the lack of quality is an unaffordable cost, especially for the poorest countries. Substandard quality of care not only contributes to the global disease burden and unmet health needs, it also exerts a substantial economic impact, with considerable cost implications for health systems and communities across the world. Approximately 15% of hospital expenditure in high-income countries is used to correct preventable complications of care and patient harm. Poor-quality care disproportionately affects the more vulnerable groups in society, and the broader economic and social costs of patient harm caused by long-term disability, impairment and lost productivity amount to trillions of dollars each year (14). In addition, duplicate services, ineffective care and avoidable hospital admissions – features of many health systems – generate considerable waste. Up to a fifth of health resources are deployed in ways that generate very few health improvements. These scarce resources could be deployed much more effectively (3). 1.3 QUALITY AS A FUNDAMENTAL FEATURE OF UNIVERSAL HEALTH COVERAGE Quality does not come automatically; it requires planning, and should be a clearly identified priority of universal health coverage, along with access, coverage and financial protection. This document shows that building quality into health systems is possible if a number of steps are followed and principles applied, namely transparency, people-centredness, measurement and generation of information, and investing in the workforce, all underpinned by leadership and a supportive culture. With these fundamentals in place, proven interventions and practices to ensure quality – such as hand hygiene, treatment protocols, checklists, education, and reporting and feedback – can be implemented and sustained. Chapter 1 Background: striving for quality in health care services 18 Transparency is paramount. It is the bedrock of continuous learning and improvement. The overarching conclusion from 15 reviews of quality in national health systems conducted by OECD between 2012 and 2016 was the need for greater transparency about performance in terms of quality and outcomes of care (15). A key component of transparency is being open and honest about results, including lapses and mistakes. In such an environment these become opportunities to learn, as is the case in other sectors, including air transport. Successful outcomes should be celebrated and shared for the same reasons. This culture of transparency can take time to build, but it can and must be instilled in all health systems, regardless of resources available. Involving people and communities in their own care and in the design of their health services is now recognized as a key determinant of better outcomes. People and the communities in which they are born, raised, live, work and play are at the heart of delivering quality health services. People who are actively engaged in their own health and care suffer fewer complications and enjoy better health and well-being. At the clinical level, this means enabling patients to partner in their care and in clinical decisions, and to actively manage their health. People-centredness is the “doorway to all qualities” (16). Indeed, the common thread of success stories detailed later in this document is putting the patient’s needs and values front and centre. This means caring with compassion and respect. But people-centredness goes beyond individual care. People and patients should be involved in priority setting and in policy development. Nowhere is this more important than in primary and community care. These services need to be designed with input from the communities that they serve, based on their unique needs and preferences, as discussed in Chapter 4 of this document. Quality requires measurement and generation of information. Health care is changing all the time, so quality needs to be continually monitored and assessed to drive improvement. This relies on accurate and timely information. The banking industry devotes 13% of its income to information systems. Health care invests less than 5% – a paltry amount for an information-intense sector. And when they exist, the data generated by health systems are too often concentrated on inputs and volume of activities. This needs to change if quality is to become a routine part of health care. Reliable quality metrics must be embedded in local and national health information infrastructures – this is even more important than measuring inputs. In the spirit of transparency, information must be available to all relevant actors, including patients, providers, regulators, purchasers and policy-makers. All dimensions of quality should be measured. It is important to know about adherence to essential protocols and the quality of processes and pathways, for example hand hygiene; surgical safety checklists; adherence to clinical practice guidelines; and clinical outcomes, for example readmissions, mortality rates, adverse drug reactions, survival after a diagnosis of cancer and adequate control of glycaemia during pregnancy. But knowledge must also be generated on the outcomes and experiences of care that are valued by patients through the measurement of patient- and community-reported quality indicators (17). All this needs to be done with a clear eye on strong linkages between measurement and improvement – measuring alone will not improve quality. A skilled, motivated and adequately supported health workforce is critical. Health care providers want to deliver the best possible care to their patients. Often, however, the systems and environments they work in make this task difficult. Many countries face significant deficiencies in both the quantity and quality of their health DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 19 workforce. Of course, not all care should be delivered by doctors. Nurses, allied and community health workers, care coordinators and managers all play important roles in delivering high-quality care in the 21st century. It is possible to achieve high quality by leveraging their skills throughout the chain of health production (18). In providing high-quality care, technical knowledge needs to be augmented by the ability to communicate and work as a team with other professionals, and to partner with patients and their carers. It also requires a workforce trained in the principles and practice of continuous quality improvement, as well as recognition of the “hidden curriculum” that arises from the fallibility of human-designed systems. Quality is also a function of how well efforts are organized and integrated with other sectors, taking account of patterns of behaviour, human interaction and relationships. This in turn depends on the incentives that are in place, including funding and remuneration, regulation, reporting and feedback, which need to be carefully built into all processes and institutions. In the end, systems provide the fertile soil in which high-quality practice and improvement can bloom. None of the above is possible without leadership and an enabling culture. A  buoyant culture in which all actors are motivated to collaborate, communicate and work with their communities to deliver high-quality people-centred care, without fear or intimidation, has been shown to deliver better outcomes (19). Many factors influence such a culture of continuous quality improvement. First and foremost, a transparent environment should be cultivated, as described above. Also important are training and socialization of workers, improvement measures, feedback on performance, and shared learning, as well as upstream factors such as financial incentives. But the key ingredient is consistency of leadership from governments, policy-makers, clinical leaders, health system managers and civil society. This does not require a high level of resources – it rather requires investment in a culture shift towards transparency for continuing improvement. These fundamentals provide the backbone for policies and practices to continually improve health care quality. But quality must be the responsibility of all stakeholders and institutions. It must be supported by a crystal-clear national strategic direction, with well defined objectives and goals, and strong stakeholder engagement across the entire health system, as well as with other sectors. 1.4 AFFORDABILITY OF QUALITY FOR ALL COUNTRIES While high-quality health care for all may seem ambitious, it can be achieved in all settings with good leadership, robust planning and intelligent investment. For example, in Uganda a model involving citizens and communities in the design of health care services has improved a range of indicators, including a 33% reduction in child mortality (20). Costa Rica has achieved remarkable improvements in primary care quality through a carefully planned, implemented and resourced improvement strategy (21). These and other examples are provided later in this document. For low- and middle-income countries, addressing quality while building universal health coverage is a huge opportunity. A health system that is maturing and becoming established can be influenced, steered and nurtured in the desired way. Quality can be embedded into policies, processes and institutions as the system grows and develops. Chapter 1 Background: striving for quality in health care services 20 The challenge is how to learn from the experiences – both the successes but also (and especially) the mistakes – of health systems in high-income countries. A key lesson is that retrofitting quality into established health systems is certainly possible but can be arduous; rather, quality must be built in from the start, along with access, coverage and financial protection. Of course, quality care cannot be conjured up entirely for free – it requires some investment of capital and other resources. This investment is not beyond reach, even for the poorest countries. The costs of poor quality to people’s lives, to health systems and to societies are massive. If applied intelligently, investment in quality will deliver better individual and population health, and value for money; the return on investment in ensuring high-quality care is likely to far outweigh the costs. Better outcomes also further economic and social development; for example, healthier people are more productive at work, and healthier children perform better at school. So striving for universal quality health coverage is not just an investment in better health – it is a commitment to building a healthier society and a healthier world. 21DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE Eight years ago, when she was diagnosed with rheumatoid arthritis, an autoimmune disease that causes inflammation, swelling and acute pain in the joints, Cecilia Rodriguez was Director of a primary health care facility. “I had very bad rheumatoid arthritis and spent a lot of time in bed,” says Rodriguez, who was in her thirties when she first experienced the painful symptoms. “I realized that what I had been promoting as a health administrator was very different from what I needed as a patient.” Rheumatoid arthritis touches people of all ages. Its exact causes are not known, but genetic and environmental factors may play a role. Up to 1% of the world’s population is affected.1 In Chile, where Rodriguez lives, 100 000 people are living with this lifelong condition. For people with chronic diseases, quality health care can be defined as “an accurate equilibrium between clinical best practices and what is best for the patient, determined with the patient,” Rodriguez explains. “We don’t always need doctors who have all the answers. We need people who understand how we are coping with our condition.” Above all, she believes patients suffering from chronic conditions that have a huge impact on daily life need to feel in control of their treatment. “As a patient, I know what I want to achieve. Clinicians can help me understand if I can achieve it and help me do so. For me, that’s the best quality of health care.” Cecilia Rodriguez and her sister Lorena, who had been diagnosed with rheumatoid arthritis a few years earlier, established a non-profit organization to support people affected by the same condition and advocate for improved patient care. “We called the NGO ‘Me Muevo’ (‘I move’) because we learned that with this condition you have to keep your body moving, but also because ‘I move’ means ‘I take action’”, she says. My Quality Ms Cecilia Rodriguez, Executive Director ‘Me Muevo’ Foundation 1. www.rheumatoidarthritis.org. 22 ‘Me Muevo’ is part of a growing movement of patient-led organizations in Chile. Rodriguez acted as spokesperson for an alliance of associations that successfully lobbied to make prescription drugs more affordable. In 2016, Chile adopted the ‘Ricarte Soto Law’ on high-cost treatments. “Now I only pay US$ 200 a year for all my medications, instead of US$ 1500 per month,” Rodriguez says. “Health care systems tend to be geared towards treating acute illnesses, and are rarely organized to help patients with lifelong diseases overcome the hurdles of daily life,” Rodriguez explains. She cites the example of her sister who works and has to travel to three locations – a process that takes at least five hours – to collect her monthly prescription drugs. “In this case, quality of care would mean being able to pick up all her medications from the primary health care facility near her house, on a Saturday morning,” she says. Rodriguez also promotes enabling patients to enter notes into their medical records between medical appointments to help physicians adjust their treatment. “If I could write that I had had a flare-up and say how I had dealt with it, my doctor would have that on record when I saw her three or four months later,” she says. After Rodriguez attended a chronic disease self-management course in the United States, which helped her better cope with the effects of her disease, her organization worked to make the programme available to patients in her own country. “Investing in teaching self-management can reduce overall costs. That is why we are bringing this programme to Chile,” she says. As a result, seven hundred people benefited from this training through the public system, last year. Image on previous page: © Rawpixel / iStock DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 23 Chapter2 About this document Chapter 2 About this document 24 Recognizing the global gap in understanding, measuring and improving quality of health care services, WHO, OECD and the World Bank have joined efforts to produce this document – Delivering quality health services: a global imperative for universal health coverage. 2.1 OBJECTIVES This document has been developed with the following objectives: • to provide governments with a description of the quality of health services and their importance to achieving broad public health goals, within the context of universal health coverage; • to provide governments with a picture of evidence-based approaches that can ensure and improve quality of health services; • to make a call for action at national and international levels. 2.2 SCOPE This document is intended for policy-makers who want to bring the fundamentals of health care quality improvement into their health systems. Therefore, it looks at the quality of health care services at the foundation. The document does not aim to provide technical guidance for front-line health care professionals, though they may find useful information herein. Nor does it examine the implications of quality for specific technical areas. 2.3 CONTENT The document begins with a chapter on the background to quality in health care services (Chapter 1), followed by a brief description of the document (Chapter 2). The main body of the publication comprises three chapters on key quality themes (Chapters 3–5), followed by a quality call to action in Chapter 6. • Chapter 3: Global state of health care quality. In this chapter a global picture of quality in health care services is provided. Data are presented to show that quality of care in most countries, particularly low- and middle-income countries, is suboptimal, and improvement in quality is associated with better health outcomes. • Chapter 4: Building quality into the foundations of health systems. This chapter describes how mechanisms to assure, monitor and continually improve quality must be built into the foundations of health systems, and addresses key issues that require attention to improve the quality of health care at country level. • Chapter 5: Understanding levers to improve quality. Quality is a complex and multifaceted concept that requires the design and simultaneous deployment of combinations of discrete interventions. This chapter highlights the importance of driving quality improvement through national policy and strategy and presents a range of levers for quality improvement. • Chapter 6: The quality call to action. A quality call to action is put forward to health policy-makers seeking to achieve the goal of access to high-quality, people-centred health services for all. This is offered with a sense of urgency, for if we do not act now, achievement of public health goals will be at stake. DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 25 Those chapters are followed by an annex, which provides a set of improvement interventions that have been selected for their potential impact on quality by reducing harm, improving front-line delivery of health care services, and building systemwide capacity for quality improvement. The illustrative interventions point to some of the options and possibilities available to health system leaders, managers, practitioners or policy-makers intent on advancing quality of care.

DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 27 Chapter3 Global state of health care quality Chapter 3 Global state of health care quality 28 3.1 THE QUALITY IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE Between 2000 and 2015, the Millennium Development Goals (MDGs) accelerated global progress towards attaining population health goals in low- and middle-income countries. Globally, child mortality fell by 53%, maternal mortality fell by 43%, and new HIV infections declined by over 38% (22). However, progress was highly unequal. In poor, rural, and hard-to-reach populations, preventable mortality remained high. For example, for children aged under 5 years in low- and middle-income countries there are significant differences in mortality between those living in the poorest households compared to those living to the richest households, between those whose mothers were the least educated compared to the most educated, and between those living in urban areas compared to rural areas (Figure 3.1). “What good does it do to offer free maternal care and have a high proportion of babies delivered in health facilities if the quality of care is substandard or even dangerous?” Margaret Chan, former WHO Director-General, World Health Assembly, May 2012 Systematic assessments of essential health services in high-mortality countries revealed major deficiencies in the quality of care received. In one such assessment across eight countries in sub-Saharan Africa, quality-adjusted (effective) coverage averaged 28% for antenatal care, 26% for family planning, and 21% for sick child care, and was substantially lower than crude service coverage (23). Over 40% of facility-based deliveries Figure 3.1 Median under-5 mortality across dimensions of inequality, 2005–2012* * Median value of 49 selected countries ** Data are not available for 10 countries Source: World Health Organization (22). 120 100 80 60 40 20 0 Q ui nt ile 1 (p oo re st ) Q ui nt ile 2 Q ui nt ile 3 Q ui nt ile 4 Q ui nt ile 5 (r ich es t) N o ed uc at io n Pr im ar y sc ho ol Se co nd ar y sc ho ol + Ru ru al Ur ba n M al e Fe m al e Economic status Mother’s education** Place of residence Sex Deaths per 1000 live births DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 29 in five countries in sub-Saharan Africa took place in primary care facilities with major gaps in resources and technical expertise (24). The MDGs did not include a specific focus on measuring and improving quality of care, yet these deficits in quality of care have had negative implications for translating increases in coverage to better population health. Poor-quality services have been shown to predict a higher risk of neonatal mortality in Africa (25). Also, an increase in institutional deliveries from 14% to 80% in India did not reduce maternal and child mortality due to the poor quality of care provided at health facilities (26). In essence, poor quality of care is responsible for persistently high levels of maternal and child mortality in low- and middle-income countries, despite substantial increases in access to essential health services achieved during the MDG era. In 2015, the United Nations General Assembly adopted a new development agenda: Transforming our world: the 2030 Agenda for Sustainable Development. The SDGs comprise a broader range of economic, social and environmental objectives than the MDGs and set a new health goal, to “ensure healthy lives and promote well- being for all at all ages”. Universal health coverage is considered fundamental to the SDGs. Simply defined, universal health coverage means ensuring that all people and communities can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship. In explicitly focusing on the quality of health care services, the 2030 Agenda for Sustainable Development recognizes the urgent need to place quality of care in the fabric of national, regional, and global action towards promoting well-being for all. While global attention has focused on universal health coverage, at the local level, the devastating outbreak of Ebola virus in West Africa reinforced the strong case for quality of care. In Guinea, Liberia and Sierra Leone, gaps in service delivery and the accompanying collapse of public trust in health systems presented herculean challenges to response and recovery efforts during the Ebola outbreak. For instance, assessments of the Sierra Leonean health system revealed a low density of human resource for health, low capacity for disease surveillance in the community, infrastructural deficits in health facilities, and weak supply chains for essential medicines (27). All three countries have since emphasized universal access to quality health service delivery to strengthen their ability to prevent large-scale outbreaks in the future, placing infection prevention and control and patient safety as key priorities. Following the outbreak, Liberia has developed an investment plan to build health system resilience and is working towards implementation of a health equity fund that places quality at its core (Box 3.1). The West African response to the Ebola outbreak demonstrates the very real and strong linkages between health system resilience, quality of care, and global health security. Achieving the SDG health targets will require new financial investments, increasing over time from an initial US$ 134 billion to US$ 371 billion annually by 2030 (28). Poor-quality care is inefficient, wasting scarce resources and increasing the cost of expanding health coverage. Inefficiencies are introduced by unnecessary care that makes no difference to health outcomes. For instance, in low- and middle-income countries, overuse of antibiotics to treat acute respiratory tract infections adds an average of 36% to the cost of care (29). Errors in service delivery may also lead to direct harm to health, at an extra cost to the health system. A recent analysis of OECD countries indicates that more than 10% of hospital expenditure goes to correcting preventable medical mistakes or treating infections that people catch in hospitals (3). At the 2017 OECD Health Ministerial Chapter 3 Global state of health care quality 30 Meeting, ministers acknowledged the intersection of the quality and efficiency agendas, agreeing that quality measurement and improvement should be at the centre of efforts to realize health outcomes at a high value for money (30). Investing in high-quality health systems for universal health coverage has the potential to accelerate progress in promoting health while strengthening global health security and maximizing value for money. 3.2 DEFINING QUALITY OF CARE 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 (31). This definition implies that quality of care can be measured, is ultimately aimed at health improvements rather than simply increasing service inputs or refining system processes, and should reflect the desires of key stakeholders, including service users and communities. By including health services in general, this definition of quality of care spans both curative and preventive care, and facility and community-based care for individuals and populations. This scope is particularly important in countries facing an increasing burden of noncommunicable disease and whose health systems must provide services across the life course, including risk reduction, screening, disease management, rehabilitation and palliative care. As there is a steadily growing evidence base on the effectiveness of various modalities for disease prevention and control, this definition of quality of care also acknowledges the need for mechanisms to incorporate new evidence into service delivery systematically. What characteristics of health services are indicative of quality? This document identifies seven measurable characteristics of health services that increase the likelihood of desired health outcomes and are consistent with current professional knowledge. Box 3.1 Liberia: embedding quality in the post-Ebola health agenda Before the 2014 Ebola outbreak, Liberia, a country recovering from years of political and economic instability, had made progress in improving the health outcomes of its population. However, the outbreak highlighted persistent health system constraints in this small West African nation. There was a lack of an adequately skilled health workforce in health facilities and within communities; there were no sustainable financing mechanisms; and there was an absence of necessary supply chain structures and integrated health information systems. In addition, infection prevention and control was largely absent where most needed, and linkages between health services and the community were inadequate. These weaknesses compromised the provision of quality service delivery and allowed the epidemic to proliferate rapidly. In response to the outbreak, the Investment Plan for Building a Resilient Health System in Liberia 2015–2021 was developed. The plan aimed to restore the gains lost in the outbreak, tackle pre-existing vulnerabilities, improve community confidence in health systems, and provide health security. A key strategic aim of the Investment Plan is to accelerate universal access to safe and quality services through improving the capacity of the health network for the provision of essential services. The Government of Liberia recognizes that successful implementation of the Investment Plan – including a strong focus on quality of care – is essential to prevent, to detect, and to respond to future infectious disease outbreaks. DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 31 While multiple quality elements have been described over decades, there is growing acknowledgement that quality health services across the world should be effective, safe, and people-centred. In addition, in order to realize the benefits of quality health care, health services should be timely, equitable, integrated and efficient (Figure 3.2) (32, 33). Consider Fatima, an 80-year-old woman who has lived alone, since retiring 15 years ago. She has long-standing type 2 diabetes mellitus, as well as hypercholesterolemia and essential hypertension. She generally stays indoors and takes only occasional walks due to her poor eyesight and recently-developed back pain. Over the past two years, she has twice been admitted to hospital for congestive cardiac failure. She does not monitor her blood pressure or blood glucose as advised, eats convenience foods, and has missed multiple follow-up appointments since her discharge. Today, Fatima has come to the clinic complaining that she is out-of-breath, that her chest feels unusually tight, that she has trouble lying flat. She has has also mentioned having difficulty keeping track of her monthly bills. The attending nurse notices that Fatima repeats herself and has trouble finding the right words to describe her symptoms. Over the course of the next four weeks, Fatima will receive care from a myriad of health providers, including a dietician, primary care provider, cardiologist and social worker. The following points illustrate what high-quality health care for Fatima might look like through the lens of the seven elements of quality. • High-quality care for Fatima is effective, thus, it would be offered based on scientific knowledge and evidence-based guidelines. The care team would adhere to clinical pathways for older patients with heart failure and significant comorbidities, developed from evidence and experience in managing similar cases. The team would reassure Fatima that she would be receiving evidence- based care and that a systematic process would be followed to arrive at an integrated management plan across the various providers taking care of her. • High-quality care for Fatima is safe, that is, it minimizes harm, including preventable injuries and medical errors, to the patient. In every facility, there would be clear guidelines to prevent hospital-acquired infections and medical errors. For example, a thorough review of her outpatient medications at admission was made to prevent interactions with medications used during her inpatient care. Source: Institute of Medicine (32). Figure 3.2 Elements of health care quality Effectiveness QUALITY TimelinessEquity Efficiency Safety People- centrednessIntegration Chapter 3 Global state of health care quality 32 • High-quality care for Fatima is people-centred, that is, it respects and responds to her preferences, needs and values. Fatima might understandably be worried and ask many questions. The multidisciplinary care team would listen to her questions and concerns, answering patiently, and codevelop the care management plan with her active involvement. • High-quality care for Fatima is timely, that is, it would keep delays in providing and receiving services to a minimum. For example, contact with each provider involved in her care would be managed by an efficient patient flow system for scheduling or modifying visits and for notifying clients of projected waiting times. Situations requiring urgent intervention would be recognized and acted on as quickly as possible. With proper planning, Fatima would not have to experience long waiting times during follow-up visits. • High-quality care for Fatima is equitable, thus, the quality of care she receives would not vary according to personal characteristics such as gender, race, ethnicity, geographical location and socioeconomic status. The services received by Fatima would reflect evidence on the potential health benefits of the treatment only, and nothing else. • High-quality care for Fatima is integrated, thus, the care she receives across facilities and providers would be coordinated. Post-discharge, the social worker would evaluate options to support her care plan, and connect her with agencies that offer dementia-related care and other services as needed. • High-quality care for Fatima is efficient, and therefore avoids waste of resources, including equipment, medicines, energy and ideas. Each of her medical providers would be able to track previous tests and procedures she has undergone via an interoperable electronic medical record system, preventing repetition and waste of resources. Use of generic medicines would be stipulated in the clinical guidelines. Her care would be provided by a cohesive team, each working to their strengths and taking on tasks that match their competencies. In summary, high-quality health care is the right care, at the right time, in a coordinated way, responding to the service users’ needs and preferences, while minimizing harm and resource waste. High-quality health care ultimately aims at increasing the probability of desired health outcomes. The quest for high-quality health care recognizes that such improvement is a continuous or dynamic rather than a static process. Regardless of the income level of a country, if there is room for improving health outcomes, the quality of care can also be increased. 3.3 GLOBAL PICTURE OF HEALTH CARE QUALITY Assessment of trends in the global state of health care quality requires consensus on the definition and measurement of indicators for quality, comparable across countries. However, there is no dataset with uniformly defined quality indicators collected globally. There is also no agreement on a minimum set of standardized indicators for quality of care to monitor progress towards attainment of the health-related SDGs across countries. However, there is a growing body of work aimed at identifying indicators to support national, regional and international quality improvement efforts, including the OECD Health Care Quality Indicators Project, the World Bank Service Delivery Indicators, the WHO Global Health Observatory, and Demographic and Health Surveys (34–37). Using data from these sources, nationally representative household surveys, and empirical research, the state of quality of health services globally is described below. DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 33 This description focuses largely on process and outcome measures of quality of care – that is, actions in health care and the effects of these actions on desired health outcomes. These measures are examined in relation to the seven domains of quality of care: effectiveness, safety, people-centredness, timeliness, integration of care, equity and efficiency. The scientific and policy literature also examines structural measures of quality of care that form the context of service delivery, including equipment, human resources, incentives and organizational characteristics (38). This document considers these structural factors to be foundations of high-quality care processes and outcomes. Chapter 4 addresses the foundations of high-quality care. 3.3.1 Are health services effective? When care is ineffective, that is, when providers do not adhere to evidence-based guidelines, this may reflect a lack of knowledge of guidelines or a lack of compliance regardless of knowledge. The effectiveness of care can be assessed using inspection of medical records, patient exit interviews, direct observation of provider–client interactions, standardized patients or clinical vignettes. While clinical vignettes measure the provider’s knowledge of evidence-based protocols for defined medical cases, other forms of measurement predominantly capture compliance with these guidelines. In particular, standardized patients provide consistent cases of illness to providers and allow for comparison of quality of care across providers. This method of effectiveness measurement is also free from observation and recall bias (39). The differences in prevalent diseases across countries and variations in clinical presentation within diseases prevent systematic comparison of the effectiveness of care across providers and countries. However, there is a growing body of evidence indicating that there are gaps in provider understanding of and compliance with evidence-based guidelines in high-, middle-, and low-income countries. For example, in Kenya, only 16% of providers correctly diagnosed all five patient cases that were presented in clinical vignettes to assess provider knowledge (Figure 3.3) (40). In a study of physicians of the former Yugoslav Republic of Macedonia and the United States of America, the mean percentage of correct diagnosis for four clinical vignettes was 48% and 67% respectively (41). Regardless of the method of measurement, there is also a significant gap between provider knowledge and actual practice in service delivery. This finding holds across countries, including Denmark, India, Kenya, the Netherlands and the United Republic of Tanzania (42–45). Figure 3.3 Number of clinical vignettes correctly diagnosed by Kenyan providers (total number of vignettes: five) Source: Martin and Pimhidzai (41). 0 10 20 30 40 50 % 1 case 0.5% 11.5% 30.3% 42.1% 15.6% 2 cases 3 cases 4 cases 5 cases Number of clinical vignettes Chapter 3 Global state of health care quality 34 3.3.2 Are health services safe? Patient harm is the 14th leading contributor to the global disease burden. The majority of this burden falls on low- and middle-income countries (Figure 3.4) (14). The main causes of harm differ between settings, including medication and diagnostic errors in primary care, pressure injury and adverse events in long-term care, and hospital- acquired infections and wrong-site surgery in hospital care (46–48). The scale of unsafe events in health services is considerable (14). In addition to the direct cost of treating adverse events, there are additional costs that result from loss of productivity and diminished trust in the health system. Approximately 15% of hospital expenditure and activity in OECD countries is attributed to safety failures. However, many adverse events are preventable. Evidence suggests that more than one in three adverse events in low- and middle-income countries occurs in non-complex situations and up to 83% may be preventable (49). The costs of safety failures also far exceed the cost of prevention. Improving patient safety in Medicare hospitals in the United States is estimated to have saved US$ 28 billion between 2010 and 2015. Figure 3.4 Burden of disease caused by adverse events, 2015 Note: Percentage of average DALYs/country. Source: Institute of Health Metrics and Evaluation, 2015. High income Upper middle income Low income Lower middle income 19% 18% 25% 38% 3.3.3 Are health services people-centred? The degree to which the needs and preferences of service users are systematically incorporated into health services differs between high-, middle-, and low-income countries. Health systems in high-income countries have introduced measures and institutions to monitor patient experiences and perceptions on their specific medical conditions and general health. While expectations and approaches to people-centred care vary between countries, most service users in OECD countries report a positive experience with regard to time spent with the provider, easy-to- understand explanations, opportunities to raise concerns, and involvement in their care (Figure 3.5) (50). Attention to respectful, compassionate and otherwise people- centred care is not as prevalent in low- and middle-income countries. For example, a growing body of research on respectful maternity care indicates that women experience poor interactions with health care providers and exclusion from care decision-making, and are often not informed about the details of their care (51, 52). DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 35 3.3.4 Are health services timely? Waiting times for elective and emergency procedures have been shown to predict satisfaction among service users (53–55). In emergency situations, delays in receiving appropriate treatment may also lead to preventable deaths (56). Nonetheless, waiting times for different health services vary across OECD countries. For example, in 2015, the mean waiting time for hip replacement was around 42 days in the Netherlands, but 290 days in Estonia and over 400 days in Chile and Poland. Time trends show that reductions in waiting time have been experienced in Finland and New Zealand while this trend has converged in recent years, with relative stability in rates since 2008 in many countries, such as Denmark and the United Kingdom of Great Britain and Northern Ireland (Figure 3.6)  (2). Much less work has been done to compare service delays across low- and middle-income countries. Empirical research from individual countries indicates that waiting times are relatively long. For example, in a study of an emergency department in Barbados, a median of 10 minutes was required for triage, 213 minutes for laboratory results, and 178 minutes to be seen by a doctor (57). Also, in an outpatient department in Nigeria, 74% of service users waited between 60 and 120 minutes to be registered and additional time to see a service provider (58). Luxembourg1 Belgium1 Portugal1 New Zealand1 United Kingdom2 Germany2 Australia2 United States2 Netherlands2 Norway2 Canada2 Czech Republic1 Switzerland2 OECD19 Sweden2 Israel1 France2 Estonia1, 2 Spain1, 2 Poland1, 2 0 20 40 60 80 100 Age-standardized rates per 100 patients 95.5 95.1 90.9 88.2 88.0 87.7 86.0 83.9 83.9 83.3 83.0 81.8 81.4 81.3 80.5 79.7 78.8 67.4 62.1 47.9 Note: 95% confidence intervals represented by . 1. National sources. 2. Data refer to patient experiences with regular doctor. Source: Commonwealth Fund International Health Policy Survey 2013 and other national sources. Figure 3.5 Doctor providing easy-to-understand explanations (2013 or nearest year) Chapter 3 Global state of health care quality 36 3.3.5 Are health services equitable? Gaps exist in health care quality everywhere in the world, but they are even more serious for disadvantaged populations. The United States National Healthcare Disparities Reports have tracked the quality of care since 2010. In 2015, half of the quality measures showed no change or had worsened amongst low-income populations. More than half of the quality measured showed no change or had worsened for rural populations (59). In Canada, patients with myocardial infarction from indigenous groups were less likely to have received recommended treatment, including cardiac angiography and revascularization procedures (60). In Kenya, the quality of maternal health services is lowest in impoverished counties, where only 17% of women had access to minimally adequate delivery care (Figure 3.7) (61). Also, in India, people who live in households of low socioeconomic status in poor communities are less likely to use knowledgeable health care providers (62). Source: Health at a glance 2017 (2). Source: Sharma et al. (63). Figure 3.6 Trends in average waiting times for hip replacement Finland United Kingdom New Zealand Denmark 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Days 200 150 100 50 0 Figure 3.7 Structural and process quality of maternal services by county poverty level in Kenya Quality of maternal care infrastructure Quality of antenatal care Quality of delivery care Quality score 80%+ poverty 60-80% poverty 40-60% poverty 20-40% poverty 0-20% poverty 1.0 0.8 0.6 0.4 0.2 0.0 DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 37 3.3.6 Are health services integrated? With emerging chronic and noncommunicable diseases, more people are living with multiple and complex chronic conditions that require coordination of care across all levels and throughout their life course. Continuity of care and care coordination can improve the care experience of people living with such conditions and support needs. However, substantial gaps in the coordination of health care exist, even in high- income countries. A survey of patients with complex care needs in 11 high-income countries found coordination problems, such as test results or records not available at appointment or duplicate tests ordered, providers failing to share important information with each other, and specialists not having information about medical history or regular doctors not informed about specialist care (63). An analysis of linked primary care and secondary care data on older adults (aged 62–82 years) from 200 general practices in England reported that patients who saw the same general practitioner a greater proportion of the time experienced fewer admissions to hospital for ambulatory care sensitive conditions (64). 3.3.7 Are health services efficient? The World health report 2010 estimated that about 20–40% of all health sector resources are wasted (65). The leading causes of inefficiency in service delivery include inappropriate medicine use, suboptimal human resources mix, overuse or oversupply of equipment, corruption, and underuse of infrastructure. Unwarranted geographical variation in the prevalence of procedures and care intensity provides an indirect estimate of overuse and hence inefficiency. For example, in India, the rates of antibiotic use for acute diarrhoea in public facilities is 43% but rises to 69% in private facilities. Also, there is a ninefold variation in the use of percutaneous coronary interventions internationally and a fivefold variation in the use of coronary bypass grafting across OECD countries (66). These differences are not explained by the variation in the cardiovascular disease burden. Inefficient health care due to overuse and other causes has negative implications for population health outcomes. Life expectancy at birth could be raised by more than two years on average in OECD countries while holding health care spending constant if all countries were to become as efficient as the best performers (67). 3.4 CONCLUSION Despite the substantial increase in access to essential health services achieved during the MDG era, there are high levels of preventable mortality and morbidity that can be addressed through quality efforts. For example, the remaining burden of maternal and child mortality in low- and middle-income countries is largely due to the poor quality of health services. The SDGs explicitly incorporate a focus on the quality of health services in attaining universal health coverage in all countries. 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, people-centredness, timeliness, equity, integration of care and efficiency. Regardless of the income level of a country, if there is room for improving health outcomes, the quality of care can also be increased. Efforts to monitor trends in health care quality for the SDG agenda will be ineffective in the absence of consensus on key indicators that are comparable across countries and are collected on a regular basis. Empirical evidence from the growing body of work on quality measurement indicates that there are gaps globally in all the domains of quality health services. These gaps present opportunities to improve the quality of care and the health of populations. 38 “In any health system, nursing is the backbone of the system,” says Bafana Msibi, Executive Manager for Compliance Inspections at South Africa’s Office of Health Standards Compliance. “In our country especially, and in other countries in Africa, primary health care is nurse-driven.” As a health care executive with over 15 years’ experience, working for an independent body whose mission is to ensure quality of care and compliance with health standards in both public and private health care facilities, Bafana Msibi is well placed to assess the important contribution made by nurses to quality of health care. He defines quality of care, in short, as “making use of the available resources to provide the best care to users.” Msibi acknowleges that good patient care requires a holistic approach that sometimes goes beyond clinical treatment. “You might see a patient presenting with symptoms, and as you try to treat her, you may find that these symptoms are caused by stress,” he says. Because nurses spend more time with patients than any other clinicians, their role is crucial. In addition, they are directly involved in the implementation of precautionary measures that promote a safe medical environment in their daily work. In South Africa, all registered nurses have to undertake one year of community service after they complete their four-year degree. Working under the supervision of experienced professionals who mentor them, the new graduates are exposed to a wide range of medical issues. They also develop a solid understanding of the communities they serve. The knowledge and skills young nurses acquire during this period prepare them well for the demands of their profession. “When I was young, I worked in a clinic in a rural area. If patients came with a problem that required the next level of care, we would refer them to the doctor or call an ambulance to take them to a hospital. There are clinics in most areas, and where there are none, mobile clinics carry out visits. Most of these clinics are nurse-run,” Msibi says. My Quality Mr Bafana Msibi, Executive Manager for Compliance Inspections, Office of Health Standards Compliance South Africa 39DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE In South Africa, some nurses hold high-level jobs as CEOs of hospitals or district managers, Msibi says, but more are needed in leadership positions. “The nursing profession needs to produce leaders for the health care system. They must be developed through the system, know it inside out, and they must also understand the processes of policy development within it.” Bafana Msibi, who was able to conduct a study in a state hospital when he was studying for his Master’s in Public Health, would like more nurses to enjoy similar opportunities to undertake research. Having more nurses involved in policy-making as members of advisory committees, commissions and boards would also contribute to further improvements in the quality of care, he believes. Msibi’s Office of Health Standards Compliance is currently negotiating a Memorandum of Understanding with the South African Nursing Council and other bodies representing medical professions to enhance cooperation across health services. Conducting joint inspections of hospitals, for example, could increase efficiency and help support high standards of care. “When we develop models and frameworks to improve quality, we must make sure they incorporate everyone and put the values of the profession up to the front,” Msibi says. “In the end, we are all interested in providing quality care and if you want to have quality, you have to ensure there is good team work.” Image on previous page: © ranplett / iStock

DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 41 Chapter4 Building quality into the foundations of health systems Chapter 4 Building quality into the foundations of health systems 42 4.1 INTRODUCTION Poor-quality services – even if made available at an affordable cost – are an impediment to achieving effective universal health coverage. This is because communities will not use services that they mistrust and that are of little benefit to them. Mechanisms to assure, monitor and continually improve quality must be built into the foundations of health care systems. This chapter considers five such foundations critical to any health service: health care workers; health care facilities; medicines, devices and other technologies; information systems; and financing. Mere availability of resources is not enough. Conscious and continuous effort is needed to ensure that they are used in ways that are effective, safe and individually tailored to patients’ needs. Governance, as well as the tools, techniques and political economy of reform, is explored in the next chapter. A comprehensive system of care allows people to access a continuum of care across their life course, comprising health promotion, disease prevention, diagnosis, treatment, disease management, rehabilitation, emotional and spiritual support, and palliative care. Three important considerations should underlie the design of any health care system: services should be built to meet local needs; accessible and high- quality primary care should be the bedrock for all other services; and individuals and communities should be engaged in the design, delivery, assessment, and improvement of each and every service (68). The principles of quality improvement must infuse all activities from the front line to the system level. 4.2 FOUNDATIONS FOR HIGH-QUALITY CARE 4.2.1 Health care workers that are motivated and supported to provide quality care Skilled doctors, nurses and other health care professionals are essential for delivering high-quality health care to individuals, families and communities. There is currently an estimated global shortfall of 2.5 million doctors, 9 million nurses and midwives, and 6 million allied health professionals. As a result, basic care is often absent or poorly delivered (69). The problem is most severe in poorer countries (Figure 4.1). Even in developed economies, health workers are too often concentrated in cities, with the consequence that quality of care is often poorer in rural and remote areas. Even within cities, certain locations – for example slums – have a particular deficiency of health workers. Community health workers can help alleviate workforce shortages. They are individuals who have been trained to deliver specific health care services, or to undertake surveillance and treatment for communicable or noncommunicable diseases. They usually come from the communities that they serve, thus providing a potential bridge to community engagement efforts. Community health workers can overcome cultural and linguistic barriers, whilst expanding access to care and providing new forms of employment. Evidence shows that community health workers are capable of delivering safe and effective care for childhood illnesses, reducing the spread of communicable and noncommunicable diseases, promoting nutrition, and providing family planning services, at low cost (70). In low-resource settings, community health workers have reduced maternal, neonatal and child mortality (71). More than 50 years’ experience with programmes shows that these positions should be paid, not voluntary; have specific responsibilities that are not too wide ranging; receive training, continuing education and ongoing supervision; be integrated into primary health care teams; and be part of data feedback loops (72). DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 43 The availability of staff does not in itself assure good care. Health workers can spend little time with patients, lack the ability to make correct diagnoses, or prescribe inappropriate treatment (73). Rural clinicians in southern China spent an average of only 1.6 minutes consulting with patients and asked only 18% of essential questions. A fully correct diagnosis was provided in only one in four consultations (44). Beyond simple headcounts of the health workforce, other critical aspects include: • accessibility, or how easily people can see or speak to a health professional with the right skills, whether in person or via video and telephone links; • acceptability, or whether people feel they have been treated with respect and have had their views taken into account when it comes to decisions related to their health; • quality, or the knowledge, skills and attitudes of health professionals according to accepted norms, and as perceived by users; • skills mix and teamwork, or whether the group of health professionals (and, in some settings, lay workers) together have the knowledge and skills to manage local mortality and morbidity patterns; • enabling environments, or the physical, legal, financial, organizational, political and cultural conditions that support high-quality care. Distribution by country (in selected WHO region) Skilled health professionals density Density per 10 000 population Density per 10 000 population 60 40 20 0 0 20 40 60 80 100 120 140 160 180 200 220 240 260 280 Bu ru nd i Co m or os Er itr ea Eq ua to ria l G ui ne a Le so th o So ut h Su da n Sã o To m é an d Pr ín cip e N ig er Et hi op ia Ce nt ra l A fri ca n Re pu bl ic Si er ra L eo ne M al aw i Ch ad M ad ag as ca r To go Se ne ga l G ui ne a Un ite d Re pu bl ic of Ta nz an ia M oz am bi qu e Li be ria M al i Ca m er oo n Cô te d ’Iv oi re Bu rk in a Fa so G ui ne a- Bi ss au Ug an da Be ni n M au rit an ia Rw an da Za m bi a G ha na De m oc ra tic R ep ub lic o f t he C on go Co ng o Zi m ba bw e Sw az ila nd An go la G am bi a Ke ny a N ig er ia Ca bo V er de Bo ts w an a Al ge ria N am ib ia G ab on M au rit iu s Se yc he lle s So ut h Af ric a Africa Americas South-East Asia Europe Eastern Mediterranean Western Pacific Regional average: 12.8 Global average: 52.8 Figure 4.1 Global density and distribution of skilled health professionals by WHO region, 2005-2016 Source: Global Health Observatory (34). Chapter 4 Building quality into the foundations of health systems 44 The first step in building a high-quality workforce with the right skills mix should be a comprehensive national workforce strategy addressing gaps in numbers, distribution and retention, both in the short term and the longer term. Health professional workforce strategies must not deprive other health systems by attracting qualified staff away from their home countries’ health systems. Workforce policies can take years to bear fruit. The most effective and sustainable solution to rural shortages lies in training students who are themselves from rural communities, including establishing clinical schools in remote areas. Modernizing curricula for pre-service training of health care workers to ensure that they acquire core medical and nursing competencies is an obvious starting point and yet remains a challenge in many countries (Box 4.1) (74). Another priority is continuous professional development to ensure that health professionals maintain and improve their knowledge and skills – spanning a wide range of competencies – throughout their working lives. Increasingly, health systems are making continuous professional development – and even recertification – mandatory. Even where continuous professional development is not in place, policy-makers can work with professional associations to encourage its use and evaluate its impact (75). Finally, integrating the principles of quality and quality improvement into pre-service and in-service education and training curricula and programmes is vital in building a competent workforce that is capable of delivering high-quality health services. Box 4.1 Case study: training and retaining health care workers in underserved areas of the Philippines Two medical schools in the Philippines have a primary focus on recruiting, training and employing students in underserved areas of the country. Ateneo de Zamboanga University School of Medicine and University of the Philippines Manila School of Health Sciences are part of the Training for Health Equity Network (THENet). This international network of medical schools stipulates that the needs of underserved communities should be integrated with all phases and aspects of medical education, from the physical location of the school to the health issues guiding the curriculum. Also, there should be reliance on community-based practitioners for teaching and mentorship. Ateneo de Zamboanga University School of Medicine opened in 1994 in Zamboanga City, on the southwest tip of the southernmost of the Philippine islands, bringing hope of greater access to health care to a population of 3.2 million people. The nearest existing medical school was 400 kilometres away. At the time, 80% of the region’s 100 municipalities had no doctor. The region was plagued by high rates of infant mortality and communicable disease. In 2011, a review of the cumulative 164 graduates found that 85% were practising in the region, with half in rural and remote areas; overall, 90% remained practising in the Philippines versus 32% of graduates nationally. Between 1994 and 2008, the infant mortality rate in Zamboanga declined by approximately 90%, far exceeding the national average decline of 50%. The school continues to recruit students from the region and follows a curriculum that is deeply integrated with local community health needs. Source: World Health Organization (76); Cristobal and Worley (77). DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 45 4.2.2 Accessible and well-equipped health care facilities Substantial variation persists in service availability and readiness. Within and across countries, the density of hospitals and clinics is very different. Basic health care may be many hours away from poorer, rural communities. In sub-Saharan Africa, basic equipment such as a thermometer and stethoscope is available in slightly over half of facilities in Ethiopia, yet in Burkina Faso it is found in almost all facilities (Figure 4.2). The availability and readiness of services to operate is a necessary condition to deliver quality care. However, as discussed throughout this document, it is not sufficient to deliver quality services (78). Figure 4.2 Variations in availability of basic equipment across health care facilities in sub-Saharan Africa Source: Primary Health Care Performance Initiative (79). 100 90 80 70 60 50 40 30 20 10 0 Be ni n Bu rk in a Fa so Co ng o Et hi op ia G ui ne a Ke ny a M ad ag as ca r M au rit an ia M al aw i N ig er Se ne ga l Si er ra L eo ne To go Ta nz an ia Ug an da Za m bi a % 86.2 89.2 74.5 63.3 72.8 67.0 84.9 83.2 70.5 82.0 87.0 81.3 87.0 68.2 78.5 85.3 The quality of health care facilities is judged first on whether the basics are present, such as clean water, reliable electricity, good sanitation and safe waste disposal. In a 2014 survey, less than one quarter of facilities in Nigeria had reliable water, sanitation and electricity. Indeed, WHO estimates indicate that 40% of health care facilities in low- and middle-income countries lack improved water and nearly 20% lack sanitation. These basic foundations are urgently required for quality of care. However, adequate infrastructure does not necessarily equate to high-quality care. Minimum standards need to be set and enforced, and continuous improvement encouraged. Accreditation, inspection and other forms of external assessment and certification are widely used to evaluate health care facilities against explicit standards. The strength of the evidence supporting one-off external assessments is however limited (80, 81). Accordingly, health care systems are increasingly moving to more continuous and formative evaluations of providers’ performance, including measurement of patient outcomes and experiences (15). 4.2.3 Medicines, devices and technologies that are safe in design and use Reliable access to safe and effective medicines, devices and technologies, including blood transfusion, is a basic requirement for effective health care services. Actively restricting unsafe or ineffective products is critical to patient safety. Access to, and minimum quality standards for, medicines and other technologies have improved but substantial gaps remain in basic provision. Extensive and serious problems with counterfeit products complicate the issue. Chapter 4 Building quality into the foundations of health systems 46 Standards of regulation vary greatly. For example, in some countries, antibiotics can be bought without a prescription, fuelling unnecessary use and increasing the threat of antimicrobial resistance (82). Even where medicine use is properly regulated, errors affect about one in 10 prescriptions issued, mostly dose-related errors  (83). According to one report, only 30–40% of patients in countries with developing or transitional economies are treated with medicines according to clinical guidelines (84). The patients’ role in making medicines and devices effective and safe is also critical. Health systems do not usually pay sufficient attention to informing and supporting patients in their use of medicines. The third WHO Global Patient Safety Challenge – Medication Without Harm – was launched at the second Global Ministerial Summit on Patient Safety, Bonn, Germany, in March 2017 with the aim of reducing severe, avoidable medication-related harm by 50% globally in the next five years. Medical equipment requires maintenance, user training, backup support and, eventually, decommissioning. Donating equipment – important in some low-income countries – raises particular concerns. Unless spare parts, consumables and staff training are available, such equipment can be unusable or unsafe. Three out of 10 countries lack a national authority that regulates what medical technologies can be used, and how (85). Blood transfusions are a special case. Many low-income countries are not able to screen blood for HIV, hepatitis B, hepatitis C and syphilis. Transfusion recipients are then at unacceptable risk of acquiring transmissible infections. National policies on medicines and devices help to ensure products of assured quality, in adequate quantities and at affordable prices. Standardized processes for health technology assessment are discussed in the next chapter. Enforceable regulatory systems that address design and development, sale, use and disposal can be powerful in assuring quality and safety in this area. Guidelines and checklists can encourage appropriate use at the bedside. They should be accompanied by surveillance systems that monitor correct use, and that can detect accidents and adverse reactions. Voluntary non-remunerated blood donation improves the supply and safety of blood. Safety would be transformed if all health systems adopted this method of donation (86). The risks of transfusion are reduced by external quality assessment of the collection, preparation and administration of blood products. 4.2.4 Information systems that continuously monitor and drive better care Developing timely, accurate quality measures of health care services, of users’ experiences and of outcomes achieved remains challenging, given how little governments and donors spend on health information systems. Most OECD health systems invest only 2–4% of total health expenditure in information systems. In most low- and middle-income countries, the figure is less than 1% (87). As a result, data on outcomes and quality are often not captured at all, or are collected in ways that cannot be analysed or benchmarked because of a lack of standardized terminology. Even when data are collected, the translation of these data into information that is actionable for quality improvement remains a fundamental challenge. Yet, good performance information matters to improving quality of care. The European Health Care Outcomes, Performance and Efficiency (EuroHOPE) project found that survival after a heart attack varied as much as twofold within a single national health system (88). To enable hospitals and clinics to offer the same level of excellent care, richer comparative data on variation in quality and outcomes need to be collected, interpreted DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 47 and used to spread best practices and support poor performers. As well as EuroHOPE, the European Collaboration for Healthcare Optimization (89) and the OECD Health Care Quality Indicators Project (35) exemplify a trend to develop such data quality schemes globally (Box 4.2). Box 4.2 Case study: OECD Health Care Quality Indicators Project The OECD Health Care Quality Indicators Project began in 2001 with the aim of developing international comparisons of health care quality and, thereby, identifying and sharing best practices to monitor, assure and improve quality. Experts engaged in the project are drawn from OECD and non-OECD countries, international organizations including WHO, the European Commission, and research institutes. Around 50 indicators are reported (covering primary care, hospital care, mental health services, patient safety and patient experiences) from around 40 countries. Comparable health care quality indicators are published alongside other OECD health statistics on expenditure, resources and utilization to facilitate their interpretation. Alongside the regular data collection, there is continuous research and development to improve the validity, utility and comparability of health care quality indicators. Another goal of the project is to strengthen national information infrastructures to produce more complex and reliable indicators in an increasing number of countries, including non-OECD countries. Source: OECD (35). Too often, data are left to moulder in poorly organized, paper-based systems, or are trapped in digital silos incompatible with each other. Timely and appropriate use of and action on information is vitally important. The Health Data Collaborative, a global initiative led by WHO, the World Bank and the United States Agency for International Development (USAID), is addressing this challenge. By working with international agencies and individual countries, the Health Data Collaborative seeks to harmonize how health systems data are collected and reported globally, and aims to enable better tracking of health system performance and progress towards the health-related targets of the SDGs (90). Similarly, the Primary Health Care Performance Initiative (79) aims at sharing internationally comparable results on the performance of primary health care systems globally and enabling performance improvement through sharing of results and best practices for performance improvement. Basic information on all births and deaths needs to be reliably registered. Effective civil registration is the spine of a health system’s information infrastructure. Registers monitoring the needs, interventions and outcomes for patient groups (such as those with HIV, cancer or mental illness) can be built from this. Civil registration allocates a unique person identifier to an individual. This allows data from various providers over time to be linked and enables the performance of health care services to be tracked. If legislation to protect privacy prevents anonymous data linkage of elements of an individual’s health experience in different places and at different times, there will be no way of evaluating an entire pathway of care (Box 4.3). Chapter 4 Building quality into the foundations of health systems 48 Effective information governance remains weak in many health systems. The use of personal health data to monitor and improve health service performance serves an important public purpose, but must always be done in ways that protect privacy. National legislation is needed that protects patient privacy whilst enabling data use and good communication with the public about data use, as well as, at global level, standards to enhance data quality and comparability (91). Moving from paper-based records to a unique electronic health record, usable in multiple health care settings, will help monitor the performance of health care services. Supporting clinicians, managers and policy-makers in interpreting service data and using them for quality improvement will be also vital. Special action is needed to improve patient safety. Encouraging transparency when things go wrong, by building a blame-free and learning culture, is a prerequisite. This can be supported if analyses focus on understanding the root causes of adverse events by exploring the multiple causal and contributory factors that provoke errors, some of which result in major harm to patients. Agreeing on an internationally standardized terminology will also enhance the ability to classify, compare and prevent adverse events across different health systems. Finally, in 2017 ministers of health from OECD countries agreed that their health systems would be benchmarked using a new wave of patient-reported indicators of performance (30). More sophisticated health information systems survey patients directly, to monitor and compare their views on the quality of care received and monitor their health outcomes (93). This strategy is an important development that will support a paradigm shift from measurement systems that are focused on health care providers to truly people-centred systems in which measurement is focused on experiences and outcomes viewed from the perspective of patients (94). Box 4.3 Case study: improving civil registration and vital statistics in Uganda Only one in five of the 1.5 million annual births in Uganda were registered with the national civil registration and vital statistics system. Families often had to travel long distances to register in person, which required a fee. A paper-based system created frequent delays in issuing birth certificates. Even amongst registered births, over half did not receive a birth certificate. The United Nations Children’s Fund (UNICEF) and Uganda Telecom implemented the Mobile Vital Records System, which links mobile phone users and hospital computers to a central government server. For births occurring outside health facilities, volunteers – typically village leaders – collect and send birth information to a government database through a free service from their mobile phones. An official reviews the information and if it is deemed credible, then a birth certificate is issued. The community volunteer is notified via text message. The roll-out of the Mobile Vital Records System increased birth registration substantially, leading to greater expansion of the programme. Now it is also implemented in schools to reach previously unregistered children. Source: UNICEF (92). DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 49 4.2.5 Financing mechanisms that enable and encourage quality care The way funds are collected, pooled and used to pay for health care services can, unsurprisingly, have large effects on the quality and outcomes of care. First, there is solid evidence that funds should be collected and pooled in advance of needing care, through mandatory insurance schemes (with subsidized contributions for those unable to afford insurance). The alternative – paying out of pocket at the moment of need – means that people go without care when they need it and end up sicker as a result, or catastrophically impoverished (65). How funding then flows from insurance agencies to the front line, to purchase or reimburse services, is equally critical. There are several possible mechanisms, such as fee for service, capitation, or annual block budgets (transferred to hospitals or clinics, based on previous or predicted spending). Each has strengths and weaknesses, in the extent to which it rewards activity over outcomes, or incentivizes preventive over reactive care. There are no “silver bullets”, and in practice a blend of mechanisms is usually employed. What is important, from the perspective of quality of care, is that the blend is intelligently designed, aligns as closely as possible with local needs, incentivizes coordination of care for individuals with complex needs, invests adequately in primary care and prevention, rewards quality care, and penalizes care that does not meet sufficient standards. Accordingly, health systems are increasingly designing mechanisms that pay for bundles or pathways of care, and experimenting with quality-based payments. One family of such innovations, applied in high- as well as in low-income settings, is pay for performance (P4P), or results-based financing. Carefully designed, often time-limited, programmes pay health care providers to deliver specific, high-priority interventions. Nearly two thirds of OECD countries have at least one P4P scheme in place, predominantly in primary care. Systematic reviews tentatively suggest a positive impact of P4P and results-based financing programmes on quality in OECD countries (93). Results for results-based financing in lower-income settings are mixed, with fairly modest results so far for quality improvement, particularly for non-targeted conditions. Overall, payment innovations can also be used to deliver sustained collateral benefits – such as improved protocols of care, improved collaboration across providers, and improved information systems – on health care needs, activities, outcomes and costs. 4.3 QUALITY OF CARE AS THE FOUNDATION OF PEOPLE-CENTRED HEALTH CARE As governments plan to deliver universal health coverage, there are three key design principles that should be considered. First, services should be built in a way that meets local health care needs. Although seemingly obvious, many health systems lack a population–health focus. Instead, available health service networks are the product of historical legacy, or are the result of political lobbying or of transient donor funding. Local communities may be innocent bystanders in the design of care that is ultimately destined for them. Many low- and middle-income countries have dealt with a high burden of communicable disease and this has meant that their systems have needed strong public health functions in areas such as surveillance, laboratories and routine immunization. They may also have received substantial donor funds in the form of programme grants to control or eliminate particular diseases. Increasingly, though, the growing burden of noncommunicable disease in these same countries necessitates services capable of supporting people over time with personalized, proactive care to manage their condition, prevent complications and enhance quality of life (Box 4.4). Chapter 4 Building quality into the foundations of health systems 50 A recent study analysed 22 initiatives to strengthen primary health care in 10 counties in China and at national and subnational levels in 12 countries. Eight tenets of high- performing primary health care systems were derived: ensuring primary health care as first point of contact for most health care needs; functioning multidisciplinary care teams; vertical integration of services; horizontal integration of services; advanced information and communication technology; integrated clinical pathways and functioning dual referral systems; measurement standards and feedback; and certification (95). The second key principle of design is to build high-quality primary care services (97). First contacts with health care, and a person’s regular point of entry into the health system, must be continuous and comprehensive (Box 4.5). No physical or mental health issue should be excluded from the oversight and coordination functions of primary care. If individuals and families in a geographically (or otherwise defined) community are formally registered with a named primary care provider, this enables creation of community health profiles, as well as surveillance of needs and delivery of preventive care. Registration also creates a structure for proactive care amongst people with chronic conditions. Primary care is also fundamental to health system resilience, and is pivotal in surveillance of communicable diseases or other hazards, and in the delivery of front-line care in the case of outbreaks. Third, engagement with patients, families and communities needs to be designed into health systems, rather than bolted on as an afterthought. A review of randomized controlled studies of integrated care programmes for the frail elderly, for example, showed that the most benefit was derived from those in which the elderly person was directly involved in care planning (98, 99). If patient groups are encouraged to engage in collective action, people benefit hugely from the support of others with similar health problems. The WHO Patients for Patient Safety programme illustrates this well. The programme has empowered a global network of patient advocates that aims to foster collaborations between patients, families, communities, health care providers and policy-makers to make health care safer through the insights and experiences of patients themselves (100). Box 4.4 Case study: unmet needs for the care of chronic diseases Hypertension, or high blood pressure, is one of the most prevalent and critical risk factors for early death and disability globally. Untreated hypertension leads to kidney disease, ischaemic heart disease and stroke (the latter are the two leading causes of death worldwide). Hypertension affects an estimated one in three adults over the age of 20 years worldwide, with the prevalence now higher in low- and middle-income countries than in high-income countries (age-standardized prevalence of 31.5% versus 28.5%, respectively). Of the approximately 1.5 billion people with hypertension, less than half will be aware of their condition; only 36.9% will be on appropriate treatment; and as few as 13.8% will have their blood pressure effectively controlled. Significant disparities in awareness and treatment exist by country income level: in high- versus low- and middle-income countries, rates of diagnosis and treatment are twice as high and 4 times the proportion of patients have their blood pressure controlled. Source: Mills et al. (96). DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 51 More broadly, collaboration with nongovernmental organizations, grass-roots community groups and patient representative organizations also offers huge potential gains. Civil society organizations focused on health issues are increasingly well established in many low- and middle-income countries (Box 4.6). These groups do far more than just offer advice and support – they also help people assert their rights to high-quality care. A review of literature by Laverack (101) illustrates the multiple avenues through which community engagement strengthens health systems. These include strengthening social networks, developing local skills such as leadership, resource mobilization, or simply asking the question “Why?” Box 4.5 Case study: primary care in Costa Rica In Costa Rica, an innovative primary care sector forms a solid base for the rest of the health care system. Community clinics, or integrated health care basic teams (equipos básicos de atención integral de salud, EBAIS) are the functional units of primary care delivery. Each EBAIS serves around 1000 households. Each consists of at least one medical doctor, one nurse and one health care assistant. Other personnel, such as social workers, dentists, laboratory technicians, pharmacists and nutritionists, may also support the clinic. To complement EBAIS, centres for integrated health care (centros de atención integral en salud, CAIS) have recently been developed. They offer an extended model of primary care, including maternity services, intermediate care beds (to avoid hospital admission or expedite early discharge), minor surgery, rehabilitation, specialty clinics (such as pain management), and diagnostics such as radiography. A detailed primary care performance framework evaluates local health authorities across 30 indicators in the domains of access, continuity, effectiveness, efficiency, patient satisfaction and organizational competence. For each indicator, a national target is set and dashboards of local results are published, allowing providers to compare their performance against national, regional and local benchmarks. National data show that 80% of primary care presentations are resolved at that level, without referral to secondary care. Referral guidelines exist, and hospital referrals are turned back if appropriate steps have not been completed in primary care. Hospital doctors also train colleagues working in EBAIS to strengthen primary care management. Source: OECD (21). Box 4.6 Case study: using Citizen Voice and Action to empower communities in Uganda Empowering communities through training and education is an important step in enabling them to engage with health care providers. The Citizen Voice and Action project model (20), for example, allows citizens to learn about the number of health workers, vaccines, equipment and materials that should be present at their local health centre. Residents then work with health workers and local government to measure the facility’s compliance with government standards. … Chapter 4 Building quality into the foundations of health systems 52 4.4 THE VISION: HEALTH SYSTEMS COMMITTED TO PEOPLE-CENTRED CARE The expectant mother with high blood pressure, or the elderly man with diabetes, arthritis and hearing loss, both require a range of services to be delivered effectively – not just within the formal health system, but in the community to which they will return to live and work. The young man with schizophrenia needs carefully coordinated care to manage his mental health problems, but also to deal with the array of chronic physical health problems that reduce life expectancy by up to 25 years in people with severe mental illness. Complex health care requires systems able to deliver an entire pathway of care (health promotion, disease prevention, diagnosis, treatment, disease management, rehabilitation and palliative care services) consistently, effectively, safely and in ways that are valued by patients and their families. Effective governance of health systems comprises several tasks, including maintaining strategic oversight of goals and priorities; generating the information and analysis required to track whether goals are being met; designing rules, policies and processes to steer the system in the desired direction; and creating and nurturing collaborations within and beyond the health system. Enshrining the right to health care, according to need, in national legislation is a valuable step in making progress towards universal health coverage. Experience shows that de jure commitments often fail to translate, de facto, into access to good-quality care. Setting up a national agency responsible for quality monitoring and improvement is also an important step. Ideally, it should be independent of health care insurers and providers, with the regulatory powers to collect, analyse and publish quality and outcome data. Its role can also encompass sharing lessons learned from high performers and supporting poorly performing services in addressing performance gaps. They can also use a community scorecard to rate the facility according to criteria that they themselves generate, and convene meetings with civil society, government and service providers where all stakeholders can review the evidence and commit to an action plan to improve services. The Citizen Voice and Action model was successfully implemented in Uganda in 2004 in response to perceived weak health care delivery at the primary care level. The main objective of the intervention was to strengthen the provider’s accountability to citizen clients by introducing a process, using trained community- based organizations as facilitators, which the communities could manage and sustain on their own. One year after implementation, health facilities in treatment villages (as compared to comparison villages) saw a 12-minute reduction in average waiting time and a 13% reduction in absenteeism. Health facilities in treatment villages also showed a 33% decrease in under 5 mortality; a 58% increase in the use of skilled birth attendants; and a 19% increase in number of patients seeking prenatal care. The improvements were maintained four years after the project started. DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 53 People-centred care means that health systems must ensure: • continuity from illness prevention to palliation, between services (e.g. intensive care and radiology) and between levels of care (primary to specialist), throughout the life course; • coordination across different care settings, in ways that meet the particular needs of the individuals and their carers; • comprehensiveness that broadens the portfolio of care – from health promotion through to palliative care – that individuals and communities can use. When health systems struggle to provide people-centred care it is often because services still place too much emphasis on treating individual diseases, rather than preventing illness or promoting better health and well-being. The system prioritizes specialist care for its investment and concentration of resources. Primary care can be designed so that it is the mediator between a community’s needs and the range of provision in a health system. It can then fulfil the enhanced coordination role that person-centred care requires (Figure 4.3). An important way of keeping people- centred care on track, and ensuring the right balance of primary and secondary care services, is to publish regular reports analysing performance of the health system as a whole. Figure 4.3 Primary care as a hub of coordination Networking within the community served and with outside partners Source: World Health Organization (102). Consultant support Referral for multi-drug resistance Self-help group Liaison community health worker Social services Other Other Referral for complications Waste disposal inspection Mammography Gender violence Alcoholism Placenta praevia Hemia Traffic accident Diagnostic support Training support Pap smears Primary care team: continuous, comprehensive, person-centred care HOSPITAL NGOs SPECIALIZED PREVENTION SERVICES DIAGNOSTIC SERVICES SPECIALIZED CARE C o m m u n i t y Community mental health unit Environmental health lab Training centre Alcoholics AnonymousWomen’s shelter Cancer screening centre Emergency department Maternity Surgery TB control centre Diabetes clinic Cytology lab CT Scan Chapter 4 Building quality into the foundations of health systems 54 4.5 CONCLUSION Quality can be built into the foundations of health care systems, no matter how far along the road a health system is to reaching universal health coverage. A quality- oriented approach to health care workers, health care facilities, medicines, devices and other technologies, information systems, and financing is vital at all stages of development. Building up the foundations of quality health systems needs to be at the forefront of thinking, planning and policy-making. But more action is urgently required to create quality health systems. Health systems must exchange a top-down hierarchy for pathways and networks based upon cooperation and collaboration, with primary care as the bedrock and people at the centre. This transformation of relations needs to be coupled with new mechanisms to hold governments and health system leaders to account and build citizens’ trust. Box 4.7 outlines key actions that can be taken to ensure that quality is built into the foundations of health care systems. The following chapter provides greater detail about what types of interventions can be brought together and implemented at macro, meso and micro levels to improve quality of care. People-centred care is a critical entry point through which to improve quality. It involves patients in decisions about their care, and asks their opinions about their outcomes of care; it questions variations in patient outcomes across different providers; it drives greater investment in electronic records that work across multiple settings; it assures transparency and learning when things go wrong; and it fosters a myriad of other actions to improve health care quality. As global health care quality expert Donald Berwick has said: “Person-centredness is not just one of the dimensions of health care quality, it is the doorway to all qualities” (16). The WHO Framework on Integrated, People-centred Health Services, adopted with overwhelming support by Member States at the World Health Assembly in May 2016, sets forth a compelling vision in which “all people have equal access to quality health services that are co-produced in a way that meets their life course needs”. It calls for the coordination of services across the continuum of care and for a supportive environment that helps caregivers practise with the skills and resources they need. This framework proposes five interrelated strategic areas (Figure 4.4) for how health services and systems can be reoriented to accomplish this vision (103). Figure 4.4 Five strategies for people-centred services DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 55 Box 4.7 Key actions: building quality into the foundations of health systems To ensure that quality is built into the foundations of systems to achieve universal health care coverage, governments, policy-makers, health system leaders, patients, and clinicians should work together to: 1. Ensure a high-quality health care workforce, by: • developing a national strategy to address gaps in numbers, distribution and retention of health professionals, both in the short term and the longer term; • modernizing training curricula for health care workers and integrating the principles of quality and quality improvement methods into training curricula; • encouraging programmes of continuous professional development and evaluating their impact. 2. Ensure excellence across all health care facilities, by: • ensuring service readiness and availability as a necessary but not sufficient condition for quality of care; • encouraging continuous and formative evaluations of facilities’ quality of care; • collecting and analysing richer data on variations in quality and outcomes across facilities, turning insights into action to spread best practices and support poor performers. 3. Ensure safe and effective use of medicines, devices and other technologies, by: • developing national policies on medicines and devices focusing on assured quality, adequate supply and affordable prices, supported by standardized health technology assessment; • developing guidelines, checklists and surveillance systems to support the correct use of medical technology, and monitor errors, accidents and adverse reactions; • adopting voluntary non-remunerated blood donation and introducing external quality assessment of the processes for collecting, preparing and administering blood products. 4. Ensure effective use of health information systems, by: • building reliable births and death registration systems and, from this, developing a national system of unique patient identifiers to support quality monitoring across pathways of care; • moving away from paper-based records to a unique electronic health record that can be used across multiple health care settings; • developing national legislation that protects individual privacy whilst enabling the use of personal health data for research and quality improvement; … Chapter 4 Building quality into the foundations of health systems 56 • supporting clinicians, managers and policy-makers in collecting and analysing service data for quality improvement, and communicating effectively with the public about how these data are used; • encouraging transparency when things go wrong, by building a learning culture that focuses on understanding root causes rather than assigning individual blame; • at global level, agreeing on standards to enhance data quality and comparability, particularly standardized terminology to classify, analyse and prevent adverse events; • including measurement of patient outcomes and experiences as a standard element in facilities’ quality assessment. 5. Develop financing mechanisms that support continuous quality improvement, by: • reducing reliance on out-of-pocket funding, and shifting to prepaid and pooled funds for the majority of health system financing through mandatory insurance schemes, with subsidies for those unable to afford contribution; • linking financing for health care providers to local health care needs, incentivizing coordination of care for individuals with complex needs, and investing adequately in primary care; • fully exploiting the potential of payment schemes to deliver sustained collateral benefits such as improved protocols of care, improved collaboration across providers, and improved information systems on health care needs, activities, costs and outcomes. 57DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE Chapter5 Understanding levers to improve quality Chapter 5 Understanding levers to improve quality 58 5.1 INTRODUCTION Quality is a complex and multifaceted concept. Its pursuit requires the design and simultaneous deployment of combinations of discrete interventions. Understanding this interdependence is critical in designing future health systems. For example, establishing standards for care is part of quality improvement, but, for the standards to be reliably implemented, additional actions are needed, such as training and supervision, monitoring for compliance and feedback to health care providers. The process of standard setting alone, without these other supporting and interdependent actions, is of limited value (104, 105). This chapter describes a range of levers to improve the quality of health services and discusses the rationale for developing national quality-related policies and strategies. Common goals addressing quality through a wide array of interventions, across all levels of the health care system – from national-level policy and regulation to the direct provision of individual patient care – are examined. The interdependence of these diverse levers for change and the avoidance of a single-track approach are explained. The levers should also be customized within countries as health-related decisions may be made at the subnational and community levels, and should also be sensitive to unique contextual factors. 5.2 DRIVING IMPROVEMENT THROUGH NATIONAL QUALITY POLICY AND STRATEGY The development, refinement and execution of a national quality policy and strategy are a growing priority as countries strive to systematically improve health system performance. A carefully designed national quality policy and strategy – applying an implementation-informed approach – is likely to be one of the pivotal considerations of countries as they work to achieve enhanced access to health services that yield the best achievable outcomes. But why are countries focused on driving quality through national efforts? Each country has its own culture, population needs, and a historical legacy shaping its health care system. Most countries, though, share a set of goals and an awareness of the strategic context for health care. There are six main areas of common ground: • belief that high-quality, safe, people-centred health care is a public good that should be secured for all citizens; • acceptance that better access to care without attention to its quality will not lead to desired population health outcomes; • acknowledgement that strategies to improve the efficiency of health systems must deliver in an increasingly constrained financial situation; • need to align the performance of public and private health care delivery in fragmented and mixed health markets; • awareness that quality health care is vital to resilience in the political context of national and global health security; • realization that good governance means satisfying the public demand for greater transparency about standards of care, treatment choices, performance and variable outcomes. Countries face the challenge of developing or refining their quality-related policies and strategies through national consensus. They must also recognize that driving change towards a future vision of better performance will almost always be limited by the practical realities of how and where health care is currently provided. DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 59 National policies on health care quality are developed through various governmental structures. In some countries, this involves enabling legislation to establish new administrative and governance structures or to create new forms of mandatory action (for example, physician registration and licensing) or to formulate new regulatory mechanisms (for example, inspection and accreditation). This may trigger the need for an explicit national quality policy document. In other situations, implementation of a national quality policy or strategy may simply be part of the routine five-year health sector plan or an internal ministry of health document. There is no single right way to do this, but most approaches involve one or more of the following processes: • quality policy and implementation strategy as part of the formal long-term 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. Boxes 5.1 and 5.2 provide country case studies on the implementation of national quality policy and strategy in the health sectors of Ethiopia and Sudan. Box 5.1 Case study: Ethiopia – National Health Care Quality Strategy 2016–2020 Ethiopia is the second most populous country in Africa, with a population of around 100 million. Since 1995, the country’s health sector has undergone significant reform through implementation of a Health Care Financing Strategy. The Health Sector Transformation Plan identifies four transformation priority agendas: ensuring the delivery of quality health services in equitable fashion; focusing on district-level transformation; strengthening health information systems; and creating a compassionate, respectful and caring health workforce. The Ethiopian National Health Care Quality Strategy was launched in March 2016. In order to operationalize the strategy, the Health Services Quality Directorate has developed a quality improvement tool for clinical audit of selected high-priority health care services in hospitals. Nationwide training on quality of care and audit methods has been conducted with selected health care cadres from all hospitals. The quality data system now allows integration of key performance indicators with the existing health management information system (106). A number of priorities are pivotal to implementation of the strategy, including strengthening the National Quality Steering Committee chaired by the State Minister; supporting the formation of quality units in regional health bureaus and health facilities; capacity-building through training of cadres and dedicated mentorship; integration of quality improvement in the pre school health curriculum; strengthening monitoring and evaluation mechanisms; and creating demand for quality within the community, with a focus on respectful care. In order to operationalize the strategy, the Health Services Quality Directorate has developed a quality improvement tool for clinical audit of selected high-priority health care services in hospitals. Chapter 5 Understanding levers to improve quality 60 At its most effective, a quality strategy acts as a bridge between where a health system currently stands and the level of quality a country aims to attain. It can accelerate the achievement of health goals and priorities, using quality management principles that incorporate planning, control and improvement processes (107). Though the form and content of the national policy and strategy of each country will vary, the following eight components are likely to receive universal consideration: • National health goals and priorities. These will help to direct resources to meet the most pressing demands of the population. The quality agenda is then aligned to them. • Definition of quality. The definition of quality used must be acceptable in the local context within the country and should underpin the national approach. Use of local language and shared understanding are essential. • Stakeholder mapping and engagement. Quality is an aggregate of the individual components of the whole health system. Including key stakeholders in the development of policy and strategy allows a comprehensive range of factors that promote good-quality health services to be addressed. • Situational analysis: state of quality. The current state of quality in any health system encompasses relevant priorities and problems; related programmes and policies; organizational capabilities and capacity; leadership and governance; and related resources. Assessment of the current state of quality defines key gaps requiring attention and areas of health care services that can be strengthened. Box 5.2 Case study: Sudan – National Health Care Quality Policy and Strategy Sudan has a decentralized health system, with the federal government responsible for national health policy-making, strategy and coordination; state governments responsible for planning and implementation at the state level; and local entities concerned with service delivery on the ground. The main administrative body is the multisectoral National Health Sector Coordination Council. Awareness of quality of care among the public and health care professionals is sporadic. While research into quality exists there is no adequate mechanism for interorganizational dissemination of results, so decision-making is not always informed by relevant data and evidence. However, measures are being undertaken to rectify these shortcomings. In line with the third National Health Sector Strategic Plan, a National Health Care Quality Policy and Strategy was formulated in 2017, to be implemented during 2017–2020. The policy addresses four main priority areas: strengthening governance and accountability, compliance with national quality standards, promotion of a people-centred approach, and reduction of avoidable harm to patients. Particular focus has been given to the health workforce through accredited training, career pathways, staffing norms, human resources for health management systems, and performance appraisal and auditing systems to help build capacity. Establishment of a formal partnership with patients and the community is high on the agenda of the National Quality Policy and Strategy. Next steps include strengthening coordination mechanisms for the National Health System; devising a retention scheme for human resources; strengthening the health management information system; institutionalizing quality at all levels; improving patient safety and infection control at the state level; and strengthening management and implementation capacity at all levels. DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 61 • Improvement methods and interventions. Judicious selection of interdependent interventions implemented across all levels of the health care system will improve health outcomes. This task is complicated by limited resources, evidence of impact, feasibility and acceptability. • Governance and organizational structure for quality. Governance, leadership and technical capacity are all necessary factors for improving quality. They need to be clearly articulated. In a growing number of countries, a national-level unit, usually in the ministry of health, has been created and coexists with other national quality bodies. • Health management information systems and data systems. Improving quality relies on clear and accurate performance data. An information system to support nationally driven quality efforts is necessary for measurement, performance feedback and reporting. • Quality measures. A core set of quality indicators is critically important for judging whether activities are producing higher quality of care leading to significant change in health outcomes; for providing feedback to providers and facility management; for promoting transparency to the public; and for comparative benchmarking to identify best practices for learning. Box 5.3 presents a case study on the implementation of national quality strategy through a coordinated Quality Management Framework in Mexico. Box 5.3 Case study: Mexico – National Strategy for Quality Consolidation in Health Care Facilities and Services Mexico, with around 120 million inhabitants, has a mixed health care system with both public and private providers. Despite major reforms, including the introduction of a free health coverage system in 2003, demographic and epidemiological transitions – such as an ageing population and an increase in the prevalence of noncommunicable diseases – continue to place tremendous pressures upon the health care system. A comprehensive systemwide quality improvement strategy was launched in Mexico in January 2001. The main objectives were to promote quality of care as a core value in the culture of health care organizations, both public and private, and to improve the quality of services across the health care system. In 2012 the National Strategy for Quality Consolidation in Health Care Facilities and Services was established, to be implemented through the General Directorate of Quality and Education in Health Care of the Ministry of Health. The strategy aimed to achieve quality improvement in the following areas: patient safety, innovation and continuous improvement, risk management, accreditation of health care facilities, health regulation, and health education. Implementation of the strategy is supported by a Quality Management Framework that provides the administrative structure for quality improvement at all levels. The framework targets five value outcomes: population health, effective access, reliable and safe organizations, satisfactory experience of the population with health care, and reasonable costs. Citizen participation is promoted, and a monitoring system with indicators has been put in place. Incentives include a national quality award, and financial incentives to networks of units for the development of specific joint quality improvement projects. Source: Ministry of Health (108), Sarabia-González et al. (109), Ruelas et al. (110). Chapter 5 Understanding levers to improve quality 62 5.3 QUALITY INTERVENTIONS Quality interventions can have a significant impact on specific health services delivered and on the health system at large. Understanding the types of commonly deployed interventions, and knowledge of the evidence regarding their use and effectiveness, can allow for more informed choices about which interventions to select in countries. The nature of health care challenges in different health systems across the world is actually quite similar, despite the different contexts of population health needs, financing and workforce capacity. Whilst priorities may differ – communicable versus noncommunicable disease, care needs of later life versus treatment of mothers and children – the same quality goals are pursued everywhere: • reduce harm to patients • improve clinical effectiveness of the health services delivered • engage and empower patients, families and communities • build systemic capacity for ongoing quality improvement activities • strengthen governance and accountability. But where does that leave action? Agreeing upon a list of goals is easier than identifying strategies to achieve them. In this context, seven categories of action stand out. They are routinely considered by quality stakeholders – providers, managers, policy-makers – when trying to improve the performance of the health care system. They are considered in the following subsections. 5.3.1 Changing clinical practice at the front line The gap between what is known to be effective care (“know”) and what is routinely performed by providers (“do”) has been well documented around the world. Closing this “know–do” gap requires multimodal changes in clinical practice at every level of a health system, from the individual encounter between the patient and the health care worker to the redesign of health care delivery. The skills, knowledge and attitudes of health care workers are fundamental. Measures to support health care providers to achieve the most effective care include clinical decision support systems ranging from written protocols to electronically supported aids. Reducing harm to patients is a key objective – It is estimated that of every 100 hospitalized patients at any given time, 7 in developed and 10 in developing countries will acquire at least one health care-associated infection (111). Away from the individual patient and provider, new models of care are being developed and implemented to address multiple dimensions of quality. The models define current best practice for the delivery of health care generically and also as related to special populations (for example, people with chronic disease or mental health conditions) or those with common characteristics (for example, children or the elderly). New models of care are often community based, extending well beyond the walls of hospitals and integrating the contributions of primary, specialized and social care organizations (104). 5.3.2 Setting standards Setting standards, with evidence-based protocols, can establish consistency in delivery of high-quality care across diverse health systems globally. Though often led by government entities, standard setting is an area of quality improvement where professional bodies should play a major role, either working independently or in partnership with governments. Some clinical standards focus on specific population DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 63 groups, others on disease conditions or treatment protocols. For example, global clinical standards of care have been developed to improve maternal and newborn care in facilities (112). Embedding clinical policy and standards-based care is often achieved through patient care protocols and clinical pathways. Whilst clinical standards are often an early step in national quality strategies, developing standards without a holistic quality approach may not yield the expected results and progress. 5.3.3 Engaging and empowering patients, families and communities Health systems need to go further than health literacy programmes to make full use of the potential of people-centredness as an entry point to higher-quality care. There is strong evidence, across all country contexts, that interventions that seek to engage and empower patients, caregivers and families can promote better care, including healthier behaviours, enhanced patient experience, more effective utilization of health services, reduced costs and improved outcomes (100). For example, engaging women’s groups in Nepal to identify the major maternal and newborn problems and strategies for improvement resulted in 30% fewer newborn deaths and an 80% reduction in maternal mortality (113). Giving patients information, advice and support can help them manage their health and co-develop treatment and health maintenance plans. Systematic, sustained community engagement mechanisms can also support programmes to improve quality of care. The need to secure or build trust in communities is also a priority. Without it there will be a fundamental barrier in willingness to access health care even when it is needed. 5.3.4 Information and education for health workers, managers and policy-makers To be effective, information systems for quality improvement must meet the needs of caregivers, facility managers, health system leaders, policy-makers and regulators. This requires targeted information and educational methods for each respective audience. Health workers need comparative information about their own performance, especially benchmarked against best practices. Leaders, managers, policy-makers, regulators and funders also need comparative information. The format and focus will vary according to the area of quality being reviewed, whether it is a service (for example maternity care), a disease condition (for example the care of people with diabetes), a group within the population (for example older people), or an intervention (for example measles vaccination uptake). One of the commitments needed from leaders is to ensure that a proper level of investment in information systems is maintained. However, advances in accessibility and utility of information do not need to depend on high-technology solutions; for example, clinical decision support may be in the form of computer prompts or as simple as paper forms with boxes to tick the basic processes related to effective child care. 5.3.5 Use of continuous quality improvement programmes and methods Quality improvement is not a static concept, but rather a continually emerging, dynamic system property. Many different methods are used to continuously assure and improve quality of health care, including broad clinical governance mechanisms; peer review and clinical audit; individual feedback; supervision and training; clinical decision support tools based on guidelines; and multidisciplinary learning collaboratives. A basic tenet underlying continuous quality improvement is activated learning mechanisms using iterative cycles of change. Further, an avoidance of “blaming and shaming” is central in avoiding the risk of promoting fear and resistance rather than Chapter 5 Understanding levers to improve quality 64 enthusiastic engagement in a shared pursuit of improved performance. There is no single effective method. Multiple interventions must be used in combination and with an understanding of the specific context. The role of institutional culture becomes a critical consideration in deciding the specific blend of quality improvement methods based on the capacity and capabilities that exist. 5.3.6 Establishing performance-based incentives (financial and non-financial) Incentives can be either financial, such as payment, or non-financial, such as recognition and awards. Performance-based financing is a broad term for the payment of health providers based on some set of performance measures and is increasingly used as a quality lever. Models include value-based purchasing; readmission penalties; withholding payment for medical errors; and performance programmes focused on strengthening primary care. The amount contingent on performance is a subcomponent of the full payment, based on a range of financing modalities. Evidence remains mixed about the ability of pay-for-performance programmes to change health outcomes by themselves. However, incentives – both financial and increasingly recognized non- financial approaches – can serve an important motivating and sustaining function when used as part of a robust quality improvement programme. At the same time, attention is required in order to avoid disincentives for quality (such as payment systems that encourage excess medicine use). 5.3.7 Legislation and regulation Governments use both legislation and regulation to achieve national health objectives. Legislation directed at improving quality of health services may address a wide range of issues, such as coverage and benefits; establishment of new (or empowerment of current) national bodies; payment reform; licensing of facilities and individual providers; and public performance reporting. Regulation is the range of factors outside clinical practice or the management of health care that influences behaviour in delivering or using health services (114). Regulation usually targets the activities of institutional and individual providers; health insurance organizations; pharmaceutical and device manufacturers; and consumers or patients. Various regulatory interventions often fail to meet their intended objectives, in part because responsible agencies lack capacity for enforcement. Regulation of private sector activity is increasingly important, given the large proportion of total services delivered. Box 5.4 provides a case study illustrating the use of legislation and regulation to support health care quality goals in Ontario, Canada. Box 5.4 Case study: Ontario, Canada – Excellent Care for All Act and Strategy With its large land mass and heterogeneous population of over 13.5 million, including First Nations, provision of equal access to high-quality care is challenging in Ontario. As with all Canadian provinces, Ontario has a single payer health system; about two thirds of health care expenditure is publicly funded, while one third is paid directly by patients or private insurance plans. Various studies have found that the relationship between quality and funding is generally weak in Ontario, and a major goal of current health system reforms is to improve that linkage. The Excellent Care for All Act became law in 2010, with the Excellent Care for All Strategy forming the vehicle for implementation. … DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 65 5.4 CONSIDERATION AND SELECTION OF QUALITY INTERVENTIONS While the seven categories of action provide a broad map of the performance improvement terrain, there is a further need to specify key quality interventions. Selecting the “right” intervention is seldom possible. No single intervention will satisfy all needs. Even interventions that are non-controversial, such as protocols for hand hygiene, are ineffective if not implemented by considering organizational culture and staff attitudes and motivation. Linkage with national goals – designed to withstand political changes – is central to long-term sustainability. Any ambition to improve quality will require a multimodal approach, using a combination of interventions. Some approaches, like accreditation of facilities, may not have a direct impact on health outcomes but can be important in building public trust and in promoting a culture of quality within the health care system. Programmes that focus only on provider behaviour fail to recognize that the wider environment of health care is pivotal in facilitating or hindering best practice. For example, appropriate prescribing of antibiotics often depends on a physician whose behaviour can be influenced by practice guidelines, performance feedback, peer review, training and supervision, financial incentives, availability of a sufficient variety of antibiotics and patient expectation. The complexity of change becomes apparent. The illustrative interventions in Table 5.1 have been identified for the following attributes: relevant in a wide variety of countries globally; commonly considered as options; having some evidence to guide selection and use; and implementable at multiple levels, from small primary care clinics to the level of a national programme. The context within which these interventions are applied is pivotal in maintaining the credibility of quality improvement endeavours. For example, developing a multimodal quality intervention strategy for a health facility without adequate water supply provides an immediate reality check for quality enthusiasts – data on water, sanitation and hygiene from health facilities across the world provide a clear context for action on the structures required for quality. The act mandates quality committees of the board in health sector organizations, and requires surveys of satisfaction for patients, families and employees. In addition, health care organizations must develop and publicly post a patient declaration of values and a quality improvement plan. The Excellent Care for All Act also created an expanded provincial quality agency, Health Quality Ontario, with a mandate to undertake health system performance monitoring and public reporting, support quality improvement, and promote the provision of best-quality health care. At the organizational level, regulations govern quality assurance and safety in hospitals, nursing homes, laboratories, and other health care settings, and health regulatory colleges have been established to ensure that health professionals provide services in a safe, responsible and ethical manner. While 65% of Ontarians rate their health status as excellent or very good, this average masks significant geographical and population variations; for example, the poorest quintile is twice as likely to report having multiple chronic conditions than the richest quintile. In response, a continued focus on leadership, accountability, and alignment of incentives and goals for improvement will continue to be cornerstones of Ontario’s strategy for a higher-quality health care system. Source: ICES (115), Ministry of Health and Long-term Care (116). Chapter 5 Understanding levers to improve quality 66 The list presented is not exhaustive; other interventions could be included. This set of interventions has been selected for their potential impact on quality by reducing harm, improving front-line delivery of health care services, and building systemwide capacity for quality improvement. The illustrative interventions are not ranked by effectiveness but point to some of the options and possibilities available to health system leaders, managers, practitioners or policy-makers intent on advancing quality of care. The interventions are presented as simply as possible, highlighting the salient issues. However, none is simple to implement. The multiple interventions grouped under system environment touch on a number of the seven categories mentioned above. Table 5.1 Illustrative quality interventions Category Interventions System environment • Registration and licensing of doctors and other health professionals, as well as health organizations, is often considered a key determinant and foundation of a well performing health system. • External evaluation and accreditation is the public recognition, by an external body (public sector, non-profit or for-profit), of an organization’s level of performance across a core set of prespecified standards. • Clinical governance is a concept used to improve management, accountability and the provision of quality health care. It incorporates clinical audit; clinical risk management; patient or service user involvement; professional education and development; clinical effectiveness research and development; use of information systems; and institutional clinical governance committees. • Public reporting and comparative benchmarking is a strategy often used to increase transparency and accountability on issues of quality and cost in the health care system by providing consumers, payers, health care organizations and providers with comparative information on performance. • Performance-based financing and contracting is a broad term for the payment of health providers based on some set of performance measures and is increasingly used as a quality lever. The amount contingent on performance is often a subcomponent of the full payment, which may be based on a range of financing modalities. • Training and supervision of the workforce are among the most common interventions to improve the quality of health care in low- and middle-income countries. • Medicines regulation to ensure quality-assured, safe and effective medicines, vaccines and medical devices is fundamental to a functioning health system. Regulation, including post-marketing surveillance, is needed to eliminate substandard and falsified medicines based on international norms and standards. Reducing harm • Inspection of institutions for minimum safety standards can be used as a mechanism to ensure there is a baseline capacity and resources to maintain a safe clinical environment. • Safety protocols, such as those for hand hygiene, address many avoidable risks that threaten the well-being of patients and cause suffering and harm. • Safety checklists, such as the WHO Surgical Safety Checklist and Trauma Care Checklist, can have a positive impact on reducing both clinical complications and mortality. • Adverse event reporting documents an unwanted medical occurrence in a patient resulting from specific health services or during patient medical encounters in a medical care setting and should be linked to a learning system. … DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 67 Category Interventions Improvement in clinical care • Clinical decision support tools provide knowledge and patient-specific information (automated or paper based) at appropriate times to enhance front-line health care delivery. • Clinical standards, pathways and protocols are tools used to guide evidence- based health care that have been implemented internationally for decades. Clinical pathways are increasingly used to improve care for diverse high-volume conditions. • Clinical audit and feedback is a strategy to improve patient care through tracking adherence to explicit standards and guidelines coupled with provision of actionable feedback on clinical practice. • Morbidity and mortality reviews provide a collaborative learning mechanism and transparent review process for clinicians to examine their practice and identify areas of improvement, such as patient outcomes and adverse events, without fear of blame. • Collaborative and team-based improvement cycles are a formalized method for hospitals or clinics to work together on improvement around a focused topic area over a fixed period of time with shared learning mechanisms. Patient, family and community engagement and empowerment • Formalized community engagement and empowerment refers to the active and intentional contribution of community members to the health of a community’s population and the performance of the health delivery system, and can function as an additional accountability mechanism. • Health literacy is the capacity to obtain and understand basic health information required to make appropriate health decisions on the part of patients, families and wider communities consistently, and is intimately linked with quality of care. • Shared decision-making is often employed to more appropriately tailor care to patient needs and preferences, with the goal of improving patient adherence and minimizing unnecessary future care. • Peer support and expert patient groups link people living with similar clinical conditions in order to share knowledge and experiences. It creates the emotional, social and practical support for improving clinical care. • Patient experience of care has received significant attention as the basis of designing improvements in clinical care. Patient-reported measures are important unto themselves; patients who have better experience are more engaged with their care, which may contribute to better outcomes. • Patient self-management tools are technologies and techniques used by patients and families to manage health issues outside formal medical institutions and are increasingly viewed as a means to improve clinical care. 5.5 CONCLUSION Improving health system performance requires choices and judgements during the promulgation of policy, prioritization of national quality goals, engagement of key stakeholders and selection of quality-related interventions. The infrastructure, context, culture and traditions of health care in a country and locality are central in deciding which levers to apply. A successful national quality strategy is multifaceted and uses many interventions in concert (Table 5.2), from those that put the patient at the centre of the care process, to those that support health workers to set standards and work effectively in teams. Leaders, managers and policy-makers play a critical role in supporting and enabling environments in which standard setting, performance-based incentives, regulation and other interventions can flourish. Chapter 5 Understanding levers to improve quality 68 Table 5.2 Quality-related interventions: engaging key actors Actors Roles Government • Definition of national priorities and quality goals • Provision of essential quality infrastructure, e.g. information technology, utilities • Improvement of regulation • Reporting data for transparency and motivation • Inspection and licensing of health care providers Health care facilities • Clinical governance • Establishing care protocols and clinical pathways • Clinical decision support • Use of safety protocols • Inter-institutional learning mechanisms Clinical providers • Clinical standards and patient pathways • Monitoring adherence to standards of care • Peer review and clinical audit • Shared decision-making Patients and public • Patient, family and community engagement • Patient education and self-management • Participation in governance • Patient feedback on experience of care One of the biggest obstacles to health care improvement is a reluctance to acknowledge the problems that exist (117–119). Another is the difficulty of selecting effective interventions and competently implementing them. The importance of leadership is something of a mantra in the field of health care quality improvement, but without it there is no way to inspire belief that improvement is possible to catalyse collective action. Another key driver of success is proof that the intervention is working. It is here that data collection and feedback are indispensable. However, local teams may lack experience in collecting and interpreting data. They may struggle with data collection systems that are poorly designed for monitoring quality (120). Excessively burdensome measures may be seen as a waste of time, while poorly chosen measures can provoke gaming and perverse incentives. Getting the monitoring aspect right from the start is vital, and this means integrating measurement systems into improvement and making sure that they are adequately resourced (121, 122). Developing national quality policy and strategies is a priority if improvement is to be an integral part of the way that the health care system operates. Nationally driven efforts are required to develop and implement a coherent approach to quality that uses multiple levers to secure the positive change being called for by populations across the world. DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 69 Box 5.5 outlines key actions that can be taken to ensure that levers to improve quality are fully utilized. Box 5.5 Key actions: understanding levers to improve quality To ensure that multiple levers are used to improve quality in health care, governments, policy-makers, health system leaders, patients and clinicians should work together to: 1. Develop, refine and execute a national quality policy and strategy, by: • adopting a definition of quality that is applicable in the local context; • conducting a situational analysis of the current state of quality; • involving the range of key stakeholders in its formulation; • identifying (or creating) organizational structures that can provide governance, leadership and technical capacity in quality; • ensuring that quality is integrated across ministry of health functions. 2. Adopt and promote universal quality goals, by: • setting realistic and measurable targets to reduce harm and improve care; • working with professional bodies to establish areas of care to improve clinical effectiveness; • engaging and empowering patients, families and communities; • building systemic capacity for ongoing quality improvement activities; • establishing and activating learning systems for continuous improvement. 3. Design a quality strategy that includes a set of quality interventions, by: • examining carefully the evidence-based quality improvement interventions in relation to the systems environment, reducing harm, improvement in clinical care, and patient, family and community engagement and empowerment. 4. Monitor and report quality of care results for continuous improvement efforts 70 Today’s hospitals are no place for the dying. Both culturally and clinically they are mostly unsuited to provide end-of- life care, according to Dr M. R. Rajagopal, the “father” of palliative care in India. The former consultant anaesthetist has spent over 20 years developing care for the dying in the tiny green and fertile state of Kerala in the south-west of the country. Today, with 3% of India’s population, Kerala has two thirds of the country’s palliative care services. His interest developed when he was working as an anaesthetist at Calicut Medical College in northern Kerala in the early 1990s. He  recognized early on that tackling pain and supporting the dying could not be achieved by medical staff alone. The need was too great. It would depend on harnessing the commitment of volunteers. “Pain is just the visible part of the iceberg of suffering. What is ignored is the part below the surface – feelings of hopelessness and despair, worries about children, about money. That is what palliative care is about.” The movement grew and today he estimates there are 300 voluntary groups across the state (there are no official figures), providing care to patients in their own homes, identifying those in need and helping direct limited medical resources to where they can do most good. The “Kerala model” now attracts attention from around the world. After moving to Trivandrum in the south, in 2006 he founded Pallium India, which supports 11 voluntary groups and five mobile medical teams providing palliative care in the area, as well as campaigning to improve palliative care throughout India. Now aged 69, he still visits patients at home and teaches younger colleagues how to approach them. “If I wear a tie, hold myself with muscular rigidity, and talk only about pain, I will not discover much. With a different, gentler approach, placing a hand on the patient’s arm, they will talk about deeper problems.” He warns about the importance of language. “You can do harm with the wrong dose of a medicine – and equally with a wrong word.” My Quality Dr M. R. Rajagopal, palliative care specialist Trivandrum, India 71DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE As diagnosis and treatment have become increasingly dependent on technology, something has been lost, he says. The growth of the commercial health care industry, driven by profit, has compounded the sense of alienation. The result is that the disease has become more important than the person who has it. Most doctors believe they have a duty to prolong life, rather than ease death. Cure has come to matter more than care. “The patient has become a bit of a stranger amidst the machines. The health care system seems to have forgotten that health is not just the absence of disease but the presence of physical, mental and social well-being.” He argues that every hospital must integrate palliative care with its disease-focused work. Most people, given the choice and the appropriate care, would choose to die at home, surrounded by their loved ones. But some feel more secure in a hospital environment, with their familiar doctor close at hand. It should be a personal choice, he says. Having access to pain relief is vital to that choice but morphine is not easy to obtain. Figures show India uses 320 kilograms of morphine a year, just 1% of the amount required to meet the need. It is not the cost that restricts access, but the law. Morphine has been highly restricted in India since 1985 because of fears about drug abuse. As a result, two generations of doctors have grown up unfamiliar with it, condemning millions of terminally ill patients to an unnecessarily painful death. Here, too, Kerala has led the way. Since 1995, palliative care centres in Kerala have been permitted to administer morphine orally. Dr Raj’s institution is now a WHO Collaborating Centre for Training and Policy on Access to Pain Relief and plays host to a stream of international visitors. “Health care should be a partnership between the doctor, the patient and the family. Doctors should not work alone but with nurses and counsellors, volunteers from the community and social workers. My duty is to build a relationship with my patients and their families and care for them as human beings. Life is not just existence – there is more to it than that.” Image on previous page: © LPETTET / iStock

Chapter6 The quality call to action 73DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE Chapter 6 The quality call to action 74 6.1 SUSTAINABLE DEVELOPMENT, QUALITY AND THE WAY FORWARD The health-related SDGs cannot be achieved through reliance on disease-specific achievements or financial reforms alone. It requires a strong commitment to creating people-centred, high-quality health services. Achieving universal health coverage built on a firm foundation of safe, high-quality care, together with all that is necessary to sustain it, is the imperative facing policy-makers today. Most past efforts at quality improvement have relied on project-based methodologies. They have shown little promise for scale-up and sustainability. More focus is needed on the foundations of high-quality health services across the care continuum. Offering high-quality health services also means linking financial reforms and reorientation of the delivery model to goals on quality of care. Finally, building on strong foundations, health systems offering sustainable improvements in quality must use national quality policy and strategy tools to create an environment where local, regional and national champions can extend and expand what is working to improve services. In such an environment, governments and providers will make locally appropriate choices on which quality improvement interventions could have the greatest impact on improving the system environment, on reducing harm, on improving clinical care and on engaging and empowering patients, families and communities. Advancing quality improvement, universal health coverage and people-centred approaches within the complexity of health systems requires systems thinking – a deliberate and comprehensive understanding of the dynamics of health systems in order to make them change for the better. By decoding the complexity of the health system, systems thinking helps foster systemwide implementation and evaluation of those interventions that are needed to support the achievement of health goals – equitably, sustainably and effectively. 6.2 CALL TO ACTION This document, from the perspective of three global institutions concerned with health – OECD, the World Bank and WHO – proposes a way forward for health policy-makers seeking to achieve the goal of access to high-quality, people-centred health services for all. In this chapter, a series of high-level actions are called for from each of the key constituencies that needs to work together with a sense of urgency to enable the promise of the SDGs for better, safer health care to be realized (Box 6.1). While no single actor will be able to effect all these changes, an integrated approach whereby different actors work together to achieve their part of the quality call to action will have a demonstrable effect on the quality of health services around the world. DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 75 Box 6.1 High-level actions by key constituencies for quality in health care 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 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.

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87DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE Annex – Improvement interventions This annex defines and presents further information and research on a selection of improvement interventions. 1. Licensing of health care providers is a key determinant of a well performing health system. However, emerging work looking at performance differences between licensed and unlicensed practitioners suggests that licensing alone is not enough to assure quality care. For example, a World Bank study on a rural area of India – where there are 15 times as many unqualified providers as those with a medical degree – found that formal training is not a guarantor of high quality. The study observed minor differences between trained and untrained doctors in adherence to safety checklists and no differences in the likelihood of providers giving the diagnosis or providing the correct treatment (1). These findings suggest that formally trained doctors may know what they should be doing clinically but that further interventions are needed to ensure compliance with higher-quality standards of care (2). Systematic monitoring of quality and individual feedback to providers, as well as patient education on provider competence, are other methods for improving quality of care (3). 2. Accreditation is the public recognition, by an external body, of an organization’s level of performance against a set of prespecified standards (4). Accreditation can be granted by public sector, non-profit and for-profit bodies. Historically, metrics used to assess accreditation have been structural and process oriented, such as the presence of adequate medical equipment, staffing ratios and adherence to programmatic standards. Minimal research has been conducted on the relationship between accreditation and clinical outcomes. In one study in Egypt, mean patient satisfaction scores were significantly higher for accredited nongovernmental health units across a few domains: cleanliness, waiting area, waiting time, unit staff and overall satisfaction (5). At least theoretically, accreditation offers some benefits, such as increased public trust and confidence, self-regulating behaviour on the part of health care institutions, and a basis for incentives and sanctions for performance management. Maintenance of an effective accreditation programme may be challenging, for several reasons: the need for additional resources to address structural and performance deficiencies of facilities in preparation for accreditation, continual adaptation to ensure standards are up to date with the evidence, and sustained funding for national or international accreditation (6, 7). In many circumstances, a period of targeted technical assistance will be necessary prior to the implementation of an accreditation programme (6). 3. Clinical governance includes the systematic promotion of activities such as clinical audit; clinical risk management; patient or service user involvement; professional education and development; clinical effectiveness research and development; use of information systems; and institutional clinical governance committees (8). Clinical governance is a concept used to improve management, accountability and the provision of quality care. The National Health Service in the United Kingdom has pioneered large-scale implementation of clinical governance activities (9). Although literature from low- and middle-income countries remains limited, a case study from Indonesia showed that clinical governance was used to improve maternal and newborn health in 22 hospitals (10). The most acceptable mechanisms to drive clinical governance are Annex Improvement interventions 88 those that recognize professional leadership and are perceived as being locally relevant and allowing reflection on personal professional practice (11). 4. Public reporting is a strategy used to increase transparency and accountability on issues of quality and cost in the health care system by providing consumers, payers, health care organizations and providers with comparative information on performance. It includes a broad range of approaches, such as report cards on hospital performance, comparative prices and costs in a community, and benchmarking on clinical indicators for providers. Public reporting has been implemented in several high-income countries, including Canada, the United Kingdom and the United States, where evidence shows that it catalyses improvement. In low-resource countries less has been published, but several cases are illustrative of potential impact. In Afghanistan, the Ministry of Public Health produced and released publicly a balanced scorecard (12), using household survey and annual hospital survey data, which showed progressive improvement in the national scores between 2004 and 2008 in all six domains, including patient and community satisfaction, capacity for service provision, overall quality of services, and reduction of user fees (13). 5. Performance-based financing is a broad term for remuneration provided to health care providers based on performance measures. Often the amount contingent on performance is a subcomponent of the full payment, which may be based on fee for service, capitation or other calculations. Payment can be allocated at the individual level or group level (for example hospital, department or care team). Evidence shows mixed success, depending on factors such as substantial buy-in from stakeholders, institutional capabilities, and the competency of the financing scheme or fund holder (14–17). A field experiment from Rwanda suggests that performance-based financing may be feasible (and preferable to input-based financing) in sub-Saharan Africa (15). The study found improvement across a number of access and knowledge indicators, for example 62% reduction in out-of-pocket costs, 144% increase in deliveries by skilled persons, and 23% increase in knowledge of HIV transmission risks through skin-piercing objects, but found no impact on clinical outcomes (15). Similarly, results from a pilot in Nigeria found an increase in antenatal care visits, and the use of skilled delivery (17). 6. Training and supervision of health workers are among the most common interventions to improve the quality of health care in low- and middle-income countries. Despite extensive investments from donors, evaluations of the long-term effect of these two interventions are scarce. One study found that training and supervision did not meaningfully improve quality of care for pregnant women or sick children in sub- Saharan Africa (18). Another study from Benin found that workers who had received integrated management of childhood illness training plus study supports provided better care than those with training plus usual supports, and both groups performed better than untrained workers (19). In a related project in Benin to strengthen supervision of health workers, after some initial success, many obstacles were encountered at multiple levels of the health system that led to a breakdown in supervision, including poor coordination, inadequate management skills, ineffective management teams, lack of motivation, decentralization, health worker resistance, less priority given to programme- specific supervision, supervision workload, non-supervision activities, incomplete implementation of project interventions, and loss of leadership and effective supervisors (20). The study concluded that support from leaders is crucial, and that donors and politicians thus need to make supervision a priority (20). 7. Medicines regulation improves the quality of medicines, both produced and available. While between 5% and 15% of WHO Member States report cases of DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 89 counterfeit medicines, this is probably a considerable underestimate. Globally, medicine regulation capacity is limited; WHO estimates that 30% of countries have no medicine regulation or a regulatory entity that does not function properly (21). A study in Uganda assessed the effectiveness of national standard treatment guidelines on rational medicine prescribing and found significant improvement in the treatment of general cases, malaria and diarrhoea (22). Due to the extent to which medicine regulatory authorities are both financially and human resource intensive, it can be challenging to ensure that guidelines are followed. This is noted to be the case especially in poorer countries (21). It has been argued that resource-constrained countries should rely on the assessment of major medicine regulatory authorities, such as those in the United States and Europe, when assessing certain categories of medicines (23). This does not solve the problem of enforcement, and high-income country guidelines may not align with the attributes other countries identify as most important. Best- practice prescribing strategies that have had proven success in both developing and industrialized countries include standard treatment guidelines, essential medicine lists, pharmacy and therapeutic committees, professional training, and targeted in-service education (24). 8. Inspection of institutions for minimum safety standards can be used as a mechanism to ensure there is baseline capacity and resources to maintain a safe clinical environment. Although there is little formal literature on the inspection of institutions for minimum safety standards at the hospital or health centre level (25), inspection factors known to improve safety practices include consistency between standards, approval of standards by a country’s ministry, and proper supervision to communicate standards and help practitioners use them in everyday practice (26). At the minimum, inspection standards can identify structural elements that are foundational for quality: a clean water source, reliable power and backup capacity, adequate coverage by skilled health care workers, clear management responsibility, complete medical records and accountability. 9. Safety protocols, such as those for hand hygiene, address many of the avoidable risks that threaten the well-being of patients and cause suffering and harm (27). Health care-associated infections are the most frequent adverse event in health care delivery worldwide (28), the most common being infections of surgical wounds, the blood stream, the urinary tract and the lower respiratory tract (29). Yet, hand hygiene is a worldwide problem, with compliance rates averaging less than 40% (30). Hand hygiene studies have shown an impact on hand hygiene rates ranging from 10% to almost 50% (31, 32). Twenty hospital-based studies published between 1977 and 2008 showed an association between improved hand hygiene practices and reduced infection (33). Additionally, hand hygiene programmes can be cost-effective: one study in Viet Nam calculated that for every health care-associated infection averted, the hospital saved US$  1000 (32). Behaviour change requires multifaceted approaches focusing on system change, administrative support, motivation, availability of alcohol-based hand sanitizers and safe, reliable water and soap, training and intensive education of health care workers, and reminders in the workplace (30, 34, 35). Compliance is a pervasive problem dependent on many structural factors, including professional position (doctor, nursing assistant, physiotherapist technician), department or type of care delivered, staffing ratios, and the presence of relevant safety equipment such as gloves (33). Moreover, programmes need to be context sensitive (for example, alcohol- based sanitizers should be used where clean water is not reliably available) (31, 35). 10. Safety checklists, such as surgical safety checklists, can have a positive impact on reducing both clinical complications and mortality. In one study performed in eight diverse hospitals in a mixture of high- and low-income settings, postoperative Annex Improvement interventions 90 complication rates fell on average by 36% and death rates fell by a similar amount following increased adherence to six core safety processes covered by a provided checklist (36). Moreover, if during the first year of instituting a checklist major complications are prevented, a hospital will realize a return on its investment (37). However, evidence suggests that the successful uptake of checklists requires education of clinical staff, material resources, and integration into broader institutional efforts and clinical context (38–40). These factors have been shown to be particularly relevant in low- and middle-income countries (38). Poor checklist implementation in low-income settings might not only fail to reduce patient safety risks, but may also introduce new risks such as gaming, disengagement and other behaviours harmful to patient care (38). Implementation of surgical checklists is more likely to be optimized in established, multifaceted patient safety programmes (38). 11. Adverse event reporting documents an adverse or unwanted medical occurrence resulting from specific health services or during a patient encounter (41). Reporting of adverse events is a strategy to raise awareness, increase transparency and foster accountability regarding unsafe care. Adverse events due to medical care represent a major source of morbidity and mortality globally. A study looking at the global burden of unsafe medical care estimated that there are 421 million hospitalizations in the world annually, with approximately 42.7 million adverse events occurring resulting in 23 million disability-adjusted life-years (DALYs) lost per year (42). Approximately two thirds of all adverse events occurred in low- and middle-income countries. Unsafe medical care may lead patients, especially in low-income countries, to opt out of using the formal health care system, thereby making unsafe care a significant barrier to access for many of the world’s poor. Consumption of resources due to prolonged stay and extra care, as well as loss of wages and productivity, is a further consequence of unsafe care. 12. Clinical decision support (CDS) is the provision of knowledge and patient- specific information presented at appropriate times to enhance front-line health care delivery. CDS encompasses a variety of tools to enhance decision-making, such as clinical guidelines, condition-specific order sets, computerized alerts and reminders, documentation templates, and diagnostic support. CDS can be automated (embedded within electronic health records or mobile devices) or paper based. Although electronic CDS has many advantages, it does require ongoing technical assistance and may be subject to challenges of poor infrastructure, such as limited access to the Internet or unreliable power supply (43). A number of studies have examined the feasibility of implementing CDS in low- and middle-income countries, but there is only minimal evidence on its impact on health so far (43, 44). Studies note the need to balance CDS prompts that are in place to standardize care for better quality with the physician’s autonomy to make decisions based on context, clinical expertise, and unique patient needs (43–45). 13. Clinical standards, pathways and protocols are tools to guide evidence-based health care that have been implemented internationally since the 1980s (46). In high- income settings, clinical pathways have been used to improve care for diverse conditions, including acute myocardial infarction and stroke. For example, a study from Australia showed that after introduction of a clinical pathway programme with checklists and reminders, an additional 48% of acute myocardial infarction patients received beta blockers within 24 hours of admission (47). Similarly, following introduction of a clinical pathway programme, an additional 55% of ischaemic stroke patients received aspirin or clopidogrel within 24 hours of admission (47). Another study from the United States incorporated “best of care” clinical protocols into clinician’s workflow via care provider order entry and showed that the decision support tool significantly increased the number of patients receiving aspirin for acute myocardial infarction (48). DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 91 Clinical  pathways and protocols are also used in low- and middle-income settings, where national guidelines are published periodically and serve as an important source of reference for clinicians and public health officials, particularly for vertical disease- focused programmes such as tuberculosis and HIV/AIDS (49, 50). 14. Clinical audit and feedback is a strategy to improve patient care through tracking adherence to explicit standards and guidelines coupled with provision of actionable feedback. A common usage worldwide is to foster implementation of clinical practice guidelines, whereby audit and feedback is used to identify unjustified variation and increase guideline adherence. Audit at both individual and hospital levels is a key part of the Catalonian Cancer Strategy (Spain) for promoting equity (51). Even in rural, resource-limited settings, for example in the United Republic of Tanzania, clinical audit has been associated with a decrease in maternal mortality and morbidity (52). Research in higher-income countries has demonstrated that higher-performing facilities tend to deliver more timely, individualized and non-punitive feedback to providers than lower-performing facilities (53). While most studies do not quantify the extent to which audit and feedback concretely impacts adherence to standards, they do highlight the frequency of medical errors and provide a descriptive account of care quality in a given setting, helping clinical staff to identify and address areas for needed improvement. Noted challenges to successful implementation include resource availability, provider buy-in and leadership support for the process, consistency in understanding and implementation of guidelines, the accuracy of information in clinical records, and the effectiveness of continuing feedback mechanisms (51, 54). 15. Morbidity and mortality reviews provide a collaborative learning mechanism and transparent review process for clinicians to examine their practice and identify areas of improvement, such as patient outcomes and adverse events, without fear of blame (55). Morbidity and mortality reviews are used to bring together clinical staff to review, for learning purposes, what contributed to complications or a patient’s death (55). As such, they promote active recognition of mistakes or errors, and are an opportunity to learn as well as to identify needed process improvements. They have been shown to improve collaboration and communication, aid team-based learning, and result in changes in record keeping and governance relevant to patient safety (55 –57). Historically they have been popular in higher-resourced contexts, but studies are emerging that demonstrate potential in low- and middle-income countries. Descriptive work from Nepal suggests that they are feasible in rural, low-resource contexts (56). Research across geographical and economic contexts points to the importance of senior administrative participation, engagement of both clinical and non-clinical staff, clear identification of goals, selection of cases based on their potential for improvement and coordinated follow-up for improvement activities as key success factors (55–57). 16. Collaborative and team-based improvement cycles are a formalized method that brings together multiple teams from hospitals or clinics to work together on improvement around a focused topic area over a defined period of time. Several of the common features of collaboratives are the sharing of ideas for improvement, iterative testing of actions leading to improvement, and mutual learning across multiple health care organizations. Studies from high-income settings, such as the National Surgical Infection Prevention Collaborative or the collaborative to decrease caesarean delivery rates, have shown that collaboratives can be very effective, reducing infection rates from 27% to 1.7% and caesarean section rates by 30% in a matter of months (58–60). Collaboratives have also been used in low-income settings. For example, the Ethiopian Hospital Alliance for Quality was a national collaborative sponsored by Ethiopia’s Federal Ministry of Health. It included 68 hospitals, of which 44 showed a 10% improvement in a 10-point measure of patient satisfaction from the beginning to the end of the study period (61). Annex Improvement interventions 92 USAID funded 54 collaboratives in 14 low- and middle-income countries during the period 1998–2008. A meta-analysis of 27 of these collaboratives in 12 low- and middle- income countries showed that high-level performance was maintained for an average of 13 months and the average time to reach 80% performance was 9.2 months, while the average time to reach 90% performance was 14.4 months (62). 17. Formalized community engagement and empowerment refers to the active and intentional contribution of community members to the health of a community’s population and the performance of the health delivery system. Community involvement in health has many forms and approaches, including the adoption of behaviours to prevent and treat diseases; effective participation in disease control activities; contribution to the design, implementation and monitoring of health programmes; and provision of resources for health. Participation and input to health systems can occur through various means, such as needs analysis, high-level priority setting or participation on governing boards. Many case examples can be found; for example, in Eritrea and Senegal, strengthened community participation in malaria control led to a decrease in severe malaria cases (63), and preliminary analysis of the Ebola outbreak indicates that more formalized community participation efforts resulted in a significant impact on the identification and tracing of cases and broader trust in local Ebola treatment units (64). Health system reform processes have increasingly recognized the essential contribution of communities; in Kenya, feasibility was tested in district-level annual health sector planning where community participation did influence target and priority setting. Challenges of formalized community involvement include building capacity to empower communities, providing tools and products to support community involvement, and appropriate follow-up and supervision by health professionals. 18. Health literacy is the capacity to obtain and understand basic health information required to make appropriate health decisions on the part of patients, families and wider communities (65). Poor health literacy is a challenge for health care quality; for example, patients with low literacy have difficulty following medical instructions, interacting with the health care system, and reading or complying with medicine prescriptions (65). Additionally, patients with low disease-specific knowledge report lower quality of life and have poorer health-related outcomes (65). Studies show educational interventions can have an impact on both knowledge improvement and clinical care seeking. For example, an intervention in Malawi led to a significant improvement in knowledge pertaining to mental health literacy (66), and a study in India found a positive association between health literacy programming and child vaccination rates (67). However, literacy gains lessen with time, so follow-up programming is key. Research suggests targeting influencers, such as teachers, to extend programmatic reach and ensure long-term impact (66, 67). Other considerations include the integration of health literacy curricula into required schooling, which is especially common with sexual health education (68). 19. Shared decision-making between providers and patients is often employed to tailor care to the patient’s needs and preferences, with the goal of achieving better patient outcomes. There is considerable evidence that patients want more information and greater involvement (69), but few studies have evaluated the impact on clinical outcomes, particularly in low- and middle-income countries. Inadequate communication between providers can result in missed services (70). Barriers to patient activation, however, exist in many public health sector settings, such as in clinics, which are often congested and overstretched (71). One study on adherence to antiretroviral therapy and shared decision-making or “patient activation” found that after diagnosis, patients actually preferred provider-led decision-making, but as they gained comfort with their HIV diagnosis, they were more open to a shared decision-making approach DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 93 to HIV treatment (71). There is no evidence that shared decision-making negatively impacts clinical care, though there may be limitations to what can be addressed in a single clinical visit, given such factors as local concepts of illness or historically grounded distrust of “Western” medicine, which may motivate patients to seek traditional medicines (70). 20. Peer support and expert patient groups link people living with similar clinical conditions in order to share knowledge and experiences. The approach complements and enhances other health care services by creating the emotional, social and practical support necessary for managing health problems and staying as healthy as possible. The extensive literature supporting the effectiveness of peer support and patient groups in HIV-infected adults provides insight into what is both feasible and achievable as a strategy for improving quality of care. A systematic review of the impact of support groups on people living with HIV showed that support groups were associated with reduced mortality and morbidity, increased retention in care and improved quality of life (72). Group visits have shown promise in providing individual patients with a peer support network to maximize adherence, improve patient retention, provide patient education, monitor side effects, and achieve therapeutic gains (73). In a South African support group, participants were significantly more likely to have an undetectable viral load and a CD4 cell count greater than 200 cells/mL at 12 months than those who did not participate in a support group (72). Given the severe human resource challenges worldwide, specifically the shortage of trained health care providers, support groups can play a larger role in improving the effectiveness of models of care (72). 21. Patient feedback and experience of care as a strategy to better understand and improve health service quality has risen dramatically, primarily in high-income countries. In these contexts there is a growing body of evidence that self-reported experience correlates with other, more objective, measures of clinical quality (74). Patient-reported measures are associated with better patient experience, adherence to treatment, greater engagement with their care, and better outcomes (75, 76). A few studies in low- and middle-income countries have shown that patients can adequately judge certain aspects of their care. For example, a study based in the United Republic of Tanzania found that patients proactively sought care based on their clinical needs, as judged by the type and severity of symptoms, as well as the perceived value of previously received care (77). Audit-based evidence from primary care settings in India found that patients have a good idea of what they both want and need from doctors and are willing to pay for it (78). Some critics are concerned that the main determinants of patient experience may be driven by factors such as the attractiveness of the environment or amicability of staff; however, it has been shown that patients are able to differentiate superficial comforts from more meaningful engagement. 22. Patient self-management tools are technologies and techniques used by patients and families to manage their health issues outside formal medical institutions. They are increasingly studied as quality improvement tools in the context of growing empowerment of patients worldwide. Given the increasing prevalence of chronic disease globally, diabetes self-management serves as a good example. Diabetic patients involved with self-management education programmes demonstrated significant reductions in glycosylated haemoglobin levels; in Uganda, patient outcomes included decreases in HbA1c percentage and diastolic blood pressure, and in Honduras, reports of self-care demonstrated improvements in over 50% of patients in blood sugar levels, diet and medication adherence (79). One economic analysis of interventions for diabetes found that diabetes self-management training reduces medical costs in developing countries in the short term (80). Because mobile phones are widely available, mHealth interventions for self-management can be a cost-effective tool (79). Annex Improvement interventions 94 Challenges to widespread implementation include both geographical and financial access to such self-management programmes, trained human resources at central and peripheral levels, and access to education (81). 23. Health technology assessment (HTA) is conducted to find out how health care technologies help maintain and improve health. HTA is used to inform policy and clinical decision-making related to both the introduction and diffusion of a wide spectrum of health technologies (82, 83). Assessing whether HTA affects quality involves looking at the long-term pay-off of policies that have been implemented and demonstrated success. HTA has many different applications, such as policy-making for influenza vaccination of children, informing the development of reimbursement schemes in Sweden (which resulted in decreased annual costs), influencing characteristics of health benefit packages in Thailand or Chile (84–86), or defining the role of specific laparoscopic surgery techniques in Kazakhstan (87). Cohesion amongst and between stakeholders is necessary for the successful implementation of HTA with participation from health care professionals, patient advocacy groups, and the industry, such as medical technology or pharmaceutical firms (88). Transparency in analytics, costs and outcomes (real-life patient data) is key for HTA assessment to be successful (83). Because timely and appropriate access to health care products, procedures and medicines can often impact patient outcomes, HTA represents an important mechanism for improving quality of care for both individuals and populations. 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Printed in Switzerland Icons designed by Freepik, from www.flaticon.com 3DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE Contents Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Executive summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Chapter 1 Background: striving for quality in health care services . . . . . . . . . . . . . 15 1.1 Widespread evidence of poor quality in all countries . . . . . . . . . . . . . . . . . . . . . . . 16 1.2 The economic argument for good quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 1.3 Quality as a fundamental feature of universal health coverage . . . . . . . . . . . 17 1.4 Affordability of quality for all countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Chapter 2 About this document . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 2.1 Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 2.2 Scope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 2.3 Content . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Chapter 3 Global state of health care quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 3.1 The quality imperative for universal health coverage . . . . . . . . . . . . . . . . . . . . . . . 28 3.2 Defining quality of care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 3.3 Global picture of health care quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 3.4 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Chapter 4 Building quality into the foundations of health systems . . . . . . . . . . . 41 4.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 4.2 Foundations for high-quality care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 4.3 Quality of care as the foundation of people-centred health care . . . . . . . . . 49 4.4 The vision: health systems committed to people-centred care . . . . . . . . . . . . 52 4.5 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 Chapter 5 Understanding levers to improve quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 5.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 5.2 Driving improvement through national quality policy and strategy . . . . . . 58 5.3 Quality interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 5.4 Consideration and selection of quality interventions . . . . . . . . . . . . . . . . . . . . . . . . 65 5.5 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 Chapter 6 The quality call to action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 6.1 Sustainable development, quality and the way forward. . . . . . . . . . . . . . . . . . . . 74 6.2 Call to action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 Annex: Improvement interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 Contents 4 Figures Figure 3.1 Median under-5 mortality across dimensions of inequality, 2005–2012 . . . . . . . . . . . . . . .28 Figure 3.2 Elements of health care quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31 Figure 3.3 Number of clinical vignettes correctly diagnosed by Kenyan providers . . . . . . . . . . . . . . . .33 Figure 3.4 Burden of disease caused by adverse events, 2015 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34 Figure 3.5 Doctor providing easy-to-understand explanations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35 Figure 3.6 Trends in average waiting times for hip replacement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36 Figure 3.7 Structural and process quality of maternal services by county poverty level in Kenya . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36 Figure 4.1 Global density and distribution of skilled health professionals . . . . . . . . . . . . . . . . . . . . . . . . . .43 Figure 4.2 Variations in availability of basic equipment across health care facilities in sub-Saharan Africa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .45 Figure 4.3 Primary care as a hub of coordination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .53 Figure 4.4 Five strategies for people-centred services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .54 Tables Table 5.1 Illustrative quality interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .66 Table 5.2 Quality-related interventions: engaging key actors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .68 Boxes Box 3.1 Liberia: embedding quality in the post-Ebola health agenda . . . . . . . . . . . . . . . . . . . . . . . . . . .30 Box 4.1 Case study: training and retaining health care workers in underserved areas of the Philippines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44 Box 4.2 Case study: OECD Health Care Quality Indicators Project . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .47 Box 4.3 Case study: improving civil registration and vital statistics in Uganda . . . . . . . . . . . . . . . . . .48 Box 4.4 Case study: unmet needs for the care of chronic diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50 Box 4.5 Case study: primary care in Costa Rica . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51 Box 4.6 Case study: using Citizen Voice and Action to empower communities in Uganda . . .51 Box 4.7 Key actions: building quality into the foundations of health systems . . . . . . . . . . . . . . . . . .55 Box 5.1 Case study: Ethiopia – National Health Care Quality Strategy 2016–2020 . . . . . . . . . . . .59 Box 5.2 Case study: Sudan – National Health Care Quality Policy and Strategy . . . . . . . . . . . . . . . .60 Box 5.3 Case study: Mexico – National Strategy for Quality Consolidation in Health Care Facilities and Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .61 Box 5.4 Case study: Ontario, Canada – Excellent Care for All Act and Strategy . . . . . . . . . . . . . . . .64 Box 5.5 Key actions: understanding levers to improve quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .69 Box 6.1 High-level actions by key constituencies for quality in health care . . . . . . . . . . . . . . . . . . . . .75 5DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE The Sustainable Development Goals (SDGs) reaffirm a global commitment to achieve universal health coverage (UHC) by 2030. This means that all people and communities, everywhere in the world, should have access to the high-quality health services they need – promotive, preventive, curative, rehabilitative, or palliative – without facing financial hardship. The way we typically measure progress in UHC is through effective coverage of essential health services and financial protection (ensuring that no one becomes impoverished because of ill-health). But even if the world achieved essential health coverage and financial protection, health outcomes would still be poor if services were low-quality and unsafe. Delivering quality health services is essential to UHC. That is the focus of this report. Evidence suggests that substandard care wastes significant resources and harms the health of populations, destroying human capital and reducing productivity. Quality of care, especially patient safety, is essential to creating trust in health services. It is also key to global health security, which starts with local health security, and in turn depends on high-quality frontline health services. Quality health services not only prevent human suffering and ensure healthier societies, they also ensure better human capital and healthier economies. Too often, quality is perceived as a luxury that only rich countries can afford. This is a fallacy. Building quality health services requires a culture of transparency, engagement, and openness about results, which are possible in all societies – regardless of their income level. Around the world, lessons abound on what works and what does not, providing a rich foundation from which to rapidly scale up a quality revolution. Technological innovation plays a key role in offering new ways to expand high-quality health care services more rapidly, and at an affordable cost. A focus on people-centredness has to be the core of quality. People and communities must be engaged in the design, delivery, and ongoing assessment of health services to ensure they are built to meet local health needs – rather than those of donors, commercial or political interests, or because “it’s always been done that way”. Focusing on quality is critical, but leadership must also focus on celebrating excellence; communicating transparently; and fostering collaboration across clinical teams, as well as with patients, and civil society – including patient groups, nongovernmental organizations, and grassroots community groups. Universal health coverage is not a dream for the future. It is already a reality in many countries; however, without quality health services, it can remain an empty promise. This foundational report builds a strong technical and political case for investing in quality health services. The collective prize is a healthier, safer and fairer world. Preface Angel Gurría Secretary-General OECD Tedros Adhanom Ghebreyesus Director-General World Health Organization Jim Yong Kim President The World Bank Group

7DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE Acknowledgements This document was jointly prepared by the World Health Organization (WHO), the Organisation for Economic Co-operation and Development (OECD) and the World Bank under the overall guidance of Marie-Paule Kieny, former Assistant Director-General, Health Systems and Innovation Cluster, WHO; Timothy Evans, Senior Director, Health, Nutrition and Population Global Practice, World Bank Group; and Stefano Scarpetta, Director of Employment, Labour and Social Affairs, OECD. The writing team comprised Edward Kelley (WHO), Niek Klazinga (OECD), Ian Forde (OECD), Jeremy Veillard (World Bank), Sheila Leatherman (Gillings School of Global Public Health, University of North Carolina), Shamsuzzoha Syed (WHO), Sun Mean Kim (WHO), Sepideh Bagheri Nejad (WHO) and Sir Liam Donaldson (WHO Envoy for Patient Safety). Development of the document was coordinated by Sepideh Bagheri Nejad. The authors wish to thank colleagues from the Dutch National Institute for Public Health and the Environment (RIVM), Michael van den Berg and Wilco Graafmans for their input to the development of the overall conceptual framework and content of the document, Stefano Scarpetta, Mark Pearson, Francesca Colombo, Caroline Berchet and Luke Slawomirski from OECD for their contribution to the writing, and Sagar Dugani and Adanna Deborah Ugochi Chukwuma from the World Bank for their help with the revision of the text at the final stage. The document benefited from the rich inputs of the Advisory Committee, composed of the following members: Sir Liam Donaldson (Chair), Clifford Hughes, Tawfik Khoja, Jan Mainz, Rashad Massoud, Robin Osborn, Enrique Ruelas, Paul Shekelle, Anuwat Supachutikul and Nana Amma Twum-Danso. Country case studies were produced by the following people: Daniel Burssa and Eyub Gebretsadik for Ethiopia; Sebastian García Saiso, Paulina Pacheco Estrello and Enrique Ruelas for Mexico; Elmuez Eltayeb for Sudan; and Michelle Rossi, Joshua Tepper and Adalsteinn Brown for Ontario, Canada. The annex on improvement interventions was produced by Sheila Leatherman (Gillings School of Global Public Health, University of North Carolina), and Liana Rosenkrantz Woskie, Anthony Moccia, Ruma Rajbhandari and Kim Reimold (the Harvard Initiative on Global Health Quality at the Harvard Global Health Institute). We wish to thank Gheorghe Sorin Banica and Laura Pearson for administrative support and Gary Humphreys for writing the initial draft of the document. We would also like to thank the following peer reviewers: Donald Berwick, Helen Haskell, Margaret Kruk and Ephrem Lemango. Finally, we would like to express our appreciation to the many other staff members from the three partner organizations who contributed to this document. Without their dedication, support and expertise this work would not have been possible: Yetmgeta Abdella, Najeeb Al Shorbaji, Benedetta Allegranzi, Broog Alsadhan, Shannon Barkley, Marie-Charlotte Bouesseau, James Campbell, Meena Cherian, Mickey Chopra, Krycia Cowling, Jishnu Das, Neelam Dhingra-Kumar, Joan Dzenowagis, Peter Engelfriet, Linda Freiheit, Ruben Frescas, Michele Gragnolati, Michelle Karen Funk, Javier Gomez Batiste-Alentorn, Joyce Hightower, Maki Kajiwara, Rania Kawar, Michael George Kay, Acknowledgements 8 Claire Kilpatrick, Ramesh Krishnamurthy, Angela Lashoher, Agnès  Leotsakos, Manon  Lette, Akiko Maeda, Nicola Magrini, Elizabeth Mason, Kellie McGee, Nana Mensah Abrampah, Hernan Montenegro Von Mühlenbrock, Margaret Murphy, Jillian Oderkirk, Shanti Pal, Felicity Pocklington, Nittita Prasopa-Plaizier, Paul Peter Schneider, Emma Scholar, Maria Cecilia Sepulveda Bermedo, Maria Angelica Sousa, Julie Storr, Nuria Toro Polanco, Andreas Ullrich, Krisantha Weerasuriya, Erica Wheeler, Tana Wuliji, Mohammad Taghi Yasamy, Junping Yu, Hongwen Zhao and Hao Zheng. 9DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE Abbreviations CAIS centres for integrated health care (centros de atención integral en salud) CDS clinical decision support DALY disability-adjusted life-year EBAIS integrated health care basic teams (equipos básicos de atención integral de salud) EuroHOPE European Health Care Outcomes, Performance and Efficiency (project) HTA health technology assessment MDG Millennium Development Goal OECD Organisation for Economic Co-operation and Development P4P pay for performance SDG Sustainable Development Goal UNICEF United Nations Children’s Fund USAID United States Agency for International Development WHO World Health Organization Abbreviations 10 11DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE This document – 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 low- and 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, people- centredness, 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 Executive summary Executive summary 12 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. DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 13 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. Executive summary 14 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. DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 15 Chapter Background: striving for quality in health care services 1 Chapter 1 Background: striving for quality in health care services 16 Universal health coverage is an important and noble objective. Enshrined in the Sustainable Development Goals (SDGs), universal health coverage aims to provide health security and universal access to essential care services without financial hardship to individuals, families and communities, thus enabling a transition to more productive and equitable societies and economies. But universal health coverage should not be discussed and planned, let alone implemented, without a focus on quality. It is essential to ensure that care is effective, safe, and in keeping with the preference and needs of the people and communities being served. Further, provision of care should be timely and equitable across populations, coordinated across the continuum of care and throughout the life course, while minimizing resource waste. Quality of care therefore underpins and is fundamental to universal health coverage. For if quality of care is not ensured, what is the point of expanding access to care? Access without quality can be considered an empty universal health coverage promise. Quality is not a prerogative of high-income countries. If countries can afford to provide any health care – and even the poorest can and should do so – they must provide care of good quality. The alternative – poor-quality care – is not only harmful but also wastes precious resources that can be invested in other important drivers of social and economic development to improve the lives of citizens. Billions of dollars are spent on the consequences of poor-quality care – money that can fund schools, social services and infrastructure. And poor quality can also undermine the trust of the population in the benefits of modern medicine. Seen this way, universal health coverage without quality of care is a job half done. 1.1 WIDESPREAD EVIDENCE OF POOR QUALITY IN ALL COUNTRIES Much progress has been made in improving some aspects of quality of health care across the world, for example with regard to cancer survival rates and mortality from cardiovascular diseases (1, 2). But in other areas, progress has been slow and uneven. The numbers speak for themselves. • In high-income countries, one in 10 patients is adversely affected during treatment (3). • In high-income countries, seven in 100 hospitalized patients can expect to acquire a health care-associated infection (in developing countries this figure is one in 10), infections that can be easily avoided through better hygiene and intelligent use of antimicrobials (4). • Unwarranted variations in health care provision and delivery persist, and a considerable proportion of patients do not receive appropriate, evidence-based care (5, 6). • Influenza vaccination rates vary across high-income countries from 1% to over 78%, despite a goal of 75% by 2010 set by the World Health Assembly in 2003 (7). • Antimicrobial resistance has become a major global public health issue, partly due to the misuse and overuse of antimicrobials in health care (8). • Globally, the cost associated with medication errors has been estimated at US$ 42 billion annually, not counting lost wages, foregone productivity or health care costs (9). DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 17 • While the rate of skilled birth attendance increased from 58% in 1990 to 73% in 2013, mainly due to increases in facility-based births, there are still many women and babies who, even after reaching a health facility, die or develop lifelong disabilities due to poor quality of care. The World Health Organization (WHO) estimates that 303 000 mothers and 2.7 million newborn infants die annually around the time of childbirth, and that many more are affected by preventable illness. Further, some 2.6 million babies are stillborn each year (10, 11). • Nearly 40% of health care facilities in low- and middle-income countries lack improved water and nearly 20% lack sanitation – the implications for quality of care are clearly evident (12). • Cross-country estimates of the distribution of diagnosis and control of raised blood pressure in selected countries outside the OECD highlights the importance of quality preventive services. In most, at least half of the adults with raised blood pressure have not been diagnosed with hypertension. Hypertension treatment coverage is therefore low, ranging from 7% to 61% among people who have presented with raised blood pressure in the household surveys. However, effective coverage is considerably lower than coverage, ranging from 1% to 31%, indicating a quality issue (13). 1.2 THE ECONOMIC ARGUMENT FOR GOOD QUALITY Beyond the effects on people’s lives, poor-quality care wastes time and money. Making quality an integral part of universal health coverage is both a matter of striving for longer and better lives and an economic necessity. Building quality in health systems is affordable for countries at all levels of economic development. In fact, the lack of quality is an unaffordable cost, especially for the poorest countries. Substandard quality of care not only contributes to the global disease burden and unmet health needs, it also exerts a substantial economic impact, with considerable cost implications for health systems and communities across the world. Approximately 15% of hospital expenditure in high-income countries is used to correct preventable complications of care and patient harm. Poor-quality care disproportionately affects the more vulnerable groups in society, and the broader economic and social costs of patient harm caused by long-term disability, impairment and lost productivity amount to trillions of dollars each year (14). In addition, duplicate services, ineffective care and avoidable hospital admissions – features of many health systems – generate considerable waste. Up to a fifth of health resources are deployed in ways that generate very few health improvements. These scarce resources could be deployed much more effectively (3). 1.3 QUALITY AS A FUNDAMENTAL FEATURE OF UNIVERSAL HEALTH COVERAGE Quality does not come automatically; it requires planning, and should be a clearly identified priority of universal health coverage, along with access, coverage and financial protection. This document shows that building quality into health systems is possible if a number of steps are followed and principles applied, namely transparency, people-centredness, measurement and generation of information, and investing in the workforce, all underpinned by leadership and a supportive culture. With these fundamentals in place, proven interventions and practices to ensure quality – such as hand hygiene, treatment protocols, checklists, education, and reporting and feedback – can be implemented and sustained. Chapter 1 Background: striving for quality in health care services 18 Transparency is paramount. It is the bedrock of continuous learning and improvement. The overarching conclusion from 15 reviews of quality in national health systems conducted by OECD between 2012 and 2016 was the need for greater transparency about performance in terms of quality and outcomes of care (15). A key component of transparency is being open and honest about results, including lapses and mistakes. In such an environment these become opportunities to learn, as is the case in other sectors, including air transport. Successful outcomes should be celebrated and shared for the same reasons. This culture of transparency can take time to build, but it can and must be instilled in all health systems, regardless of resources available. Involving people and communities in their own care and in the design of their health services is now recognized as a key determinant of better outcomes. People and the communities in which they are born, raised, live, work and play are at the heart of delivering quality health services. People who are actively engaged in their own health and care suffer fewer complications and enjoy better health and well-being. At the clinical level, this means enabling patients to partner in their care and in clinical decisions, and to actively manage their health. People-centredness is the “doorway to all qualities” (16). Indeed, the common thread of success stories detailed later in this document is putting the patient’s needs and values front and centre. This means caring with compassion and respect. But people-centredness goes beyond individual care. People and patients should be involved in priority setting and in policy development. Nowhere is this more important than in primary and community care. These services need to be designed with input from the communities that they serve, based on their unique needs and preferences, as discussed in Chapter 4 of this document. Quality requires measurement and generation of information. Health care is changing all the time, so quality needs to be continually monitored and assessed to drive improvement. This relies on accurate and timely information. The banking industry devotes 13% of its income to information systems. Health care invests less than 5% – a paltry amount for an information-intense sector. And when they exist, the data generated by health systems are too often concentrated on inputs and volume of activities. This needs to change if quality is to become a routine part of health care. Reliable quality metrics must be embedded in local and national health information infrastructures – this is even more important than measuring inputs. In the spirit of transparency, information must be available to all relevant actors, including patients, providers, regulators, purchasers and policy-makers. All dimensions of quality should be measured. It is important to know about adherence to essential protocols and the quality of processes and pathways, for example hand hygiene; surgical safety checklists; adherence to clinical practice guidelines; and clinical outcomes, for example readmissions, mortality rates, adverse drug reactions, survival after a diagnosis of cancer and adequate control of glycaemia during pregnancy. But knowledge must also be generated on the outcomes and experiences of care that are valued by patients through the measurement of patient- and community-reported quality indicators (17). All this needs to be done with a clear eye on strong linkages between measurement and improvement – measuring alone will not improve quality. A skilled, motivated and adequately supported health workforce is critical. Health care providers want to deliver the best possible care to their patients. Often, however, the systems and environments they work in make this task difficult. Many countries face significant deficiencies in both the quantity and quality of their health DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 19 workforce. Of course, not all care should be delivered by doctors. Nurses, allied and community health workers, care coordinators and managers all play important roles in delivering high-quality care in the 21st century. It is possible to achieve high quality by leveraging their skills throughout the chain of health production (18). In providing high-quality care, technical knowledge needs to be augmented by the ability to communicate and work as a team with other professionals, and to partner with patients and their carers. It also requires a workforce trained in the principles and practice of continuous quality improvement, as well as recognition of the “hidden curriculum” that arises from the fallibility of human-designed systems. Quality is also a function of how well efforts are organized and integrated with other sectors, taking account of patterns of behaviour, human interaction and relationships. This in turn depends on the incentives that are in place, including funding and remuneration, regulation, reporting and feedback, which need to be carefully built into all processes and institutions. In the end, systems provide the fertile soil in which high-quality practice and improvement can bloom. None of the above is possible without leadership and an enabling culture. A  buoyant culture in which all actors are motivated to collaborate, communicate and work with their communities to deliver high-quality people-centred care, without fear or intimidation, has been shown to deliver better outcomes (19). Many factors influence such a culture of continuous quality improvement. First and foremost, a transparent environment should be cultivated, as described above. Also important are training and socialization of workers, improvement measures, feedback on performance, and shared learning, as well as upstream factors such as financial incentives. But the key ingredient is consistency of leadership from governments, policy-makers, clinical leaders, health system managers and civil society. This does not require a high level of resources – it rather requires investment in a culture shift towards transparency for continuing improvement. These fundamentals provide the backbone for policies and practices to continually improve health care quality. But quality must be the responsibility of all stakeholders and institutions. It must be supported by a crystal-clear national strategic direction, with well defined objectives and goals, and strong stakeholder engagement across the entire health system, as well as with other sectors. 1.4 AFFORDABILITY OF QUALITY FOR ALL COUNTRIES While high-quality health care for all may seem ambitious, it can be achieved in all settings with good leadership, robust planning and intelligent investment. For example, in Uganda a model involving citizens and communities in the design of health care services has improved a range of indicators, including a 33% reduction in child mortality (20). Costa Rica has achieved remarkable improvements in primary care quality through a carefully planned, implemented and resourced improvement strategy (21). These and other examples are provided later in this document. For low- and middle-income countries, addressing quality while building universal health coverage is a huge opportunity. A health system that is maturing and becoming established can be influenced, steered and nurtured in the desired way. Quality can be embedded into policies, processes and institutions as the system grows and develops. Chapter 1 Background: striving for quality in health care services 20 The challenge is how to learn from the experiences – both the successes but also (and especially) the mistakes – of health systems in high-income countries. A key lesson is that retrofitting quality into established health systems is certainly possible but can be arduous; rather, quality must be built in from the start, along with access, coverage and financial protection. Of course, quality care cannot be conjured up entirely for free – it requires some investment of capital and other resources. This investment is not beyond reach, even for the poorest countries. The costs of poor quality to people’s lives, to health systems and to societies are massive. If applied intelligently, investment in quality will deliver better individual and population health, and value for money; the return on investment in ensuring high-quality care is likely to far outweigh the costs. Better outcomes also further economic and social development; for example, healthier people are more productive at work, and healthier children perform better at school. So striving for universal quality health coverage is not just an investment in better health – it is a commitment to building a healthier society and a healthier world. 21DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE Eight years ago, when she was diagnosed with rheumatoid arthritis, an autoimmune disease that causes inflammation, swelling and acute pain in the joints, Cecilia Rodriguez was Director of a primary health care facility. “I had very bad rheumatoid arthritis and spent a lot of time in bed,” says Rodriguez, who was in her thirties when she first experienced the painful symptoms. “I realized that what I had been promoting as a health administrator was very different from what I needed as a patient.” Rheumatoid arthritis touches people of all ages. Its exact causes are not known, but genetic and environmental factors may play a role. Up to 1% of the world’s population is affected.1 In Chile, where Rodriguez lives, 100 000 people are living with this lifelong condition. For people with chronic diseases, quality health care can be defined as “an accurate equilibrium between clinical best practices and what is best for the patient, determined with the patient,” Rodriguez explains. “We don’t always need doctors who have all the answers. We need people who understand how we are coping with our condition.” Above all, she believes patients suffering from chronic conditions that have a huge impact on daily life need to feel in control of their treatment. “As a patient, I know what I want to achieve. Clinicians can help me understand if I can achieve it and help me do so. For me, that’s the best quality of health care.” Cecilia Rodriguez and her sister Lorena, who had been diagnosed with rheumatoid arthritis a few years earlier, established a non-profit organization to support people affected by the same condition and advocate for improved patient care. “We called the NGO ‘Me Muevo’ (‘I move’) because we learned that with this condition you have to keep your body moving, but also because ‘I move’ means ‘I take action’”, she says. My Quality Ms Cecilia Rodriguez, Executive Director ‘Me Muevo’ Foundation 1. www.rheumatoidarthritis.org. 22 ‘Me Muevo’ is part of a growing movement of patient-led organizations in Chile. Rodriguez acted as spokesperson for an alliance of associations that successfully lobbied to make prescription drugs more affordable. In 2016, Chile adopted the ‘Ricarte Soto Law’ on high-cost treatments. “Now I only pay US$ 200 a year for all my medications, instead of US$ 1500 per month,” Rodriguez says. “Health care systems tend to be geared towards treating acute illnesses, and are rarely organized to help patients with lifelong diseases overcome the hurdles of daily life,” Rodriguez explains. She cites the example of her sister who works and has to travel to three locations – a process that takes at least five hours – to collect her monthly prescription drugs. “In this case, quality of care would mean being able to pick up all her medications from the primary health care facility near her house, on a Saturday morning,” she says. Rodriguez also promotes enabling patients to enter notes into their medical records between medical appointments to help physicians adjust their treatment. “If I could write that I had had a flare-up and say how I had dealt with it, my doctor would have that on record when I saw her three or four months later,” she says. After Rodriguez attended a chronic disease self-management course in the United States, which helped her better cope with the effects of her disease, her organization worked to make the programme available to patients in her own country. “Investing in teaching self-management can reduce overall costs. That is why we are bringing this programme to Chile,” she says. As a result, seven hundred people benefited from this training through the public system, last year. Image on previous page: © Rawpixel / iStock DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 23 Chapter2 About this document Chapter 2 About this document 24 Recognizing the global gap in understanding, measuring and improving quality of health care services, WHO, OECD and the World Bank have joined efforts to produce this document – Delivering quality health services: a global imperative for universal health coverage. 2.1 OBJECTIVES This document has been developed with the following objectives: • to provide governments with a description of the quality of health services and their importance to achieving broad public health goals, within the context of universal health coverage; • to provide governments with a picture of evidence-based approaches that can ensure and improve quality of health services; • to make a call for action at national and international levels. 2.2 SCOPE This document is intended for policy-makers who want to bring the fundamentals of health care quality improvement into their health systems. Therefore, it looks at the quality of health care services at the foundation. The document does not aim to provide technical guidance for front-line health care professionals, though they may find useful information herein. Nor does it examine the implications of quality for specific technical areas. 2.3 CONTENT The document begins with a chapter on the background to quality in health care services (Chapter 1), followed by a brief description of the document (Chapter 2). The main body of the publication comprises three chapters on key quality themes (Chapters 3–5), followed by a quality call to action in Chapter 6. • Chapter 3: Global state of health care quality. In this chapter a global picture of quality in health care services is provided. Data are presented to show that quality of care in most countries, particularly low- and middle-income countries, is suboptimal, and improvement in quality is associated with better health outcomes. • Chapter 4: Building quality into the foundations of health systems. This chapter describes how mechanisms to assure, monitor and continually improve quality must be built into the foundations of health systems, and addresses key issues that require attention to improve the quality of health care at country level. • Chapter 5: Understanding levers to improve quality. Quality is a complex and multifaceted concept that requires the design and simultaneous deployment of combinations of discrete interventions. This chapter highlights the importance of driving quality improvement through national policy and strategy and presents a range of levers for quality improvement. • Chapter 6: The quality call to action. A quality call to action is put forward to health policy-makers seeking to achieve the goal of access to high-quality, people-centred health services for all. This is offered with a sense of urgency, for if we do not act now, achievement of public health goals will be at stake. DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 25 Those chapters are followed by an annex, which provides a set of improvement interventions that have been selected for their potential impact on quality by reducing harm, improving front-line delivery of health care services, and building systemwide capacity for quality improvement. The illustrative interventions point to some of the options and possibilities available to health system leaders, managers, practitioners or policy-makers intent on advancing quality of care.

DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 27 Chapter3 Global state of health care quality Chapter 3 Global state of health care quality 28 3.1 THE QUALITY IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE Between 2000 and 2015, the Millennium Development Goals (MDGs) accelerated global progress towards attaining population health goals in low- and middle-income countries. Globally, child mortality fell by 53%, maternal mortality fell by 43%, and new HIV infections declined by over 38% (22). However, progress was highly unequal. In poor, rural, and hard-to-reach populations, preventable mortality remained high. For example, for children aged under 5 years in low- and middle-income countries there are significant differences in mortality between those living in the poorest households compared to those living to the richest households, between those whose mothers were the least educated compared to the most educated, and between those living in urban areas compared to rural areas (Figure 3.1). “What good does it do to offer free maternal care and have a high proportion of babies delivered in health facilities if the quality of care is substandard or even dangerous?” Margaret Chan, former WHO Director-General, World Health Assembly, May 2012 Systematic assessments of essential health services in high-mortality countries revealed major deficiencies in the quality of care received. In one such assessment across eight countries in sub-Saharan Africa, quality-adjusted (effective) coverage averaged 28% for antenatal care, 26% for family planning, and 21% for sick child care, and was substantially lower than crude service coverage (23). Over 40% of facility-based deliveries Figure 3.1 Median under-5 mortality across dimensions of inequality, 2005–2012* * Median value of 49 selected countries ** Data are not available for 10 countries Source: World Health Organization (22). 120 100 80 60 40 20 0 Q ui nt ile 1 (p oo re st ) Q ui nt ile 2 Q ui nt ile 3 Q ui nt ile 4 Q ui nt ile 5 (r ich es t) N o ed uc at io n Pr im ar y sc ho ol Se co nd ar y sc ho ol + Ru ru al Ur ba n M al e Fe m al e Economic status Mother’s education** Place of residence Sex Deaths per 1000 live births DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 29 in five countries in sub-Saharan Africa took place in primary care facilities with major gaps in resources and technical expertise (24). The MDGs did not include a specific focus on measuring and improving quality of care, yet these deficits in quality of care have had negative implications for translating increases in coverage to better population health. Poor-quality services have been shown to predict a higher risk of neonatal mortality in Africa (25). Also, an increase in institutional deliveries from 14% to 80% in India did not reduce maternal and child mortality due to the poor quality of care provided at health facilities (26). In essence, poor quality of care is responsible for persistently high levels of maternal and child mortality in low- and middle-income countries, despite substantial increases in access to essential health services achieved during the MDG era. In 2015, the United Nations General Assembly adopted a new development agenda: Transforming our world: the 2030 Agenda for Sustainable Development. The SDGs comprise a broader range of economic, social and environmental objectives than the MDGs and set a new health goal, to “ensure healthy lives and promote well- being for all at all ages”. Universal health coverage is considered fundamental to the SDGs. Simply defined, universal health coverage means ensuring that all people and communities can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship. In explicitly focusing on the quality of health care services, the 2030 Agenda for Sustainable Development recognizes the urgent need to place quality of care in the fabric of national, regional, and global action towards promoting well-being for all. While global attention has focused on universal health coverage, at the local level, the devastating outbreak of Ebola virus in West Africa reinforced the strong case for quality of care. In Guinea, Liberia and Sierra Leone, gaps in service delivery and the accompanying collapse of public trust in health systems presented herculean challenges to response and recovery efforts during the Ebola outbreak. For instance, assessments of the Sierra Leonean health system revealed a low density of human resource for health, low capacity for disease surveillance in the community, infrastructural deficits in health facilities, and weak supply chains for essential medicines (27). All three countries have since emphasized universal access to quality health service delivery to strengthen their ability to prevent large-scale outbreaks in the future, placing infection prevention and control and patient safety as key priorities. Following the outbreak, Liberia has developed an investment plan to build health system resilience and is working towards implementation of a health equity fund that places quality at its core (Box 3.1). The West African response to the Ebola outbreak demonstrates the very real and strong linkages between health system resilience, quality of care, and global health security. Achieving the SDG health targets will require new financial investments, increasing over time from an initial US$ 134 billion to US$ 371 billion annually by 2030 (28). Poor-quality care is inefficient, wasting scarce resources and increasing the cost of expanding health coverage. Inefficiencies are introduced by unnecessary care that makes no difference to health outcomes. For instance, in low- and middle-income countries, overuse of antibiotics to treat acute respiratory tract infections adds an average of 36% to the cost of care (29). Errors in service delivery may also lead to direct harm to health, at an extra cost to the health system. A recent analysis of OECD countries indicates that more than 10% of hospital expenditure goes to correcting preventable medical mistakes or treating infections that people catch in hospitals (3). At the 2017 OECD Health Ministerial Chapter 3 Global state of health care quality 30 Meeting, ministers acknowledged the intersection of the quality and efficiency agendas, agreeing that quality measurement and improvement should be at the centre of efforts to realize health outcomes at a high value for money (30). Investing in high-quality health systems for universal health coverage has the potential to accelerate progress in promoting health while strengthening global health security and maximizing value for money. 3.2 DEFINING QUALITY OF CARE 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 (31). This definition implies that quality of care can be measured, is ultimately aimed at health improvements rather than simply increasing service inputs or refining system processes, and should reflect the desires of key stakeholders, including service users and communities. By including health services in general, this definition of quality of care spans both curative and preventive care, and facility and community-based care for individuals and populations. This scope is particularly important in countries facing an increasing burden of noncommunicable disease and whose health systems must provide services across the life course, including risk reduction, screening, disease management, rehabilitation and palliative care. As there is a steadily growing evidence base on the effectiveness of various modalities for disease prevention and control, this definition of quality of care also acknowledges the need for mechanisms to incorporate new evidence into service delivery systematically. What characteristics of health services are indicative of quality? This document identifies seven measurable characteristics of health services that increase the likelihood of desired health outcomes and are consistent with current professional knowledge. Box 3.1 Liberia: embedding quality in the post-Ebola health agenda Before the 2014 Ebola outbreak, Liberia, a country recovering from years of political and economic instability, had made progress in improving the health outcomes of its population. However, the outbreak highlighted persistent health system constraints in this small West African nation. There was a lack of an adequately skilled health workforce in health facilities and within communities; there were no sustainable financing mechanisms; and there was an absence of necessary supply chain structures and integrated health information systems. In addition, infection prevention and control was largely absent where most needed, and linkages between health services and the community were inadequate. These weaknesses compromised the provision of quality service delivery and allowed the epidemic to proliferate rapidly. In response to the outbreak, the Investment Plan for Building a Resilient Health System in Liberia 2015–2021 was developed. The plan aimed to restore the gains lost in the outbreak, tackle pre-existing vulnerabilities, improve community confidence in health systems, and provide health security. A key strategic aim of the Investment Plan is to accelerate universal access to safe and quality services through improving the capacity of the health network for the provision of essential services. The Government of Liberia recognizes that successful implementation of the Investment Plan – including a strong focus on quality of care – is essential to prevent, to detect, and to respond to future infectious disease outbreaks. DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 31 While multiple quality elements have been described over decades, there is growing acknowledgement that quality health services across the world should be effective, safe, and people-centred. In addition, in order to realize the benefits of quality health care, health services should be timely, equitable, integrated and efficient (Figure 3.2) (32, 33). Consider Fatima, an 80-year-old woman who has lived alone, since retiring 15 years ago. She has long-standing type 2 diabetes mellitus, as well as hypercholesterolemia and essential hypertension. She generally stays indoors and takes only occasional walks due to her poor eyesight and recently-developed back pain. Over the past two years, she has twice been admitted to hospital for congestive cardiac failure. She does not monitor her blood pressure or blood glucose as advised, eats convenience foods, and has missed multiple follow-up appointments since her discharge. Today, Fatima has come to the clinic complaining that she is out-of-breath, that her chest feels unusually tight, that she has trouble lying flat. She has has also mentioned having difficulty keeping track of her monthly bills. The attending nurse notices that Fatima repeats herself and has trouble finding the right words to describe her symptoms. Over the course of the next four weeks, Fatima will receive care from a myriad of health providers, including a dietician, primary care provider, cardiologist and social worker. The following points illustrate what high-quality health care for Fatima might look like through the lens of the seven elements of quality. • High-quality care for Fatima is effective, thus, it would be offered based on scientific knowledge and evidence-based guidelines. The care team would adhere to clinical pathways for older patients with heart failure and significant comorbidities, developed from evidence and experience in managing similar cases. The team would reassure Fatima that she would be receiving evidence- based care and that a systematic process would be followed to arrive at an integrated management plan across the various providers taking care of her. • High-quality care for Fatima is safe, that is, it minimizes harm, including preventable injuries and medical errors, to the patient. In every facility, there would be clear guidelines to prevent hospital-acquired infections and medical errors. For example, a thorough review of her outpatient medications at admission was made to prevent interactions with medications used during her inpatient care. Source: Institute of Medicine (32). Figure 3.2 Elements of health care quality Effectiveness QUALITY TimelinessEquity Efficiency Safety People- centrednessIntegration Chapter 3 Global state of health care quality 32 • High-quality care for Fatima is people-centred, that is, it respects and responds to her preferences, needs and values. Fatima might understandably be worried and ask many questions. The multidisciplinary care team would listen to her questions and concerns, answering patiently, and codevelop the care management plan with her active involvement. • High-quality care for Fatima is timely, that is, it would keep delays in providing and receiving services to a minimum. For example, contact with each provider involved in her care would be managed by an efficient patient flow system for scheduling or modifying visits and for notifying clients of projected waiting times. Situations requiring urgent intervention would be recognized and acted on as quickly as possible. With proper planning, Fatima would not have to experience long waiting times during follow-up visits. • High-quality care for Fatima is equitable, thus, the quality of care she receives would not vary according to personal characteristics such as gender, race, ethnicity, geographical location and socioeconomic status. The services received by Fatima would reflect evidence on the potential health benefits of the treatment only, and nothing else. • High-quality care for Fatima is integrated, thus, the care she receives across facilities and providers would be coordinated. Post-discharge, the social worker would evaluate options to support her care plan, and connect her with agencies that offer dementia-related care and other services as needed. • High-quality care for Fatima is efficient, and therefore avoids waste of resources, including equipment, medicines, energy and ideas. Each of her medical providers would be able to track previous tests and procedures she has undergone via an interoperable electronic medical record system, preventing repetition and waste of resources. Use of generic medicines would be stipulated in the clinical guidelines. Her care would be provided by a cohesive team, each working to their strengths and taking on tasks that match their competencies. In summary, high-quality health care is the right care, at the right time, in a coordinated way, responding to the service users’ needs and preferences, while minimizing harm and resource waste. High-quality health care ultimately aims at increasing the probability of desired health outcomes. The quest for high-quality health care recognizes that such improvement is a continuous or dynamic rather than a static process. Regardless of the income level of a country, if there is room for improving health outcomes, the quality of care can also be increased. 3.3 GLOBAL PICTURE OF HEALTH CARE QUALITY Assessment of trends in the global state of health care quality requires consensus on the definition and measurement of indicators for quality, comparable across countries. However, there is no dataset with uniformly defined quality indicators collected globally. There is also no agreement on a minimum set of standardized indicators for quality of care to monitor progress towards attainment of the health-related SDGs across countries. However, there is a growing body of work aimed at identifying indicators to support national, regional and international quality improvement efforts, including the OECD Health Care Quality Indicators Project, the World Bank Service Delivery Indicators, the WHO Global Health Observatory, and Demographic and Health Surveys (34–37). Using data from these sources, nationally representative household surveys, and empirical research, the state of quality of health services globally is described below. DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 33 This description focuses largely on process and outcome measures of quality of care – that is, actions in health care and the effects of these actions on desired health outcomes. These measures are examined in relation to the seven domains of quality of care: effectiveness, safety, people-centredness, timeliness, integration of care, equity and efficiency. The scientific and policy literature also examines structural measures of quality of care that form the context of service delivery, including equipment, human resources, incentives and organizational characteristics (38). This document considers these structural factors to be foundations of high-quality care processes and outcomes. Chapter 4 addresses the foundations of high-quality care. 3.3.1 Are health services effective? When care is ineffective, that is, when providers do not adhere to evidence-based guidelines, this may reflect a lack of knowledge of guidelines or a lack of compliance regardless of knowledge. The effectiveness of care can be assessed using inspection of medical records, patient exit interviews, direct observation of provider–client interactions, standardized patients or clinical vignettes. While clinical vignettes measure the provider’s knowledge of evidence-based protocols for defined medical cases, other forms of measurement predominantly capture compliance with these guidelines. In particular, standardized patients provide consistent cases of illness to providers and allow for comparison of quality of care across providers. This method of effectiveness measurement is also free from observation and recall bias (39). The differences in prevalent diseases across countries and variations in clinical presentation within diseases prevent systematic comparison of the effectiveness of care across providers and countries. However, there is a growing body of evidence indicating that there are gaps in provider understanding of and compliance with evidence-based guidelines in high-, middle-, and low-income countries. For example, in Kenya, only 16% of providers correctly diagnosed all five patient cases that were presented in clinical vignettes to assess provider knowledge (Figure 3.3) (40). In a study of physicians of the former Yugoslav Republic of Macedonia and the United States of America, the mean percentage of correct diagnosis for four clinical vignettes was 48% and 67% respectively (41). Regardless of the method of measurement, there is also a significant gap between provider knowledge and actual practice in service delivery. This finding holds across countries, including Denmark, India, Kenya, the Netherlands and the United Republic of Tanzania (42–45). Figure 3.3 Number of clinical vignettes correctly diagnosed by Kenyan providers (total number of vignettes: five) Source: Martin and Pimhidzai (41). 0 10 20 30 40 50 % 1 case 0.5% 11.5% 30.3% 42.1% 15.6% 2 cases 3 cases 4 cases 5 cases Number of clinical vignettes Chapter 3 Global state of health care quality 34 3.3.2 Are health services safe? Patient harm is the 14th leading contributor to the global disease burden. The majority of this burden falls on low- and middle-income countries (Figure 3.4) (14). The main causes of harm differ between settings, including medication and diagnostic errors in primary care, pressure injury and adverse events in long-term care, and hospital- acquired infections and wrong-site surgery in hospital care (46–48). The scale of unsafe events in health services is considerable (14). In addition to the direct cost of treating adverse events, there are additional costs that result from loss of productivity and diminished trust in the health system. Approximately 15% of hospital expenditure and activity in OECD countries is attributed to safety failures. However, many adverse events are preventable. Evidence suggests that more than one in three adverse events in low- and middle-income countries occurs in non-complex situations and up to 83% may be preventable (49). The costs of safety failures also far exceed the cost of prevention. Improving patient safety in Medicare hospitals in the United States is estimated to have saved US$ 28 billion between 2010 and 2015. Figure 3.4 Burden of disease caused by adverse events, 2015 Note: Percentage of average DALYs/country. Source: Institute of Health Metrics and Evaluation, 2015. High income Upper middle income Low income Lower middle income 19% 18% 25% 38% 3.3.3 Are health services people-centred? The degree to which the needs and preferences of service users are systematically incorporated into health services differs between high-, middle-, and low-income countries. Health systems in high-income countries have introduced measures and institutions to monitor patient experiences and perceptions on their specific medical conditions and general health. While expectations and approaches to people-centred care vary between countries, most service users in OECD countries report a positive experience with regard to time spent with the provider, easy-to- understand explanations, opportunities to raise concerns, and involvement in their care (Figure 3.5) (50). Attention to respectful, compassionate and otherwise people- centred care is not as prevalent in low- and middle-income countries. For example, a growing body of research on respectful maternity care indicates that women experience poor interactions with health care providers and exclusion from care decision-making, and are often not informed about the details of their care (51, 52). DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 35 3.3.4 Are health services timely? Waiting times for elective and emergency procedures have been shown to predict satisfaction among service users (53–55). In emergency situations, delays in receiving appropriate treatment may also lead to preventable deaths (56). Nonetheless, waiting times for different health services vary across OECD countries. For example, in 2015, the mean waiting time for hip replacement was around 42 days in the Netherlands, but 290 days in Estonia and over 400 days in Chile and Poland. Time trends show that reductions in waiting time have been experienced in Finland and New Zealand while this trend has converged in recent years, with relative stability in rates since 2008 in many countries, such as Denmark and the United Kingdom of Great Britain and Northern Ireland (Figure 3.6)  (2). Much less work has been done to compare service delays across low- and middle-income countries. Empirical research from individual countries indicates that waiting times are relatively long. For example, in a study of an emergency department in Barbados, a median of 10 minutes was required for triage, 213 minutes for laboratory results, and 178 minutes to be seen by a doctor (57). Also, in an outpatient department in Nigeria, 74% of service users waited between 60 and 120 minutes to be registered and additional time to see a service provider (58). Luxembourg1 Belgium1 Portugal1 New Zealand1 United Kingdom2 Germany2 Australia2 United States2 Netherlands2 Norway2 Canada2 Czech Republic1 Switzerland2 OECD19 Sweden2 Israel1 France2 Estonia1, 2 Spain1, 2 Poland1, 2 0 20 40 60 80 100 Age-standardized rates per 100 patients 95.5 95.1 90.9 88.2 88.0 87.7 86.0 83.9 83.9 83.3 83.0 81.8 81.4 81.3 80.5 79.7 78.8 67.4 62.1 47.9 Note: 95% confidence intervals represented by . 1. National sources. 2. Data refer to patient experiences with regular doctor. Source: Commonwealth Fund International Health Policy Survey 2013 and other national sources. Figure 3.5 Doctor providing easy-to-understand explanations (2013 or nearest year) Chapter 3 Global state of health care quality 36 3.3.5 Are health services equitable? Gaps exist in health care quality everywhere in the world, but they are even more serious for disadvantaged populations. The United States National Healthcare Disparities Reports have tracked the quality of care since 2010. In 2015, half of the quality measures showed no change or had worsened amongst low-income populations. More than half of the quality measured showed no change or had worsened for rural populations (59). In Canada, patients with myocardial infarction from indigenous groups were less likely to have received recommended treatment, including cardiac angiography and revascularization procedures (60). In Kenya, the quality of maternal health services is lowest in impoverished counties, where only 17% of women had access to minimally adequate delivery care (Figure 3.7) (61). Also, in India, people who live in households of low socioeconomic status in poor communities are less likely to use knowledgeable health care providers (62). Source: Health at a glance 2017 (2). Source: Sharma et al. (63). Figure 3.6 Trends in average waiting times for hip replacement Finland United Kingdom New Zealand Denmark 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Days 200 150 100 50 0 Figure 3.7 Structural and process quality of maternal services by county poverty level in Kenya Quality of maternal care infrastructure Quality of antenatal care Quality of delivery care Quality score 80%+ poverty 60-80% poverty 40-60% poverty 20-40% poverty 0-20% poverty 1.0 0.8 0.6 0.4 0.2 0.0 DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 37 3.3.6 Are health services integrated? With emerging chronic and noncommunicable diseases, more people are living with multiple and complex chronic conditions that require coordination of care across all levels and throughout their life course. Continuity of care and care coordination can improve the care experience of people living with such conditions and support needs. However, substantial gaps in the coordination of health care exist, even in high- income countries. A survey of patients with complex care needs in 11 high-income countries found coordination problems, such as test results or records not available at appointment or duplicate tests ordered, providers failing to share important information with each other, and specialists not having information about medical history or regular doctors not informed about specialist care (63). An analysis of linked primary care and secondary care data on older adults (aged 62–82 years) from 200 general practices in England reported that patients who saw the same general practitioner a greater proportion of the time experienced fewer admissions to hospital for ambulatory care sensitive conditions (64). 3.3.7 Are health services efficient? The World health report 2010 estimated that about 20–40% of all health sector resources are wasted (65). The leading causes of inefficiency in service delivery include inappropriate medicine use, suboptimal human resources mix, overuse or oversupply of equipment, corruption, and underuse of infrastructure. Unwarranted geographical variation in the prevalence of procedures and care intensity provides an indirect estimate of overuse and hence inefficiency. For example, in India, the rates of antibiotic use for acute diarrhoea in public facilities is 43% but rises to 69% in private facilities. Also, there is a ninefold variation in the use of percutaneous coronary interventions internationally and a fivefold variation in the use of coronary bypass grafting across OECD countries (66). These differences are not explained by the variation in the cardiovascular disease burden. Inefficient health care due to overuse and other causes has negative implications for population health outcomes. Life expectancy at birth could be raised by more than two years on average in OECD countries while holding health care spending constant if all countries were to become as efficient as the best performers (67). 3.4 CONCLUSION Despite the substantial increase in access to essential health services achieved during the MDG era, there are high levels of preventable mortality and morbidity that can be addressed through quality efforts. For example, the remaining burden of maternal and child mortality in low- and middle-income countries is largely due to the poor quality of health services. The SDGs explicitly incorporate a focus on the quality of health services in attaining universal health coverage in all countries. 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, people-centredness, timeliness, equity, integration of care and efficiency. Regardless of the income level of a country, if there is room for improving health outcomes, the quality of care can also be increased. Efforts to monitor trends in health care quality for the SDG agenda will be ineffective in the absence of consensus on key indicators that are comparable across countries and are collected on a regular basis. Empirical evidence from the growing body of work on quality measurement indicates that there are gaps globally in all the domains of quality health services. These gaps present opportunities to improve the quality of care and the health of populations. 38 “In any health system, nursing is the backbone of the system,” says Bafana Msibi, Executive Manager for Compliance Inspections at South Africa’s Office of Health Standards Compliance. “In our country especially, and in other countries in Africa, primary health care is nurse-driven.” As a health care executive with over 15 years’ experience, working for an independent body whose mission is to ensure quality of care and compliance with health standards in both public and private health care facilities, Bafana Msibi is well placed to assess the important contribution made by nurses to quality of health care. He defines quality of care, in short, as “making use of the available resources to provide the best care to users.” Msibi acknowleges that good patient care requires a holistic approach that sometimes goes beyond clinical treatment. “You might see a patient presenting with symptoms, and as you try to treat her, you may find that these symptoms are caused by stress,” he says. Because nurses spend more time with patients than any other clinicians, their role is crucial. In addition, they are directly involved in the implementation of precautionary measures that promote a safe medical environment in their daily work. In South Africa, all registered nurses have to undertake one year of community service after they complete their four-year degree. Working under the supervision of experienced professionals who mentor them, the new graduates are exposed to a wide range of medical issues. They also develop a solid understanding of the communities they serve. The knowledge and skills young nurses acquire during this period prepare them well for the demands of their profession. “When I was young, I worked in a clinic in a rural area. If patients came with a problem that required the next level of care, we would refer them to the doctor or call an ambulance to take them to a hospital. There are clinics in most areas, and where there are none, mobile clinics carry out visits. Most of these clinics are nurse-run,” Msibi says. My Quality Mr Bafana Msibi, Executive Manager for Compliance Inspections, Office of Health Standards Compliance South Africa 39DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE In South Africa, some nurses hold high-level jobs as CEOs of hospitals or district managers, Msibi says, but more are needed in leadership positions. “The nursing profession needs to produce leaders for the health care system. They must be developed through the system, know it inside out, and they must also understand the processes of policy development within it.” Bafana Msibi, who was able to conduct a study in a state hospital when he was studying for his Master’s in Public Health, would like more nurses to enjoy similar opportunities to undertake research. Having more nurses involved in policy-making as members of advisory committees, commissions and boards would also contribute to further improvements in the quality of care, he believes. Msibi’s Office of Health Standards Compliance is currently negotiating a Memorandum of Understanding with the South African Nursing Council and other bodies representing medical professions to enhance cooperation across health services. Conducting joint inspections of hospitals, for example, could increase efficiency and help support high standards of care. “When we develop models and frameworks to improve quality, we must make sure they incorporate everyone and put the values of the profession up to the front,” Msibi says. “In the end, we are all interested in providing quality care and if you want to have quality, you have to ensure there is good team work.” Image on previous page: © ranplett / iStock

DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 41 Chapter4 Building quality into the foundations of health systems Chapter 4 Building quality into the foundations of health systems 42 4.1 INTRODUCTION Poor-quality services – even if made available at an affordable cost – are an impediment to achieving effective universal health coverage. This is because communities will not use services that they mistrust and that are of little benefit to them. Mechanisms to assure, monitor and continually improve quality must be built into the foundations of health care systems. This chapter considers five such foundations critical to any health service: health care workers; health care facilities; medicines, devices and other technologies; information systems; and financing. Mere availability of resources is not enough. Conscious and continuous effort is needed to ensure that they are used in ways that are effective, safe and individually tailored to patients’ needs. Governance, as well as the tools, techniques and political economy of reform, is explored in the next chapter. A comprehensive system of care allows people to access a continuum of care across their life course, comprising health promotion, disease prevention, diagnosis, treatment, disease management, rehabilitation, emotional and spiritual support, and palliative care. Three important considerations should underlie the design of any health care system: services should be built to meet local needs; accessible and high- quality primary care should be the bedrock for all other services; and individuals and communities should be engaged in the design, delivery, assessment, and improvement of each and every service (68). The principles of quality improvement must infuse all activities from the front line to the system level. 4.2 FOUNDATIONS FOR HIGH-QUALITY CARE 4.2.1 Health care workers that are motivated and supported to provide quality care Skilled doctors, nurses and other health care professionals are essential for delivering high-quality health care to individuals, families and communities. There is currently an estimated global shortfall of 2.5 million doctors, 9 million nurses and midwives, and 6 million allied health professionals. As a result, basic care is often absent or poorly delivered (69). The problem is most severe in poorer countries (Figure 4.1). Even in developed economies, health workers are too often concentrated in cities, with the consequence that quality of care is often poorer in rural and remote areas. Even within cities, certain locations – for example slums – have a particular deficiency of health workers. Community health workers can help alleviate workforce shortages. They are individuals who have been trained to deliver specific health care services, or to undertake surveillance and treatment for communicable or noncommunicable diseases. They usually come from the communities that they serve, thus providing a potential bridge to community engagement efforts. Community health workers can overcome cultural and linguistic barriers, whilst expanding access to care and providing new forms of employment. Evidence shows that community health workers are capable of delivering safe and effective care for childhood illnesses, reducing the spread of communicable and noncommunicable diseases, promoting nutrition, and providing family planning services, at low cost (70). In low-resource settings, community health workers have reduced maternal, neonatal and child mortality (71). More than 50 years’ experience with programmes shows that these positions should be paid, not voluntary; have specific responsibilities that are not too wide ranging; receive training, continuing education and ongoing supervision; be integrated into primary health care teams; and be part of data feedback loops (72). DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 43 The availability of staff does not in itself assure good care. Health workers can spend little time with patients, lack the ability to make correct diagnoses, or prescribe inappropriate treatment (73). Rural clinicians in southern China spent an average of only 1.6 minutes consulting with patients and asked only 18% of essential questions. A fully correct diagnosis was provided in only one in four consultations (44). Beyond simple headcounts of the health workforce, other critical aspects include: • accessibility, or how easily people can see or speak to a health professional with the right skills, whether in person or via video and telephone links; • acceptability, or whether people feel they have been treated with respect and have had their views taken into account when it comes to decisions related to their health; • quality, or the knowledge, skills and attitudes of health professionals according to accepted norms, and as perceived by users; • skills mix and teamwork, or whether the group of health professionals (and, in some settings, lay workers) together have the knowledge and skills to manage local mortality and morbidity patterns; • enabling environments, or the physical, legal, financial, organizational, political and cultural conditions that support high-quality care. Distribution by country (in selected WHO region) Skilled health professionals density Density per 10 000 population Density per 10 000 population 60 40 20 0 0 20 40 60 80 100 120 140 160 180 200 220 240 260 280 Bu ru nd i Co m or os Er itr ea Eq ua to ria l G ui ne a Le so th o So ut h Su da n Sã o To m é an d Pr ín cip e N ig er Et hi op ia Ce nt ra l A fri ca n Re pu bl ic Si er ra L eo ne M al aw i Ch ad M ad ag as ca r To go Se ne ga l G ui ne a Un ite d Re pu bl ic of Ta nz an ia M oz am bi qu e Li be ria M al i Ca m er oo n Cô te d ’Iv oi re Bu rk in a Fa so G ui ne a- Bi ss au Ug an da Be ni n M au rit an ia Rw an da Za m bi a G ha na De m oc ra tic R ep ub lic o f t he C on go Co ng o Zi m ba bw e Sw az ila nd An go la G am bi a Ke ny a N ig er ia Ca bo V er de Bo ts w an a Al ge ria N am ib ia G ab on M au rit iu s Se yc he lle s So ut h Af ric a Africa Americas South-East Asia Europe Eastern Mediterranean Western Pacific Regional average: 12.8 Global average: 52.8 Figure 4.1 Global density and distribution of skilled health professionals by WHO region, 2005-2016 Source: Global Health Observatory (34). Chapter 4 Building quality into the foundations of health systems 44 The first step in building a high-quality workforce with the right skills mix should be a comprehensive national workforce strategy addressing gaps in numbers, distribution and retention, both in the short term and the longer term. Health professional workforce strategies must not deprive other health systems by attracting qualified staff away from their home countries’ health systems. Workforce policies can take years to bear fruit. The most effective and sustainable solution to rural shortages lies in training students who are themselves from rural communities, including establishing clinical schools in remote areas. Modernizing curricula for pre-service training of health care workers to ensure that they acquire core medical and nursing competencies is an obvious starting point and yet remains a challenge in many countries (Box 4.1) (74). Another priority is continuous professional development to ensure that health professionals maintain and improve their knowledge and skills – spanning a wide range of competencies – throughout their working lives. Increasingly, health systems are making continuous professional development – and even recertification – mandatory. Even where continuous professional development is not in place, policy-makers can work with professional associations to encourage its use and evaluate its impact (75). Finally, integrating the principles of quality and quality improvement into pre-service and in-service education and training curricula and programmes is vital in building a competent workforce that is capable of delivering high-quality health services. Box 4.1 Case study: training and retaining health care workers in underserved areas of the Philippines Two medical schools in the Philippines have a primary focus on recruiting, training and employing students in underserved areas of the country. Ateneo de Zamboanga University School of Medicine and University of the Philippines Manila School of Health Sciences are part of the Training for Health Equity Network (THENet). This international network of medical schools stipulates that the needs of underserved communities should be integrated with all phases and aspects of medical education, from the physical location of the school to the health issues guiding the curriculum. Also, there should be reliance on community-based practitioners for teaching and mentorship. Ateneo de Zamboanga University School of Medicine opened in 1994 in Zamboanga City, on the southwest tip of the southernmost of the Philippine islands, bringing hope of greater access to health care to a population of 3.2 million people. The nearest existing medical school was 400 kilometres away. At the time, 80% of the region’s 100 municipalities had no doctor. The region was plagued by high rates of infant mortality and communicable disease. In 2011, a review of the cumulative 164 graduates found that 85% were practising in the region, with half in rural and remote areas; overall, 90% remained practising in the Philippines versus 32% of graduates nationally. Between 1994 and 2008, the infant mortality rate in Zamboanga declined by approximately 90%, far exceeding the national average decline of 50%. The school continues to recruit students from the region and follows a curriculum that is deeply integrated with local community health needs. Source: World Health Organization (76); Cristobal and Worley (77). DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 45 4.2.2 Accessible and well-equipped health care facilities Substantial variation persists in service availability and readiness. Within and across countries, the density of hospitals and clinics is very different. Basic health care may be many hours away from poorer, rural communities. In sub-Saharan Africa, basic equipment such as a thermometer and stethoscope is available in slightly over half of facilities in Ethiopia, yet in Burkina Faso it is found in almost all facilities (Figure 4.2). The availability and readiness of services to operate is a necessary condition to deliver quality care. However, as discussed throughout this document, it is not sufficient to deliver quality services (78). Figure 4.2 Variations in availability of basic equipment across health care facilities in sub-Saharan Africa Source: Primary Health Care Performance Initiative (79). 100 90 80 70 60 50 40 30 20 10 0 Be ni n Bu rk in a Fa so Co ng o Et hi op ia G ui ne a Ke ny a M ad ag as ca r M au rit an ia M al aw i N ig er Se ne ga l Si er ra L eo ne To go Ta nz an ia Ug an da Za m bi a % 86.2 89.2 74.5 63.3 72.8 67.0 84.9 83.2 70.5 82.0 87.0 81.3 87.0 68.2 78.5 85.3 The quality of health care facilities is judged first on whether the basics are present, such as clean water, reliable electricity, good sanitation and safe waste disposal. In a 2014 survey, less than one quarter of facilities in Nigeria had reliable water, sanitation and electricity. Indeed, WHO estimates indicate that 40% of health care facilities in low- and middle-income countries lack improved water and nearly 20% lack sanitation. These basic foundations are urgently required for quality of care. However, adequate infrastructure does not necessarily equate to high-quality care. Minimum standards need to be set and enforced, and continuous improvement encouraged. Accreditation, inspection and other forms of external assessment and certification are widely used to evaluate health care facilities against explicit standards. The strength of the evidence supporting one-off external assessments is however limited (80, 81). Accordingly, health care systems are increasingly moving to more continuous and formative evaluations of providers’ performance, including measurement of patient outcomes and experiences (15). 4.2.3 Medicines, devices and technologies that are safe in design and use Reliable access to safe and effective medicines, devices and technologies, including blood transfusion, is a basic requirement for effective health care services. Actively restricting unsafe or ineffective products is critical to patient safety. Access to, and minimum quality standards for, medicines and other technologies have improved but substantial gaps remain in basic provision. Extensive and serious problems with counterfeit products complicate the issue. Chapter 4 Building quality into the foundations of health systems 46 Standards of regulation vary greatly. For example, in some countries, antibiotics can be bought without a prescription, fuelling unnecessary use and increasing the threat of antimicrobial resistance (82). Even where medicine use is properly regulated, errors affect about one in 10 prescriptions issued, mostly dose-related errors  (83). According to one report, only 30–40% of patients in countries with developing or transitional economies are treated with medicines according to clinical guidelines (84). The patients’ role in making medicines and devices effective and safe is also critical. Health systems do not usually pay sufficient attention to informing and supporting patients in their use of medicines. The third WHO Global Patient Safety Challenge – Medication Without Harm – was launched at the second Global Ministerial Summit on Patient Safety, Bonn, Germany, in March 2017 with the aim of reducing severe, avoidable medication-related harm by 50% globally in the next five years. Medical equipment requires maintenance, user training, backup support and, eventually, decommissioning. Donating equipment – important in some low-income countries – raises particular concerns. Unless spare parts, consumables and staff training are available, such equipment can be unusable or unsafe. Three out of 10 countries lack a national authority that regulates what medical technologies can be used, and how (85). Blood transfusions are a special case. Many low-income countries are not able to screen blood for HIV, hepatitis B, hepatitis C and syphilis. Transfusion recipients are then at unacceptable risk of acquiring transmissible infections. National policies on medicines and devices help to ensure products of assured quality, in adequate quantities and at affordable prices. Standardized processes for health technology assessment are discussed in the next chapter. Enforceable regulatory systems that address design and development, sale, use and disposal can be powerful in assuring quality and safety in this area. Guidelines and checklists can encourage appropriate use at the bedside. They should be accompanied by surveillance systems that monitor correct use, and that can detect accidents and adverse reactions. Voluntary non-remunerated blood donation improves the supply and safety of blood. Safety would be transformed if all health systems adopted this method of donation (86). The risks of transfusion are reduced by external quality assessment of the collection, preparation and administration of blood products. 4.2.4 Information systems that continuously monitor and drive better care Developing timely, accurate quality measures of health care services, of users’ experiences and of outcomes achieved remains challenging, given how little governments and donors spend on health information systems. Most OECD health systems invest only 2–4% of total health expenditure in information systems. In most low- and middle-income countries, the figure is less than 1% (87). As a result, data on outcomes and quality are often not captured at all, or are collected in ways that cannot be analysed or benchmarked because of a lack of standardized terminology. Even when data are collected, the translation of these data into information that is actionable for quality improvement remains a fundamental challenge. Yet, good performance information matters to improving quality of care. The European Health Care Outcomes, Performance and Efficiency (EuroHOPE) project found that survival after a heart attack varied as much as twofold within a single national health system (88). To enable hospitals and clinics to offer the same level of excellent care, richer comparative data on variation in quality and outcomes need to be collected, interpreted DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 47 and used to spread best practices and support poor performers. As well as EuroHOPE, the European Collaboration for Healthcare Optimization (89) and the OECD Health Care Quality Indicators Project (35) exemplify a trend to develop such data quality schemes globally (Box 4.2). Box 4.2 Case study: OECD Health Care Quality Indicators Project The OECD Health Care Quality Indicators Project began in 2001 with the aim of developing international comparisons of health care quality and, thereby, identifying and sharing best practices to monitor, assure and improve quality. Experts engaged in the project are drawn from OECD and non-OECD countries, international organizations including WHO, the European Commission, and research institutes. Around 50 indicators are reported (covering primary care, hospital care, mental health services, patient safety and patient experiences) from around 40 countries. Comparable health care quality indicators are published alongside other OECD health statistics on expenditure, resources and utilization to facilitate their interpretation. Alongside the regular data collection, there is continuous research and development to improve the validity, utility and comparability of health care quality indicators. Another goal of the project is to strengthen national information infrastructures to produce more complex and reliable indicators in an increasing number of countries, including non-OECD countries. Source: OECD (35). Too often, data are left to moulder in poorly organized, paper-based systems, or are trapped in digital silos incompatible with each other. Timely and appropriate use of and action on information is vitally important. The Health Data Collaborative, a global initiative led by WHO, the World Bank and the United States Agency for International Development (USAID), is addressing this challenge. By working with international agencies and individual countries, the Health Data Collaborative seeks to harmonize how health systems data are collected and reported globally, and aims to enable better tracking of health system performance and progress towards the health-related targets of the SDGs (90). Similarly, the Primary Health Care Performance Initiative (79) aims at sharing internationally comparable results on the performance of primary health care systems globally and enabling performance improvement through sharing of results and best practices for performance improvement. Basic information on all births and deaths needs to be reliably registered. Effective civil registration is the spine of a health system’s information infrastructure. Registers monitoring the needs, interventions and outcomes for patient groups (such as those with HIV, cancer or mental illness) can be built from this. Civil registration allocates a unique person identifier to an individual. This allows data from various providers over time to be linked and enables the performance of health care services to be tracked. If legislation to protect privacy prevents anonymous data linkage of elements of an individual’s health experience in different places and at different times, there will be no way of evaluating an entire pathway of care (Box 4.3). Chapter 4 Building quality into the foundations of health systems 48 Effective information governance remains weak in many health systems. The use of personal health data to monitor and improve health service performance serves an important public purpose, but must always be done in ways that protect privacy. National legislation is needed that protects patient privacy whilst enabling data use and good communication with the public about data use, as well as, at global level, standards to enhance data quality and comparability (91). Moving from paper-based records to a unique electronic health record, usable in multiple health care settings, will help monitor the performance of health care services. Supporting clinicians, managers and policy-makers in interpreting service data and using them for quality improvement will be also vital. Special action is needed to improve patient safety. Encouraging transparency when things go wrong, by building a blame-free and learning culture, is a prerequisite. This can be supported if analyses focus on understanding the root causes of adverse events by exploring the multiple causal and contributory factors that provoke errors, some of which result in major harm to patients. Agreeing on an internationally standardized terminology will also enhance the ability to classify, compare and prevent adverse events across different health systems. Finally, in 2017 ministers of health from OECD countries agreed that their health systems would be benchmarked using a new wave of patient-reported indicators of performance (30). More sophisticated health information systems survey patients directly, to monitor and compare their views on the quality of care received and monitor their health outcomes (93). This strategy is an important development that will support a paradigm shift from measurement systems that are focused on health care providers to truly people-centred systems in which measurement is focused on experiences and outcomes viewed from the perspective of patients (94). Box 4.3 Case study: improving civil registration and vital statistics in Uganda Only one in five of the 1.5 million annual births in Uganda were registered with the national civil registration and vital statistics system. Families often had to travel long distances to register in person, which required a fee. A paper-based system created frequent delays in issuing birth certificates. Even amongst registered births, over half did not receive a birth certificate. The United Nations Children’s Fund (UNICEF) and Uganda Telecom implemented the Mobile Vital Records System, which links mobile phone users and hospital computers to a central government server. For births occurring outside health facilities, volunteers – typically village leaders – collect and send birth information to a government database through a free service from their mobile phones. An official reviews the information and if it is deemed credible, then a birth certificate is issued. The community volunteer is notified via text message. The roll-out of the Mobile Vital Records System increased birth registration substantially, leading to greater expansion of the programme. Now it is also implemented in schools to reach previously unregistered children. Source: UNICEF (92). DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 49 4.2.5 Financing mechanisms that enable and encourage quality care The way funds are collected, pooled and used to pay for health care services can, unsurprisingly, have large effects on the quality and outcomes of care. First, there is solid evidence that funds should be collected and pooled in advance of needing care, through mandatory insurance schemes (with subsidized contributions for those unable to afford insurance). The alternative – paying out of pocket at the moment of need – means that people go without care when they need it and end up sicker as a result, or catastrophically impoverished (65). How funding then flows from insurance agencies to the front line, to purchase or reimburse services, is equally critical. There are several possible mechanisms, such as fee for service, capitation, or annual block budgets (transferred to hospitals or clinics, based on previous or predicted spending). Each has strengths and weaknesses, in the extent to which it rewards activity over outcomes, or incentivizes preventive over reactive care. There are no “silver bullets”, and in practice a blend of mechanisms is usually employed. What is important, from the perspective of quality of care, is that the blend is intelligently designed, aligns as closely as possible with local needs, incentivizes coordination of care for individuals with complex needs, invests adequately in primary care and prevention, rewards quality care, and penalizes care that does not meet sufficient standards. Accordingly, health systems are increasingly designing mechanisms that pay for bundles or pathways of care, and experimenting with quality-based payments. One family of such innovations, applied in high- as well as in low-income settings, is pay for performance (P4P), or results-based financing. Carefully designed, often time-limited, programmes pay health care providers to deliver specific, high-priority interventions. Nearly two thirds of OECD countries have at least one P4P scheme in place, predominantly in primary care. Systematic reviews tentatively suggest a positive impact of P4P and results-based financing programmes on quality in OECD countries (93). Results for results-based financing in lower-income settings are mixed, with fairly modest results so far for quality improvement, particularly for non-targeted conditions. Overall, payment innovations can also be used to deliver sustained collateral benefits – such as improved protocols of care, improved collaboration across providers, and improved information systems – on health care needs, activities, outcomes and costs. 4.3 QUALITY OF CARE AS THE FOUNDATION OF PEOPLE-CENTRED HEALTH CARE As governments plan to deliver universal health coverage, there are three key design principles that should be considered. First, services should be built in a way that meets local health care needs. Although seemingly obvious, many health systems lack a population–health focus. Instead, available health service networks are the product of historical legacy, or are the result of political lobbying or of transient donor funding. Local communities may be innocent bystanders in the design of care that is ultimately destined for them. Many low- and middle-income countries have dealt with a high burden of communicable disease and this has meant that their systems have needed strong public health functions in areas such as surveillance, laboratories and routine immunization. They may also have received substantial donor funds in the form of programme grants to control or eliminate particular diseases. Increasingly, though, the growing burden of noncommunicable disease in these same countries necessitates services capable of supporting people over time with personalized, proactive care to manage their condition, prevent complications and enhance quality of life (Box 4.4). Chapter 4 Building quality into the foundations of health systems 50 A recent study analysed 22 initiatives to strengthen primary health care in 10 counties in China and at national and subnational levels in 12 countries. Eight tenets of high- performing primary health care systems were derived: ensuring primary health care as first point of contact for most health care needs; functioning multidisciplinary care teams; vertical integration of services; horizontal integration of services; advanced information and communication technology; integrated clinical pathways and functioning dual referral systems; measurement standards and feedback; and certification (95). The second key principle of design is to build high-quality primary care services (97). First contacts with health care, and a person’s regular point of entry into the health system, must be continuous and comprehensive (Box 4.5). No physical or mental health issue should be excluded from the oversight and coordination functions of primary care. If individuals and families in a geographically (or otherwise defined) community are formally registered with a named primary care provider, this enables creation of community health profiles, as well as surveillance of needs and delivery of preventive care. Registration also creates a structure for proactive care amongst people with chronic conditions. Primary care is also fundamental to health system resilience, and is pivotal in surveillance of communicable diseases or other hazards, and in the delivery of front-line care in the case of outbreaks. Third, engagement with patients, families and communities needs to be designed into health systems, rather than bolted on as an afterthought. A review of randomized controlled studies of integrated care programmes for the frail elderly, for example, showed that the most benefit was derived from those in which the elderly person was directly involved in care planning (98, 99). If patient groups are encouraged to engage in collective action, people benefit hugely from the support of others with similar health problems. The WHO Patients for Patient Safety programme illustrates this well. The programme has empowered a global network of patient advocates that aims to foster collaborations between patients, families, communities, health care providers and policy-makers to make health care safer through the insights and experiences of patients themselves (100). Box 4.4 Case study: unmet needs for the care of chronic diseases Hypertension, or high blood pressure, is one of the most prevalent and critical risk factors for early death and disability globally. Untreated hypertension leads to kidney disease, ischaemic heart disease and stroke (the latter are the two leading causes of death worldwide). Hypertension affects an estimated one in three adults over the age of 20 years worldwide, with the prevalence now higher in low- and middle-income countries than in high-income countries (age-standardized prevalence of 31.5% versus 28.5%, respectively). Of the approximately 1.5 billion people with hypertension, less than half will be aware of their condition; only 36.9% will be on appropriate treatment; and as few as 13.8% will have their blood pressure effectively controlled. Significant disparities in awareness and treatment exist by country income level: in high- versus low- and middle-income countries, rates of diagnosis and treatment are twice as high and 4 times the proportion of patients have their blood pressure controlled. Source: Mills et al. (96). DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 51 More broadly, collaboration with nongovernmental organizations, grass-roots community groups and patient representative organizations also offers huge potential gains. Civil society organizations focused on health issues are increasingly well established in many low- and middle-income countries (Box 4.6). These groups do far more than just offer advice and support – they also help people assert their rights to high-quality care. A review of literature by Laverack (101) illustrates the multiple avenues through which community engagement strengthens health systems. These include strengthening social networks, developing local skills such as leadership, resource mobilization, or simply asking the question “Why?” Box 4.5 Case study: primary care in Costa Rica In Costa Rica, an innovative primary care sector forms a solid base for the rest of the health care system. Community clinics, or integrated health care basic teams (equipos básicos de atención integral de salud, EBAIS) are the functional units of primary care delivery. Each EBAIS serves around 1000 households. Each consists of at least one medical doctor, one nurse and one health care assistant. Other personnel, such as social workers, dentists, laboratory technicians, pharmacists and nutritionists, may also support the clinic. To complement EBAIS, centres for integrated health care (centros de atención integral en salud, CAIS) have recently been developed. They offer an extended model of primary care, including maternity services, intermediate care beds (to avoid hospital admission or expedite early discharge), minor surgery, rehabilitation, specialty clinics (such as pain management), and diagnostics such as radiography. A detailed primary care performance framework evaluates local health authorities across 30 indicators in the domains of access, continuity, effectiveness, efficiency, patient satisfaction and organizational competence. For each indicator, a national target is set and dashboards of local results are published, allowing providers to compare their performance against national, regional and local benchmarks. National data show that 80% of primary care presentations are resolved at that level, without referral to secondary care. Referral guidelines exist, and hospital referrals are turned back if appropriate steps have not been completed in primary care. Hospital doctors also train colleagues working in EBAIS to strengthen primary care management. Source: OECD (21). Box 4.6 Case study: using Citizen Voice and Action to empower communities in Uganda Empowering communities through training and education is an important step in enabling them to engage with health care providers. The Citizen Voice and Action project model (20), for example, allows citizens to learn about the number of health workers, vaccines, equipment and materials that should be present at their local health centre. Residents then work with health workers and local government to measure the facility’s compliance with government standards. … Chapter 4 Building quality into the foundations of health systems 52 4.4 THE VISION: HEALTH SYSTEMS COMMITTED TO PEOPLE-CENTRED CARE The expectant mother with high blood pressure, or the elderly man with diabetes, arthritis and hearing loss, both require a range of services to be delivered effectively – not just within the formal health system, but in the community to which they will return to live and work. The young man with schizophrenia needs carefully coordinated care to manage his mental health problems, but also to deal with the array of chronic physical health problems that reduce life expectancy by up to 25 years in people with severe mental illness. Complex health care requires systems able to deliver an entire pathway of care (health promotion, disease prevention, diagnosis, treatment, disease management, rehabilitation and palliative care services) consistently, effectively, safely and in ways that are valued by patients and their families. Effective governance of health systems comprises several tasks, including maintaining strategic oversight of goals and priorities; generating the information and analysis required to track whether goals are being met; designing rules, policies and processes to steer the system in the desired direction; and creating and nurturing collaborations within and beyond the health system. Enshrining the right to health care, according to need, in national legislation is a valuable step in making progress towards universal health coverage. Experience shows that de jure commitments often fail to translate, de facto, into access to good-quality care. Setting up a national agency responsible for quality monitoring and improvement is also an important step. Ideally, it should be independent of health care insurers and providers, with the regulatory powers to collect, analyse and publish quality and outcome data. Its role can also encompass sharing lessons learned from high performers and supporting poorly performing services in addressing performance gaps. They can also use a community scorecard to rate the facility according to criteria that they themselves generate, and convene meetings with civil society, government and service providers where all stakeholders can review the evidence and commit to an action plan to improve services. The Citizen Voice and Action model was successfully implemented in Uganda in 2004 in response to perceived weak health care delivery at the primary care level. The main objective of the intervention was to strengthen the provider’s accountability to citizen clients by introducing a process, using trained community- based organizations as facilitators, which the communities could manage and sustain on their own. One year after implementation, health facilities in treatment villages (as compared to comparison villages) saw a 12-minute reduction in average waiting time and a 13% reduction in absenteeism. Health facilities in treatment villages also showed a 33% decrease in under 5 mortality; a 58% increase in the use of skilled birth attendants; and a 19% increase in number of patients seeking prenatal care. The improvements were maintained four years after the project started. DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 53 People-centred care means that health systems must ensure: • continuity from illness prevention to palliation, between services (e.g. intensive care and radiology) and between levels of care (primary to specialist), throughout the life course; • coordination across different care settings, in ways that meet the particular needs of the individuals and their carers; • comprehensiveness that broadens the portfolio of care – from health promotion through to palliative care – that individuals and communities can use. When health systems struggle to provide people-centred care it is often because services still place too much emphasis on treating individual diseases, rather than preventing illness or promoting better health and well-being. The system prioritizes specialist care for its investment and concentration of resources. Primary care can be designed so that it is the mediator between a community’s needs and the range of provision in a health system. It can then fulfil the enhanced coordination role that person-centred care requires (Figure 4.3). An important way of keeping people- centred care on track, and ensuring the right balance of primary and secondary care services, is to publish regular reports analysing performance of the health system as a whole. Figure 4.3 Primary care as a hub of coordination Networking within the community served and with outside partners Source: World Health Organization (102). Consultant support Referral for multi-drug resistance Self-help group Liaison community health worker Social services Other Other Referral for complications Waste disposal inspection Mammography Gender violence Alcoholism Placenta praevia Hemia Traffic accident Diagnostic support Training support Pap smears Primary care team: continuous, comprehensive, person-centred care HOSPITAL NGOs SPECIALIZED PREVENTION SERVICES DIAGNOSTIC SERVICES SPECIALIZED CARE C o m m u n i t y Community mental health unit Environmental health lab Training centre Alcoholics AnonymousWomen’s shelter Cancer screening centre Emergency department Maternity Surgery TB control centre Diabetes clinic Cytology lab CT Scan Chapter 4 Building quality into the foundations of health systems 54 4.5 CONCLUSION Quality can be built into the foundations of health care systems, no matter how far along the road a health system is to reaching universal health coverage. A quality- oriented approach to health care workers, health care facilities, medicines, devices and other technologies, information systems, and financing is vital at all stages of development. Building up the foundations of quality health systems needs to be at the forefront of thinking, planning and policy-making. But more action is urgently required to create quality health systems. Health systems must exchange a top-down hierarchy for pathways and networks based upon cooperation and collaboration, with primary care as the bedrock and people at the centre. This transformation of relations needs to be coupled with new mechanisms to hold governments and health system leaders to account and build citizens’ trust. Box 4.7 outlines key actions that can be taken to ensure that quality is built into the foundations of health care systems. The following chapter provides greater detail about what types of interventions can be brought together and implemented at macro, meso and micro levels to improve quality of care. People-centred care is a critical entry point through which to improve quality. It involves patients in decisions about their care, and asks their opinions about their outcomes of care; it questions variations in patient outcomes across different providers; it drives greater investment in electronic records that work across multiple settings; it assures transparency and learning when things go wrong; and it fosters a myriad of other actions to improve health care quality. As global health care quality expert Donald Berwick has said: “Person-centredness is not just one of the dimensions of health care quality, it is the doorway to all qualities” (16). The WHO Framework on Integrated, People-centred Health Services, adopted with overwhelming support by Member States at the World Health Assembly in May 2016, sets forth a compelling vision in which “all people have equal access to quality health services that are co-produced in a way that meets their life course needs”. It calls for the coordination of services across the continuum of care and for a supportive environment that helps caregivers practise with the skills and resources they need. This framework proposes five interrelated strategic areas (Figure 4.4) for how health services and systems can be reoriented to accomplish this vision (103). Figure 4.4 Five strategies for people-centred services DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 55 Box 4.7 Key actions: building quality into the foundations of health systems To ensure that quality is built into the foundations of systems to achieve universal health care coverage, governments, policy-makers, health system leaders, patients, and clinicians should work together to: 1. Ensure a high-quality health care workforce, by: • developing a national strategy to address gaps in numbers, distribution and retention of health professionals, both in the short term and the longer term; • modernizing training curricula for health care workers and integrating the principles of quality and quality improvement methods into training curricula; • encouraging programmes of continuous professional development and evaluating their impact. 2. Ensure excellence across all health care facilities, by: • ensuring service readiness and availability as a necessary but not sufficient condition for quality of care; • encouraging continuous and formative evaluations of facilities’ quality of care; • collecting and analysing richer data on variations in quality and outcomes across facilities, turning insights into action to spread best practices and support poor performers. 3. Ensure safe and effective use of medicines, devices and other technologies, by: • developing national policies on medicines and devices focusing on assured quality, adequate supply and affordable prices, supported by standardized health technology assessment; • developing guidelines, checklists and surveillance systems to support the correct use of medical technology, and monitor errors, accidents and adverse reactions; • adopting voluntary non-remunerated blood donation and introducing external quality assessment of the processes for collecting, preparing and administering blood products. 4. Ensure effective use of health information systems, by: • building reliable births and death registration systems and, from this, developing a national system of unique patient identifiers to support quality monitoring across pathways of care; • moving away from paper-based records to a unique electronic health record that can be used across multiple health care settings; • developing national legislation that protects individual privacy whilst enabling the use of personal health data for research and quality improvement; … Chapter 4 Building quality into the foundations of health systems 56 • supporting clinicians, managers and policy-makers in collecting and analysing service data for quality improvement, and communicating effectively with the public about how these data are used; • encouraging transparency when things go wrong, by building a learning culture that focuses on understanding root causes rather than assigning individual blame; • at global level, agreeing on standards to enhance data quality and comparability, particularly standardized terminology to classify, analyse and prevent adverse events; • including measurement of patient outcomes and experiences as a standard element in facilities’ quality assessment. 5. Develop financing mechanisms that support continuous quality improvement, by: • reducing reliance on out-of-pocket funding, and shifting to prepaid and pooled funds for the majority of health system financing through mandatory insurance schemes, with subsidies for those unable to afford contribution; • linking financing for health care providers to local health care needs, incentivizing coordination of care for individuals with complex needs, and investing adequately in primary care; • fully exploiting the potential of payment schemes to deliver sustained collateral benefits such as improved protocols of care, improved collaboration across providers, and improved information systems on health care needs, activities, costs and outcomes. 57DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE Chapter5 Understanding levers to improve quality Chapter 5 Understanding levers to improve quality 58 5.1 INTRODUCTION Quality is a complex and multifaceted concept. Its pursuit requires the design and simultaneous deployment of combinations of discrete interventions. Understanding this interdependence is critical in designing future health systems. For example, establishing standards for care is part of quality improvement, but, for the standards to be reliably implemented, additional actions are needed, such as training and supervision, monitoring for compliance and feedback to health care providers. The process of standard setting alone, without these other supporting and interdependent actions, is of limited value (104, 105). This chapter describes a range of levers to improve the quality of health services and discusses the rationale for developing national quality-related policies and strategies. Common goals addressing quality through a wide array of interventions, across all levels of the health care system – from national-level policy and regulation to the direct provision of individual patient care – are examined. The interdependence of these diverse levers for change and the avoidance of a single-track approach are explained. The levers should also be customized within countries as health-related decisions may be made at the subnational and community levels, and should also be sensitive to unique contextual factors. 5.2 DRIVING IMPROVEMENT THROUGH NATIONAL QUALITY POLICY AND STRATEGY The development, refinement and execution of a national quality policy and strategy are a growing priority as countries strive to systematically improve health system performance. A carefully designed national quality policy and strategy – applying an implementation-informed approach – is likely to be one of the pivotal considerations of countries as they work to achieve enhanced access to health services that yield the best achievable outcomes. But why are countries focused on driving quality through national efforts? Each country has its own culture, population needs, and a historical legacy shaping its health care system. Most countries, though, share a set of goals and an awareness of the strategic context for health care. There are six main areas of common ground: • belief that high-quality, safe, people-centred health care is a public good that should be secured for all citizens; • acceptance that better access to care without attention to its quality will not lead to desired population health outcomes; • acknowledgement that strategies to improve the efficiency of health systems must deliver in an increasingly constrained financial situation; • need to align the performance of public and private health care delivery in fragmented and mixed health markets; • awareness that quality health care is vital to resilience in the political context of national and global health security; • realization that good governance means satisfying the public demand for greater transparency about standards of care, treatment choices, performance and variable outcomes. Countries face the challenge of developing or refining their quality-related policies and strategies through national consensus. They must also recognize that driving change towards a future vision of better performance will almost always be limited by the practical realities of how and where health care is currently provided. DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 59 National policies on health care quality are developed through various governmental structures. In some countries, this involves enabling legislation to establish new administrative and governance structures or to create new forms of mandatory action (for example, physician registration and licensing) or to formulate new regulatory mechanisms (for example, inspection and accreditation). This may trigger the need for an explicit national quality policy document. In other situations, implementation of a national quality policy or strategy may simply be part of the routine five-year health sector plan or an internal ministry of health document. There is no single right way to do this, but most approaches involve one or more of the following processes: • quality policy and implementation strategy as part of the formal long-term 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. Boxes 5.1 and 5.2 provide country case studies on the implementation of national quality policy and strategy in the health sectors of Ethiopia and Sudan. Box 5.1 Case study: Ethiopia – National Health Care Quality Strategy 2016–2020 Ethiopia is the second most populous country in Africa, with a population of around 100 million. Since 1995, the country’s health sector has undergone significant reform through implementation of a Health Care Financing Strategy. The Health Sector Transformation Plan identifies four transformation priority agendas: ensuring the delivery of quality health services in equitable fashion; focusing on district-level transformation; strengthening health information systems; and creating a compassionate, respectful and caring health workforce. The Ethiopian National Health Care Quality Strategy was launched in March 2016. In order to operationalize the strategy, the Health Services Quality Directorate has developed a quality improvement tool for clinical audit of selected high-priority health care services in hospitals. Nationwide training on quality of care and audit methods has been conducted with selected health care cadres from all hospitals. The quality data system now allows integration of key performance indicators with the existing health management information system (106). A number of priorities are pivotal to implementation of the strategy, including strengthening the National Quality Steering Committee chaired by the State Minister; supporting the formation of quality units in regional health bureaus and health facilities; capacity-building through training of cadres and dedicated mentorship; integration of quality improvement in the pre school health curriculum; strengthening monitoring and evaluation mechanisms; and creating demand for quality within the community, with a focus on respectful care. In order to operationalize the strategy, the Health Services Quality Directorate has developed a quality improvement tool for clinical audit of selected high-priority health care services in hospitals. Chapter 5 Understanding levers to improve quality 60 At its most effective, a quality strategy acts as a bridge between where a health system currently stands and the level of quality a country aims to attain. It can accelerate the achievement of health goals and priorities, using quality management principles that incorporate planning, control and improvement processes (107). Though the form and content of the national policy and strategy of each country will vary, the following eight components are likely to receive universal consideration: • National health goals and priorities. These will help to direct resources to meet the most pressing demands of the population. The quality agenda is then aligned to them. • Definition of quality. The definition of quality used must be acceptable in the local context within the country and should underpin the national approach. Use of local language and shared understanding are essential. • Stakeholder mapping and engagement. Quality is an aggregate of the individual components of the whole health system. Including key stakeholders in the development of policy and strategy allows a comprehensive range of factors that promote good-quality health services to be addressed. • Situational analysis: state of quality. The current state of quality in any health system encompasses relevant priorities and problems; related programmes and policies; organizational capabilities and capacity; leadership and governance; and related resources. Assessment of the current state of quality defines key gaps requiring attention and areas of health care services that can be strengthened. Box 5.2 Case study: Sudan – National Health Care Quality Policy and Strategy Sudan has a decentralized health system, with the federal government responsible for national health policy-making, strategy and coordination; state governments responsible for planning and implementation at the state level; and local entities concerned with service delivery on the ground. The main administrative body is the multisectoral National Health Sector Coordination Council. Awareness of quality of care among the public and health care professionals is sporadic. While research into quality exists there is no adequate mechanism for interorganizational dissemination of results, so decision-making is not always informed by relevant data and evidence. However, measures are being undertaken to rectify these shortcomings. In line with the third National Health Sector Strategic Plan, a National Health Care Quality Policy and Strategy was formulated in 2017, to be implemented during 2017–2020. The policy addresses four main priority areas: strengthening governance and accountability, compliance with national quality standards, promotion of a people-centred approach, and reduction of avoidable harm to patients. Particular focus has been given to the health workforce through accredited training, career pathways, staffing norms, human resources for health management systems, and performance appraisal and auditing systems to help build capacity. Establishment of a formal partnership with patients and the community is high on the agenda of the National Quality Policy and Strategy. Next steps include strengthening coordination mechanisms for the National Health System; devising a retention scheme for human resources; strengthening the health management information system; institutionalizing quality at all levels; improving patient safety and infection control at the state level; and strengthening management and implementation capacity at all levels. DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 61 • Improvement methods and interventions. Judicious selection of interdependent interventions implemented across all levels of the health care system will improve health outcomes. This task is complicated by limited resources, evidence of impact, feasibility and acceptability. • Governance and organizational structure for quality. Governance, leadership and technical capacity are all necessary factors for improving quality. They need to be clearly articulated. In a growing number of countries, a national-level unit, usually in the ministry of health, has been created and coexists with other national quality bodies. • Health management information systems and data systems. Improving quality relies on clear and accurate performance data. An information system to support nationally driven quality efforts is necessary for measurement, performance feedback and reporting. • Quality measures. A core set of quality indicators is critically important for judging whether activities are producing higher quality of care leading to significant change in health outcomes; for providing feedback to providers and facility management; for promoting transparency to the public; and for comparative benchmarking to identify best practices for learning. Box 5.3 presents a case study on the implementation of national quality strategy through a coordinated Quality Management Framework in Mexico. Box 5.3 Case study: Mexico – National Strategy for Quality Consolidation in Health Care Facilities and Services Mexico, with around 120 million inhabitants, has a mixed health care system with both public and private providers. Despite major reforms, including the introduction of a free health coverage system in 2003, demographic and epidemiological transitions – such as an ageing population and an increase in the prevalence of noncommunicable diseases – continue to place tremendous pressures upon the health care system. A comprehensive systemwide quality improvement strategy was launched in Mexico in January 2001. The main objectives were to promote quality of care as a core value in the culture of health care organizations, both public and private, and to improve the quality of services across the health care system. In 2012 the National Strategy for Quality Consolidation in Health Care Facilities and Services was established, to be implemented through the General Directorate of Quality and Education in Health Care of the Ministry of Health. The strategy aimed to achieve quality improvement in the following areas: patient safety, innovation and continuous improvement, risk management, accreditation of health care facilities, health regulation, and health education. Implementation of the strategy is supported by a Quality Management Framework that provides the administrative structure for quality improvement at all levels. The framework targets five value outcomes: population health, effective access, reliable and safe organizations, satisfactory experience of the population with health care, and reasonable costs. Citizen participation is promoted, and a monitoring system with indicators has been put in place. Incentives include a national quality award, and financial incentives to networks of units for the development of specific joint quality improvement projects. Source: Ministry of Health (108), Sarabia-González et al. (109), Ruelas et al. (110). Chapter 5 Understanding levers to improve quality 62 5.3 QUALITY INTERVENTIONS Quality interventions can have a significant impact on specific health services delivered and on the health system at large. Understanding the types of commonly deployed interventions, and knowledge of the evidence regarding their use and effectiveness, can allow for more informed choices about which interventions to select in countries. The nature of health care challenges in different health systems across the world is actually quite similar, despite the different contexts of population health needs, financing and workforce capacity. Whilst priorities may differ – communicable versus noncommunicable disease, care needs of later life versus treatment of mothers and children – the same quality goals are pursued everywhere: • reduce harm to patients • improve clinical effectiveness of the health services delivered • engage and empower patients, families and communities • build systemic capacity for ongoing quality improvement activities • strengthen governance and accountability. But where does that leave action? Agreeing upon a list of goals is easier than identifying strategies to achieve them. In this context, seven categories of action stand out. They are routinely considered by quality stakeholders – providers, managers, policy-makers – when trying to improve the performance of the health care system. They are considered in the following subsections. 5.3.1 Changing clinical practice at the front line The gap between what is known to be effective care (“know”) and what is routinely performed by providers (“do”) has been well documented around the world. Closing this “know–do” gap requires multimodal changes in clinical practice at every level of a health system, from the individual encounter between the patient and the health care worker to the redesign of health care delivery. The skills, knowledge and attitudes of health care workers are fundamental. Measures to support health care providers to achieve the most effective care include clinical decision support systems ranging from written protocols to electronically supported aids. Reducing harm to patients is a key objective – It is estimated that of every 100 hospitalized patients at any given time, 7 in developed and 10 in developing countries will acquire at least one health care-associated infection (111). Away from the individual patient and provider, new models of care are being developed and implemented to address multiple dimensions of quality. The models define current best practice for the delivery of health care generically and also as related to special populations (for example, people with chronic disease or mental health conditions) or those with common characteristics (for example, children or the elderly). New models of care are often community based, extending well beyond the walls of hospitals and integrating the contributions of primary, specialized and social care organizations (104). 5.3.2 Setting standards Setting standards, with evidence-based protocols, can establish consistency in delivery of high-quality care across diverse health systems globally. Though often led by government entities, standard setting is an area of quality improvement where professional bodies should play a major role, either working independently or in partnership with governments. Some clinical standards focus on specific population DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 63 groups, others on disease conditions or treatment protocols. For example, global clinical standards of care have been developed to improve maternal and newborn care in facilities (112). Embedding clinical policy and standards-based care is often achieved through patient care protocols and clinical pathways. Whilst clinical standards are often an early step in national quality strategies, developing standards without a holistic quality approach may not yield the expected results and progress. 5.3.3 Engaging and empowering patients, families and communities Health systems need to go further than health literacy programmes to make full use of the potential of people-centredness as an entry point to higher-quality care. There is strong evidence, across all country contexts, that interventions that seek to engage and empower patients, caregivers and families can promote better care, including healthier behaviours, enhanced patient experience, more effective utilization of health services, reduced costs and improved outcomes (100). For example, engaging women’s groups in Nepal to identify the major maternal and newborn problems and strategies for improvement resulted in 30% fewer newborn deaths and an 80% reduction in maternal mortality (113). Giving patients information, advice and support can help them manage their health and co-develop treatment and health maintenance plans. Systematic, sustained community engagement mechanisms can also support programmes to improve quality of care. The need to secure or build trust in communities is also a priority. Without it there will be a fundamental barrier in willingness to access health care even when it is needed. 5.3.4 Information and education for health workers, managers and policy-makers To be effective, information systems for quality improvement must meet the needs of caregivers, facility managers, health system leaders, policy-makers and regulators. This requires targeted information and educational methods for each respective audience. Health workers need comparative information about their own performance, especially benchmarked against best practices. Leaders, managers, policy-makers, regulators and funders also need comparative information. The format and focus will vary according to the area of quality being reviewed, whether it is a service (for example maternity care), a disease condition (for example the care of people with diabetes), a group within the population (for example older people), or an intervention (for example measles vaccination uptake). One of the commitments needed from leaders is to ensure that a proper level of investment in information systems is maintained. However, advances in accessibility and utility of information do not need to depend on high-technology solutions; for example, clinical decision support may be in the form of computer prompts or as simple as paper forms with boxes to tick the basic processes related to effective child care. 5.3.5 Use of continuous quality improvement programmes and methods Quality improvement is not a static concept, but rather a continually emerging, dynamic system property. Many different methods are used to continuously assure and improve quality of health care, including broad clinical governance mechanisms; peer review and clinical audit; individual feedback; supervision and training; clinical decision support tools based on guidelines; and multidisciplinary learning collaboratives. A basic tenet underlying continuous quality improvement is activated learning mechanisms using iterative cycles of change. Further, an avoidance of “blaming and shaming” is central in avoiding the risk of promoting fear and resistance rather than Chapter 5 Understanding levers to improve quality 64 enthusiastic engagement in a shared pursuit of improved performance. There is no single effective method. Multiple interventions must be used in combination and with an understanding of the specific context. The role of institutional culture becomes a critical consideration in deciding the specific blend of quality improvement methods based on the capacity and capabilities that exist. 5.3.6 Establishing performance-based incentives (financial and non-financial) Incentives can be either financial, such as payment, or non-financial, such as recognition and awards. Performance-based financing is a broad term for the payment of health providers based on some set of performance measures and is increasingly used as a quality lever. Models include value-based purchasing; readmission penalties; withholding payment for medical errors; and performance programmes focused on strengthening primary care. The amount contingent on performance is a subcomponent of the full payment, based on a range of financing modalities. Evidence remains mixed about the ability of pay-for-performance programmes to change health outcomes by themselves. However, incentives – both financial and increasingly recognized non- financial approaches – can serve an important motivating and sustaining function when used as part of a robust quality improvement programme. At the same time, attention is required in order to avoid disincentives for quality (such as payment systems that encourage excess medicine use). 5.3.7 Legislation and regulation Governments use both legislation and regulation to achieve national health objectives. Legislation directed at improving quality of health services may address a wide range of issues, such as coverage and benefits; establishment of new (or empowerment of current) national bodies; payment reform; licensing of facilities and individual providers; and public performance reporting. Regulation is the range of factors outside clinical practice or the management of health care that influences behaviour in delivering or using health services (114). Regulation usually targets the activities of institutional and individual providers; health insurance organizations; pharmaceutical and device manufacturers; and consumers or patients. Various regulatory interventions often fail to meet their intended objectives, in part because responsible agencies lack capacity for enforcement. Regulation of private sector activity is increasingly important, given the large proportion of total services delivered. Box 5.4 provides a case study illustrating the use of legislation and regulation to support health care quality goals in Ontario, Canada. Box 5.4 Case study: Ontario, Canada – Excellent Care for All Act and Strategy With its large land mass and heterogeneous population of over 13.5 million, including First Nations, provision of equal access to high-quality care is challenging in Ontario. As with all Canadian provinces, Ontario has a single payer health system; about two thirds of health care expenditure is publicly funded, while one third is paid directly by patients or private insurance plans. Various studies have found that the relationship between quality and funding is generally weak in Ontario, and a major goal of current health system reforms is to improve that linkage. The Excellent Care for All Act became law in 2010, with the Excellent Care for All Strategy forming the vehicle for implementation. … DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 65 5.4 CONSIDERATION AND SELECTION OF QUALITY INTERVENTIONS While the seven categories of action provide a broad map of the performance improvement terrain, there is a further need to specify key quality interventions. Selecting the “right” intervention is seldom possible. No single intervention will satisfy all needs. Even interventions that are non-controversial, such as protocols for hand hygiene, are ineffective if not implemented by considering organizational culture and staff attitudes and motivation. Linkage with national goals – designed to withstand political changes – is central to long-term sustainability. Any ambition to improve quality will require a multimodal approach, using a combination of interventions. Some approaches, like accreditation of facilities, may not have a direct impact on health outcomes but can be important in building public trust and in promoting a culture of quality within the health care system. Programmes that focus only on provider behaviour fail to recognize that the wider environment of health care is pivotal in facilitating or hindering best practice. For example, appropriate prescribing of antibiotics often depends on a physician whose behaviour can be influenced by practice guidelines, performance feedback, peer review, training and supervision, financial incentives, availability of a sufficient variety of antibiotics and patient expectation. The complexity of change becomes apparent. The illustrative interventions in Table 5.1 have been identified for the following attributes: relevant in a wide variety of countries globally; commonly considered as options; having some evidence to guide selection and use; and implementable at multiple levels, from small primary care clinics to the level of a national programme. The context within which these interventions are applied is pivotal in maintaining the credibility of quality improvement endeavours. For example, developing a multimodal quality intervention strategy for a health facility without adequate water supply provides an immediate reality check for quality enthusiasts – data on water, sanitation and hygiene from health facilities across the world provide a clear context for action on the structures required for quality. The act mandates quality committees of the board in health sector organizations, and requires surveys of satisfaction for patients, families and employees. In addition, health care organizations must develop and publicly post a patient declaration of values and a quality improvement plan. The Excellent Care for All Act also created an expanded provincial quality agency, Health Quality Ontario, with a mandate to undertake health system performance monitoring and public reporting, support quality improvement, and promote the provision of best-quality health care. At the organizational level, regulations govern quality assurance and safety in hospitals, nursing homes, laboratories, and other health care settings, and health regulatory colleges have been established to ensure that health professionals provide services in a safe, responsible and ethical manner. While 65% of Ontarians rate their health status as excellent or very good, this average masks significant geographical and population variations; for example, the poorest quintile is twice as likely to report having multiple chronic conditions than the richest quintile. In response, a continued focus on leadership, accountability, and alignment of incentives and goals for improvement will continue to be cornerstones of Ontario’s strategy for a higher-quality health care system. Source: ICES (115), Ministry of Health and Long-term Care (116). Chapter 5 Understanding levers to improve quality 66 The list presented is not exhaustive; other interventions could be included. This set of interventions has been selected for their potential impact on quality by reducing harm, improving front-line delivery of health care services, and building systemwide capacity for quality improvement. The illustrative interventions are not ranked by effectiveness but point to some of the options and possibilities available to health system leaders, managers, practitioners or policy-makers intent on advancing quality of care. The interventions are presented as simply as possible, highlighting the salient issues. However, none is simple to implement. The multiple interventions grouped under system environment touch on a number of the seven categories mentioned above. Table 5.1 Illustrative quality interventions Category Interventions System environment • Registration and licensing of doctors and other health professionals, as well as health organizations, is often considered a key determinant and foundation of a well performing health system. • External evaluation and accreditation is the public recognition, by an external body (public sector, non-profit or for-profit), of an organization’s level of performance across a core set of prespecified standards. • Clinical governance is a concept used to improve management, accountability and the provision of quality health care. It incorporates clinical audit; clinical risk management; patient or service user involvement; professional education and development; clinical effectiveness research and development; use of information systems; and institutional clinical governance committees. • Public reporting and comparative benchmarking is a strategy often used to increase transparency and accountability on issues of quality and cost in the health care system by providing consumers, payers, health care organizations and providers with comparative information on performance. • Performance-based financing and contracting is a broad term for the payment of health providers based on some set of performance measures and is increasingly used as a quality lever. The amount contingent on performance is often a subcomponent of the full payment, which may be based on a range of financing modalities. • Training and supervision of the workforce are among the most common interventions to improve the quality of health care in low- and middle-income countries. • Medicines regulation to ensure quality-assured, safe and effective medicines, vaccines and medical devices is fundamental to a functioning health system. Regulation, including post-marketing surveillance, is needed to eliminate substandard and falsified medicines based on international norms and standards. Reducing harm • Inspection of institutions for minimum safety standards can be used as a mechanism to ensure there is a baseline capacity and resources to maintain a safe clinical environment. • Safety protocols, such as those for hand hygiene, address many avoidable risks that threaten the well-being of patients and cause suffering and harm. • Safety checklists, such as the WHO Surgical Safety Checklist and Trauma Care Checklist, can have a positive impact on reducing both clinical complications and mortality. • Adverse event reporting documents an unwanted medical occurrence in a patient resulting from specific health services or during patient medical encounters in a medical care setting and should be linked to a learning system. … DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 67 Category Interventions Improvement in clinical care • Clinical decision support tools provide knowledge and patient-specific information (automated or paper based) at appropriate times to enhance front-line health care delivery. • Clinical standards, pathways and protocols are tools used to guide evidence- based health care that have been implemented internationally for decades. Clinical pathways are increasingly used to improve care for diverse high-volume conditions. • Clinical audit and feedback is a strategy to improve patient care through tracking adherence to explicit standards and guidelines coupled with provision of actionable feedback on clinical practice. • Morbidity and mortality reviews provide a collaborative learning mechanism and transparent review process for clinicians to examine their practice and identify areas of improvement, such as patient outcomes and adverse events, without fear of blame. • Collaborative and team-based improvement cycles are a formalized method for hospitals or clinics to work together on improvement around a focused topic area over a fixed period of time with shared learning mechanisms. Patient, family and community engagement and empowerment • Formalized community engagement and empowerment refers to the active and intentional contribution of community members to the health of a community’s population and the performance of the health delivery system, and can function as an additional accountability mechanism. • Health literacy is the capacity to obtain and understand basic health information required to make appropriate health decisions on the part of patients, families and wider communities consistently, and is intimately linked with quality of care. • Shared decision-making is often employed to more appropriately tailor care to patient needs and preferences, with the goal of improving patient adherence and minimizing unnecessary future care. • Peer support and expert patient groups link people living with similar clinical conditions in order to share knowledge and experiences. It creates the emotional, social and practical support for improving clinical care. • Patient experience of care has received significant attention as the basis of designing improvements in clinical care. Patient-reported measures are important unto themselves; patients who have better experience are more engaged with their care, which may contribute to better outcomes. • Patient self-management tools are technologies and techniques used by patients and families to manage health issues outside formal medical institutions and are increasingly viewed as a means to improve clinical care. 5.5 CONCLUSION Improving health system performance requires choices and judgements during the promulgation of policy, prioritization of national quality goals, engagement of key stakeholders and selection of quality-related interventions. The infrastructure, context, culture and traditions of health care in a country and locality are central in deciding which levers to apply. A successful national quality strategy is multifaceted and uses many interventions in concert (Table 5.2), from those that put the patient at the centre of the care process, to those that support health workers to set standards and work effectively in teams. Leaders, managers and policy-makers play a critical role in supporting and enabling environments in which standard setting, performance-based incentives, regulation and other interventions can flourish. Chapter 5 Understanding levers to improve quality 68 Table 5.2 Quality-related interventions: engaging key actors Actors Roles Government • Definition of national priorities and quality goals • Provision of essential quality infrastructure, e.g. information technology, utilities • Improvement of regulation • Reporting data for transparency and motivation • Inspection and licensing of health care providers Health care facilities • Clinical governance • Establishing care protocols and clinical pathways • Clinical decision support • Use of safety protocols • Inter-institutional learning mechanisms Clinical providers • Clinical standards and patient pathways • Monitoring adherence to standards of care • Peer review and clinical audit • Shared decision-making Patients and public • Patient, family and community engagement • Patient education and self-management • Participation in governance • Patient feedback on experience of care One of the biggest obstacles to health care improvement is a reluctance to acknowledge the problems that exist (117–119). Another is the difficulty of selecting effective interventions and competently implementing them. The importance of leadership is something of a mantra in the field of health care quality improvement, but without it there is no way to inspire belief that improvement is possible to catalyse collective action. Another key driver of success is proof that the intervention is working. It is here that data collection and feedback are indispensable. However, local teams may lack experience in collecting and interpreting data. They may struggle with data collection systems that are poorly designed for monitoring quality (120). Excessively burdensome measures may be seen as a waste of time, while poorly chosen measures can provoke gaming and perverse incentives. Getting the monitoring aspect right from the start is vital, and this means integrating measurement systems into improvement and making sure that they are adequately resourced (121, 122). Developing national quality policy and strategies is a priority if improvement is to be an integral part of the way that the health care system operates. Nationally driven efforts are required to develop and implement a coherent approach to quality that uses multiple levers to secure the positive change being called for by populations across the world. DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 69 Box 5.5 outlines key actions that can be taken to ensure that levers to improve quality are fully utilized. Box 5.5 Key actions: understanding levers to improve quality To ensure that multiple levers are used to improve quality in health care, governments, policy-makers, health system leaders, patients and clinicians should work together to: 1. Develop, refine and execute a national quality policy and strategy, by: • adopting a definition of quality that is applicable in the local context; • conducting a situational analysis of the current state of quality; • involving the range of key stakeholders in its formulation; • identifying (or creating) organizational structures that can provide governance, leadership and technical capacity in quality; • ensuring that quality is integrated across ministry of health functions. 2. Adopt and promote universal quality goals, by: • setting realistic and measurable targets to reduce harm and improve care; • working with professional bodies to establish areas of care to improve clinical effectiveness; • engaging and empowering patients, families and communities; • building systemic capacity for ongoing quality improvement activities; • establishing and activating learning systems for continuous improvement. 3. Design a quality strategy that includes a set of quality interventions, by: • examining carefully the evidence-based quality improvement interventions in relation to the systems environment, reducing harm, improvement in clinical care, and patient, family and community engagement and empowerment. 4. Monitor and report quality of care results for continuous improvement efforts 70 Today’s hospitals are no place for the dying. Both culturally and clinically they are mostly unsuited to provide end-of- life care, according to Dr M. R. Rajagopal, the “father” of palliative care in India. The former consultant anaesthetist has spent over 20 years developing care for the dying in the tiny green and fertile state of Kerala in the south-west of the country. Today, with 3% of India’s population, Kerala has two thirds of the country’s palliative care services. His interest developed when he was working as an anaesthetist at Calicut Medical College in northern Kerala in the early 1990s. He  recognized early on that tackling pain and supporting the dying could not be achieved by medical staff alone. The need was too great. It would depend on harnessing the commitment of volunteers. “Pain is just the visible part of the iceberg of suffering. What is ignored is the part below the surface – feelings of hopelessness and despair, worries about children, about money. That is what palliative care is about.” The movement grew and today he estimates there are 300 voluntary groups across the state (there are no official figures), providing care to patients in their own homes, identifying those in need and helping direct limited medical resources to where they can do most good. The “Kerala model” now attracts attention from around the world. After moving to Trivandrum in the south, in 2006 he founded Pallium India, which supports 11 voluntary groups and five mobile medical teams providing palliative care in the area, as well as campaigning to improve palliative care throughout India. Now aged 69, he still visits patients at home and teaches younger colleagues how to approach them. “If I wear a tie, hold myself with muscular rigidity, and talk only about pain, I will not discover much. With a different, gentler approach, placing a hand on the patient’s arm, they will talk about deeper problems.” He warns about the importance of language. “You can do harm with the wrong dose of a medicine – and equally with a wrong word.” My Quality Dr M. R. Rajagopal, palliative care specialist Trivandrum, India 71DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE As diagnosis and treatment have become increasingly dependent on technology, something has been lost, he says. The growth of the commercial health care industry, driven by profit, has compounded the sense of alienation. The result is that the disease has become more important than the person who has it. Most doctors believe they have a duty to prolong life, rather than ease death. Cure has come to matter more than care. “The patient has become a bit of a stranger amidst the machines. The health care system seems to have forgotten that health is not just the absence of disease but the presence of physical, mental and social well-being.” He argues that every hospital must integrate palliative care with its disease-focused work. Most people, given the choice and the appropriate care, would choose to die at home, surrounded by their loved ones. But some feel more secure in a hospital environment, with their familiar doctor close at hand. It should be a personal choice, he says. Having access to pain relief is vital to that choice but morphine is not easy to obtain. Figures show India uses 320 kilograms of morphine a year, just 1% of the amount required to meet the need. It is not the cost that restricts access, but the law. Morphine has been highly restricted in India since 1985 because of fears about drug abuse. As a result, two generations of doctors have grown up unfamiliar with it, condemning millions of terminally ill patients to an unnecessarily painful death. Here, too, Kerala has led the way. Since 1995, palliative care centres in Kerala have been permitted to administer morphine orally. Dr Raj’s institution is now a WHO Collaborating Centre for Training and Policy on Access to Pain Relief and plays host to a stream of international visitors. “Health care should be a partnership between the doctor, the patient and the family. Doctors should not work alone but with nurses and counsellors, volunteers from the community and social workers. My duty is to build a relationship with my patients and their families and care for them as human beings. Life is not just existence – there is more to it than that.” Image on previous page: © LPETTET / iStock

Chapter6 The quality call to action 73DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE Chapter 6 The quality call to action 74 6.1 SUSTAINABLE DEVELOPMENT, QUALITY AND THE WAY FORWARD The health-related SDGs cannot be achieved through reliance on disease-specific achievements or financial reforms alone. It requires a strong commitment to creating people-centred, high-quality health services. Achieving universal health coverage built on a firm foundation of safe, high-quality care, together with all that is necessary to sustain it, is the imperative facing policy-makers today. Most past efforts at quality improvement have relied on project-based methodologies. They have shown little promise for scale-up and sustainability. More focus is needed on the foundations of high-quality health services across the care continuum. Offering high-quality health services also means linking financial reforms and reorientation of the delivery model to goals on quality of care. Finally, building on strong foundations, health systems offering sustainable improvements in quality must use national quality policy and strategy tools to create an environment where local, regional and national champions can extend and expand what is working to improve services. In such an environment, governments and providers will make locally appropriate choices on which quality improvement interventions could have the greatest impact on improving the system environment, on reducing harm, on improving clinical care and on engaging and empowering patients, families and communities. Advancing quality improvement, universal health coverage and people-centred approaches within the complexity of health systems requires systems thinking – a deliberate and comprehensive understanding of the dynamics of health systems in order to make them change for the better. By decoding the complexity of the health system, systems thinking helps foster systemwide implementation and evaluation of those interventions that are needed to support the achievement of health goals – equitably, sustainably and effectively. 6.2 CALL TO ACTION This document, from the perspective of three global institutions concerned with health – OECD, the World Bank and WHO – proposes a way forward for health policy-makers seeking to achieve the goal of access to high-quality, people-centred health services for all. In this chapter, a series of high-level actions are called for from each of the key constituencies that needs to work together with a sense of urgency to enable the promise of the SDGs for better, safer health care to be realized (Box 6.1). While no single actor will be able to effect all these changes, an integrated approach whereby different actors work together to achieve their part of the quality call to action will have a demonstrable effect on the quality of health services around the world. DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 75 Box 6.1 High-level actions by key constituencies for quality in health care 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 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.

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87DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE Annex – Improvement interventions This annex defines and presents further information and research on a selection of improvement interventions. 1. Licensing of health care providers is a key determinant of a well performing health system. However, emerging work looking at performance differences between licensed and unlicensed practitioners suggests that licensing alone is not enough to assure quality care. For example, a World Bank study on a rural area of India – where there are 15 times as many unqualified providers as those with a medical degree – found that formal training is not a guarantor of high quality. The study observed minor differences between trained and untrained doctors in adherence to safety checklists and no differences in the likelihood of providers giving the diagnosis or providing the correct treatment (1). These findings suggest that formally trained doctors may know what they should be doing clinically but that further interventions are needed to ensure compliance with higher-quality standards of care (2). Systematic monitoring of quality and individual feedback to providers, as well as patient education on provider competence, are other methods for improving quality of care (3). 2. Accreditation is the public recognition, by an external body, of an organization’s level of performance against a set of prespecified standards (4). Accreditation can be granted by public sector, non-profit and for-profit bodies. Historically, metrics used to assess accreditation have been structural and process oriented, such as the presence of adequate medical equipment, staffing ratios and adherence to programmatic standards. Minimal research has been conducted on the relationship between accreditation and clinical outcomes. In one study in Egypt, mean patient satisfaction scores were significantly higher for accredited nongovernmental health units across a few domains: cleanliness, waiting area, waiting time, unit staff and overall satisfaction (5). At least theoretically, accreditation offers some benefits, such as increased public trust and confidence, self-regulating behaviour on the part of health care institutions, and a basis for incentives and sanctions for performance management. Maintenance of an effective accreditation programme may be challenging, for several reasons: the need for additional resources to address structural and performance deficiencies of facilities in preparation for accreditation, continual adaptation to ensure standards are up to date with the evidence, and sustained funding for national or international accreditation (6, 7). In many circumstances, a period of targeted technical assistance will be necessary prior to the implementation of an accreditation programme (6). 3. Clinical governance includes the systematic promotion of activities such as clinical audit; clinical risk management; patient or service user involvement; professional education and development; clinical effectiveness research and development; use of information systems; and institutional clinical governance committees (8). Clinical governance is a concept used to improve management, accountability and the provision of quality care. The National Health Service in the United Kingdom has pioneered large-scale implementation of clinical governance activities (9). Although literature from low- and middle-income countries remains limited, a case study from Indonesia showed that clinical governance was used to improve maternal and newborn health in 22 hospitals (10). The most acceptable mechanisms to drive clinical governance are Annex Improvement interventions 88 those that recognize professional leadership and are perceived as being locally relevant and allowing reflection on personal professional practice (11). 4. Public reporting is a strategy used to increase transparency and accountability on issues of quality and cost in the health care system by providing consumers, payers, health care organizations and providers with comparative information on performance. It includes a broad range of approaches, such as report cards on hospital performance, comparative prices and costs in a community, and benchmarking on clinical indicators for providers. Public reporting has been implemented in several high-income countries, including Canada, the United Kingdom and the United States, where evidence shows that it catalyses improvement. In low-resource countries less has been published, but several cases are illustrative of potential impact. In Afghanistan, the Ministry of Public Health produced and released publicly a balanced scorecard (12), using household survey and annual hospital survey data, which showed progressive improvement in the national scores between 2004 and 2008 in all six domains, including patient and community satisfaction, capacity for service provision, overall quality of services, and reduction of user fees (13). 5. Performance-based financing is a broad term for remuneration provided to health care providers based on performance measures. Often the amount contingent on performance is a subcomponent of the full payment, which may be based on fee for service, capitation or other calculations. Payment can be allocated at the individual level or group level (for example hospital, department or care team). Evidence shows mixed success, depending on factors such as substantial buy-in from stakeholders, institutional capabilities, and the competency of the financing scheme or fund holder (14–17). A field experiment from Rwanda suggests that performance-based financing may be feasible (and preferable to input-based financing) in sub-Saharan Africa (15). The study found improvement across a number of access and knowledge indicators, for example 62% reduction in out-of-pocket costs, 144% increase in deliveries by skilled persons, and 23% increase in knowledge of HIV transmission risks through skin-piercing objects, but found no impact on clinical outcomes (15). Similarly, results from a pilot in Nigeria found an increase in antenatal care visits, and the use of skilled delivery (17). 6. Training and supervision of health workers are among the most common interventions to improve the quality of health care in low- and middle-income countries. Despite extensive investments from donors, evaluations of the long-term effect of these two interventions are scarce. One study found that training and supervision did not meaningfully improve quality of care for pregnant women or sick children in sub- Saharan Africa (18). Another study from Benin found that workers who had received integrated management of childhood illness training plus study supports provided better care than those with training plus usual supports, and both groups performed better than untrained workers (19). In a related project in Benin to strengthen supervision of health workers, after some initial success, many obstacles were encountered at multiple levels of the health system that led to a breakdown in supervision, including poor coordination, inadequate management skills, ineffective management teams, lack of motivation, decentralization, health worker resistance, less priority given to programme- specific supervision, supervision workload, non-supervision activities, incomplete implementation of project interventions, and loss of leadership and effective supervisors (20). The study concluded that support from leaders is crucial, and that donors and politicians thus need to make supervision a priority (20). 7. Medicines regulation improves the quality of medicines, both produced and available. While between 5% and 15% of WHO Member States report cases of DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 89 counterfeit medicines, this is probably a considerable underestimate. Globally, medicine regulation capacity is limited; WHO estimates that 30% of countries have no medicine regulation or a regulatory entity that does not function properly (21). A study in Uganda assessed the effectiveness of national standard treatment guidelines on rational medicine prescribing and found significant improvement in the treatment of general cases, malaria and diarrhoea (22). Due to the extent to which medicine regulatory authorities are both financially and human resource intensive, it can be challenging to ensure that guidelines are followed. This is noted to be the case especially in poorer countries (21). It has been argued that resource-constrained countries should rely on the assessment of major medicine regulatory authorities, such as those in the United States and Europe, when assessing certain categories of medicines (23). This does not solve the problem of enforcement, and high-income country guidelines may not align with the attributes other countries identify as most important. Best- practice prescribing strategies that have had proven success in both developing and industrialized countries include standard treatment guidelines, essential medicine lists, pharmacy and therapeutic committees, professional training, and targeted in-service education (24). 8. Inspection of institutions for minimum safety standards can be used as a mechanism to ensure there is baseline capacity and resources to maintain a safe clinical environment. Although there is little formal literature on the inspection of institutions for minimum safety standards at the hospital or health centre level (25), inspection factors known to improve safety practices include consistency between standards, approval of standards by a country’s ministry, and proper supervision to communicate standards and help practitioners use them in everyday practice (26). At the minimum, inspection standards can identify structural elements that are foundational for quality: a clean water source, reliable power and backup capacity, adequate coverage by skilled health care workers, clear management responsibility, complete medical records and accountability. 9. Safety protocols, such as those for hand hygiene, address many of the avoidable risks that threaten the well-being of patients and cause suffering and harm (27). Health care-associated infections are the most frequent adverse event in health care delivery worldwide (28), the most common being infections of surgical wounds, the blood stream, the urinary tract and the lower respiratory tract (29). Yet, hand hygiene is a worldwide problem, with compliance rates averaging less than 40% (30). Hand hygiene studies have shown an impact on hand hygiene rates ranging from 10% to almost 50% (31, 32). Twenty hospital-based studies published between 1977 and 2008 showed an association between improved hand hygiene practices and reduced infection (33). Additionally, hand hygiene programmes can be cost-effective: one study in Viet Nam calculated that for every health care-associated infection averted, the hospital saved US$  1000 (32). Behaviour change requires multifaceted approaches focusing on system change, administrative support, motivation, availability of alcohol-based hand sanitizers and safe, reliable water and soap, training and intensive education of health care workers, and reminders in the workplace (30, 34, 35). Compliance is a pervasive problem dependent on many structural factors, including professional position (doctor, nursing assistant, physiotherapist technician), department or type of care delivered, staffing ratios, and the presence of relevant safety equipment such as gloves (33). Moreover, programmes need to be context sensitive (for example, alcohol- based sanitizers should be used where clean water is not reliably available) (31, 35). 10. Safety checklists, such as surgical safety checklists, can have a positive impact on reducing both clinical complications and mortality. In one study performed in eight diverse hospitals in a mixture of high- and low-income settings, postoperative Annex Improvement interventions 90 complication rates fell on average by 36% and death rates fell by a similar amount following increased adherence to six core safety processes covered by a provided checklist (36). Moreover, if during the first year of instituting a checklist major complications are prevented, a hospital will realize a return on its investment (37). However, evidence suggests that the successful uptake of checklists requires education of clinical staff, material resources, and integration into broader institutional efforts and clinical context (38–40). These factors have been shown to be particularly relevant in low- and middle-income countries (38). Poor checklist implementation in low-income settings might not only fail to reduce patient safety risks, but may also introduce new risks such as gaming, disengagement and other behaviours harmful to patient care (38). Implementation of surgical checklists is more likely to be optimized in established, multifaceted patient safety programmes (38). 11. Adverse event reporting documents an adverse or unwanted medical occurrence resulting from specific health services or during a patient encounter (41). Reporting of adverse events is a strategy to raise awareness, increase transparency and foster accountability regarding unsafe care. Adverse events due to medical care represent a major source of morbidity and mortality globally. A study looking at the global burden of unsafe medical care estimated that there are 421 million hospitalizations in the world annually, with approximately 42.7 million adverse events occurring resulting in 23 million disability-adjusted life-years (DALYs) lost per year (42). Approximately two thirds of all adverse events occurred in low- and middle-income countries. Unsafe medical care may lead patients, especially in low-income countries, to opt out of using the formal health care system, thereby making unsafe care a significant barrier to access for many of the world’s poor. Consumption of resources due to prolonged stay and extra care, as well as loss of wages and productivity, is a further consequence of unsafe care. 12. Clinical decision support (CDS) is the provision of knowledge and patient- specific information presented at appropriate times to enhance front-line health care delivery. CDS encompasses a variety of tools to enhance decision-making, such as clinical guidelines, condition-specific order sets, computerized alerts and reminders, documentation templates, and diagnostic support. CDS can be automated (embedded within electronic health records or mobile devices) or paper based. Although electronic CDS has many advantages, it does require ongoing technical assistance and may be subject to challenges of poor infrastructure, such as limited access to the Internet or unreliable power supply (43). A number of studies have examined the feasibility of implementing CDS in low- and middle-income countries, but there is only minimal evidence on its impact on health so far (43, 44). Studies note the need to balance CDS prompts that are in place to standardize care for better quality with the physician’s autonomy to make decisions based on context, clinical expertise, and unique patient needs (43–45). 13. Clinical standards, pathways and protocols are tools to guide evidence-based health care that have been implemented internationally since the 1980s (46). In high- income settings, clinical pathways have been used to improve care for diverse conditions, including acute myocardial infarction and stroke. For example, a study from Australia showed that after introduction of a clinical pathway programme with checklists and reminders, an additional 48% of acute myocardial infarction patients received beta blockers within 24 hours of admission (47). Similarly, following introduction of a clinical pathway programme, an additional 55% of ischaemic stroke patients received aspirin or clopidogrel within 24 hours of admission (47). Another study from the United States incorporated “best of care” clinical protocols into clinician’s workflow via care provider order entry and showed that the decision support tool significantly increased the number of patients receiving aspirin for acute myocardial infarction (48). DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 91 Clinical  pathways and protocols are also used in low- and middle-income settings, where national guidelines are published periodically and serve as an important source of reference for clinicians and public health officials, particularly for vertical disease- focused programmes such as tuberculosis and HIV/AIDS (49, 50). 14. Clinical audit and feedback is a strategy to improve patient care through tracking adherence to explicit standards and guidelines coupled with provision of actionable feedback. A common usage worldwide is to foster implementation of clinical practice guidelines, whereby audit and feedback is used to identify unjustified variation and increase guideline adherence. Audit at both individual and hospital levels is a key part of the Catalonian Cancer Strategy (Spain) for promoting equity (51). Even in rural, resource-limited settings, for example in the United Republic of Tanzania, clinical audit has been associated with a decrease in maternal mortality and morbidity (52). Research in higher-income countries has demonstrated that higher-performing facilities tend to deliver more timely, individualized and non-punitive feedback to providers than lower-performing facilities (53). While most studies do not quantify the extent to which audit and feedback concretely impacts adherence to standards, they do highlight the frequency of medical errors and provide a descriptive account of care quality in a given setting, helping clinical staff to identify and address areas for needed improvement. Noted challenges to successful implementation include resource availability, provider buy-in and leadership support for the process, consistency in understanding and implementation of guidelines, the accuracy of information in clinical records, and the effectiveness of continuing feedback mechanisms (51, 54). 15. Morbidity and mortality reviews provide a collaborative learning mechanism and transparent review process for clinicians to examine their practice and identify areas of improvement, such as patient outcomes and adverse events, without fear of blame (55). Morbidity and mortality reviews are used to bring together clinical staff to review, for learning purposes, what contributed to complications or a patient’s death (55). As such, they promote active recognition of mistakes or errors, and are an opportunity to learn as well as to identify needed process improvements. They have been shown to improve collaboration and communication, aid team-based learning, and result in changes in record keeping and governance relevant to patient safety (55 –57). Historically they have been popular in higher-resourced contexts, but studies are emerging that demonstrate potential in low- and middle-income countries. Descriptive work from Nepal suggests that they are feasible in rural, low-resource contexts (56). Research across geographical and economic contexts points to the importance of senior administrative participation, engagement of both clinical and non-clinical staff, clear identification of goals, selection of cases based on their potential for improvement and coordinated follow-up for improvement activities as key success factors (55–57). 16. Collaborative and team-based improvement cycles are a formalized method that brings together multiple teams from hospitals or clinics to work together on improvement around a focused topic area over a defined period of time. Several of the common features of collaboratives are the sharing of ideas for improvement, iterative testing of actions leading to improvement, and mutual learning across multiple health care organizations. Studies from high-income settings, such as the National Surgical Infection Prevention Collaborative or the collaborative to decrease caesarean delivery rates, have shown that collaboratives can be very effective, reducing infection rates from 27% to 1.7% and caesarean section rates by 30% in a matter of months (58–60). Collaboratives have also been used in low-income settings. For example, the Ethiopian Hospital Alliance for Quality was a national collaborative sponsored by Ethiopia’s Federal Ministry of Health. It included 68 hospitals, of which 44 showed a 10% improvement in a 10-point measure of patient satisfaction from the beginning to the end of the study period (61). Annex Improvement interventions 92 USAID funded 54 collaboratives in 14 low- and middle-income countries during the period 1998–2008. A meta-analysis of 27 of these collaboratives in 12 low- and middle- income countries showed that high-level performance was maintained for an average of 13 months and the average time to reach 80% performance was 9.2 months, while the average time to reach 90% performance was 14.4 months (62). 17. Formalized community engagement and empowerment refers to the active and intentional contribution of community members to the health of a community’s population and the performance of the health delivery system. Community involvement in health has many forms and approaches, including the adoption of behaviours to prevent and treat diseases; effective participation in disease control activities; contribution to the design, implementation and monitoring of health programmes; and provision of resources for health. Participation and input to health systems can occur through various means, such as needs analysis, high-level priority setting or participation on governing boards. Many case examples can be found; for example, in Eritrea and Senegal, strengthened community participation in malaria control led to a decrease in severe malaria cases (63), and preliminary analysis of the Ebola outbreak indicates that more formalized community participation efforts resulted in a significant impact on the identification and tracing of cases and broader trust in local Ebola treatment units (64). Health system reform processes have increasingly recognized the essential contribution of communities; in Kenya, feasibility was tested in district-level annual health sector planning where community participation did influence target and priority setting. Challenges of formalized community involvement include building capacity to empower communities, providing tools and products to support community involvement, and appropriate follow-up and supervision by health professionals. 18. Health literacy is the capacity to obtain and understand basic health information required to make appropriate health decisions on the part of patients, families and wider communities (65). Poor health literacy is a challenge for health care quality; for example, patients with low literacy have difficulty following medical instructions, interacting with the health care system, and reading or complying with medicine prescriptions (65). Additionally, patients with low disease-specific knowledge report lower quality of life and have poorer health-related outcomes (65). Studies show educational interventions can have an impact on both knowledge improvement and clinical care seeking. For example, an intervention in Malawi led to a significant improvement in knowledge pertaining to mental health literacy (66), and a study in India found a positive association between health literacy programming and child vaccination rates (67). However, literacy gains lessen with time, so follow-up programming is key. Research suggests targeting influencers, such as teachers, to extend programmatic reach and ensure long-term impact (66, 67). Other considerations include the integration of health literacy curricula into required schooling, which is especially common with sexual health education (68). 19. Shared decision-making between providers and patients is often employed to tailor care to the patient’s needs and preferences, with the goal of achieving better patient outcomes. There is considerable evidence that patients want more information and greater involvement (69), but few studies have evaluated the impact on clinical outcomes, particularly in low- and middle-income countries. Inadequate communication between providers can result in missed services (70). Barriers to patient activation, however, exist in many public health sector settings, such as in clinics, which are often congested and overstretched (71). One study on adherence to antiretroviral therapy and shared decision-making or “patient activation” found that after diagnosis, patients actually preferred provider-led decision-making, but as they gained comfort with their HIV diagnosis, they were more open to a shared decision-making approach DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 93 to HIV treatment (71). There is no evidence that shared decision-making negatively impacts clinical care, though there may be limitations to what can be addressed in a single clinical visit, given such factors as local concepts of illness or historically grounded distrust of “Western” medicine, which may motivate patients to seek traditional medicines (70). 20. Peer support and expert patient groups link people living with similar clinical conditions in order to share knowledge and experiences. The approach complements and enhances other health care services by creating the emotional, social and practical support necessary for managing health problems and staying as healthy as possible. The extensive literature supporting the effectiveness of peer support and patient groups in HIV-infected adults provides insight into what is both feasible and achievable as a strategy for improving quality of care. A systematic review of the impact of support groups on people living with HIV showed that support groups were associated with reduced mortality and morbidity, increased retention in care and improved quality of life (72). Group visits have shown promise in providing individual patients with a peer support network to maximize adherence, improve patient retention, provide patient education, monitor side effects, and achieve therapeutic gains (73). In a South African support group, participants were significantly more likely to have an undetectable viral load and a CD4 cell count greater than 200 cells/mL at 12 months than those who did not participate in a support group (72). Given the severe human resource challenges worldwide, specifically the shortage of trained health care providers, support groups can play a larger role in improving the effectiveness of models of care (72). 21. Patient feedback and experience of care as a strategy to better understand and improve health service quality has risen dramatically, primarily in high-income countries. In these contexts there is a growing body of evidence that self-reported experience correlates with other, more objective, measures of clinical quality (74). Patient-reported measures are associated with better patient experience, adherence to treatment, greater engagement with their care, and better outcomes (75, 76). A few studies in low- and middle-income countries have shown that patients can adequately judge certain aspects of their care. For example, a study based in the United Republic of Tanzania found that patients proactively sought care based on their clinical needs, as judged by the type and severity of symptoms, as well as the perceived value of previously received care (77). Audit-based evidence from primary care settings in India found that patients have a good idea of what they both want and need from doctors and are willing to pay for it (78). Some critics are concerned that the main determinants of patient experience may be driven by factors such as the attractiveness of the environment or amicability of staff; however, it has been shown that patients are able to differentiate superficial comforts from more meaningful engagement. 22. Patient self-management tools are technologies and techniques used by patients and families to manage their health issues outside formal medical institutions. They are increasingly studied as quality improvement tools in the context of growing empowerment of patients worldwide. Given the increasing prevalence of chronic disease globally, diabetes self-management serves as a good example. Diabetic patients involved with self-management education programmes demonstrated significant reductions in glycosylated haemoglobin levels; in Uganda, patient outcomes included decreases in HbA1c percentage and diastolic blood pressure, and in Honduras, reports of self-care demonstrated improvements in over 50% of patients in blood sugar levels, diet and medication adherence (79). One economic analysis of interventions for diabetes found that diabetes self-management training reduces medical costs in developing countries in the short term (80). Because mobile phones are widely available, mHealth interventions for self-management can be a cost-effective tool (79). Annex Improvement interventions 94 Challenges to widespread implementation include both geographical and financial access to such self-management programmes, trained human resources at central and peripheral levels, and access to education (81). 23. Health technology assessment (HTA) is conducted to find out how health care technologies help maintain and improve health. HTA is used to inform policy and clinical decision-making related to both the introduction and diffusion of a wide spectrum of health technologies (82, 83). Assessing whether HTA affects quality involves looking at the long-term pay-off of policies that have been implemented and demonstrated success. HTA has many different applications, such as policy-making for influenza vaccination of children, informing the development of reimbursement schemes in Sweden (which resulted in decreased annual costs), influencing characteristics of health benefit packages in Thailand or Chile (84–86), or defining the role of specific laparoscopic surgery techniques in Kazakhstan (87). Cohesion amongst and between stakeholders is necessary for the successful implementation of HTA with participation from health care professionals, patient advocacy groups, and the industry, such as medical technology or pharmaceutical firms (88). Transparency in analytics, costs and outcomes (real-life patient data) is key for HTA assessment to be successful (83). Because timely and appropriate access to health care products, procedures and medicines can often impact patient outcomes, HTA represents an important mechanism for improving quality of care for both individuals and populations. 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Printed in Switzerland Icons designed by Freepik, from www.flaticon.com 3DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE Contents Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Executive summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Chapter 1 Background: striving for quality in health care services . . . . . . . . . . . . . 15 1.1 Widespread evidence of poor quality in all countries . . . . . . . . . . . . . . . . . . . . . . . 16 1.2 The economic argument for good quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 1.3 Quality as a fundamental feature of universal health coverage . . . . . . . . . . . 17 1.4 Affordability of quality for all countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Chapter 2 About this document . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 2.1 Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 2.2 Scope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 2.3 Content . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Chapter 3 Global state of health care quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 3.1 The quality imperative for universal health coverage . . . . . . . . . . . . . . . . . . . . . . . 28 3.2 Defining quality of care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 3.3 Global picture of health care quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 3.4 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Chapter 4 Building quality into the foundations of health systems . . . . . . . . . . . 41 4.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 4.2 Foundations for high-quality care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 4.3 Quality of care as the foundation of people-centred health care . . . . . . . . . 49 4.4 The vision: health systems committed to people-centred care . . . . . . . . . . . . 52 4.5 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 Chapter 5 Understanding levers to improve quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 5.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 5.2 Driving improvement through national quality policy and strategy . . . . . . 58 5.3 Quality interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 5.4 Consideration and selection of quality interventions . . . . . . . . . . . . . . . . . . . . . . . . 65 5.5 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 Chapter 6 The quality call to action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 6.1 Sustainable development, quality and the way forward. . . . . . . . . . . . . . . . . . . . 74 6.2 Call to action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 Annex: Improvement interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 Contents 4 Figures Figure 3.1 Median under-5 mortality across dimensions of inequality, 2005–2012 . . . . . . . . . . . . . . .28 Figure 3.2 Elements of health care quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31 Figure 3.3 Number of clinical vignettes correctly diagnosed by Kenyan providers . . . . . . . . . . . . . . . .33 Figure 3.4 Burden of disease caused by adverse events, 2015 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34 Figure 3.5 Doctor providing easy-to-understand explanations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35 Figure 3.6 Trends in average waiting times for hip replacement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36 Figure 3.7 Structural and process quality of maternal services by county poverty level in Kenya . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36 Figure 4.1 Global density and distribution of skilled health professionals . . . . . . . . . . . . . . . . . . . . . . . . . .43 Figure 4.2 Variations in availability of basic equipment across health care facilities in sub-Saharan Africa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .45 Figure 4.3 Primary care as a hub of coordination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .53 Figure 4.4 Five strategies for people-centred services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .54 Tables Table 5.1 Illustrative quality interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .66 Table 5.2 Quality-related interventions: engaging key actors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .68 Boxes Box 3.1 Liberia: embedding quality in the post-Ebola health agenda . . . . . . . . . . . . . . . . . . . . . . . . . . .30 Box 4.1 Case study: training and retaining health care workers in underserved areas of the Philippines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44 Box 4.2 Case study: OECD Health Care Quality Indicators Project . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .47 Box 4.3 Case study: improving civil registration and vital statistics in Uganda . . . . . . . . . . . . . . . . . .48 Box 4.4 Case study: unmet needs for the care of chronic diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50 Box 4.5 Case study: primary care in Costa Rica . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51 Box 4.6 Case study: using Citizen Voice and Action to empower communities in Uganda . . .51 Box 4.7 Key actions: building quality into the foundations of health systems . . . . . . . . . . . . . . . . . .55 Box 5.1 Case study: Ethiopia – National Health Care Quality Strategy 2016–2020 . . . . . . . . . . . .59 Box 5.2 Case study: Sudan – National Health Care Quality Policy and Strategy . . . . . . . . . . . . . . . .60 Box 5.3 Case study: Mexico – National Strategy for Quality Consolidation in Health Care Facilities and Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .61 Box 5.4 Case study: Ontario, Canada – Excellent Care for All Act and Strategy . . . . . . . . . . . . . . . .64 Box 5.5 Key actions: understanding levers to improve quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .69 Box 6.1 High-level actions by key constituencies for quality in health care . . . . . . . . . . . . . . . . . . . . .75 5DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE The Sustainable Development Goals (SDGs) reaffirm a global commitment to achieve universal health coverage (UHC) by 2030. This means that all people and communities, everywhere in the world, should have access to the high-quality health services they need – promotive, preventive, curative, rehabilitative, or palliative – without facing financial hardship. The way we typically measure progress in UHC is through effective coverage of essential health services and financial protection (ensuring that no one becomes impoverished because of ill-health). But even if the world achieved essential health coverage and financial protection, health outcomes would still be poor if services were low-quality and unsafe. Delivering quality health services is essential to UHC. That is the focus of this report. Evidence suggests that substandard care wastes significant resources and harms the health of populations, destroying human capital and reducing productivity. Quality of care, especially patient safety, is essential to creating trust in health services. It is also key to global health security, which starts with local health security, and in turn depends on high-quality frontline health services. Quality health services not only prevent human suffering and ensure healthier societies, they also ensure better human capital and healthier economies. Too often, quality is perceived as a luxury that only rich countries can afford. This is a fallacy. Building quality health services requires a culture of transparency, engagement, and openness about results, which are possible in all societies – regardless of their income level. Around the world, lessons abound on what works and what does not, providing a rich foundation from which to rapidly scale up a quality revolution. Technological innovation plays a key role in offering new ways to expand high-quality health care services more rapidly, and at an affordable cost. A focus on people-centredness has to be the core of quality. People and communities must be engaged in the design, delivery, and ongoing assessment of health services to ensure they are built to meet local health needs – rather than those of donors, commercial or political interests, or because “it’s always been done that way”. Focusing on quality is critical, but leadership must also focus on celebrating excellence; communicating transparently; and fostering collaboration across clinical teams, as well as with patients, and civil society – including patient groups, nongovernmental organizations, and grassroots community groups. Universal health coverage is not a dream for the future. It is already a reality in many countries; however, without quality health services, it can remain an empty promise. This foundational report builds a strong technical and political case for investing in quality health services. The collective prize is a healthier, safer and fairer world. Preface Angel Gurría Secretary-General OECD Tedros Adhanom Ghebreyesus Director-General World Health Organization Jim Yong Kim President The World Bank Group

7DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE Acknowledgements This document was jointly prepared by the World Health Organization (WHO), the Organisation for Economic Co-operation and Development (OECD) and the World Bank under the overall guidance of Marie-Paule Kieny, former Assistant Director-General, Health Systems and Innovation Cluster, WHO; Timothy Evans, Senior Director, Health, Nutrition and Population Global Practice, World Bank Group; and Stefano Scarpetta, Director of Employment, Labour and Social Affairs, OECD. The writing team comprised Edward Kelley (WHO), Niek Klazinga (OECD), Ian Forde (OECD), Jeremy Veillard (World Bank), Sheila Leatherman (Gillings School of Global Public Health, University of North Carolina), Shamsuzzoha Syed (WHO), Sun Mean Kim (WHO), Sepideh Bagheri Nejad (WHO) and Sir Liam Donaldson (WHO Envoy for Patient Safety). Development of the document was coordinated by Sepideh Bagheri Nejad. The authors wish to thank colleagues from the Dutch National Institute for Public Health and the Environment (RIVM), Michael van den Berg and Wilco Graafmans for their input to the development of the overall conceptual framework and content of the document, Stefano Scarpetta, Mark Pearson, Francesca Colombo, Caroline Berchet and Luke Slawomirski from OECD for their contribution to the writing, and Sagar Dugani and Adanna Deborah Ugochi Chukwuma from the World Bank for their help with the revision of the text at the final stage. The document benefited from the rich inputs of the Advisory Committee, composed of the following members: Sir Liam Donaldson (Chair), Clifford Hughes, Tawfik Khoja, Jan Mainz, Rashad Massoud, Robin Osborn, Enrique Ruelas, Paul Shekelle, Anuwat Supachutikul and Nana Amma Twum-Danso. Country case studies were produced by the following people: Daniel Burssa and Eyub Gebretsadik for Ethiopia; Sebastian García Saiso, Paulina Pacheco Estrello and Enrique Ruelas for Mexico; Elmuez Eltayeb for Sudan; and Michelle Rossi, Joshua Tepper and Adalsteinn Brown for Ontario, Canada. The annex on improvement interventions was produced by Sheila Leatherman (Gillings School of Global Public Health, University of North Carolina), and Liana Rosenkrantz Woskie, Anthony Moccia, Ruma Rajbhandari and Kim Reimold (the Harvard Initiative on Global Health Quality at the Harvard Global Health Institute). We wish to thank Gheorghe Sorin Banica and Laura Pearson for administrative support and Gary Humphreys for writing the initial draft of the document. We would also like to thank the following peer reviewers: Donald Berwick, Helen Haskell, Margaret Kruk and Ephrem Lemango. Finally, we would like to express our appreciation to the many other staff members from the three partner organizations who contributed to this document. Without their dedication, support and expertise this work would not have been possible: Yetmgeta Abdella, Najeeb Al Shorbaji, Benedetta Allegranzi, Broog Alsadhan, Shannon Barkley, Marie-Charlotte Bouesseau, James Campbell, Meena Cherian, Mickey Chopra, Krycia Cowling, Jishnu Das, Neelam Dhingra-Kumar, Joan Dzenowagis, Peter Engelfriet, Linda Freiheit, Ruben Frescas, Michele Gragnolati, Michelle Karen Funk, Javier Gomez Batiste-Alentorn, Joyce Hightower, Maki Kajiwara, Rania Kawar, Michael George Kay, Acknowledgements 8 Claire Kilpatrick, Ramesh Krishnamurthy, Angela Lashoher, Agnès  Leotsakos, Manon  Lette, Akiko Maeda, Nicola Magrini, Elizabeth Mason, Kellie McGee, Nana Mensah Abrampah, Hernan Montenegro Von Mühlenbrock, Margaret Murphy, Jillian Oderkirk, Shanti Pal, Felicity Pocklington, Nittita Prasopa-Plaizier, Paul Peter Schneider, Emma Scholar, Maria Cecilia Sepulveda Bermedo, Maria Angelica Sousa, Julie Storr, Nuria Toro Polanco, Andreas Ullrich, Krisantha Weerasuriya, Erica Wheeler, Tana Wuliji, Mohammad Taghi Yasamy, Junping Yu, Hongwen Zhao and Hao Zheng. 9DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE Abbreviations CAIS centres for integrated health care (centros de atención integral en salud) CDS clinical decision support DALY disability-adjusted life-year EBAIS integrated health care basic teams (equipos básicos de atención integral de salud) EuroHOPE European Health Care Outcomes, Performance and Efficiency (project) HTA health technology assessment MDG Millennium Development Goal OECD Organisation for Economic Co-operation and Development P4P pay for performance SDG Sustainable Development Goal UNICEF United Nations Children’s Fund USAID United States Agency for International Development WHO World Health Organization Abbreviations 10 11DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE This document – 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 low- and 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, people- centredness, 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 Executive summary Executive summary 12 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. DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 13 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. Executive summary 14 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. DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 15 Chapter Background: striving for quality in health care services 1 Chapter 1 Background: striving for quality in health care services 16 Universal health coverage is an important and noble objective. Enshrined in the Sustainable Development Goals (SDGs), universal health coverage aims to provide health security and universal access to essential care services without financial hardship to individuals, families and communities, thus enabling a transition to more productive and equitable societies and economies. But universal health coverage should not be discussed and planned, let alone implemented, without a focus on quality. It is essential to ensure that care is effective, safe, and in keeping with the preference and needs of the people and communities being served. Further, provision of care should be timely and equitable across populations, coordinated across the continuum of care and throughout the life course, while minimizing resource waste. Quality of care therefore underpins and is fundamental to universal health coverage. For if quality of care is not ensured, what is the point of expanding access to care? Access without quality can be considered an empty universal health coverage promise. Quality is not a prerogative of high-income countries. If countries can afford to provide any health care – and even the poorest can and should do so – they must provide care of good quality. The alternative – poor-quality care – is not only harmful but also wastes precious resources that can be invested in other important drivers of social and economic development to improve the lives of citizens. Billions of dollars are spent on the consequences of poor-quality care – money that can fund schools, social services and infrastructure. And poor quality can also undermine the trust of the population in the benefits of modern medicine. Seen this way, universal health coverage without quality of care is a job half done. 1.1 WIDESPREAD EVIDENCE OF POOR QUALITY IN ALL COUNTRIES Much progress has been made in improving some aspects of quality of health care across the world, for example with regard to cancer survival rates and mortality from cardiovascular diseases (1, 2). But in other areas, progress has been slow and uneven. The numbers speak for themselves. • In high-income countries, one in 10 patients is adversely affected during treatment (3). • In high-income countries, seven in 100 hospitalized patients can expect to acquire a health care-associated infection (in developing countries this figure is one in 10), infections that can be easily avoided through better hygiene and intelligent use of antimicrobials (4). • Unwarranted variations in health care provision and delivery persist, and a considerable proportion of patients do not receive appropriate, evidence-based care (5, 6). • Influenza vaccination rates vary across high-income countries from 1% to over 78%, despite a goal of 75% by 2010 set by the World Health Assembly in 2003 (7). • Antimicrobial resistance has become a major global public health issue, partly due to the misuse and overuse of antimicrobials in health care (8). • Globally, the cost associated with medication errors has been estimated at US$ 42 billion annually, not counting lost wages, foregone productivity or health care costs (9). DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 17 • While the rate of skilled birth attendance increased from 58% in 1990 to 73% in 2013, mainly due to increases in facility-based births, there are still many women and babies who, even after reaching a health facility, die or develop lifelong disabilities due to poor quality of care. The World Health Organization (WHO) estimates that 303 000 mothers and 2.7 million newborn infants die annually around the time of childbirth, and that many more are affected by preventable illness. Further, some 2.6 million babies are stillborn each year (10, 11). • Nearly 40% of health care facilities in low- and middle-income countries lack improved water and nearly 20% lack sanitation – the implications for quality of care are clearly evident (12). • Cross-country estimates of the distribution of diagnosis and control of raised blood pressure in selected countries outside the OECD highlights the importance of quality preventive services. In most, at least half of the adults with raised blood pressure have not been diagnosed with hypertension. Hypertension treatment coverage is therefore low, ranging from 7% to 61% among people who have presented with raised blood pressure in the household surveys. However, effective coverage is considerably lower than coverage, ranging from 1% to 31%, indicating a quality issue (13). 1.2 THE ECONOMIC ARGUMENT FOR GOOD QUALITY Beyond the effects on people’s lives, poor-quality care wastes time and money. Making quality an integral part of universal health coverage is both a matter of striving for longer and better lives and an economic necessity. Building quality in health systems is affordable for countries at all levels of economic development. In fact, the lack of quality is an unaffordable cost, especially for the poorest countries. Substandard quality of care not only contributes to the global disease burden and unmet health needs, it also exerts a substantial economic impact, with considerable cost implications for health systems and communities across the world. Approximately 15% of hospital expenditure in high-income countries is used to correct preventable complications of care and patient harm. Poor-quality care disproportionately affects the more vulnerable groups in society, and the broader economic and social costs of patient harm caused by long-term disability, impairment and lost productivity amount to trillions of dollars each year (14). In addition, duplicate services, ineffective care and avoidable hospital admissions – features of many health systems – generate considerable waste. Up to a fifth of health resources are deployed in ways that generate very few health improvements. These scarce resources could be deployed much more effectively (3). 1.3 QUALITY AS A FUNDAMENTAL FEATURE OF UNIVERSAL HEALTH COVERAGE Quality does not come automatically; it requires planning, and should be a clearly identified priority of universal health coverage, along with access, coverage and financial protection. This document shows that building quality into health systems is possible if a number of steps are followed and principles applied, namely transparency, people-centredness, measurement and generation of information, and investing in the workforce, all underpinned by leadership and a supportive culture. With these fundamentals in place, proven interventions and practices to ensure quality – such as hand hygiene, treatment protocols, checklists, education, and reporting and feedback – can be implemented and sustained. Chapter 1 Background: striving for quality in health care services 18 Transparency is paramount. It is the bedrock of continuous learning and improvement. The overarching conclusion from 15 reviews of quality in national health systems conducted by OECD between 2012 and 2016 was the need for greater transparency about performance in terms of quality and outcomes of care (15). A key component of transparency is being open and honest about results, including lapses and mistakes. In such an environment these become opportunities to learn, as is the case in other sectors, including air transport. Successful outcomes should be celebrated and shared for the same reasons. This culture of transparency can take time to build, but it can and must be instilled in all health systems, regardless of resources available. Involving people and communities in their own care and in the design of their health services is now recognized as a key determinant of better outcomes. People and the communities in which they are born, raised, live, work and play are at the heart of delivering quality health services. People who are actively engaged in their own health and care suffer fewer complications and enjoy better health and well-being. At the clinical level, this means enabling patients to partner in their care and in clinical decisions, and to actively manage their health. People-centredness is the “doorway to all qualities” (16). Indeed, the common thread of success stories detailed later in this document is putting the patient’s needs and values front and centre. This means caring with compassion and respect. But people-centredness goes beyond individual care. People and patients should be involved in priority setting and in policy development. Nowhere is this more important than in primary and community care. These services need to be designed with input from the communities that they serve, based on their unique needs and preferences, as discussed in Chapter 4 of this document. Quality requires measurement and generation of information. Health care is changing all the time, so quality needs to be continually monitored and assessed to drive improvement. This relies on accurate and timely information. The banking industry devotes 13% of its income to information systems. Health care invests less than 5% – a paltry amount for an information-intense sector. And when they exist, the data generated by health systems are too often concentrated on inputs and volume of activities. This needs to change if quality is to become a routine part of health care. Reliable quality metrics must be embedded in local and national health information infrastructures – this is even more important than measuring inputs. In the spirit of transparency, information must be available to all relevant actors, including patients, providers, regulators, purchasers and policy-makers. All dimensions of quality should be measured. It is important to know about adherence to essential protocols and the quality of processes and pathways, for example hand hygiene; surgical safety checklists; adherence to clinical practice guidelines; and clinical outcomes, for example readmissions, mortality rates, adverse drug reactions, survival after a diagnosis of cancer and adequate control of glycaemia during pregnancy. But knowledge must also be generated on the outcomes and experiences of care that are valued by patients through the measurement of patient- and community-reported quality indicators (17). All this needs to be done with a clear eye on strong linkages between measurement and improvement – measuring alone will not improve quality. A skilled, motivated and adequately supported health workforce is critical. Health care providers want to deliver the best possible care to their patients. Often, however, the systems and environments they work in make this task difficult. Many countries face significant deficiencies in both the quantity and quality of their health DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 19 workforce. Of course, not all care should be delivered by doctors. Nurses, allied and community health workers, care coordinators and managers all play important roles in delivering high-quality care in the 21st century. It is possible to achieve high quality by leveraging their skills throughout the chain of health production (18). In providing high-quality care, technical knowledge needs to be augmented by the ability to communicate and work as a team with other professionals, and to partner with patients and their carers. It also requires a workforce trained in the principles and practice of continuous quality improvement, as well as recognition of the “hidden curriculum” that arises from the fallibility of human-designed systems. Quality is also a function of how well efforts are organized and integrated with other sectors, taking account of patterns of behaviour, human interaction and relationships. This in turn depends on the incentives that are in place, including funding and remuneration, regulation, reporting and feedback, which need to be carefully built into all processes and institutions. In the end, systems provide the fertile soil in which high-quality practice and improvement can bloom. None of the above is possible without leadership and an enabling culture. A  buoyant culture in which all actors are motivated to collaborate, communicate and work with their communities to deliver high-quality people-centred care, without fear or intimidation, has been shown to deliver better outcomes (19). Many factors influence such a culture of continuous quality improvement. First and foremost, a transparent environment should be cultivated, as described above. Also important are training and socialization of workers, improvement measures, feedback on performance, and shared learning, as well as upstream factors such as financial incentives. But the key ingredient is consistency of leadership from governments, policy-makers, clinical leaders, health system managers and civil society. This does not require a high level of resources – it rather requires investment in a culture shift towards transparency for continuing improvement. These fundamentals provide the backbone for policies and practices to continually improve health care quality. But quality must be the responsibility of all stakeholders and institutions. It must be supported by a crystal-clear national strategic direction, with well defined objectives and goals, and strong stakeholder engagement across the entire health system, as well as with other sectors. 1.4 AFFORDABILITY OF QUALITY FOR ALL COUNTRIES While high-quality health care for all may seem ambitious, it can be achieved in all settings with good leadership, robust planning and intelligent investment. For example, in Uganda a model involving citizens and communities in the design of health care services has improved a range of indicators, including a 33% reduction in child mortality (20). Costa Rica has achieved remarkable improvements in primary care quality through a carefully planned, implemented and resourced improvement strategy (21). These and other examples are provided later in this document. For low- and middle-income countries, addressing quality while building universal health coverage is a huge opportunity. A health system that is maturing and becoming established can be influenced, steered and nurtured in the desired way. Quality can be embedded into policies, processes and institutions as the system grows and develops. Chapter 1 Background: striving for quality in health care services 20 The challenge is how to learn from the experiences – both the successes but also (and especially) the mistakes – of health systems in high-income countries. A key lesson is that retrofitting quality into established health systems is certainly possible but can be arduous; rather, quality must be built in from the start, along with access, coverage and financial protection. Of course, quality care cannot be conjured up entirely for free – it requires some investment of capital and other resources. This investment is not beyond reach, even for the poorest countries. The costs of poor quality to people’s lives, to health systems and to societies are massive. If applied intelligently, investment in quality will deliver better individual and population health, and value for money; the return on investment in ensuring high-quality care is likely to far outweigh the costs. Better outcomes also further economic and social development; for example, healthier people are more productive at work, and healthier children perform better at school. So striving for universal quality health coverage is not just an investment in better health – it is a commitment to building a healthier society and a healthier world. 21DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE Eight years ago, when she was diagnosed with rheumatoid arthritis, an autoimmune disease that causes inflammation, swelling and acute pain in the joints, Cecilia Rodriguez was Director of a primary health care facility. “I had very bad rheumatoid arthritis and spent a lot of time in bed,” says Rodriguez, who was in her thirties when she first experienced the painful symptoms. “I realized that what I had been promoting as a health administrator was very different from what I needed as a patient.” Rheumatoid arthritis touches people of all ages. Its exact causes are not known, but genetic and environmental factors may play a role. Up to 1% of the world’s population is affected.1 In Chile, where Rodriguez lives, 100 000 people are living with this lifelong condition. For people with chronic diseases, quality health care can be defined as “an accurate equilibrium between clinical best practices and what is best for the patient, determined with the patient,” Rodriguez explains. “We don’t always need doctors who have all the answers. We need people who understand how we are coping with our condition.” Above all, she believes patients suffering from chronic conditions that have a huge impact on daily life need to feel in control of their treatment. “As a patient, I know what I want to achieve. Clinicians can help me understand if I can achieve it and help me do so. For me, that’s the best quality of health care.” Cecilia Rodriguez and her sister Lorena, who had been diagnosed with rheumatoid arthritis a few years earlier, established a non-profit organization to support people affected by the same condition and advocate for improved patient care. “We called the NGO ‘Me Muevo’ (‘I move’) because we learned that with this condition you have to keep your body moving, but also because ‘I move’ means ‘I take action’”, she says. My Quality Ms Cecilia Rodriguez, Executive Director ‘Me Muevo’ Foundation 1. www.rheumatoidarthritis.org. 22 ‘Me Muevo’ is part of a growing movement of patient-led organizations in Chile. Rodriguez acted as spokesperson for an alliance of associations that successfully lobbied to make prescription drugs more affordable. In 2016, Chile adopted the ‘Ricarte Soto Law’ on high-cost treatments. “Now I only pay US$ 200 a year for all my medications, instead of US$ 1500 per month,” Rodriguez says. “Health care systems tend to be geared towards treating acute illnesses, and are rarely organized to help patients with lifelong diseases overcome the hurdles of daily life,” Rodriguez explains. She cites the example of her sister who works and has to travel to three locations – a process that takes at least five hours – to collect her monthly prescription drugs. “In this case, quality of care would mean being able to pick up all her medications from the primary health care facility near her house, on a Saturday morning,” she says. Rodriguez also promotes enabling patients to enter notes into their medical records between medical appointments to help physicians adjust their treatment. “If I could write that I had had a flare-up and say how I had dealt with it, my doctor would have that on record when I saw her three or four months later,” she says. After Rodriguez attended a chronic disease self-management course in the United States, which helped her better cope with the effects of her disease, her organization worked to make the programme available to patients in her own country. “Investing in teaching self-management can reduce overall costs. That is why we are bringing this programme to Chile,” she says. As a result, seven hundred people benefited from this training through the public system, last year. Image on previous page: © Rawpixel / iStock DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 23 Chapter2 About this document Chapter 2 About this document 24 Recognizing the global gap in understanding, measuring and improving quality of health care services, WHO, OECD and the World Bank have joined efforts to produce this document – Delivering quality health services: a global imperative for universal health coverage. 2.1 OBJECTIVES This document has been developed with the following objectives: • to provide governments with a description of the quality of health services and their importance to achieving broad public health goals, within the context of universal health coverage; • to provide governments with a picture of evidence-based approaches that can ensure and improve quality of health services; • to make a call for action at national and international levels. 2.2 SCOPE This document is intended for policy-makers who want to bring the fundamentals of health care quality improvement into their health systems. Therefore, it looks at the quality of health care services at the foundation. The document does not aim to provide technical guidance for front-line health care professionals, though they may find useful information herein. Nor does it examine the implications of quality for specific technical areas. 2.3 CONTENT The document begins with a chapter on the background to quality in health care services (Chapter 1), followed by a brief description of the document (Chapter 2). The main body of the publication comprises three chapters on key quality themes (Chapters 3–5), followed by a quality call to action in Chapter 6. • Chapter 3: Global state of health care quality. In this chapter a global picture of quality in health care services is provided. Data are presented to show that quality of care in most countries, particularly low- and middle-income countries, is suboptimal, and improvement in quality is associated with better health outcomes. • Chapter 4: Building quality into the foundations of health systems. This chapter describes how mechanisms to assure, monitor and continually improve quality must be built into the foundations of health systems, and addresses key issues that require attention to improve the quality of health care at country level. • Chapter 5: Understanding levers to improve quality. Quality is a complex and multifaceted concept that requires the design and simultaneous deployment of combinations of discrete interventions. This chapter highlights the importance of driving quality improvement through national policy and strategy and presents a range of levers for quality improvement. • Chapter 6: The quality call to action. A quality call to action is put forward to health policy-makers seeking to achieve the goal of access to high-quality, people-centred health services for all. This is offered with a sense of urgency, for if we do not act now, achievement of public health goals will be at stake. DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 25 Those chapters are followed by an annex, which provides a set of improvement interventions that have been selected for their potential impact on quality by reducing harm, improving front-line delivery of health care services, and building systemwide capacity for quality improvement. The illustrative interventions point to some of the options and possibilities available to health system leaders, managers, practitioners or policy-makers intent on advancing quality of care.

DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 27 Chapter3 Global state of health care quality Chapter 3 Global state of health care quality 28 3.1 THE QUALITY IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE Between 2000 and 2015, the Millennium Development Goals (MDGs) accelerated global progress towards attaining population health goals in low- and middle-income countries. Globally, child mortality fell by 53%, maternal mortality fell by 43%, and new HIV infections declined by over 38% (22). However, progress was highly unequal. In poor, rural, and hard-to-reach populations, preventable mortality remained high. For example, for children aged under 5 years in low- and middle-income countries there are significant differences in mortality between those living in the poorest households compared to those living to the richest households, between those whose mothers were the least educated compared to the most educated, and between those living in urban areas compared to rural areas (Figure 3.1). “What good does it do to offer free maternal care and have a high proportion of babies delivered in health facilities if the quality of care is substandard or even dangerous?” Margaret Chan, former WHO Director-General, World Health Assembly, May 2012 Systematic assessments of essential health services in high-mortality countries revealed major deficiencies in the quality of care received. In one such assessment across eight countries in sub-Saharan Africa, quality-adjusted (effective) coverage averaged 28% for antenatal care, 26% for family planning, and 21% for sick child care, and was substantially lower than crude service coverage (23). Over 40% of facility-based deliveries Figure 3.1 Median under-5 mortality across dimensions of inequality, 2005–2012* * Median value of 49 selected countries ** Data are not available for 10 countries Source: World Health Organization (22). 120 100 80 60 40 20 0 Q ui nt ile 1 (p oo re st ) Q ui nt ile 2 Q ui nt ile 3 Q ui nt ile 4 Q ui nt ile 5 (r ich es t) N o ed uc at io n Pr im ar y sc ho ol Se co nd ar y sc ho ol + Ru ru al Ur ba n M al e Fe m al e Economic status Mother’s education** Place of residence Sex Deaths per 1000 live births DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 29 in five countries in sub-Saharan Africa took place in primary care facilities with major gaps in resources and technical expertise (24). The MDGs did not include a specific focus on measuring and improving quality of care, yet these deficits in quality of care have had negative implications for translating increases in coverage to better population health. Poor-quality services have been shown to predict a higher risk of neonatal mortality in Africa (25). Also, an increase in institutional deliveries from 14% to 80% in India did not reduce maternal and child mortality due to the poor quality of care provided at health facilities (26). In essence, poor quality of care is responsible for persistently high levels of maternal and child mortality in low- and middle-income countries, despite substantial increases in access to essential health services achieved during the MDG era. In 2015, the United Nations General Assembly adopted a new development agenda: Transforming our world: the 2030 Agenda for Sustainable Development. The SDGs comprise a broader range of economic, social and environmental objectives than the MDGs and set a new health goal, to “ensure healthy lives and promote well- being for all at all ages”. Universal health coverage is considered fundamental to the SDGs. Simply defined, universal health coverage means ensuring that all people and communities can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship. In explicitly focusing on the quality of health care services, the 2030 Agenda for Sustainable Development recognizes the urgent need to place quality of care in the fabric of national, regional, and global action towards promoting well-being for all. While global attention has focused on universal health coverage, at the local level, the devastating outbreak of Ebola virus in West Africa reinforced the strong case for quality of care. In Guinea, Liberia and Sierra Leone, gaps in service delivery and the accompanying collapse of public trust in health systems presented herculean challenges to response and recovery efforts during the Ebola outbreak. For instance, assessments of the Sierra Leonean health system revealed a low density of human resource for health, low capacity for disease surveillance in the community, infrastructural deficits in health facilities, and weak supply chains for essential medicines (27). All three countries have since emphasized universal access to quality health service delivery to strengthen their ability to prevent large-scale outbreaks in the future, placing infection prevention and control and patient safety as key priorities. Following the outbreak, Liberia has developed an investment plan to build health system resilience and is working towards implementation of a health equity fund that places quality at its core (Box 3.1). The West African response to the Ebola outbreak demonstrates the very real and strong linkages between health system resilience, quality of care, and global health security. Achieving the SDG health targets will require new financial investments, increasing over time from an initial US$ 134 billion to US$ 371 billion annually by 2030 (28). Poor-quality care is inefficient, wasting scarce resources and increasing the cost of expanding health coverage. Inefficiencies are introduced by unnecessary care that makes no difference to health outcomes. For instance, in low- and middle-income countries, overuse of antibiotics to treat acute respiratory tract infections adds an average of 36% to the cost of care (29). Errors in service delivery may also lead to direct harm to health, at an extra cost to the health system. A recent analysis of OECD countries indicates that more than 10% of hospital expenditure goes to correcting preventable medical mistakes or treating infections that people catch in hospitals (3). At the 2017 OECD Health Ministerial Chapter 3 Global state of health care quality 30 Meeting, ministers acknowledged the intersection of the quality and efficiency agendas, agreeing that quality measurement and improvement should be at the centre of efforts to realize health outcomes at a high value for money (30). Investing in high-quality health systems for universal health coverage has the potential to accelerate progress in promoting health while strengthening global health security and maximizing value for money. 3.2 DEFINING QUALITY OF CARE 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 (31). This definition implies that quality of care can be measured, is ultimately aimed at health improvements rather than simply increasing service inputs or refining system processes, and should reflect the desires of key stakeholders, including service users and communities. By including health services in general, this definition of quality of care spans both curative and preventive care, and facility and community-based care for individuals and populations. This scope is particularly important in countries facing an increasing burden of noncommunicable disease and whose health systems must provide services across the life course, including risk reduction, screening, disease management, rehabilitation and palliative care. As there is a steadily growing evidence base on the effectiveness of various modalities for disease prevention and control, this definition of quality of care also acknowledges the need for mechanisms to incorporate new evidence into service delivery systematically. What characteristics of health services are indicative of quality? This document identifies seven measurable characteristics of health services that increase the likelihood of desired health outcomes and are consistent with current professional knowledge. Box 3.1 Liberia: embedding quality in the post-Ebola health agenda Before the 2014 Ebola outbreak, Liberia, a country recovering from years of political and economic instability, had made progress in improving the health outcomes of its population. However, the outbreak highlighted persistent health system constraints in this small West African nation. There was a lack of an adequately skilled health workforce in health facilities and within communities; there were no sustainable financing mechanisms; and there was an absence of necessary supply chain structures and integrated health information systems. In addition, infection prevention and control was largely absent where most needed, and linkages between health services and the community were inadequate. These weaknesses compromised the provision of quality service delivery and allowed the epidemic to proliferate rapidly. In response to the outbreak, the Investment Plan for Building a Resilient Health System in Liberia 2015–2021 was developed. The plan aimed to restore the gains lost in the outbreak, tackle pre-existing vulnerabilities, improve community confidence in health systems, and provide health security. A key strategic aim of the Investment Plan is to accelerate universal access to safe and quality services through improving the capacity of the health network for the provision of essential services. The Government of Liberia recognizes that successful implementation of the Investment Plan – including a strong focus on quality of care – is essential to prevent, to detect, and to respond to future infectious disease outbreaks. DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 31 While multiple quality elements have been described over decades, there is growing acknowledgement that quality health services across the world should be effective, safe, and people-centred. In addition, in order to realize the benefits of quality health care, health services should be timely, equitable, integrated and efficient (Figure 3.2) (32, 33). Consider Fatima, an 80-year-old woman who has lived alone, since retiring 15 years ago. She has long-standing type 2 diabetes mellitus, as well as hypercholesterolemia and essential hypertension. She generally stays indoors and takes only occasional walks due to her poor eyesight and recently-developed back pain. Over the past two years, she has twice been admitted to hospital for congestive cardiac failure. She does not monitor her blood pressure or blood glucose as advised, eats convenience foods, and has missed multiple follow-up appointments since her discharge. Today, Fatima has come to the clinic complaining that she is out-of-breath, that her chest feels unusually tight, that she has trouble lying flat. She has has also mentioned having difficulty keeping track of her monthly bills. The attending nurse notices that Fatima repeats herself and has trouble finding the right words to describe her symptoms. Over the course of the next four weeks, Fatima will receive care from a myriad of health providers, including a dietician, primary care provider, cardiologist and social worker. The following points illustrate what high-quality health care for Fatima might look like through the lens of the seven elements of quality. • High-quality care for Fatima is effective, thus, it would be offered based on scientific knowledge and evidence-based guidelines. The care team would adhere to clinical pathways for older patients with heart failure and significant comorbidities, developed from evidence and experience in managing similar cases. The team would reassure Fatima that she would be receiving evidence- based care and that a systematic process would be followed to arrive at an integrated management plan across the various providers taking care of her. • High-quality care for Fatima is safe, that is, it minimizes harm, including preventable injuries and medical errors, to the patient. In every facility, there would be clear guidelines to prevent hospital-acquired infections and medical errors. For example, a thorough review of her outpatient medications at admission was made to prevent interactions with medications used during her inpatient care. Source: Institute of Medicine (32). Figure 3.2 Elements of health care quality Effectiveness QUALITY TimelinessEquity Efficiency Safety People- centrednessIntegration Chapter 3 Global state of health care quality 32 • High-quality care for Fatima is people-centred, that is, it respects and responds to her preferences, needs and values. Fatima might understandably be worried and ask many questions. The multidisciplinary care team would listen to her questions and concerns, answering patiently, and codevelop the care management plan with her active involvement. • High-quality care for Fatima is timely, that is, it would keep delays in providing and receiving services to a minimum. For example, contact with each provider involved in her care would be managed by an efficient patient flow system for scheduling or modifying visits and for notifying clients of projected waiting times. Situations requiring urgent intervention would be recognized and acted on as quickly as possible. With proper planning, Fatima would not have to experience long waiting times during follow-up visits. • High-quality care for Fatima is equitable, thus, the quality of care she receives would not vary according to personal characteristics such as gender, race, ethnicity, geographical location and socioeconomic status. The services received by Fatima would reflect evidence on the potential health benefits of the treatment only, and nothing else. • High-quality care for Fatima is integrated, thus, the care she receives across facilities and providers would be coordinated. Post-discharge, the social worker would evaluate options to support her care plan, and connect her with agencies that offer dementia-related care and other services as needed. • High-quality care for Fatima is efficient, and therefore avoids waste of resources, including equipment, medicines, energy and ideas. Each of her medical providers would be able to track previous tests and procedures she has undergone via an interoperable electronic medical record system, preventing repetition and waste of resources. Use of generic medicines would be stipulated in the clinical guidelines. Her care would be provided by a cohesive team, each working to their strengths and taking on tasks that match their competencies. In summary, high-quality health care is the right care, at the right time, in a coordinated way, responding to the service users’ needs and preferences, while minimizing harm and resource waste. High-quality health care ultimately aims at increasing the probability of desired health outcomes. The quest for high-quality health care recognizes that such improvement is a continuous or dynamic rather than a static process. Regardless of the income level of a country, if there is room for improving health outcomes, the quality of care can also be increased. 3.3 GLOBAL PICTURE OF HEALTH CARE QUALITY Assessment of trends in the global state of health care quality requires consensus on the definition and measurement of indicators for quality, comparable across countries. However, there is no dataset with uniformly defined quality indicators collected globally. There is also no agreement on a minimum set of standardized indicators for quality of care to monitor progress towards attainment of the health-related SDGs across countries. However, there is a growing body of work aimed at identifying indicators to support national, regional and international quality improvement efforts, including the OECD Health Care Quality Indicators Project, the World Bank Service Delivery Indicators, the WHO Global Health Observatory, and Demographic and Health Surveys (34–37). Using data from these sources, nationally representative household surveys, and empirical research, the state of quality of health services globally is described below. DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 33 This description focuses largely on process and outcome measures of quality of care – that is, actions in health care and the effects of these actions on desired health outcomes. These measures are examined in relation to the seven domains of quality of care: effectiveness, safety, people-centredness, timeliness, integration of care, equity and efficiency. The scientific and policy literature also examines structural measures of quality of care that form the context of service delivery, including equipment, human resources, incentives and organizational characteristics (38). This document considers these structural factors to be foundations of high-quality care processes and outcomes. Chapter 4 addresses the foundations of high-quality care. 3.3.1 Are health services effective? When care is ineffective, that is, when providers do not adhere to evidence-based guidelines, this may reflect a lack of knowledge of guidelines or a lack of compliance regardless of knowledge. The effectiveness of care can be assessed using inspection of medical records, patient exit interviews, direct observation of provider–client interactions, standardized patients or clinical vignettes. While clinical vignettes measure the provider’s knowledge of evidence-based protocols for defined medical cases, other forms of measurement predominantly capture compliance with these guidelines. In particular, standardized patients provide consistent cases of illness to providers and allow for comparison of quality of care across providers. This method of effectiveness measurement is also free from observation and recall bias (39). The differences in prevalent diseases across countries and variations in clinical presentation within diseases prevent systematic comparison of the effectiveness of care across providers and countries. However, there is a growing body of evidence indicating that there are gaps in provider understanding of and compliance with evidence-based guidelines in high-, middle-, and low-income countries. For example, in Kenya, only 16% of providers correctly diagnosed all five patient cases that were presented in clinical vignettes to assess provider knowledge (Figure 3.3) (40). In a study of physicians of the former Yugoslav Republic of Macedonia and the United States of America, the mean percentage of correct diagnosis for four clinical vignettes was 48% and 67% respectively (41). Regardless of the method of measurement, there is also a significant gap between provider knowledge and actual practice in service delivery. This finding holds across countries, including Denmark, India, Kenya, the Netherlands and the United Republic of Tanzania (42–45). Figure 3.3 Number of clinical vignettes correctly diagnosed by Kenyan providers (total number of vignettes: five) Source: Martin and Pimhidzai (41). 0 10 20 30 40 50 % 1 case 0.5% 11.5% 30.3% 42.1% 15.6% 2 cases 3 cases 4 cases 5 cases Number of clinical vignettes Chapter 3 Global state of health care quality 34 3.3.2 Are health services safe? Patient harm is the 14th leading contributor to the global disease burden. The majority of this burden falls on low- and middle-income countries (Figure 3.4) (14). The main causes of harm differ between settings, including medication and diagnostic errors in primary care, pressure injury and adverse events in long-term care, and hospital- acquired infections and wrong-site surgery in hospital care (46–48). The scale of unsafe events in health services is considerable (14). In addition to the direct cost of treating adverse events, there are additional costs that result from loss of productivity and diminished trust in the health system. Approximately 15% of hospital expenditure and activity in OECD countries is attributed to safety failures. However, many adverse events are preventable. Evidence suggests that more than one in three adverse events in low- and middle-income countries occurs in non-complex situations and up to 83% may be preventable (49). The costs of safety failures also far exceed the cost of prevention. Improving patient safety in Medicare hospitals in the United States is estimated to have saved US$ 28 billion between 2010 and 2015. Figure 3.4 Burden of disease caused by adverse events, 2015 Note: Percentage of average DALYs/country. Source: Institute of Health Metrics and Evaluation, 2015. High income Upper middle income Low income Lower middle income 19% 18% 25% 38% 3.3.3 Are health services people-centred? The degree to which the needs and preferences of service users are systematically incorporated into health services differs between high-, middle-, and low-income countries. Health systems in high-income countries have introduced measures and institutions to monitor patient experiences and perceptions on their specific medical conditions and general health. While expectations and approaches to people-centred care vary between countries, most service users in OECD countries report a positive experience with regard to time spent with the provider, easy-to- understand explanations, opportunities to raise concerns, and involvement in their care (Figure 3.5) (50). Attention to respectful, compassionate and otherwise people- centred care is not as prevalent in low- and middle-income countries. For example, a growing body of research on respectful maternity care indicates that women experience poor interactions with health care providers and exclusion from care decision-making, and are often not informed about the details of their care (51, 52). DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 35 3.3.4 Are health services timely? Waiting times for elective and emergency procedures have been shown to predict satisfaction among service users (53–55). In emergency situations, delays in receiving appropriate treatment may also lead to preventable deaths (56). Nonetheless, waiting times for different health services vary across OECD countries. For example, in 2015, the mean waiting time for hip replacement was around 42 days in the Netherlands, but 290 days in Estonia and over 400 days in Chile and Poland. Time trends show that reductions in waiting time have been experienced in Finland and New Zealand while this trend has converged in recent years, with relative stability in rates since 2008 in many countries, such as Denmark and the United Kingdom of Great Britain and Northern Ireland (Figure 3.6)  (2). Much less work has been done to compare service delays across low- and middle-income countries. Empirical research from individual countries indicates that waiting times are relatively long. For example, in a study of an emergency department in Barbados, a median of 10 minutes was required for triage, 213 minutes for laboratory results, and 178 minutes to be seen by a doctor (57). Also, in an outpatient department in Nigeria, 74% of service users waited between 60 and 120 minutes to be registered and additional time to see a service provider (58). Luxembourg1 Belgium1 Portugal1 New Zealand1 United Kingdom2 Germany2 Australia2 United States2 Netherlands2 Norway2 Canada2 Czech Republic1 Switzerland2 OECD19 Sweden2 Israel1 France2 Estonia1, 2 Spain1, 2 Poland1, 2 0 20 40 60 80 100 Age-standardized rates per 100 patients 95.5 95.1 90.9 88.2 88.0 87.7 86.0 83.9 83.9 83.3 83.0 81.8 81.4 81.3 80.5 79.7 78.8 67.4 62.1 47.9 Note: 95% confidence intervals represented by . 1. National sources. 2. Data refer to patient experiences with regular doctor. Source: Commonwealth Fund International Health Policy Survey 2013 and other national sources. Figure 3.5 Doctor providing easy-to-understand explanations (2013 or nearest year) Chapter 3 Global state of health care quality 36 3.3.5 Are health services equitable? Gaps exist in health care quality everywhere in the world, but they are even more serious for disadvantaged populations. The United States National Healthcare Disparities Reports have tracked the quality of care since 2010. In 2015, half of the quality measures showed no change or had worsened amongst low-income populations. More than half of the quality measured showed no change or had worsened for rural populations (59). In Canada, patients with myocardial infarction from indigenous groups were less likely to have received recommended treatment, including cardiac angiography and revascularization procedures (60). In Kenya, the quality of maternal health services is lowest in impoverished counties, where only 17% of women had access to minimally adequate delivery care (Figure 3.7) (61). Also, in India, people who live in households of low socioeconomic status in poor communities are less likely to use knowledgeable health care providers (62). Source: Health at a glance 2017 (2). Source: Sharma et al. (63). Figure 3.6 Trends in average waiting times for hip replacement Finland United Kingdom New Zealand Denmark 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Days 200 150 100 50 0 Figure 3.7 Structural and process quality of maternal services by county poverty level in Kenya Quality of maternal care infrastructure Quality of antenatal care Quality of delivery care Quality score 80%+ poverty 60-80% poverty 40-60% poverty 20-40% poverty 0-20% poverty 1.0 0.8 0.6 0.4 0.2 0.0 DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 37 3.3.6 Are health services integrated? With emerging chronic and noncommunicable diseases, more people are living with multiple and complex chronic conditions that require coordination of care across all levels and throughout their life course. Continuity of care and care coordination can improve the care experience of people living with such conditions and support needs. However, substantial gaps in the coordination of health care exist, even in high- income countries. A survey of patients with complex care needs in 11 high-income countries found coordination problems, such as test results or records not available at appointment or duplicate tests ordered, providers failing to share important information with each other, and specialists not having information about medical history or regular doctors not informed about specialist care (63). An analysis of linked primary care and secondary care data on older adults (aged 62–82 years) from 200 general practices in England reported that patients who saw the same general practitioner a greater proportion of the time experienced fewer admissions to hospital for ambulatory care sensitive conditions (64). 3.3.7 Are health services efficient? The World health report 2010 estimated that about 20–40% of all health sector resources are wasted (65). The leading causes of inefficiency in service delivery include inappropriate medicine use, suboptimal human resources mix, overuse or oversupply of equipment, corruption, and underuse of infrastructure. Unwarranted geographical variation in the prevalence of procedures and care intensity provides an indirect estimate of overuse and hence inefficiency. For example, in India, the rates of antibiotic use for acute diarrhoea in public facilities is 43% but rises to 69% in private facilities. Also, there is a ninefold variation in the use of percutaneous coronary interventions internationally and a fivefold variation in the use of coronary bypass grafting across OECD countries (66). These differences are not explained by the variation in the cardiovascular disease burden. Inefficient health care due to overuse and other causes has negative implications for population health outcomes. Life expectancy at birth could be raised by more than two years on average in OECD countries while holding health care spending constant if all countries were to become as efficient as the best performers (67). 3.4 CONCLUSION Despite the substantial increase in access to essential health services achieved during the MDG era, there are high levels of preventable mortality and morbidity that can be addressed through quality efforts. For example, the remaining burden of maternal and child mortality in low- and middle-income countries is largely due to the poor quality of health services. The SDGs explicitly incorporate a focus on the quality of health services in attaining universal health coverage in all countries. 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, people-centredness, timeliness, equity, integration of care and efficiency. Regardless of the income level of a country, if there is room for improving health outcomes, the quality of care can also be increased. Efforts to monitor trends in health care quality for the SDG agenda will be ineffective in the absence of consensus on key indicators that are comparable across countries and are collected on a regular basis. Empirical evidence from the growing body of work on quality measurement indicates that there are gaps globally in all the domains of quality health services. These gaps present opportunities to improve the quality of care and the health of populations. 38 “In any health system, nursing is the backbone of the system,” says Bafana Msibi, Executive Manager for Compliance Inspections at South Africa’s Office of Health Standards Compliance. “In our country especially, and in other countries in Africa, primary health care is nurse-driven.” As a health care executive with over 15 years’ experience, working for an independent body whose mission is to ensure quality of care and compliance with health standards in both public and private health care facilities, Bafana Msibi is well placed to assess the important contribution made by nurses to quality of health care. He defines quality of care, in short, as “making use of the available resources to provide the best care to users.” Msibi acknowleges that good patient care requires a holistic approach that sometimes goes beyond clinical treatment. “You might see a patient presenting with symptoms, and as you try to treat her, you may find that these symptoms are caused by stress,” he says. Because nurses spend more time with patients than any other clinicians, their role is crucial. In addition, they are directly involved in the implementation of precautionary measures that promote a safe medical environment in their daily work. In South Africa, all registered nurses have to undertake one year of community service after they complete their four-year degree. Working under the supervision of experienced professionals who mentor them, the new graduates are exposed to a wide range of medical issues. They also develop a solid understanding of the communities they serve. The knowledge and skills young nurses acquire during this period prepare them well for the demands of their profession. “When I was young, I worked in a clinic in a rural area. If patients came with a problem that required the next level of care, we would refer them to the doctor or call an ambulance to take them to a hospital. There are clinics in most areas, and where there are none, mobile clinics carry out visits. Most of these clinics are nurse-run,” Msibi says. My Quality Mr Bafana Msibi, Executive Manager for Compliance Inspections, Office of Health Standards Compliance South Africa 39DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE In South Africa, some nurses hold high-level jobs as CEOs of hospitals or district managers, Msibi says, but more are needed in leadership positions. “The nursing profession needs to produce leaders for the health care system. They must be developed through the system, know it inside out, and they must also understand the processes of policy development within it.” Bafana Msibi, who was able to conduct a study in a state hospital when he was studying for his Master’s in Public Health, would like more nurses to enjoy similar opportunities to undertake research. Having more nurses involved in policy-making as members of advisory committees, commissions and boards would also contribute to further improvements in the quality of care, he believes. Msibi’s Office of Health Standards Compliance is currently negotiating a Memorandum of Understanding with the South African Nursing Council and other bodies representing medical professions to enhance cooperation across health services. Conducting joint inspections of hospitals, for example, could increase efficiency and help support high standards of care. “When we develop models and frameworks to improve quality, we must make sure they incorporate everyone and put the values of the profession up to the front,” Msibi says. “In the end, we are all interested in providing quality care and if you want to have quality, you have to ensure there is good team work.” Image on previous page: © ranplett / iStock

DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 41 Chapter4 Building quality into the foundations of health systems Chapter 4 Building quality into the foundations of health systems 42 4.1 INTRODUCTION Poor-quality services – even if made available at an affordable cost – are an impediment to achieving effective universal health coverage. This is because communities will not use services that they mistrust and that are of little benefit to them. Mechanisms to assure, monitor and continually improve quality must be built into the foundations of health care systems. This chapter considers five such foundations critical to any health service: health care workers; health care facilities; medicines, devices and other technologies; information systems; and financing. Mere availability of resources is not enough. Conscious and continuous effort is needed to ensure that they are used in ways that are effective, safe and individually tailored to patients’ needs. Governance, as well as the tools, techniques and political economy of reform, is explored in the next chapter. A comprehensive system of care allows people to access a continuum of care across their life course, comprising health promotion, disease prevention, diagnosis, treatment, disease management, rehabilitation, emotional and spiritual support, and palliative care. Three important considerations should underlie the design of any health care system: services should be built to meet local needs; accessible and high- quality primary care should be the bedrock for all other services; and individuals and communities should be engaged in the design, delivery, assessment, and improvement of each and every service (68). The principles of quality improvement must infuse all activities from the front line to the system level. 4.2 FOUNDATIONS FOR HIGH-QUALITY CARE 4.2.1 Health care workers that are motivated and supported to provide quality care Skilled doctors, nurses and other health care professionals are essential for delivering high-quality health care to individuals, families and communities. There is currently an estimated global shortfall of 2.5 million doctors, 9 million nurses and midwives, and 6 million allied health professionals. As a result, basic care is often absent or poorly delivered (69). The problem is most severe in poorer countries (Figure 4.1). Even in developed economies, health workers are too often concentrated in cities, with the consequence that quality of care is often poorer in rural and remote areas. Even within cities, certain locations – for example slums – have a particular deficiency of health workers. Community health workers can help alleviate workforce shortages. They are individuals who have been trained to deliver specific health care services, or to undertake surveillance and treatment for communicable or noncommunicable diseases. They usually come from the communities that they serve, thus providing a potential bridge to community engagement efforts. Community health workers can overcome cultural and linguistic barriers, whilst expanding access to care and providing new forms of employment. Evidence shows that community health workers are capable of delivering safe and effective care for childhood illnesses, reducing the spread of communicable and noncommunicable diseases, promoting nutrition, and providing family planning services, at low cost (70). In low-resource settings, community health workers have reduced maternal, neonatal and child mortality (71). More than 50 years’ experience with programmes shows that these positions should be paid, not voluntary; have specific responsibilities that are not too wide ranging; receive training, continuing education and ongoing supervision; be integrated into primary health care teams; and be part of data feedback loops (72). DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 43 The availability of staff does not in itself assure good care. Health workers can spend little time with patients, lack the ability to make correct diagnoses, or prescribe inappropriate treatment (73). Rural clinicians in southern China spent an average of only 1.6 minutes consulting with patients and asked only 18% of essential questions. A fully correct diagnosis was provided in only one in four consultations (44). Beyond simple headcounts of the health workforce, other critical aspects include: • accessibility, or how easily people can see or speak to a health professional with the right skills, whether in person or via video and telephone links; • acceptability, or whether people feel they have been treated with respect and have had their views taken into account when it comes to decisions related to their health; • quality, or the knowledge, skills and attitudes of health professionals according to accepted norms, and as perceived by users; • skills mix and teamwork, or whether the group of health professionals (and, in some settings, lay workers) together have the knowledge and skills to manage local mortality and morbidity patterns; • enabling environments, or the physical, legal, financial, organizational, political and cultural conditions that support high-quality care. Distribution by country (in selected WHO region) Skilled health professionals density Density per 10 000 population Density per 10 000 population 60 40 20 0 0 20 40 60 80 100 120 140 160 180 200 220 240 260 280 Bu ru nd i Co m or os Er itr ea Eq ua to ria l G ui ne a Le so th o So ut h Su da n Sã o To m é an d Pr ín cip e N ig er Et hi op ia Ce nt ra l A fri ca n Re pu bl ic Si er ra L eo ne M al aw i Ch ad M ad ag as ca r To go Se ne ga l G ui ne a Un ite d Re pu bl ic of Ta nz an ia M oz am bi qu e Li be ria M al i Ca m er oo n Cô te d ’Iv oi re Bu rk in a Fa so G ui ne a- Bi ss au Ug an da Be ni n M au rit an ia Rw an da Za m bi a G ha na De m oc ra tic R ep ub lic o f t he C on go Co ng o Zi m ba bw e Sw az ila nd An go la G am bi a Ke ny a N ig er ia Ca bo V er de Bo ts w an a Al ge ria N am ib ia G ab on M au rit iu s Se yc he lle s So ut h Af ric a Africa Americas South-East Asia Europe Eastern Mediterranean Western Pacific Regional average: 12.8 Global average: 52.8 Figure 4.1 Global density and distribution of skilled health professionals by WHO region, 2005-2016 Source: Global Health Observatory (34). Chapter 4 Building quality into the foundations of health systems 44 The first step in building a high-quality workforce with the right skills mix should be a comprehensive national workforce strategy addressing gaps in numbers, distribution and retention, both in the short term and the longer term. Health professional workforce strategies must not deprive other health systems by attracting qualified staff away from their home countries’ health systems. Workforce policies can take years to bear fruit. The most effective and sustainable solution to rural shortages lies in training students who are themselves from rural communities, including establishing clinical schools in remote areas. Modernizing curricula for pre-service training of health care workers to ensure that they acquire core medical and nursing competencies is an obvious starting point and yet remains a challenge in many countries (Box 4.1) (74). Another priority is continuous professional development to ensure that health professionals maintain and improve their knowledge and skills – spanning a wide range of competencies – throughout their working lives. Increasingly, health systems are making continuous professional development – and even recertification – mandatory. Even where continuous professional development is not in place, policy-makers can work with professional associations to encourage its use and evaluate its impact (75). Finally, integrating the principles of quality and quality improvement into pre-service and in-service education and training curricula and programmes is vital in building a competent workforce that is capable of delivering high-quality health services. Box 4.1 Case study: training and retaining health care workers in underserved areas of the Philippines Two medical schools in the Philippines have a primary focus on recruiting, training and employing students in underserved areas of the country. Ateneo de Zamboanga University School of Medicine and University of the Philippines Manila School of Health Sciences are part of the Training for Health Equity Network (THENet). This international network of medical schools stipulates that the needs of underserved communities should be integrated with all phases and aspects of medical education, from the physical location of the school to the health issues guiding the curriculum. Also, there should be reliance on community-based practitioners for teaching and mentorship. Ateneo de Zamboanga University School of Medicine opened in 1994 in Zamboanga City, on the southwest tip of the southernmost of the Philippine islands, bringing hope of greater access to health care to a population of 3.2 million people. The nearest existing medical school was 400 kilometres away. At the time, 80% of the region’s 100 municipalities had no doctor. The region was plagued by high rates of infant mortality and communicable disease. In 2011, a review of the cumulative 164 graduates found that 85% were practising in the region, with half in rural and remote areas; overall, 90% remained practising in the Philippines versus 32% of graduates nationally. Between 1994 and 2008, the infant mortality rate in Zamboanga declined by approximately 90%, far exceeding the national average decline of 50%. The school continues to recruit students from the region and follows a curriculum that is deeply integrated with local community health needs. Source: World Health Organization (76); Cristobal and Worley (77). DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 45 4.2.2 Accessible and well-equipped health care facilities Substantial variation persists in service availability and readiness. Within and across countries, the density of hospitals and clinics is very different. Basic health care may be many hours away from poorer, rural communities. In sub-Saharan Africa, basic equipment such as a thermometer and stethoscope is available in slightly over half of facilities in Ethiopia, yet in Burkina Faso it is found in almost all facilities (Figure 4.2). The availability and readiness of services to operate is a necessary condition to deliver quality care. However, as discussed throughout this document, it is not sufficient to deliver quality services (78). Figure 4.2 Variations in availability of basic equipment across health care facilities in sub-Saharan Africa Source: Primary Health Care Performance Initiative (79). 100 90 80 70 60 50 40 30 20 10 0 Be ni n Bu rk in a Fa so Co ng o Et hi op ia G ui ne a Ke ny a M ad ag as ca r M au rit an ia M al aw i N ig er Se ne ga l Si er ra L eo ne To go Ta nz an ia Ug an da Za m bi a % 86.2 89.2 74.5 63.3 72.8 67.0 84.9 83.2 70.5 82.0 87.0 81.3 87.0 68.2 78.5 85.3 The quality of health care facilities is judged first on whether the basics are present, such as clean water, reliable electricity, good sanitation and safe waste disposal. In a 2014 survey, less than one quarter of facilities in Nigeria had reliable water, sanitation and electricity. Indeed, WHO estimates indicate that 40% of health care facilities in low- and middle-income countries lack improved water and nearly 20% lack sanitation. These basic foundations are urgently required for quality of care. However, adequate infrastructure does not necessarily equate to high-quality care. Minimum standards need to be set and enforced, and continuous improvement encouraged. Accreditation, inspection and other forms of external assessment and certification are widely used to evaluate health care facilities against explicit standards. The strength of the evidence supporting one-off external assessments is however limited (80, 81). Accordingly, health care systems are increasingly moving to more continuous and formative evaluations of providers’ performance, including measurement of patient outcomes and experiences (15). 4.2.3 Medicines, devices and technologies that are safe in design and use Reliable access to safe and effective medicines, devices and technologies, including blood transfusion, is a basic requirement for effective health care services. Actively restricting unsafe or ineffective products is critical to patient safety. Access to, and minimum quality standards for, medicines and other technologies have improved but substantial gaps remain in basic provision. Extensive and serious problems with counterfeit products complicate the issue. Chapter 4 Building quality into the foundations of health systems 46 Standards of regulation vary greatly. For example, in some countries, antibiotics can be bought without a prescription, fuelling unnecessary use and increasing the threat of antimicrobial resistance (82). Even where medicine use is properly regulated, errors affect about one in 10 prescriptions issued, mostly dose-related errors  (83). According to one report, only 30–40% of patients in countries with developing or transitional economies are treated with medicines according to clinical guidelines (84). The patients’ role in making medicines and devices effective and safe is also critical. Health systems do not usually pay sufficient attention to informing and supporting patients in their use of medicines. The third WHO Global Patient Safety Challenge – Medication Without Harm – was launched at the second Global Ministerial Summit on Patient Safety, Bonn, Germany, in March 2017 with the aim of reducing severe, avoidable medication-related harm by 50% globally in the next five years. Medical equipment requires maintenance, user training, backup support and, eventually, decommissioning. Donating equipment – important in some low-income countries – raises particular concerns. Unless spare parts, consumables and staff training are available, such equipment can be unusable or unsafe. Three out of 10 countries lack a national authority that regulates what medical technologies can be used, and how (85). Blood transfusions are a special case. Many low-income countries are not able to screen blood for HIV, hepatitis B, hepatitis C and syphilis. Transfusion recipients are then at unacceptable risk of acquiring transmissible infections. National policies on medicines and devices help to ensure products of assured quality, in adequate quantities and at affordable prices. Standardized processes for health technology assessment are discussed in the next chapter. Enforceable regulatory systems that address design and development, sale, use and disposal can be powerful in assuring quality and safety in this area. Guidelines and checklists can encourage appropriate use at the bedside. They should be accompanied by surveillance systems that monitor correct use, and that can detect accidents and adverse reactions. Voluntary non-remunerated blood donation improves the supply and safety of blood. Safety would be transformed if all health systems adopted this method of donation (86). The risks of transfusion are reduced by external quality assessment of the collection, preparation and administration of blood products. 4.2.4 Information systems that continuously monitor and drive better care Developing timely, accurate quality measures of health care services, of users’ experiences and of outcomes achieved remains challenging, given how little governments and donors spend on health information systems. Most OECD health systems invest only 2–4% of total health expenditure in information systems. In most low- and middle-income countries, the figure is less than 1% (87). As a result, data on outcomes and quality are often not captured at all, or are collected in ways that cannot be analysed or benchmarked because of a lack of standardized terminology. Even when data are collected, the translation of these data into information that is actionable for quality improvement remains a fundamental challenge. Yet, good performance information matters to improving quality of care. The European Health Care Outcomes, Performance and Efficiency (EuroHOPE) project found that survival after a heart attack varied as much as twofold within a single national health system (88). To enable hospitals and clinics to offer the same level of excellent care, richer comparative data on variation in quality and outcomes need to be collected, interpreted DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 47 and used to spread best practices and support poor performers. As well as EuroHOPE, the European Collaboration for Healthcare Optimization (89) and the OECD Health Care Quality Indicators Project (35) exemplify a trend to develop such data quality schemes globally (Box 4.2). Box 4.2 Case study: OECD Health Care Quality Indicators Project The OECD Health Care Quality Indicators Project began in 2001 with the aim of developing international comparisons of health care quality and, thereby, identifying and sharing best practices to monitor, assure and improve quality. Experts engaged in the project are drawn from OECD and non-OECD countries, international organizations including WHO, the European Commission, and research institutes. Around 50 indicators are reported (covering primary care, hospital care, mental health services, patient safety and patient experiences) from around 40 countries. Comparable health care quality indicators are published alongside other OECD health statistics on expenditure, resources and utilization to facilitate their interpretation. Alongside the regular data collection, there is continuous research and development to improve the validity, utility and comparability of health care quality indicators. Another goal of the project is to strengthen national information infrastructures to produce more complex and reliable indicators in an increasing number of countries, including non-OECD countries. Source: OECD (35). Too often, data are left to moulder in poorly organized, paper-based systems, or are trapped in digital silos incompatible with each other. Timely and appropriate use of and action on information is vitally important. The Health Data Collaborative, a global initiative led by WHO, the World Bank and the United States Agency for International Development (USAID), is addressing this challenge. By working with international agencies and individual countries, the Health Data Collaborative seeks to harmonize how health systems data are collected and reported globally, and aims to enable better tracking of health system performance and progress towards the health-related targets of the SDGs (90). Similarly, the Primary Health Care Performance Initiative (79) aims at sharing internationally comparable results on the performance of primary health care systems globally and enabling performance improvement through sharing of results and best practices for performance improvement. Basic information on all births and deaths needs to be reliably registered. Effective civil registration is the spine of a health system’s information infrastructure. Registers monitoring the needs, interventions and outcomes for patient groups (such as those with HIV, cancer or mental illness) can be built from this. Civil registration allocates a unique person identifier to an individual. This allows data from various providers over time to be linked and enables the performance of health care services to be tracked. If legislation to protect privacy prevents anonymous data linkage of elements of an individual’s health experience in different places and at different times, there will be no way of evaluating an entire pathway of care (Box 4.3). Chapter 4 Building quality into the foundations of health systems 48 Effective information governance remains weak in many health systems. The use of personal health data to monitor and improve health service performance serves an important public purpose, but must always be done in ways that protect privacy. National legislation is needed that protects patient privacy whilst enabling data use and good communication with the public about data use, as well as, at global level, standards to enhance data quality and comparability (91). Moving from paper-based records to a unique electronic health record, usable in multiple health care settings, will help monitor the performance of health care services. Supporting clinicians, managers and policy-makers in interpreting service data and using them for quality improvement will be also vital. Special action is needed to improve patient safety. Encouraging transparency when things go wrong, by building a blame-free and learning culture, is a prerequisite. This can be supported if analyses focus on understanding the root causes of adverse events by exploring the multiple causal and contributory factors that provoke errors, some of which result in major harm to patients. Agreeing on an internationally standardized terminology will also enhance the ability to classify, compare and prevent adverse events across different health systems. Finally, in 2017 ministers of health from OECD countries agreed that their health systems would be benchmarked using a new wave of patient-reported indicators of performance (30). More sophisticated health information systems survey patients directly, to monitor and compare their views on the quality of care received and monitor their health outcomes (93). This strategy is an important development that will support a paradigm shift from measurement systems that are focused on health care providers to truly people-centred systems in which measurement is focused on experiences and outcomes viewed from the perspective of patients (94). Box 4.3 Case study: improving civil registration and vital statistics in Uganda Only one in five of the 1.5 million annual births in Uganda were registered with the national civil registration and vital statistics system. Families often had to travel long distances to register in person, which required a fee. A paper-based system created frequent delays in issuing birth certificates. Even amongst registered births, over half did not receive a birth certificate. The United Nations Children’s Fund (UNICEF) and Uganda Telecom implemented the Mobile Vital Records System, which links mobile phone users and hospital computers to a central government server. For births occurring outside health facilities, volunteers – typically village leaders – collect and send birth information to a government database through a free service from their mobile phones. An official reviews the information and if it is deemed credible, then a birth certificate is issued. The community volunteer is notified via text message. The roll-out of the Mobile Vital Records System increased birth registration substantially, leading to greater expansion of the programme. Now it is also implemented in schools to reach previously unregistered children. Source: UNICEF (92). DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 49 4.2.5 Financing mechanisms that enable and encourage quality care The way funds are collected, pooled and used to pay for health care services can, unsurprisingly, have large effects on the quality and outcomes of care. First, there is solid evidence that funds should be collected and pooled in advance of needing care, through mandatory insurance schemes (with subsidized contributions for those unable to afford insurance). The alternative – paying out of pocket at the moment of need – means that people go without care when they need it and end up sicker as a result, or catastrophically impoverished (65). How funding then flows from insurance agencies to the front line, to purchase or reimburse services, is equally critical. There are several possible mechanisms, such as fee for service, capitation, or annual block budgets (transferred to hospitals or clinics, based on previous or predicted spending). Each has strengths and weaknesses, in the extent to which it rewards activity over outcomes, or incentivizes preventive over reactive care. There are no “silver bullets”, and in practice a blend of mechanisms is usually employed. What is important, from the perspective of quality of care, is that the blend is intelligently designed, aligns as closely as possible with local needs, incentivizes coordination of care for individuals with complex needs, invests adequately in primary care and prevention, rewards quality care, and penalizes care that does not meet sufficient standards. Accordingly, health systems are increasingly designing mechanisms that pay for bundles or pathways of care, and experimenting with quality-based payments. One family of such innovations, applied in high- as well as in low-income settings, is pay for performance (P4P), or results-based financing. Carefully designed, often time-limited, programmes pay health care providers to deliver specific, high-priority interventions. Nearly two thirds of OECD countries have at least one P4P scheme in place, predominantly in primary care. Systematic reviews tentatively suggest a positive impact of P4P and results-based financing programmes on quality in OECD countries (93). Results for results-based financing in lower-income settings are mixed, with fairly modest results so far for quality improvement, particularly for non-targeted conditions. Overall, payment innovations can also be used to deliver sustained collateral benefits – such as improved protocols of care, improved collaboration across providers, and improved information systems – on health care needs, activities, outcomes and costs. 4.3 QUALITY OF CARE AS THE FOUNDATION OF PEOPLE-CENTRED HEALTH CARE As governments plan to deliver universal health coverage, there are three key design principles that should be considered. First, services should be built in a way that meets local health care needs. Although seemingly obvious, many health systems lack a population–health focus. Instead, available health service networks are the product of historical legacy, or are the result of political lobbying or of transient donor funding. Local communities may be innocent bystanders in the design of care that is ultimately destined for them. Many low- and middle-income countries have dealt with a high burden of communicable disease and this has meant that their systems have needed strong public health functions in areas such as surveillance, laboratories and routine immunization. They may also have received substantial donor funds in the form of programme grants to control or eliminate particular diseases. Increasingly, though, the growing burden of noncommunicable disease in these same countries necessitates services capable of supporting people over time with personalized, proactive care to manage their condition, prevent complications and enhance quality of life (Box 4.4). Chapter 4 Building quality into the foundations of health systems 50 A recent study analysed 22 initiatives to strengthen primary health care in 10 counties in China and at national and subnational levels in 12 countries. Eight tenets of high- performing primary health care systems were derived: ensuring primary health care as first point of contact for most health care needs; functioning multidisciplinary care teams; vertical integration of services; horizontal integration of services; advanced information and communication technology; integrated clinical pathways and functioning dual referral systems; measurement standards and feedback; and certification (95). The second key principle of design is to build high-quality primary care services (97). First contacts with health care, and a person’s regular point of entry into the health system, must be continuous and comprehensive (Box 4.5). No physical or mental health issue should be excluded from the oversight and coordination functions of primary care. If individuals and families in a geographically (or otherwise defined) community are formally registered with a named primary care provider, this enables creation of community health profiles, as well as surveillance of needs and delivery of preventive care. Registration also creates a structure for proactive care amongst people with chronic conditions. Primary care is also fundamental to health system resilience, and is pivotal in surveillance of communicable diseases or other hazards, and in the delivery of front-line care in the case of outbreaks. Third, engagement with patients, families and communities needs to be designed into health systems, rather than bolted on as an afterthought. A review of randomized controlled studies of integrated care programmes for the frail elderly, for example, showed that the most benefit was derived from those in which the elderly person was directly involved in care planning (98, 99). If patient groups are encouraged to engage in collective action, people benefit hugely from the support of others with similar health problems. The WHO Patients for Patient Safety programme illustrates this well. The programme has empowered a global network of patient advocates that aims to foster collaborations between patients, families, communities, health care providers and policy-makers to make health care safer through the insights and experiences of patients themselves (100). Box 4.4 Case study: unmet needs for the care of chronic diseases Hypertension, or high blood pressure, is one of the most prevalent and critical risk factors for early death and disability globally. Untreated hypertension leads to kidney disease, ischaemic heart disease and stroke (the latter are the two leading causes of death worldwide). Hypertension affects an estimated one in three adults over the age of 20 years worldwide, with the prevalence now higher in low- and middle-income countries than in high-income countries (age-standardized prevalence of 31.5% versus 28.5%, respectively). Of the approximately 1.5 billion people with hypertension, less than half will be aware of their condition; only 36.9% will be on appropriate treatment; and as few as 13.8% will have their blood pressure effectively controlled. Significant disparities in awareness and treatment exist by country income level: in high- versus low- and middle-income countries, rates of diagnosis and treatment are twice as high and 4 times the proportion of patients have their blood pressure controlled. Source: Mills et al. (96). DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 51 More broadly, collaboration with nongovernmental organizations, grass-roots community groups and patient representative organizations also offers huge potential gains. Civil society organizations focused on health issues are increasingly well established in many low- and middle-income countries (Box 4.6). These groups do far more than just offer advice and support – they also help people assert their rights to high-quality care. A review of literature by Laverack (101) illustrates the multiple avenues through which community engagement strengthens health systems. These include strengthening social networks, developing local skills such as leadership, resource mobilization, or simply asking the question “Why?” Box 4.5 Case study: primary care in Costa Rica In Costa Rica, an innovative primary care sector forms a solid base for the rest of the health care system. Community clinics, or integrated health care basic teams (equipos básicos de atención integral de salud, EBAIS) are the functional units of primary care delivery. Each EBAIS serves around 1000 households. Each consists of at least one medical doctor, one nurse and one health care assistant. Other personnel, such as social workers, dentists, laboratory technicians, pharmacists and nutritionists, may also support the clinic. To complement EBAIS, centres for integrated health care (centros de atención integral en salud, CAIS) have recently been developed. They offer an extended model of primary care, including maternity services, intermediate care beds (to avoid hospital admission or expedite early discharge), minor surgery, rehabilitation, specialty clinics (such as pain management), and diagnostics such as radiography. A detailed primary care performance framework evaluates local health authorities across 30 indicators in the domains of access, continuity, effectiveness, efficiency, patient satisfaction and organizational competence. For each indicator, a national target is set and dashboards of local results are published, allowing providers to compare their performance against national, regional and local benchmarks. National data show that 80% of primary care presentations are resolved at that level, without referral to secondary care. Referral guidelines exist, and hospital referrals are turned back if appropriate steps have not been completed in primary care. Hospital doctors also train colleagues working in EBAIS to strengthen primary care management. Source: OECD (21). Box 4.6 Case study: using Citizen Voice and Action to empower communities in Uganda Empowering communities through training and education is an important step in enabling them to engage with health care providers. The Citizen Voice and Action project model (20), for example, allows citizens to learn about the number of health workers, vaccines, equipment and materials that should be present at their local health centre. Residents then work with health workers and local government to measure the facility’s compliance with government standards. … Chapter 4 Building quality into the foundations of health systems 52 4.4 THE VISION: HEALTH SYSTEMS COMMITTED TO PEOPLE-CENTRED CARE The expectant mother with high blood pressure, or the elderly man with diabetes, arthritis and hearing loss, both require a range of services to be delivered effectively – not just within the formal health system, but in the community to which they will return to live and work. The young man with schizophrenia needs carefully coordinated care to manage his mental health problems, but also to deal with the array of chronic physical health problems that reduce life expectancy by up to 25 years in people with severe mental illness. Complex health care requires systems able to deliver an entire pathway of care (health promotion, disease prevention, diagnosis, treatment, disease management, rehabilitation and palliative care services) consistently, effectively, safely and in ways that are valued by patients and their families. Effective governance of health systems comprises several tasks, including maintaining strategic oversight of goals and priorities; generating the information and analysis required to track whether goals are being met; designing rules, policies and processes to steer the system in the desired direction; and creating and nurturing collaborations within and beyond the health system. Enshrining the right to health care, according to need, in national legislation is a valuable step in making progress towards universal health coverage. Experience shows that de jure commitments often fail to translate, de facto, into access to good-quality care. Setting up a national agency responsible for quality monitoring and improvement is also an important step. Ideally, it should be independent of health care insurers and providers, with the regulatory powers to collect, analyse and publish quality and outcome data. Its role can also encompass sharing lessons learned from high performers and supporting poorly performing services in addressing performance gaps. They can also use a community scorecard to rate the facility according to criteria that they themselves generate, and convene meetings with civil society, government and service providers where all stakeholders can review the evidence and commit to an action plan to improve services. The Citizen Voice and Action model was successfully implemented in Uganda in 2004 in response to perceived weak health care delivery at the primary care level. The main objective of the intervention was to strengthen the provider’s accountability to citizen clients by introducing a process, using trained community- based organizations as facilitators, which the communities could manage and sustain on their own. One year after implementation, health facilities in treatment villages (as compared to comparison villages) saw a 12-minute reduction in average waiting time and a 13% reduction in absenteeism. Health facilities in treatment villages also showed a 33% decrease in under 5 mortality; a 58% increase in the use of skilled birth attendants; and a 19% increase in number of patients seeking prenatal care. The improvements were maintained four years after the project started. DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 53 People-centred care means that health systems must ensure: • continuity from illness prevention to palliation, between services (e.g. intensive care and radiology) and between levels of care (primary to specialist), throughout the life course; • coordination across different care settings, in ways that meet the particular needs of the individuals and their carers; • comprehensiveness that broadens the portfolio of care – from health promotion through to palliative care – that individuals and communities can use. When health systems struggle to provide people-centred care it is often because services still place too much emphasis on treating individual diseases, rather than preventing illness or promoting better health and well-being. The system prioritizes specialist care for its investment and concentration of resources. Primary care can be designed so that it is the mediator between a community’s needs and the range of provision in a health system. It can then fulfil the enhanced coordination role that person-centred care requires (Figure 4.3). An important way of keeping people- centred care on track, and ensuring the right balance of primary and secondary care services, is to publish regular reports analysing performance of the health system as a whole. Figure 4.3 Primary care as a hub of coordination Networking within the community served and with outside partners Source: World Health Organization (102). Consultant support Referral for multi-drug resistance Self-help group Liaison community health worker Social services Other Other Referral for complications Waste disposal inspection Mammography Gender violence Alcoholism Placenta praevia Hemia Traffic accident Diagnostic support Training support Pap smears Primary care team: continuous, comprehensive, person-centred care HOSPITAL NGOs SPECIALIZED PREVENTION SERVICES DIAGNOSTIC SERVICES SPECIALIZED CARE C o m m u n i t y Community mental health unit Environmental health lab Training centre Alcoholics AnonymousWomen’s shelter Cancer screening centre Emergency department Maternity Surgery TB control centre Diabetes clinic Cytology lab CT Scan Chapter 4 Building quality into the foundations of health systems 54 4.5 CONCLUSION Quality can be built into the foundations of health care systems, no matter how far along the road a health system is to reaching universal health coverage. A quality- oriented approach to health care workers, health care facilities, medicines, devices and other technologies, information systems, and financing is vital at all stages of development. Building up the foundations of quality health systems needs to be at the forefront of thinking, planning and policy-making. But more action is urgently required to create quality health systems. Health systems must exchange a top-down hierarchy for pathways and networks based upon cooperation and collaboration, with primary care as the bedrock and people at the centre. This transformation of relations needs to be coupled with new mechanisms to hold governments and health system leaders to account and build citizens’ trust. Box 4.7 outlines key actions that can be taken to ensure that quality is built into the foundations of health care systems. The following chapter provides greater detail about what types of interventions can be brought together and implemented at macro, meso and micro levels to improve quality of care. People-centred care is a critical entry point through which to improve quality. It involves patients in decisions about their care, and asks their opinions about their outcomes of care; it questions variations in patient outcomes across different providers; it drives greater investment in electronic records that work across multiple settings; it assures transparency and learning when things go wrong; and it fosters a myriad of other actions to improve health care quality. As global health care quality expert Donald Berwick has said: “Person-centredness is not just one of the dimensions of health care quality, it is the doorway to all qualities” (16). The WHO Framework on Integrated, People-centred Health Services, adopted with overwhelming support by Member States at the World Health Assembly in May 2016, sets forth a compelling vision in which “all people have equal access to quality health services that are co-produced in a way that meets their life course needs”. It calls for the coordination of services across the continuum of care and for a supportive environment that helps caregivers practise with the skills and resources they need. This framework proposes five interrelated strategic areas (Figure 4.4) for how health services and systems can be reoriented to accomplish this vision (103). Figure 4.4 Five strategies for people-centred services DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 55 Box 4.7 Key actions: building quality into the foundations of health systems To ensure that quality is built into the foundations of systems to achieve universal health care coverage, governments, policy-makers, health system leaders, patients, and clinicians should work together to: 1. Ensure a high-quality health care workforce, by: • developing a national strategy to address gaps in numbers, distribution and retention of health professionals, both in the short term and the longer term; • modernizing training curricula for health care workers and integrating the principles of quality and quality improvement methods into training curricula; • encouraging programmes of continuous professional development and evaluating their impact. 2. Ensure excellence across all health care facilities, by: • ensuring service readiness and availability as a necessary but not sufficient condition for quality of care; • encouraging continuous and formative evaluations of facilities’ quality of care; • collecting and analysing richer data on variations in quality and outcomes across facilities, turning insights into action to spread best practices and support poor performers. 3. Ensure safe and effective use of medicines, devices and other technologies, by: • developing national policies on medicines and devices focusing on assured quality, adequate supply and affordable prices, supported by standardized health technology assessment; • developing guidelines, checklists and surveillance systems to support the correct use of medical technology, and monitor errors, accidents and adverse reactions; • adopting voluntary non-remunerated blood donation and introducing external quality assessment of the processes for collecting, preparing and administering blood products. 4. Ensure effective use of health information systems, by: • building reliable births and death registration systems and, from this, developing a national system of unique patient identifiers to support quality monitoring across pathways of care; • moving away from paper-based records to a unique electronic health record that can be used across multiple health care settings; • developing national legislation that protects individual privacy whilst enabling the use of personal health data for research and quality improvement; … Chapter 4 Building quality into the foundations of health systems 56 • supporting clinicians, managers and policy-makers in collecting and analysing service data for quality improvement, and communicating effectively with the public about how these data are used; • encouraging transparency when things go wrong, by building a learning culture that focuses on understanding root causes rather than assigning individual blame; • at global level, agreeing on standards to enhance data quality and comparability, particularly standardized terminology to classify, analyse and prevent adverse events; • including measurement of patient outcomes and experiences as a standard element in facilities’ quality assessment. 5. Develop financing mechanisms that support continuous quality improvement, by: • reducing reliance on out-of-pocket funding, and shifting to prepaid and pooled funds for the majority of health system financing through mandatory insurance schemes, with subsidies for those unable to afford contribution; • linking financing for health care providers to local health care needs, incentivizing coordination of care for individuals with complex needs, and investing adequately in primary care; • fully exploiting the potential of payment schemes to deliver sustained collateral benefits such as improved protocols of care, improved collaboration across providers, and improved information systems on health care needs, activities, costs and outcomes. 57DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE Chapter5 Understanding levers to improve quality Chapter 5 Understanding levers to improve quality 58 5.1 INTRODUCTION Quality is a complex and multifaceted concept. Its pursuit requires the design and simultaneous deployment of combinations of discrete interventions. Understanding this interdependence is critical in designing future health systems. For example, establishing standards for care is part of quality improvement, but, for the standards to be reliably implemented, additional actions are needed, such as training and supervision, monitoring for compliance and feedback to health care providers. The process of standard setting alone, without these other supporting and interdependent actions, is of limited value (104, 105). This chapter describes a range of levers to improve the quality of health services and discusses the rationale for developing national quality-related policies and strategies. Common goals addressing quality through a wide array of interventions, across all levels of the health care system – from national-level policy and regulation to the direct provision of individual patient care – are examined. The interdependence of these diverse levers for change and the avoidance of a single-track approach are explained. The levers should also be customized within countries as health-related decisions may be made at the subnational and community levels, and should also be sensitive to unique contextual factors. 5.2 DRIVING IMPROVEMENT THROUGH NATIONAL QUALITY POLICY AND STRATEGY The development, refinement and execution of a national quality policy and strategy are a growing priority as countries strive to systematically improve health system performance. A carefully designed national quality policy and strategy – applying an implementation-informed approach – is likely to be one of the pivotal considerations of countries as they work to achieve enhanced access to health services that yield the best achievable outcomes. But why are countries focused on driving quality through national efforts? Each country has its own culture, population needs, and a historical legacy shaping its health care system. Most countries, though, share a set of goals and an awareness of the strategic context for health care. There are six main areas of common ground: • belief that high-quality, safe, people-centred health care is a public good that should be secured for all citizens; • acceptance that better access to care without attention to its quality will not lead to desired population health outcomes; • acknowledgement that strategies to improve the efficiency of health systems must deliver in an increasingly constrained financial situation; • need to align the performance of public and private health care delivery in fragmented and mixed health markets; • awareness that quality health care is vital to resilience in the political context of national and global health security; • realization that good governance means satisfying the public demand for greater transparency about standards of care, treatment choices, performance and variable outcomes. Countries face the challenge of developing or refining their quality-related policies and strategies through national consensus. They must also recognize that driving change towards a future vision of better performance will almost always be limited by the practical realities of how and where health care is currently provided. DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 59 National policies on health care quality are developed through various governmental structures. In some countries, this involves enabling legislation to establish new administrative and governance structures or to create new forms of mandatory action (for example, physician registration and licensing) or to formulate new regulatory mechanisms (for example, inspection and accreditation). This may trigger the need for an explicit national quality policy document. In other situations, implementation of a national quality policy or strategy may simply be part of the routine five-year health sector plan or an internal ministry of health document. There is no single right way to do this, but most approaches involve one or more of the following processes: • quality policy and implementation strategy as part of the formal long-term 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. Boxes 5.1 and 5.2 provide country case studies on the implementation of national quality policy and strategy in the health sectors of Ethiopia and Sudan. Box 5.1 Case study: Ethiopia – National Health Care Quality Strategy 2016–2020 Ethiopia is the second most populous country in Africa, with a population of around 100 million. Since 1995, the country’s health sector has undergone significant reform through implementation of a Health Care Financing Strategy. The Health Sector Transformation Plan identifies four transformation priority agendas: ensuring the delivery of quality health services in equitable fashion; focusing on district-level transformation; strengthening health information systems; and creating a compassionate, respectful and caring health workforce. The Ethiopian National Health Care Quality Strategy was launched in March 2016. In order to operationalize the strategy, the Health Services Quality Directorate has developed a quality improvement tool for clinical audit of selected high-priority health care services in hospitals. Nationwide training on quality of care and audit methods has been conducted with selected health care cadres from all hospitals. The quality data system now allows integration of key performance indicators with the existing health management information system (106). A number of priorities are pivotal to implementation of the strategy, including strengthening the National Quality Steering Committee chaired by the State Minister; supporting the formation of quality units in regional health bureaus and health facilities; capacity-building through training of cadres and dedicated mentorship; integration of quality improvement in the pre school health curriculum; strengthening monitoring and evaluation mechanisms; and creating demand for quality within the community, with a focus on respectful care. In order to operationalize the strategy, the Health Services Quality Directorate has developed a quality improvement tool for clinical audit of selected high-priority health care services in hospitals. Chapter 5 Understanding levers to improve quality 60 At its most effective, a quality strategy acts as a bridge between where a health system currently stands and the level of quality a country aims to attain. It can accelerate the achievement of health goals and priorities, using quality management principles that incorporate planning, control and improvement processes (107). Though the form and content of the national policy and strategy of each country will vary, the following eight components are likely to receive universal consideration: • National health goals and priorities. These will help to direct resources to meet the most pressing demands of the population. The quality agenda is then aligned to them. • Definition of quality. The definition of quality used must be acceptable in the local context within the country and should underpin the national approach. Use of local language and shared understanding are essential. • Stakeholder mapping and engagement. Quality is an aggregate of the individual components of the whole health system. Including key stakeholders in the development of policy and strategy allows a comprehensive range of factors that promote good-quality health services to be addressed. • Situational analysis: state of quality. The current state of quality in any health system encompasses relevant priorities and problems; related programmes and policies; organizational capabilities and capacity; leadership and governance; and related resources. Assessment of the current state of quality defines key gaps requiring attention and areas of health care services that can be strengthened. Box 5.2 Case study: Sudan – National Health Care Quality Policy and Strategy Sudan has a decentralized health system, with the federal government responsible for national health policy-making, strategy and coordination; state governments responsible for planning and implementation at the state level; and local entities concerned with service delivery on the ground. The main administrative body is the multisectoral National Health Sector Coordination Council. Awareness of quality of care among the public and health care professionals is sporadic. While research into quality exists there is no adequate mechanism for interorganizational dissemination of results, so decision-making is not always informed by relevant data and evidence. However, measures are being undertaken to rectify these shortcomings. In line with the third National Health Sector Strategic Plan, a National Health Care Quality Policy and Strategy was formulated in 2017, to be implemented during 2017–2020. The policy addresses four main priority areas: strengthening governance and accountability, compliance with national quality standards, promotion of a people-centred approach, and reduction of avoidable harm to patients. Particular focus has been given to the health workforce through accredited training, career pathways, staffing norms, human resources for health management systems, and performance appraisal and auditing systems to help build capacity. Establishment of a formal partnership with patients and the community is high on the agenda of the National Quality Policy and Strategy. Next steps include strengthening coordination mechanisms for the National Health System; devising a retention scheme for human resources; strengthening the health management information system; institutionalizing quality at all levels; improving patient safety and infection control at the state level; and strengthening management and implementation capacity at all levels. DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 61 • Improvement methods and interventions. Judicious selection of interdependent interventions implemented across all levels of the health care system will improve health outcomes. This task is complicated by limited resources, evidence of impact, feasibility and acceptability. • Governance and organizational structure for quality. Governance, leadership and technical capacity are all necessary factors for improving quality. They need to be clearly articulated. In a growing number of countries, a national-level unit, usually in the ministry of health, has been created and coexists with other national quality bodies. • Health management information systems and data systems. Improving quality relies on clear and accurate performance data. An information system to support nationally driven quality efforts is necessary for measurement, performance feedback and reporting. • Quality measures. A core set of quality indicators is critically important for judging whether activities are producing higher quality of care leading to significant change in health outcomes; for providing feedback to providers and facility management; for promoting transparency to the public; and for comparative benchmarking to identify best practices for learning. Box 5.3 presents a case study on the implementation of national quality strategy through a coordinated Quality Management Framework in Mexico. Box 5.3 Case study: Mexico – National Strategy for Quality Consolidation in Health Care Facilities and Services Mexico, with around 120 million inhabitants, has a mixed health care system with both public and private providers. Despite major reforms, including the introduction of a free health coverage system in 2003, demographic and epidemiological transitions – such as an ageing population and an increase in the prevalence of noncommunicable diseases – continue to place tremendous pressures upon the health care system. A comprehensive systemwide quality improvement strategy was launched in Mexico in January 2001. The main objectives were to promote quality of care as a core value in the culture of health care organizations, both public and private, and to improve the quality of services across the health care system. In 2012 the National Strategy for Quality Consolidation in Health Care Facilities and Services was established, to be implemented through the General Directorate of Quality and Education in Health Care of the Ministry of Health. The strategy aimed to achieve quality improvement in the following areas: patient safety, innovation and continuous improvement, risk management, accreditation of health care facilities, health regulation, and health education. Implementation of the strategy is supported by a Quality Management Framework that provides the administrative structure for quality improvement at all levels. The framework targets five value outcomes: population health, effective access, reliable and safe organizations, satisfactory experience of the population with health care, and reasonable costs. Citizen participation is promoted, and a monitoring system with indicators has been put in place. Incentives include a national quality award, and financial incentives to networks of units for the development of specific joint quality improvement projects. Source: Ministry of Health (108), Sarabia-González et al. (109), Ruelas et al. (110). Chapter 5 Understanding levers to improve quality 62 5.3 QUALITY INTERVENTIONS Quality interventions can have a significant impact on specific health services delivered and on the health system at large. Understanding the types of commonly deployed interventions, and knowledge of the evidence regarding their use and effectiveness, can allow for more informed choices about which interventions to select in countries. The nature of health care challenges in different health systems across the world is actually quite similar, despite the different contexts of population health needs, financing and workforce capacity. Whilst priorities may differ – communicable versus noncommunicable disease, care needs of later life versus treatment of mothers and children – the same quality goals are pursued everywhere: • reduce harm to patients • improve clinical effectiveness of the health services delivered • engage and empower patients, families and communities • build systemic capacity for ongoing quality improvement activities • strengthen governance and accountability. But where does that leave action? Agreeing upon a list of goals is easier than identifying strategies to achieve them. In this context, seven categories of action stand out. They are routinely considered by quality stakeholders – providers, managers, policy-makers – when trying to improve the performance of the health care system. They are considered in the following subsections. 5.3.1 Changing clinical practice at the front line The gap between what is known to be effective care (“know”) and what is routinely performed by providers (“do”) has been well documented around the world. Closing this “know–do” gap requires multimodal changes in clinical practice at every level of a health system, from the individual encounter between the patient and the health care worker to the redesign of health care delivery. The skills, knowledge and attitudes of health care workers are fundamental. Measures to support health care providers to achieve the most effective care include clinical decision support systems ranging from written protocols to electronically supported aids. Reducing harm to patients is a key objective – It is estimated that of every 100 hospitalized patients at any given time, 7 in developed and 10 in developing countries will acquire at least one health care-associated infection (111). Away from the individual patient and provider, new models of care are being developed and implemented to address multiple dimensions of quality. The models define current best practice for the delivery of health care generically and also as related to special populations (for example, people with chronic disease or mental health conditions) or those with common characteristics (for example, children or the elderly). New models of care are often community based, extending well beyond the walls of hospitals and integrating the contributions of primary, specialized and social care organizations (104). 5.3.2 Setting standards Setting standards, with evidence-based protocols, can establish consistency in delivery of high-quality care across diverse health systems globally. Though often led by government entities, standard setting is an area of quality improvement where professional bodies should play a major role, either working independently or in partnership with governments. Some clinical standards focus on specific population DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 63 groups, others on disease conditions or treatment protocols. For example, global clinical standards of care have been developed to improve maternal and newborn care in facilities (112). Embedding clinical policy and standards-based care is often achieved through patient care protocols and clinical pathways. Whilst clinical standards are often an early step in national quality strategies, developing standards without a holistic quality approach may not yield the expected results and progress. 5.3.3 Engaging and empowering patients, families and communities Health systems need to go further than health literacy programmes to make full use of the potential of people-centredness as an entry point to higher-quality care. There is strong evidence, across all country contexts, that interventions that seek to engage and empower patients, caregivers and families can promote better care, including healthier behaviours, enhanced patient experience, more effective utilization of health services, reduced costs and improved outcomes (100). For example, engaging women’s groups in Nepal to identify the major maternal and newborn problems and strategies for improvement resulted in 30% fewer newborn deaths and an 80% reduction in maternal mortality (113). Giving patients information, advice and support can help them manage their health and co-develop treatment and health maintenance plans. Systematic, sustained community engagement mechanisms can also support programmes to improve quality of care. The need to secure or build trust in communities is also a priority. Without it there will be a fundamental barrier in willingness to access health care even when it is needed. 5.3.4 Information and education for health workers, managers and policy-makers To be effective, information systems for quality improvement must meet the needs of caregivers, facility managers, health system leaders, policy-makers and regulators. This requires targeted information and educational methods for each respective audience. Health workers need comparative information about their own performance, especially benchmarked against best practices. Leaders, managers, policy-makers, regulators and funders also need comparative information. The format and focus will vary according to the area of quality being reviewed, whether it is a service (for example maternity care), a disease condition (for example the care of people with diabetes), a group within the population (for example older people), or an intervention (for example measles vaccination uptake). One of the commitments needed from leaders is to ensure that a proper level of investment in information systems is maintained. However, advances in accessibility and utility of information do not need to depend on high-technology solutions; for example, clinical decision support may be in the form of computer prompts or as simple as paper forms with boxes to tick the basic processes related to effective child care. 5.3.5 Use of continuous quality improvement programmes and methods Quality improvement is not a static concept, but rather a continually emerging, dynamic system property. Many different methods are used to continuously assure and improve quality of health care, including broad clinical governance mechanisms; peer review and clinical audit; individual feedback; supervision and training; clinical decision support tools based on guidelines; and multidisciplinary learning collaboratives. A basic tenet underlying continuous quality improvement is activated learning mechanisms using iterative cycles of change. Further, an avoidance of “blaming and shaming” is central in avoiding the risk of promoting fear and resistance rather than Chapter 5 Understanding levers to improve quality 64 enthusiastic engagement in a shared pursuit of improved performance. There is no single effective method. Multiple interventions must be used in combination and with an understanding of the specific context. The role of institutional culture becomes a critical consideration in deciding the specific blend of quality improvement methods based on the capacity and capabilities that exist. 5.3.6 Establishing performance-based incentives (financial and non-financial) Incentives can be either financial, such as payment, or non-financial, such as recognition and awards. Performance-based financing is a broad term for the payment of health providers based on some set of performance measures and is increasingly used as a quality lever. Models include value-based purchasing; readmission penalties; withholding payment for medical errors; and performance programmes focused on strengthening primary care. The amount contingent on performance is a subcomponent of the full payment, based on a range of financing modalities. Evidence remains mixed about the ability of pay-for-performance programmes to change health outcomes by themselves. However, incentives – both financial and increasingly recognized non- financial approaches – can serve an important motivating and sustaining function when used as part of a robust quality improvement programme. At the same time, attention is required in order to avoid disincentives for quality (such as payment systems that encourage excess medicine use). 5.3.7 Legislation and regulation Governments use both legislation and regulation to achieve national health objectives. Legislation directed at improving quality of health services may address a wide range of issues, such as coverage and benefits; establishment of new (or empowerment of current) national bodies; payment reform; licensing of facilities and individual providers; and public performance reporting. Regulation is the range of factors outside clinical practice or the management of health care that influences behaviour in delivering or using health services (114). Regulation usually targets the activities of institutional and individual providers; health insurance organizations; pharmaceutical and device manufacturers; and consumers or patients. Various regulatory interventions often fail to meet their intended objectives, in part because responsible agencies lack capacity for enforcement. Regulation of private sector activity is increasingly important, given the large proportion of total services delivered. Box 5.4 provides a case study illustrating the use of legislation and regulation to support health care quality goals in Ontario, Canada. Box 5.4 Case study: Ontario, Canada – Excellent Care for All Act and Strategy With its large land mass and heterogeneous population of over 13.5 million, including First Nations, provision of equal access to high-quality care is challenging in Ontario. As with all Canadian provinces, Ontario has a single payer health system; about two thirds of health care expenditure is publicly funded, while one third is paid directly by patients or private insurance plans. Various studies have found that the relationship between quality and funding is generally weak in Ontario, and a major goal of current health system reforms is to improve that linkage. The Excellent Care for All Act became law in 2010, with the Excellent Care for All Strategy forming the vehicle for implementation. … DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 65 5.4 CONSIDERATION AND SELECTION OF QUALITY INTERVENTIONS While the seven categories of action provide a broad map of the performance improvement terrain, there is a further need to specify key quality interventions. Selecting the “right” intervention is seldom possible. No single intervention will satisfy all needs. Even interventions that are non-controversial, such as protocols for hand hygiene, are ineffective if not implemented by considering organizational culture and staff attitudes and motivation. Linkage with national goals – designed to withstand political changes – is central to long-term sustainability. Any ambition to improve quality will require a multimodal approach, using a combination of interventions. Some approaches, like accreditation of facilities, may not have a direct impact on health outcomes but can be important in building public trust and in promoting a culture of quality within the health care system. Programmes that focus only on provider behaviour fail to recognize that the wider environment of health care is pivotal in facilitating or hindering best practice. For example, appropriate prescribing of antibiotics often depends on a physician whose behaviour can be influenced by practice guidelines, performance feedback, peer review, training and supervision, financial incentives, availability of a sufficient variety of antibiotics and patient expectation. The complexity of change becomes apparent. The illustrative interventions in Table 5.1 have been identified for the following attributes: relevant in a wide variety of countries globally; commonly considered as options; having some evidence to guide selection and use; and implementable at multiple levels, from small primary care clinics to the level of a national programme. The context within which these interventions are applied is pivotal in maintaining the credibility of quality improvement endeavours. For example, developing a multimodal quality intervention strategy for a health facility without adequate water supply provides an immediate reality check for quality enthusiasts – data on water, sanitation and hygiene from health facilities across the world provide a clear context for action on the structures required for quality. The act mandates quality committees of the board in health sector organizations, and requires surveys of satisfaction for patients, families and employees. In addition, health care organizations must develop and publicly post a patient declaration of values and a quality improvement plan. The Excellent Care for All Act also created an expanded provincial quality agency, Health Quality Ontario, with a mandate to undertake health system performance monitoring and public reporting, support quality improvement, and promote the provision of best-quality health care. At the organizational level, regulations govern quality assurance and safety in hospitals, nursing homes, laboratories, and other health care settings, and health regulatory colleges have been established to ensure that health professionals provide services in a safe, responsible and ethical manner. While 65% of Ontarians rate their health status as excellent or very good, this average masks significant geographical and population variations; for example, the poorest quintile is twice as likely to report having multiple chronic conditions than the richest quintile. In response, a continued focus on leadership, accountability, and alignment of incentives and goals for improvement will continue to be cornerstones of Ontario’s strategy for a higher-quality health care system. Source: ICES (115), Ministry of Health and Long-term Care (116). Chapter 5 Understanding levers to improve quality 66 The list presented is not exhaustive; other interventions could be included. This set of interventions has been selected for their potential impact on quality by reducing harm, improving front-line delivery of health care services, and building systemwide capacity for quality improvement. The illustrative interventions are not ranked by effectiveness but point to some of the options and possibilities available to health system leaders, managers, practitioners or policy-makers intent on advancing quality of care. The interventions are presented as simply as possible, highlighting the salient issues. However, none is simple to implement. The multiple interventions grouped under system environment touch on a number of the seven categories mentioned above. Table 5.1 Illustrative quality interventions Category Interventions System environment • Registration and licensing of doctors and other health professionals, as well as health organizations, is often considered a key determinant and foundation of a well performing health system. • External evaluation and accreditation is the public recognition, by an external body (public sector, non-profit or for-profit), of an organization’s level of performance across a core set of prespecified standards. • Clinical governance is a concept used to improve management, accountability and the provision of quality health care. It incorporates clinical audit; clinical risk management; patient or service user involvement; professional education and development; clinical effectiveness research and development; use of information systems; and institutional clinical governance committees. • Public reporting and comparative benchmarking is a strategy often used to increase transparency and accountability on issues of quality and cost in the health care system by providing consumers, payers, health care organizations and providers with comparative information on performance. • Performance-based financing and contracting is a broad term for the payment of health providers based on some set of performance measures and is increasingly used as a quality lever. The amount contingent on performance is often a subcomponent of the full payment, which may be based on a range of financing modalities. • Training and supervision of the workforce are among the most common interventions to improve the quality of health care in low- and middle-income countries. • Medicines regulation to ensure quality-assured, safe and effective medicines, vaccines and medical devices is fundamental to a functioning health system. Regulation, including post-marketing surveillance, is needed to eliminate substandard and falsified medicines based on international norms and standards. Reducing harm • Inspection of institutions for minimum safety standards can be used as a mechanism to ensure there is a baseline capacity and resources to maintain a safe clinical environment. • Safety protocols, such as those for hand hygiene, address many avoidable risks that threaten the well-being of patients and cause suffering and harm. • Safety checklists, such as the WHO Surgical Safety Checklist and Trauma Care Checklist, can have a positive impact on reducing both clinical complications and mortality. • Adverse event reporting documents an unwanted medical occurrence in a patient resulting from specific health services or during patient medical encounters in a medical care setting and should be linked to a learning system. … DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 67 Category Interventions Improvement in clinical care • Clinical decision support tools provide knowledge and patient-specific information (automated or paper based) at appropriate times to enhance front-line health care delivery. • Clinical standards, pathways and protocols are tools used to guide evidence- based health care that have been implemented internationally for decades. Clinical pathways are increasingly used to improve care for diverse high-volume conditions. • Clinical audit and feedback is a strategy to improve patient care through tracking adherence to explicit standards and guidelines coupled with provision of actionable feedback on clinical practice. • Morbidity and mortality reviews provide a collaborative learning mechanism and transparent review process for clinicians to examine their practice and identify areas of improvement, such as patient outcomes and adverse events, without fear of blame. • Collaborative and team-based improvement cycles are a formalized method for hospitals or clinics to work together on improvement around a focused topic area over a fixed period of time with shared learning mechanisms. Patient, family and community engagement and empowerment • Formalized community engagement and empowerment refers to the active and intentional contribution of community members to the health of a community’s population and the performance of the health delivery system, and can function as an additional accountability mechanism. • Health literacy is the capacity to obtain and understand basic health information required to make appropriate health decisions on the part of patients, families and wider communities consistently, and is intimately linked with quality of care. • Shared decision-making is often employed to more appropriately tailor care to patient needs and preferences, with the goal of improving patient adherence and minimizing unnecessary future care. • Peer support and expert patient groups link people living with similar clinical conditions in order to share knowledge and experiences. It creates the emotional, social and practical support for improving clinical care. • Patient experience of care has received significant attention as the basis of designing improvements in clinical care. Patient-reported measures are important unto themselves; patients who have better experience are more engaged with their care, which may contribute to better outcomes. • Patient self-management tools are technologies and techniques used by patients and families to manage health issues outside formal medical institutions and are increasingly viewed as a means to improve clinical care. 5.5 CONCLUSION Improving health system performance requires choices and judgements during the promulgation of policy, prioritization of national quality goals, engagement of key stakeholders and selection of quality-related interventions. The infrastructure, context, culture and traditions of health care in a country and locality are central in deciding which levers to apply. A successful national quality strategy is multifaceted and uses many interventions in concert (Table 5.2), from those that put the patient at the centre of the care process, to those that support health workers to set standards and work effectively in teams. Leaders, managers and policy-makers play a critical role in supporting and enabling environments in which standard setting, performance-based incentives, regulation and other interventions can flourish. Chapter 5 Understanding levers to improve quality 68 Table 5.2 Quality-related interventions: engaging key actors Actors Roles Government • Definition of national priorities and quality goals • Provision of essential quality infrastructure, e.g. information technology, utilities • Improvement of regulation • Reporting data for transparency and motivation • Inspection and licensing of health care providers Health care facilities • Clinical governance • Establishing care protocols and clinical pathways • Clinical decision support • Use of safety protocols • Inter-institutional learning mechanisms Clinical providers • Clinical standards and patient pathways • Monitoring adherence to standards of care • Peer review and clinical audit • Shared decision-making Patients and public • Patient, family and community engagement • Patient education and self-management • Participation in governance • Patient feedback on experience of care One of the biggest obstacles to health care improvement is a reluctance to acknowledge the problems that exist (117–119). Another is the difficulty of selecting effective interventions and competently implementing them. The importance of leadership is something of a mantra in the field of health care quality improvement, but without it there is no way to inspire belief that improvement is possible to catalyse collective action. Another key driver of success is proof that the intervention is working. It is here that data collection and feedback are indispensable. However, local teams may lack experience in collecting and interpreting data. They may struggle with data collection systems that are poorly designed for monitoring quality (120). Excessively burdensome measures may be seen as a waste of time, while poorly chosen measures can provoke gaming and perverse incentives. Getting the monitoring aspect right from the start is vital, and this means integrating measurement systems into improvement and making sure that they are adequately resourced (121, 122). Developing national quality policy and strategies is a priority if improvement is to be an integral part of the way that the health care system operates. Nationally driven efforts are required to develop and implement a coherent approach to quality that uses multiple levers to secure the positive change being called for by populations across the world. DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 69 Box 5.5 outlines key actions that can be taken to ensure that levers to improve quality are fully utilized. Box 5.5 Key actions: understanding levers to improve quality To ensure that multiple levers are used to improve quality in health care, governments, policy-makers, health system leaders, patients and clinicians should work together to: 1. Develop, refine and execute a national quality policy and strategy, by: • adopting a definition of quality that is applicable in the local context; • conducting a situational analysis of the current state of quality; • involving the range of key stakeholders in its formulation; • identifying (or creating) organizational structures that can provide governance, leadership and technical capacity in quality; • ensuring that quality is integrated across ministry of health functions. 2. Adopt and promote universal quality goals, by: • setting realistic and measurable targets to reduce harm and improve care; • working with professional bodies to establish areas of care to improve clinical effectiveness; • engaging and empowering patients, families and communities; • building systemic capacity for ongoing quality improvement activities; • establishing and activating learning systems for continuous improvement. 3. Design a quality strategy that includes a set of quality interventions, by: • examining carefully the evidence-based quality improvement interventions in relation to the systems environment, reducing harm, improvement in clinical care, and patient, family and community engagement and empowerment. 4. Monitor and report quality of care results for continuous improvement efforts 70 Today’s hospitals are no place for the dying. Both culturally and clinically they are mostly unsuited to provide end-of- life care, according to Dr M. R. Rajagopal, the “father” of palliative care in India. The former consultant anaesthetist has spent over 20 years developing care for the dying in the tiny green and fertile state of Kerala in the south-west of the country. Today, with 3% of India’s population, Kerala has two thirds of the country’s palliative care services. His interest developed when he was working as an anaesthetist at Calicut Medical College in northern Kerala in the early 1990s. He  recognized early on that tackling pain and supporting the dying could not be achieved by medical staff alone. The need was too great. It would depend on harnessing the commitment of volunteers. “Pain is just the visible part of the iceberg of suffering. What is ignored is the part below the surface – feelings of hopelessness and despair, worries about children, about money. That is what palliative care is about.” The movement grew and today he estimates there are 300 voluntary groups across the state (there are no official figures), providing care to patients in their own homes, identifying those in need and helping direct limited medical resources to where they can do most good. The “Kerala model” now attracts attention from around the world. After moving to Trivandrum in the south, in 2006 he founded Pallium India, which supports 11 voluntary groups and five mobile medical teams providing palliative care in the area, as well as campaigning to improve palliative care throughout India. Now aged 69, he still visits patients at home and teaches younger colleagues how to approach them. “If I wear a tie, hold myself with muscular rigidity, and talk only about pain, I will not discover much. With a different, gentler approach, placing a hand on the patient’s arm, they will talk about deeper problems.” He warns about the importance of language. “You can do harm with the wrong dose of a medicine – and equally with a wrong word.” My Quality Dr M. R. Rajagopal, palliative care specialist Trivandrum, India 71DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE As diagnosis and treatment have become increasingly dependent on technology, something has been lost, he says. The growth of the commercial health care industry, driven by profit, has compounded the sense of alienation. The result is that the disease has become more important than the person who has it. Most doctors believe they have a duty to prolong life, rather than ease death. Cure has come to matter more than care. “The patient has become a bit of a stranger amidst the machines. The health care system seems to have forgotten that health is not just the absence of disease but the presence of physical, mental and social well-being.” He argues that every hospital must integrate palliative care with its disease-focused work. Most people, given the choice and the appropriate care, would choose to die at home, surrounded by their loved ones. But some feel more secure in a hospital environment, with their familiar doctor close at hand. It should be a personal choice, he says. Having access to pain relief is vital to that choice but morphine is not easy to obtain. Figures show India uses 320 kilograms of morphine a year, just 1% of the amount required to meet the need. It is not the cost that restricts access, but the law. Morphine has been highly restricted in India since 1985 because of fears about drug abuse. As a result, two generations of doctors have grown up unfamiliar with it, condemning millions of terminally ill patients to an unnecessarily painful death. Here, too, Kerala has led the way. Since 1995, palliative care centres in Kerala have been permitted to administer morphine orally. Dr Raj’s institution is now a WHO Collaborating Centre for Training and Policy on Access to Pain Relief and plays host to a stream of international visitors. “Health care should be a partnership between the doctor, the patient and the family. Doctors should not work alone but with nurses and counsellors, volunteers from the community and social workers. My duty is to build a relationship with my patients and their families and care for them as human beings. Life is not just existence – there is more to it than that.” Image on previous page: © LPETTET / iStock

Chapter6 The quality call to action 73DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE Chapter 6 The quality call to action 74 6.1 SUSTAINABLE DEVELOPMENT, QUALITY AND THE WAY FORWARD The health-related SDGs cannot be achieved through reliance on disease-specific achievements or financial reforms alone. It requires a strong commitment to creating people-centred, high-quality health services. Achieving universal health coverage built on a firm foundation of safe, high-quality care, together with all that is necessary to sustain it, is the imperative facing policy-makers today. Most past efforts at quality improvement have relied on project-based methodologies. They have shown little promise for scale-up and sustainability. More focus is needed on the foundations of high-quality health services across the care continuum. Offering high-quality health services also means linking financial reforms and reorientation of the delivery model to goals on quality of care. Finally, building on strong foundations, health systems offering sustainable improvements in quality must use national quality policy and strategy tools to create an environment where local, regional and national champions can extend and expand what is working to improve services. In such an environment, governments and providers will make locally appropriate choices on which quality improvement interventions could have the greatest impact on improving the system environment, on reducing harm, on improving clinical care and on engaging and empowering patients, families and communities. Advancing quality improvement, universal health coverage and people-centred approaches within the complexity of health systems requires systems thinking – a deliberate and comprehensive understanding of the dynamics of health systems in order to make them change for the better. By decoding the complexity of the health system, systems thinking helps foster systemwide implementation and evaluation of those interventions that are needed to support the achievement of health goals – equitably, sustainably and effectively. 6.2 CALL TO ACTION This document, from the perspective of three global institutions concerned with health – OECD, the World Bank and WHO – proposes a way forward for health policy-makers seeking to achieve the goal of access to high-quality, people-centred health services for all. In this chapter, a series of high-level actions are called for from each of the key constituencies that needs to work together with a sense of urgency to enable the promise of the SDGs for better, safer health care to be realized (Box 6.1). While no single actor will be able to effect all these changes, an integrated approach whereby different actors work together to achieve their part of the quality call to action will have a demonstrable effect on the quality of health services around the world. DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 75 Box 6.1 High-level actions by key constituencies for quality in health care 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 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.

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87DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE Annex – Improvement interventions This annex defines and presents further information and research on a selection of improvement interventions. 1. Licensing of health care providers is a key determinant of a well performing health system. However, emerging work looking at performance differences between licensed and unlicensed practitioners suggests that licensing alone is not enough to assure quality care. For example, a World Bank study on a rural area of India – where there are 15 times as many unqualified providers as those with a medical degree – found that formal training is not a guarantor of high quality. The study observed minor differences between trained and untrained doctors in adherence to safety checklists and no differences in the likelihood of providers giving the diagnosis or providing the correct treatment (1). These findings suggest that formally trained doctors may know what they should be doing clinically but that further interventions are needed to ensure compliance with higher-quality standards of care (2). Systematic monitoring of quality and individual feedback to providers, as well as patient education on provider competence, are other methods for improving quality of care (3). 2. Accreditation is the public recognition, by an external body, of an organization’s level of performance against a set of prespecified standards (4). Accreditation can be granted by public sector, non-profit and for-profit bodies. Historically, metrics used to assess accreditation have been structural and process oriented, such as the presence of adequate medical equipment, staffing ratios and adherence to programmatic standards. Minimal research has been conducted on the relationship between accreditation and clinical outcomes. In one study in Egypt, mean patient satisfaction scores were significantly higher for accredited nongovernmental health units across a few domains: cleanliness, waiting area, waiting time, unit staff and overall satisfaction (5). At least theoretically, accreditation offers some benefits, such as increased public trust and confidence, self-regulating behaviour on the part of health care institutions, and a basis for incentives and sanctions for performance management. Maintenance of an effective accreditation programme may be challenging, for several reasons: the need for additional resources to address structural and performance deficiencies of facilities in preparation for accreditation, continual adaptation to ensure standards are up to date with the evidence, and sustained funding for national or international accreditation (6, 7). In many circumstances, a period of targeted technical assistance will be necessary prior to the implementation of an accreditation programme (6). 3. Clinical governance includes the systematic promotion of activities such as clinical audit; clinical risk management; patient or service user involvement; professional education and development; clinical effectiveness research and development; use of information systems; and institutional clinical governance committees (8). Clinical governance is a concept used to improve management, accountability and the provision of quality care. The National Health Service in the United Kingdom has pioneered large-scale implementation of clinical governance activities (9). Although literature from low- and middle-income countries remains limited, a case study from Indonesia showed that clinical governance was used to improve maternal and newborn health in 22 hospitals (10). The most acceptable mechanisms to drive clinical governance are Annex Improvement interventions 88 those that recognize professional leadership and are perceived as being locally relevant and allowing reflection on personal professional practice (11). 4. Public reporting is a strategy used to increase transparency and accountability on issues of quality and cost in the health care system by providing consumers, payers, health care organizations and providers with comparative information on performance. It includes a broad range of approaches, such as report cards on hospital performance, comparative prices and costs in a community, and benchmarking on clinical indicators for providers. Public reporting has been implemented in several high-income countries, including Canada, the United Kingdom and the United States, where evidence shows that it catalyses improvement. In low-resource countries less has been published, but several cases are illustrative of potential impact. In Afghanistan, the Ministry of Public Health produced and released publicly a balanced scorecard (12), using household survey and annual hospital survey data, which showed progressive improvement in the national scores between 2004 and 2008 in all six domains, including patient and community satisfaction, capacity for service provision, overall quality of services, and reduction of user fees (13). 5. Performance-based financing is a broad term for remuneration provided to health care providers based on performance measures. Often the amount contingent on performance is a subcomponent of the full payment, which may be based on fee for service, capitation or other calculations. Payment can be allocated at the individual level or group level (for example hospital, department or care team). Evidence shows mixed success, depending on factors such as substantial buy-in from stakeholders, institutional capabilities, and the competency of the financing scheme or fund holder (14–17). A field experiment from Rwanda suggests that performance-based financing may be feasible (and preferable to input-based financing) in sub-Saharan Africa (15). The study found improvement across a number of access and knowledge indicators, for example 62% reduction in out-of-pocket costs, 144% increase in deliveries by skilled persons, and 23% increase in knowledge of HIV transmission risks through skin-piercing objects, but found no impact on clinical outcomes (15). Similarly, results from a pilot in Nigeria found an increase in antenatal care visits, and the use of skilled delivery (17). 6. Training and supervision of health workers are among the most common interventions to improve the quality of health care in low- and middle-income countries. Despite extensive investments from donors, evaluations of the long-term effect of these two interventions are scarce. One study found that training and supervision did not meaningfully improve quality of care for pregnant women or sick children in sub- Saharan Africa (18). Another study from Benin found that workers who had received integrated management of childhood illness training plus study supports provided better care than those with training plus usual supports, and both groups performed better than untrained workers (19). In a related project in Benin to strengthen supervision of health workers, after some initial success, many obstacles were encountered at multiple levels of the health system that led to a breakdown in supervision, including poor coordination, inadequate management skills, ineffective management teams, lack of motivation, decentralization, health worker resistance, less priority given to programme- specific supervision, supervision workload, non-supervision activities, incomplete implementation of project interventions, and loss of leadership and effective supervisors (20). The study concluded that support from leaders is crucial, and that donors and politicians thus need to make supervision a priority (20). 7. Medicines regulation improves the quality of medicines, both produced and available. While between 5% and 15% of WHO Member States report cases of DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 89 counterfeit medicines, this is probably a considerable underestimate. Globally, medicine regulation capacity is limited; WHO estimates that 30% of countries have no medicine regulation or a regulatory entity that does not function properly (21). A study in Uganda assessed the effectiveness of national standard treatment guidelines on rational medicine prescribing and found significant improvement in the treatment of general cases, malaria and diarrhoea (22). Due to the extent to which medicine regulatory authorities are both financially and human resource intensive, it can be challenging to ensure that guidelines are followed. This is noted to be the case especially in poorer countries (21). It has been argued that resource-constrained countries should rely on the assessment of major medicine regulatory authorities, such as those in the United States and Europe, when assessing certain categories of medicines (23). This does not solve the problem of enforcement, and high-income country guidelines may not align with the attributes other countries identify as most important. Best- practice prescribing strategies that have had proven success in both developing and industrialized countries include standard treatment guidelines, essential medicine lists, pharmacy and therapeutic committees, professional training, and targeted in-service education (24). 8. Inspection of institutions for minimum safety standards can be used as a mechanism to ensure there is baseline capacity and resources to maintain a safe clinical environment. Although there is little formal literature on the inspection of institutions for minimum safety standards at the hospital or health centre level (25), inspection factors known to improve safety practices include consistency between standards, approval of standards by a country’s ministry, and proper supervision to communicate standards and help practitioners use them in everyday practice (26). At the minimum, inspection standards can identify structural elements that are foundational for quality: a clean water source, reliable power and backup capacity, adequate coverage by skilled health care workers, clear management responsibility, complete medical records and accountability. 9. Safety protocols, such as those for hand hygiene, address many of the avoidable risks that threaten the well-being of patients and cause suffering and harm (27). Health care-associated infections are the most frequent adverse event in health care delivery worldwide (28), the most common being infections of surgical wounds, the blood stream, the urinary tract and the lower respiratory tract (29). Yet, hand hygiene is a worldwide problem, with compliance rates averaging less than 40% (30). Hand hygiene studies have shown an impact on hand hygiene rates ranging from 10% to almost 50% (31, 32). Twenty hospital-based studies published between 1977 and 2008 showed an association between improved hand hygiene practices and reduced infection (33). Additionally, hand hygiene programmes can be cost-effective: one study in Viet Nam calculated that for every health care-associated infection averted, the hospital saved US$  1000 (32). Behaviour change requires multifaceted approaches focusing on system change, administrative support, motivation, availability of alcohol-based hand sanitizers and safe, reliable water and soap, training and intensive education of health care workers, and reminders in the workplace (30, 34, 35). Compliance is a pervasive problem dependent on many structural factors, including professional position (doctor, nursing assistant, physiotherapist technician), department or type of care delivered, staffing ratios, and the presence of relevant safety equipment such as gloves (33). Moreover, programmes need to be context sensitive (for example, alcohol- based sanitizers should be used where clean water is not reliably available) (31, 35). 10. Safety checklists, such as surgical safety checklists, can have a positive impact on reducing both clinical complications and mortality. In one study performed in eight diverse hospitals in a mixture of high- and low-income settings, postoperative Annex Improvement interventions 90 complication rates fell on average by 36% and death rates fell by a similar amount following increased adherence to six core safety processes covered by a provided checklist (36). Moreover, if during the first year of instituting a checklist major complications are prevented, a hospital will realize a return on its investment (37). However, evidence suggests that the successful uptake of checklists requires education of clinical staff, material resources, and integration into broader institutional efforts and clinical context (38–40). These factors have been shown to be particularly relevant in low- and middle-income countries (38). Poor checklist implementation in low-income settings might not only fail to reduce patient safety risks, but may also introduce new risks such as gaming, disengagement and other behaviours harmful to patient care (38). Implementation of surgical checklists is more likely to be optimized in established, multifaceted patient safety programmes (38). 11. Adverse event reporting documents an adverse or unwanted medical occurrence resulting from specific health services or during a patient encounter (41). Reporting of adverse events is a strategy to raise awareness, increase transparency and foster accountability regarding unsafe care. Adverse events due to medical care represent a major source of morbidity and mortality globally. A study looking at the global burden of unsafe medical care estimated that there are 421 million hospitalizations in the world annually, with approximately 42.7 million adverse events occurring resulting in 23 million disability-adjusted life-years (DALYs) lost per year (42). Approximately two thirds of all adverse events occurred in low- and middle-income countries. Unsafe medical care may lead patients, especially in low-income countries, to opt out of using the formal health care system, thereby making unsafe care a significant barrier to access for many of the world’s poor. Consumption of resources due to prolonged stay and extra care, as well as loss of wages and productivity, is a further consequence of unsafe care. 12. Clinical decision support (CDS) is the provision of knowledge and patient- specific information presented at appropriate times to enhance front-line health care delivery. CDS encompasses a variety of tools to enhance decision-making, such as clinical guidelines, condition-specific order sets, computerized alerts and reminders, documentation templates, and diagnostic support. CDS can be automated (embedded within electronic health records or mobile devices) or paper based. Although electronic CDS has many advantages, it does require ongoing technical assistance and may be subject to challenges of poor infrastructure, such as limited access to the Internet or unreliable power supply (43). A number of studies have examined the feasibility of implementing CDS in low- and middle-income countries, but there is only minimal evidence on its impact on health so far (43, 44). Studies note the need to balance CDS prompts that are in place to standardize care for better quality with the physician’s autonomy to make decisions based on context, clinical expertise, and unique patient needs (43–45). 13. Clinical standards, pathways and protocols are tools to guide evidence-based health care that have been implemented internationally since the 1980s (46). In high- income settings, clinical pathways have been used to improve care for diverse conditions, including acute myocardial infarction and stroke. For example, a study from Australia showed that after introduction of a clinical pathway programme with checklists and reminders, an additional 48% of acute myocardial infarction patients received beta blockers within 24 hours of admission (47). Similarly, following introduction of a clinical pathway programme, an additional 55% of ischaemic stroke patients received aspirin or clopidogrel within 24 hours of admission (47). Another study from the United States incorporated “best of care” clinical protocols into clinician’s workflow via care provider order entry and showed that the decision support tool significantly increased the number of patients receiving aspirin for acute myocardial infarction (48). DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 91 Clinical  pathways and protocols are also used in low- and middle-income settings, where national guidelines are published periodically and serve as an important source of reference for clinicians and public health officials, particularly for vertical disease- focused programmes such as tuberculosis and HIV/AIDS (49, 50). 14. Clinical audit and feedback is a strategy to improve patient care through tracking adherence to explicit standards and guidelines coupled with provision of actionable feedback. A common usage worldwide is to foster implementation of clinical practice guidelines, whereby audit and feedback is used to identify unjustified variation and increase guideline adherence. Audit at both individual and hospital levels is a key part of the Catalonian Cancer Strategy (Spain) for promoting equity (51). Even in rural, resource-limited settings, for example in the United Republic of Tanzania, clinical audit has been associated with a decrease in maternal mortality and morbidity (52). Research in higher-income countries has demonstrated that higher-performing facilities tend to deliver more timely, individualized and non-punitive feedback to providers than lower-performing facilities (53). While most studies do not quantify the extent to which audit and feedback concretely impacts adherence to standards, they do highlight the frequency of medical errors and provide a descriptive account of care quality in a given setting, helping clinical staff to identify and address areas for needed improvement. Noted challenges to successful implementation include resource availability, provider buy-in and leadership support for the process, consistency in understanding and implementation of guidelines, the accuracy of information in clinical records, and the effectiveness of continuing feedback mechanisms (51, 54). 15. Morbidity and mortality reviews provide a collaborative learning mechanism and transparent review process for clinicians to examine their practice and identify areas of improvement, such as patient outcomes and adverse events, without fear of blame (55). Morbidity and mortality reviews are used to bring together clinical staff to review, for learning purposes, what contributed to complications or a patient’s death (55). As such, they promote active recognition of mistakes or errors, and are an opportunity to learn as well as to identify needed process improvements. They have been shown to improve collaboration and communication, aid team-based learning, and result in changes in record keeping and governance relevant to patient safety (55 –57). Historically they have been popular in higher-resourced contexts, but studies are emerging that demonstrate potential in low- and middle-income countries. Descriptive work from Nepal suggests that they are feasible in rural, low-resource contexts (56). Research across geographical and economic contexts points to the importance of senior administrative participation, engagement of both clinical and non-clinical staff, clear identification of goals, selection of cases based on their potential for improvement and coordinated follow-up for improvement activities as key success factors (55–57). 16. Collaborative and team-based improvement cycles are a formalized method that brings together multiple teams from hospitals or clinics to work together on improvement around a focused topic area over a defined period of time. Several of the common features of collaboratives are the sharing of ideas for improvement, iterative testing of actions leading to improvement, and mutual learning across multiple health care organizations. Studies from high-income settings, such as the National Surgical Infection Prevention Collaborative or the collaborative to decrease caesarean delivery rates, have shown that collaboratives can be very effective, reducing infection rates from 27% to 1.7% and caesarean section rates by 30% in a matter of months (58–60). Collaboratives have also been used in low-income settings. For example, the Ethiopian Hospital Alliance for Quality was a national collaborative sponsored by Ethiopia’s Federal Ministry of Health. It included 68 hospitals, of which 44 showed a 10% improvement in a 10-point measure of patient satisfaction from the beginning to the end of the study period (61). Annex Improvement interventions 92 USAID funded 54 collaboratives in 14 low- and middle-income countries during the period 1998–2008. A meta-analysis of 27 of these collaboratives in 12 low- and middle- income countries showed that high-level performance was maintained for an average of 13 months and the average time to reach 80% performance was 9.2 months, while the average time to reach 90% performance was 14.4 months (62). 17. Formalized community engagement and empowerment refers to the active and intentional contribution of community members to the health of a community’s population and the performance of the health delivery system. Community involvement in health has many forms and approaches, including the adoption of behaviours to prevent and treat diseases; effective participation in disease control activities; contribution to the design, implementation and monitoring of health programmes; and provision of resources for health. Participation and input to health systems can occur through various means, such as needs analysis, high-level priority setting or participation on governing boards. Many case examples can be found; for example, in Eritrea and Senegal, strengthened community participation in malaria control led to a decrease in severe malaria cases (63), and preliminary analysis of the Ebola outbreak indicates that more formalized community participation efforts resulted in a significant impact on the identification and tracing of cases and broader trust in local Ebola treatment units (64). Health system reform processes have increasingly recognized the essential contribution of communities; in Kenya, feasibility was tested in district-level annual health sector planning where community participation did influence target and priority setting. Challenges of formalized community involvement include building capacity to empower communities, providing tools and products to support community involvement, and appropriate follow-up and supervision by health professionals. 18. Health literacy is the capacity to obtain and understand basic health information required to make appropriate health decisions on the part of patients, families and wider communities (65). Poor health literacy is a challenge for health care quality; for example, patients with low literacy have difficulty following medical instructions, interacting with the health care system, and reading or complying with medicine prescriptions (65). Additionally, patients with low disease-specific knowledge report lower quality of life and have poorer health-related outcomes (65). Studies show educational interventions can have an impact on both knowledge improvement and clinical care seeking. For example, an intervention in Malawi led to a significant improvement in knowledge pertaining to mental health literacy (66), and a study in India found a positive association between health literacy programming and child vaccination rates (67). However, literacy gains lessen with time, so follow-up programming is key. Research suggests targeting influencers, such as teachers, to extend programmatic reach and ensure long-term impact (66, 67). Other considerations include the integration of health literacy curricula into required schooling, which is especially common with sexual health education (68). 19. Shared decision-making between providers and patients is often employed to tailor care to the patient’s needs and preferences, with the goal of achieving better patient outcomes. There is considerable evidence that patients want more information and greater involvement (69), but few studies have evaluated the impact on clinical outcomes, particularly in low- and middle-income countries. Inadequate communication between providers can result in missed services (70). Barriers to patient activation, however, exist in many public health sector settings, such as in clinics, which are often congested and overstretched (71). One study on adherence to antiretroviral therapy and shared decision-making or “patient activation” found that after diagnosis, patients actually preferred provider-led decision-making, but as they gained comfort with their HIV diagnosis, they were more open to a shared decision-making approach DELIVERING QUALITY HEALTH SERVICES: A GLOBAL IMPERATIVE FOR UNIVERSAL HEALTH COVERAGE 93 to HIV treatment (71). There is no evidence that shared decision-making negatively impacts clinical care, though there may be limitations to what can be addressed in a single clinical visit, given such factors as local concepts of illness or historically grounded distrust of “Western” medicine, which may motivate patients to seek traditional medicines (70). 20. Peer support and expert patient groups link people living with similar clinical conditions in order to share knowledge and experiences. The approach complements and enhances other health care services by creating the emotional, social and practical support necessary for managing health problems and staying as healthy as possible. The extensive literature supporting the effectiveness of peer support and patient groups in HIV-infected adults provides insight into what is both feasible and achievable as a strategy for improving quality of care. A systematic review of the impact of support groups on people living with HIV showed that support groups were associated with reduced mortality and morbidity, increased retention in care and improved quality of life (72). Group visits have shown promise in providing individual patients with a peer support network to maximize adherence, improve patient retention, provide patient education, monitor side effects, and achieve therapeutic gains (73). In a South African support group, participants were significantly more likely to have an undetectable viral load and a CD4 cell count greater than 200 cells/mL at 12 months than those who did not participate in a support group (72). Given the severe human resource challenges worldwide, specifically the shortage of trained health care providers, support groups can play a larger role in improving the effectiveness of models of care (72). 21. Patient feedback and experience of care as a strategy to better understand and improve health service quality has risen dramatically, primarily in high-income countries. In these contexts there is a growing body of evidence that self-reported experience correlates with other, more objective, measures of clinical quality (74). Patient-reported measures are associated with better patient experience, adherence to treatment, greater engagement with their care, and better outcomes (75, 76). A few studies in low- and middle-income countries have shown that patients can adequately judge certain aspects of their care. For example, a study based in the United Republic of Tanzania found that patients proactively sought care based on their clinical needs, as judged by the type and severity of symptoms, as well as the perceived value of previously received care (77). Audit-based evidence from primary care settings in India found that patients have a good idea of what they both want and need from doctors and are willing to pay for it (78). Some critics are concerned that the main determinants of patient experience may be driven by factors such as the attractiveness of the environment or amicability of staff; however, it has been shown that patients are able to differentiate superficial comforts from more meaningful engagement. 22. Patient self-management tools are technologies and techniques used by patients and families to manage their health issues outside formal medical institutions. They are increasingly studied as quality improvement tools in the context of growing empowerment of patients worldwide. Given the increasing prevalence of chronic disease globally, diabetes self-management serves as a good example. Diabetic patients involved with self-management education programmes demonstrated significant reductions in glycosylated haemoglobin levels; in Uganda, patient outcomes included decreases in HbA1c percentage and diastolic blood pressure, and in Honduras, reports of self-care demonstrated improvements in over 50% of patients in blood sugar levels, diet and medication adherence (79). One economic analysis of interventions for diabetes found that diabetes self-management training reduces medical costs in developing countries in the short term (80). Because mobile phones are widely available, mHealth interventions for self-management can be a cost-effective tool (79). Annex Improvement interventions 94 Challenges to widespread implementation include both geographical and financial access to such self-management programmes, trained human resources at central and peripheral levels, and access to education (81). 23. Health technology assessment (HTA) is conducted to find out how health care technologies help maintain and improve health. HTA is used to inform policy and clinical decision-making related to both the introduction and diffusion of a wide spectrum of health technologies (82, 83). Assessing whether HTA affects quality involves looking at the long-term pay-off of policies that have been implemented and demonstrated success. HTA has many different applications, such as policy-making for influenza vaccination of children, informing the development of reimbursement schemes in Sweden (which resulted in decreased annual costs), influencing characteristics of health benefit packages in Thailand or Chile (84–86), or defining the role of specific laparoscopic surgery techniques in Kazakhstan (87). Cohesion amongst and between stakeholders is necessary for the successful implementation of HTA with participation from health care professionals, patient advocacy groups, and the industry, such as medical technology or pharmaceutical firms (88). Transparency in analytics, costs and outcomes (real-life patient data) is key for HTA assessment to be successful (83). Because timely and appropriate access to health care products, procedures and medicines can often impact patient outcomes, HTA represents an important mechanism for improving quality of care for both individuals and populations. 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تقديم خدمات صحية عالية الجودة ضرورة عالمية للتغطية الصحية الشاملة تقديم خدمات صحية عالية الجودة ضرورة عالمية للتغطية الصحية الشاملة تقديم خدمات صحية عالية الجودة: ضرورة عالمية للتغطية الصحية الشاملة [egarevoc htlaeh lasrevinu rof evitarepmi labolg a :secivres htlaeh ytilauq gnirevileD] OHW 1-093156-4-29-879 NBSI © منظمة الصحة العالمية، منظمة التعاون والتنمية في الميدان الاقتصادي والبنك الدولي للإنشاء والتعمير/البنك الدولي، (9102) بعض الحقوق محفوظة. هذا المصنف متاح بمقتضى ترخيص المشاع الإبداعي "نسب المصنف – غير تجاري – المشاركة بالمثل 0.3 لفائدة المنظمات الحكومية الدولية" (/ogi/0.3/as-cn-yb/sesnecil/gro.snommocevitaerc//:sptth ;OGI 0.3 AS-CN-YB CC). وبمقتضى هذا الترخيص يجوز أن تنسخوا المصنف وتعيدوا توزيعه وتحوروه للأغراض غير التجارية، وذلك شريطة أن يتم اقتباس المصنف على النحو الملائم كما هو مبين أدناه. ولا ينبغي في أي استخدام لهذا المصنف الإيحاء بأن منظمة الصحة العالمية و منظمة التعاون والتنمية في الميدان الاقتصادي و البنك الدولي للإنشاء والتعمير/البنك الدولي يعتمدن أي منظمة أو منتجات أو خدمات محددة. ولا يُسمح باستخدام شعار منظمة الصحة العالمية أو منظمة التعاون والتنمية في الميدان الاقتصادي و البنك الدولي للإنشاء والتعمير/البنك الدولي. إذا قمتم بتعديل المصنف فيجب عندئٍذ أن تحصلوا على ترخيص لمصنفكم بمقتضى نفس ترخيص المشاع الإبداعي (ecnecil snommoC evitaerC) أو ترخيص يعادله, وينبغي أن تدرجوا بيان إخلاء المسؤولية التالي مع الاقتباس المقترح: "هذا التعديل مدخل على عمل من إعداد منظمة الصحة العالمية و منظمة التعاون والتنمية في الميدان الاقتصادي والبنك الدولي, ولا تقع المسؤولية عن وجهات النظر والآراء المعرب عنها فيه سوى على الجهة او الجهات التي ادخلته، علما ًبانها لا تحظى بتأييد لا منظمة الصحة العالمية ولا منظمة التعاون والتنمية في الميدان الاقتصادي ولا أي مؤسسة من اعضاء مجموعة البنك الدولي." وإذا قمتم بترجمة المصنف فينبغي أن تدرجوا بيان إخلاء المسؤولية التالي مع الاقتباس المقترح: "هذه الترجمة ليست من إعداد منظمة الصحة العالمية أو منظمة التعاون والتنمية في الميدان الاقتصادي, أو البنك الدولي للإنشاء والتعمير/البنك الدولي، وهي ليست مسؤولة عن محتوى هذه الترجمة أو دقتها. ويجب أن يكون إصدار الأصل الإنكليزي هو الإصدار الملزم وذو الحجية." ويجب أن تتم أية وساطة فيما يتعلق بالمنازعات التي تنشأ في إطار هذا الترخيص وفقا ً لقواعد الوساطة للمنظمة العالمية للملكية الفكرية. (/selur/noitaidem/ne/cma/tni.opiw.www//:ptth). الاقتباس المقترح. تقديم خدمات صحية عالية الجودة: ضرورة عالمية للتغطية الصحية الشاملة [egarevoc htlaeh lasrevinu rof evitarepmi labolg a :secivres htlaeh ytilauq gnirevileD] جنيف: منظمة الصحة العالمية، منظمة التعاون والتنمية في الميدان الاقتصادي والبنك الدولي للإنشاء والتعمير/البنك الدولي:9102. الترخيص OGI 0.3 AS-CN-YB CC. بيانات الفهرسة أثناء النشر. بيانات الفهرسة أثناء النشر متاحة في الرابط siri/tni.ohw.sppa//:ptth/. المبيعات والحقوق والترخيص. لشراء مطبوعات منظمة الصحة العالمية انظر الرابط sredrokoob/tni.ohw.sppa//:ptth. ولتقديم طلبات الاستخدام التجاري والاستفسارات الخاصة بالحقوق والترخيص انظر الرابط gnisnecil/tuoba/tni.ohw.www//:ptth. مواد الطرف الثالث. إذا كنتم ترغبون في إعادة استخدام مواد واردة في هذا المصنف ومنسوبة إلى طرف ثالث، مثل الجداول أو الأشكال أو الصور فإنكم تتحملون مسؤولية تحديد ما إذا كان يلزم الحصول على إذن لإعادة الاستخدام هذه أم لا، وعن الحصول على الإذن من صاحب حقوق المؤلف. ويتحمل المستخدم وحده أية مخاطر لحدوث مطالبات نتيجة انتهاك أي عنصر يملكه طرف ثالث في المصنف. بيانات عامة لإخلاء المسؤولية. التسميات المستعملة في هذا المطبوع، وطريقة عرض المواد الواردة فيه، لا تعبر ضمنا ًعن أي رأي كان من جانب منظمة الصحة العالمية أو منظمة التعاون والتنمية في الميدان الاقتصادي, أو البنك الدولي للإنشاء والتعمير/البنك الدولي بشأن الوضع القانوني لأي بلد أو أرض أو مدينة أو منطقة أو لسلطات أي منها أو بشأن تحديد حدودها أو تخومها. وتشكل الخطوط المنقوطة على الخرائط خطوطا ًحدودية تقريبية قد لا يوجد بعد اتفاق كامل بشأنها. كما أن ذكر شركات محددة أو منتجات جهات صانعة معينة لا يعني أن هذه الشركات والمنتجات معتمدة أو موصى بها من جانب منظمة الصحة العالمية أو منظمة التعاون والتنمية في الميدان الاقتصادي، أو البنك الدولي للإنشاء والتعمير/البنك الدولي تفضيلاً لها على سواها مما يماثلها في الطابع ولم يرد ذكره. وفيما عدا الخطأ والسهو، تميز أسماء المنتجات المسجلة الملكية بالأحرف الاستهلالية (في النص الإنكليزي). وقد اتخذت كل من منظمة الصحة العالمية و منظمة التعاون والتنمية في الميدان الاقتصادي، و البنك الدولي للإنشاء والتعمير/البنك الدولي كل الاحتياطات المعقولة للتحقق من المعلومات الواردة في هذا المطبوع. ومع ذلك فإن المواد المنشورة تُوزع دون أي ضمان من أي نوع، سواء أكان بشكل صريح أم بشكل ضمني. والقارئ هو المسؤول عن تفسير واستعمال المواد. منظمة الصحة العالمية و منظمة التعاون والتنمية في الميدان الاقتصادي, و البنك الدولي للإنشاء والتعمير/البنك الدولي ليست مسؤولة بأي حال عن الأضرار التي قد تترتب على استعمالها. لا تعكس النتائج والتفسيرات والاستنتاجات الواردة في هذا المطبوع بالضرورة وجهات نظر منظمة الصحة العالمية أو البنك الدولي، أو المديرين التنفيذيين للبنك الدولي أو الحكومات التي يمثلونها. تصميم النسخة العربية: يات للتواصل. تقديم خدمة صحية عالية الجودة: ضرورة عالمية للتغطية الصحية الشاملة 3 فهرس تمهيد......................................................................................................................................................................... 5 شكر وتقدير .............................................................................................................................................................. 7 الملخص التنفيذي................................................................................................................................................... 9 الفصل الأول خلفية: السعي لتحقيق الجودة في خدمات الرعاية الصحية ................................... 31 1-1 أدلة كثيرة على ضعف الجودة في جميع البلدان........................................................ 41 1-2 الحجج الاقتصادية بشأن الجودة ...................................................................................... 51 1-3 الجودة كحتمية أساسية للتغطية الصحية الشاملة ...................................................... 51 1-4 القدرة على تحمل تكاليف الجودة لجميع البلدان......................................................... 71 الفصل الثاني حول هذا التقرير ................................................................................................................... 12 2-1 الأهداف ............................................................................................................................. 22 2-2 النطاق................................................................................................................................. 22 2-3 المحتوى............................................................................................................................. 22 الفصل الثالث الحالة العالمية لجودة الرعاية الصحية............................................................................ 52 3-1 الجودة المطلوبة من أجل تحقيق التغطية الصحية الشاملة....................................... 62 3-2 تعريف جودة الرعاية.......................................................................................................... 82 3-3 الصورة العالمية لجودة الرعاية الصحية.......................................................................... 03 3-4 الخلاصة............................................................................................................................... 53 الفصل الرابع دمج الجودة في أسس النظم الصحية............................................................................ 93 4-1 المقدمة.............................................................................................................................. 04 4-2 أسس لرعاية عالية الجودة................................................................................................ 04 4-3 جودة الرعاية كأساس لرعاية صحية محورها الفرد........................................................ 74 4-4 الرؤية: الأنظمة الصحية التي تلتزم بالتمركز حول الناس.............................................. 05 4-5 خاتمة .................................................................................................................................. 25 الفصل الخامس فهم وسائل تحسين الجودة............................................................................................... 55 5-1 مقدمة ................................................................................................................................ 65 5-2 تحقيق التحسين من خلال سياسة الجودة والاستراتيجية الوطنية .............................. 65 5-3 تدخلات لتحسين الجودة ................................................................................................... 06 5-4 النظر في نوعية التدخلات واختيارها.............................................................................. 36 5-5 خاتمة .................................................................................................................................. 56 الفصل السادس دعوة للعمل على تحقيق الجودة.................................................................................... 17 6-1 التنمية المستدامة والجودة والطريق إلى الأمام........................................................ 27 6-2 دعوة للعمل....................................................................................................................... 27 المراجع...................................................................................................................................................................... 57 الملحق تدخلات لتحسين الجودة......................................................................................................................... 58 فهرس 4 الأشكال شكل 3-1 متوسط معدل وفيات الأطفال دون سن الخامسة عبر حالات عدم المساواة، 5002-2102............................ 62 شكل 3-2 عناصر جودة الرعاية الصحية.............................................................................................................................................. 92 شكل 3-3 عدد بطاقات الاختبار السريرية التي يتم تشخيصها تشخيًصا صحيًحا من جانب مقدمي الخدمات الكينيين ........ 13 شكل 3-4 عبء الأمراض الناجم عن الأحداث الضائرة، 5102 ...................................................................................................... 23 شكل 3-5 تقديم الطبيب لتفسيرات سهلة الفهم (3102 أو أقرب عام) ................................................................................... 33 شكل 3-6 الاتجاهات في متوسط أوقات الانتظار لاستبدال مفصل الورك.............................................................................. 43 شكل 3-7 الجودة الهيكلية وجودة عملية خدمات الأمومة حسب مستوى الفقر في المقاطعات في كينيا ................ 43 شكل 4-1 التوزيع العالمي للأخصائيين الصحيين المهرة وكثافتهم وفًقا للإقليم بمنظمة الصحة العالمية، 5002-6102 ..................................................................................................................................................................... 14 شكل 4-2 الاختلافات في توافر المعدات الأساسية عبر مرافق الرعاية الصحية في أفريقيا جنوب الصحراء الكبرى ....... 34 شكل 4-3 الرعاية الأولية كمركز للتنسيق......................................................................................................................................... 15 شكل 4-4 خمس استراتيجيات لخدمات محورها الفرد.................................................................................................................... 25 الجداول جدول 5-1 تدخلات الجودة التوضيحية............................................................................................................................................... 46 جدول 5-2 التدخلات المعنية بالجودة: إشراك العناصر الفاعلة الرئيسية ..................................................................................... 66 الإطارات إطار 3-1 ليبيريا: تضمين الجودة في خطة العمل الصحية بعد تفشي فيروس إيبولا ............................................................ 82 إطار 4-1 دراسة حالة: تدريب العاملين في مجال الرعاية الصحية واستبقائهم في المناطق المحرومة من الخدمة في الفلبين.................................................................................................................................................................................. 24 إطار 4-2 دراسة حالة: مشروع مؤشرات جودة الرعاية الصحية لمنظمة التعاون الاقتصادي والتنمية............................... 54 إطار 4-3 دراسة حالة: تطوير التسجيل المدني والإحصاءات الحيوية في أوغندا ................................................................... 64 إطار 4-4 دراسة حالة: الاحتياجات غير الملباة لرعاية الأمراض المزمنة...................................................................................... 84 إطار 4-5 دراسة حالة: الرعاية الأولية في كوستاريكا.................................................................................................................. 94 إطار 4-6 دراسة حالة: استخدام "صوت المواطن والعمل" لتمكين المجتمعات في أوغندا................................................ 94 إطار 4-7 الإجراءات الرئيسية: دمج الجودة في أسس الأنظمة الصحية................................................................................... 35 إطار 5-1 دراسة حالة: إثيوبيا – استراتيجية جودة الرعاية الصحية الوطنية 6102-0202....................................................... 75 إطار 5-2 دراسة حالة: السودان – سياسة جودة الرعاية الصحية الوطنية واستراتيجيتها ......................................................... 85 إطار 5-3 دراسة حالة: المكسيك – الاستراتيجية الوطنية لتوحيد الجودة في مرافق وخدمات الرعاية الصحية................. 95 إطار 5-4 دراسة حالة: أونتاريو، كندا - الرعاية الممتازة لجميع القوانين والاستراتيجيات........................................................ 26 إطار 5-5 الإجراءات الرئيسية: فهم أدوات تحسين الجودة.......................................................................................................... 76 إطار 6-1 الإجراءات رفيعة المستوى من قبل الجهات الفاعلة الرئيسية لتحقيق الجودة في مجال الرعاية الصحية........ 37 تقديم خدمة صحية عالية الجودة: ضرورة عالمية للتغطية الصحية الشاملة 5 تؤكد أهداف التنمية المستدامة (sGDS) على الالتزام العالمي بتحقيق التغطية الصحية الشاملة بحلول عام 0302، وهذا يعني ضرورة حصول كافة الأشخاص والمجتمعات – في كل مكان في العالم – على الخدمات الصحية عالية الجودة التي يحتاجون إليها – سواء التعزيزية أو الوقائية أو العلاجية أو التأهيلية أو المخففة للآلام – دون مواجهة أي ضائقة مالية. الطريقة التي نقيس بها التقدم المحرز في التغطية الصحية الشاملة تكون من خلال التغطية الفعالة للخدمات الصحية الأساسية والحماية المالية (ضمان عدم تعرض أي شخص للفقر بسبب اعتلال الصحة)؛ ولكن حتى لو حقق العالم التغطية الصحية الأساسية والحماية المالية؛ فإن النتائج الصحية ستظل ضعيفة إذا كانت الخدمات منخفضة الجودة وغير آمنة، وبالتالي فإن تقديم خدمات صحية عالية الجودة أمر ضروري للتغطية الصحية الشاملة. وهذا هو محور هذا التقرير. تشير الأدلة إلى أن الرعاية دون المستوى تهدر الكثير من الموارد وتضر بصحة السكان وتدمر رأس المال البشري وتحد من الإنتاجية. إن جودة الرعاية – لا سيما سلامة المرضى – ضرورية لخلق الثقة في الخدمات الصحية، كما أنها مفتاح لتحقيق الأمن الصحي العالمي، الذي يبدأ بأمن صحي محلي، ويعتمد بدوره على خدمات صحية عالية الجودة في الخطوط الأمامية. والخدمات الصحية الجيدة لا تمنع المعاناة الإنسانية وتضمن مجتمعات أكثر صحة فحسب؛ بل تضمن أيضا ًرأس مال بشري أفضل واقتصادات أكثر صحة. يُنظر إلى الجودة – في كثير من الأحيان - على أنها رفاهية لا يمكن إلا للبلدان الغنية تحمل تكاليفها. وهذه مغالطة؛ إذ يتطلب بناء خدمات صحية عالية الجودة التمتع بثقافة الشفافية والمشاركة والانفتاح حول النتائج، والتي يمكن تحقيقها في جميع المجتمعات بغض النظر عن مستوى دخلها. إن العالم مليء بالدروس حول ما يُفلح وما لا يُفلح، مما يوفر أساًسا غنيًا يمكن من خلاله النهوض بمستوى الجودة بسرعة. كما يلعب الإبداع التقني دوًرا رئيسيًا في تقديم طرق جديدة لتوسيع نطاق خدمات الرعاية الصحية عالية الجودة بسرعة أكبر وبتكلفة معقولة. وينبغي أن يكون التركيز على الاهتمام بالفرد هو جوهر الجودة. كما يجب أن يشارك الناس والمجتمعات في تصميم الخدمات الصحية وتقديمها وتقييمها باستمرار لضمان أنها مبنية على نحو يلبي الاحتياجات الصحية المحلية – بدلاً من تلك الخدمات الخاصة بالجهات المانحة أو المصالح التجارية أو السياسية – أو لأنه "هذه هي الطريقة المعتادة لإتمام ذلك الأمر". إن التركيز على الجودة أمر بالغ الأهمية؛ ولكن يجب أن تركز القيادة أيًضا على السعي للتفوق، والتواصل بشفافية، وتعزيز التعاون عبر الفرق الطبية، وكذلك مع المرضى والمجتمع المدني – بما في ذلك مجموعات المرضى، والمنظمات غير الحكومية، ومكونات المجتمع المحلي –. إن التغطية الصحية الشاملة ليست حلًما للمستقبل؛ إنها بالفعل أمر واقع في العديد من البلدان؛ ومع ذلك، فبدون خدمات صحية عالية الجودة، يمكن أن تظل وعًدا فارًغا. ويبني هذا التقرير التأسيسي حالة تقنية وسياسية قوية للاستثمار في خدمات صحية جيدة. إن الهدف الأسمى هو عالم أكثر صحة وأكثر أمانًا وإنصافًا. suseyerbehG monahdA sordeT lareneG-rotceriD noitazinagrO htlaeH dlroW تمهيد جيم يونج كيم رئيس البنك الدولي انجيل غوريا السكرتير العام منظمة التعاون الاقتصادي والتنمية تيدروس أدهانوم غبرياسوس مدير عام منظمة الصحة العالمية 6 تقديم خدمة صحية عالية الجودة: ضرورة عالمية للتغطية الصحية الشاملة 7 شكر وتقدير تم إعداد هذا التقرير بشكل مشترك بواسطة منظمة الصحة العالمية (OHW) ومنظمة التعاون الاقتصادي والتنمية (DCEO) البنك الدولي في إطار التوجيه العام الذي قدمته ماري بول كيني، المدير العام المساعد السابق للأنظمة الصحية ومجموعة الابتكار، منظمة الصحة العالمية، وتيموثي إيفانز، مدير أول الممارسة العالمية للصحة والتغذية والسكان، مجموعة البنك الدولي، وستيفانو سكاربيتا، مدير العمل والشؤون الاجتماعية، منظمة التعاون الاقتصادي والتنمية. وتألف فريق الكتابة من إدوارد كيلي (منظمة الصحة العالمية)، و نيك كلازينجا (منظمة التعاون الاقتصادي والتنمية)، وإيان فورد (منظمة التعاون الاقتصادي والتنمية)، وجيرمي فيلارد (البنك الدولي)، وشيلا ليثرمان (كلية جيلينجز للصحة العامة العالمية، جامعة نورث كارولينا) شمس الزهى سيد (منظمة الصحة العالمية)، وصن مين كيم (منظمة الصحة العالمية)، وسبيده باقري نجاد (منظمة الصحة العالمية)، والسير ليام دونالدسون (مبعوث منظمة الصحة العالمية لسلامة المرضى). وقد نسق هذا التقرير سبيده باقري نجاد. يود المؤلفون أن يشكروا الزملاء من المعهد الوطني الهولندي للصحة العامة والبيئة (MVIR)، مايكل فان دن بيرج، وويلكو جرافمانز لمساهمتهم في تطوير الإطار المفاهيمي الشامل ومحتوى التقرير، و ستيفانو سكاربيتا، ومارك بيرسون، وفرانشيسكا كولمبو، وكارولين بيرشيت، ولوك سلاوميرسكي من منظمة التعاون الاقتصادي والتنمية لمساهمتهم في الكتابة، وساجار دوجاني، أدنا ديبورا أوجوتشي تشوكوما من البنك الدولي لمساعدتهما في مراجعة النص في المرحلة النهائية. استفاد التقرير من المدخلات الغنية للجنة الاستشارية، المؤلفة من الأعضاء التالية أسماؤهم: السير ليام دونالدسون (رئيًسا)، وكليفورد هيوز، وتوفيق خوجة، وجان مينز، ورشاد مسعود ، وروبين أوزبورن، وإنريكي رويلاس، وبول شيكيل، وأنوات سوباشوتيكول، ونانا أما توم دانسو. الأشخاص التالية أسماؤهم قدموا دراسات الحالة القطرية: دانيال بورسا، وأيوب غبريتساديك لإثيوبيا؛ سيباستيان غارسيا سايسو، وبولينا باتشيكو استريلو، وإنريكي رويلاس للمكسيك؛ والمعز الطيب للسودان؛ وميشيل روسي، وجوشوا تيبر، وأدالستين براون لأونتاريو- كندا. تم إعداد المرفق الخاص بالتدخلات التحسينية بواسطة: شيلا ليثرمان (كلية غيلينغز للصحة العامة العالمية، جامعة نورث كارولينا)، وليانا روزنكرانتس ووسكي، وأنتوني موتشيا، وروما راجبهانداري، وكيم ريمولد (مبادرة هارفارد لجودة الصحة العالمية في معهد هارفارد للصحة العالمية). نود أن نتوجه بالشكر إلى جورجي سورين بانيكا، و لورا بيرسون على الدعم الإداري، وغاري همفريز لكتابة المسودة الأولى للتقرير. كما نود أن نشكر المراجعين الأقران التاليين: دونالد بيرويك، وهيلين هاسكل، ومارغريت كروك، وإفريم ليمانغو. وأخيرا،ً نود أن نعرب عن تقديرنا للعديد من الموظفين الآخرين من المنظمات الشريكة الثلاث الذين ساهموا في إعداد هذا التقرير؛ فمن دون تفانيهم ودعمهم وخبرتهم، لم يكن هذا العمل ممكنا:ً يتمغيتا عبد الله، ونجيب الشوربجي، وبنديتا اليغرانزي، وبروغ السدحان، وشانون باركلي، وماري شارلوت بويسو، وجيمس كامبل، ومينا شيريان، وميكي شوبرا، وكريسيا كاولينغ، وجيشنو داس، ونيلام دهنجرا كومار، وجوان دزينواجيس، وبيتر إنجلفريت، وليندا فريهيت، وروبن فريسكاس، وميشيل غراغنولاتي، وميشيل كارين فونك، وخافيير جوميز باتيست ألينتورن، وجويس هايتاور، وماكي كاجيوارا، ورانيا كاوار، ومايكل جورج كاي، وكلير كيلباتريك، وراميش كريشنامورثي، وأنجيلا لاشوهير، وأنييس ليوتساكوس، ومانون ليت، وأكيكو مايدا، ونيكولا ماغريني، وإليزابيث ماسون، وكيلي ماكجي، ونانا مينساه أبرامبا، وهيرنان مونتينيجرو فون مولينبروك، ومارغريت مورفي، وجيليان أوديركيرك، وشانتي بال، وفيليسيتي بوكلينغتون، ونيتيتا براسوبا بلايزير، وبول بيتر شنايدر، وإيما سكولار، وماريا سيسيليا سيبولفيدا بيرميدو، ماريا أنجليكا سوزا، وجولي ستور، ونوريا تورو بولانكو، وأندرياس أولريش، وكريسانثا ويراسوريا، وإريكا ويلر، وتانا وليجي، ومحمد تاجي ياسامي، وجونبينغ يو، وهونغون تشاو، وهاو زينغ. كما نتوجه بالشكر لـ رؤى احمد، وسارة أبوزيد، وهيثم عوض الله على مساهماتهم الهامة والقيمة في التحقق من الترجمة إلى اللغة العربية.

تقديم خدمة صحية عالية الجودة: ضرورة عالمية للتغطية الصحية الشاملة 9 الملخص التنفيذي يصف هذا التقرير - تقديم خدمات صحية عالية الجودة: ضرورة عالمية للتغطية الصحية الشاملة - الدور الأساسي للجودة في تقديم خدمات الرعاية الصحية. ومع التزام الدول بتحقيق تغطية صحية شاملة بحلول عام 0302، هناك اعتراف متزايد بأن الرعاية الصحية المثلى لا يمكن تقديمها بمجرد ضمان وجود: البنية التحتية والإمدادات الطبية ومقدمي الرعاية الصحية معا؛ فتحسين تقديم الرعاية الصحية يتطلب تركيزًا متعمًدا على جودة الخدمات الصحية، وهو ما ينطوي على توفير رعاية فعالة وآمنة ومنصفة ومتكاملة ومتمركزة حول الناس في التوقيت المناسب. إن جودة الرعاية هي الدرجة التي تزيد بها الخدمات الصحية للأفراد والسكان من احتمالية الوصول إلى النتائج الصحية المنشودة والتي تتوافق مع المعرفة التخصصية الحالية. تشير البيانات إلى أن جودة الرعاية في معظم البلدان – وخاصًة البلدان منخفضة ومتوسطة الدخل – دون المستوى الأمثل، كما هو موضح في الأمثلة التالية: • كان الالتزام بالمبادئ التوجيهية للممارسات السريرية في ثمانية بلدان منخفضة ومتوسطة الدخل أقل من 05 في المائة في عدة حالات؛ مما أسفر عن انخفاض جودة الرعاية قبل الولادة ورعاية الأطفال ونقص في تنظيم الأسرة. • أظهرت المبادرة الخاصة بـ "مؤشرات تقديم الخدمات" في سبعة بلدان منخفضة ومتوسطة الدخل تبايًنا كبيرًا في نسبة تغيب مقدمي الخدمات (3.41-3.44٪)، والإنتاجية اليومية (2.5-4.71 مريًضا)، ودقة التشخيص (43-2.27٪)، والالتزام بالمبادئ التوجيهية السريرية (22-8.34٪). • أظهرت مراجعة منهجية لـ 08 دراسة شيوع الممارسة السريرية دون المثالية في المنشآت الخاصة والعامة التي تقدم الرعاية الصحية الأولية في العديد من البلدان المنخفضة والمتوسطة الدخل. • تشير بيانات منظمة التعاون الاقتصادي والتنمية (DCEO) المأخوذة من البلدان عالية الدخل والبلدان المتوسطة الدخل إلى أن نسبة تتراوح بين 91 و 35٪ من النساء اللواتي تتراوح أعمارهن بين 05-96 سنة لم يخضعن لفحص التصوير الشعاعي للثدي، وأن 72-37٪ من كبار السن (56 سنة وما فوقها) لم يتلق التطعيم ضد الأنفلونزا. نتائج صحية أفضل من خلال تحسين الجودة تشمل الخدمات الصحية عالية الجودة تقديم الرعاية المناسبة - في الوقت المناسب - والاستجابة لاحتياجات مستخدمي الخدمة وتفضيلاتهم، مع التقليل - إلى أدنى حد - من الأضرار وتبديد الموارد. وتزيد الرعاية الصحية عالية الجودة من احتمالية النتائج الصحية المرغوبة وتتسق مع سبع خصائص قابلة للقياس: الفعالية، والسلامة، والتركيز على السكان، والتوقيت المناسب، والإنصاف، وتكامل الرعاية، والكفاءة؛ ففي باكستان - على سبيل المثال - أدت زيادة إمكانية الوصول لموظفي الرعاية الصحية من المرة الأولى من خلال برنامج العاملات بالقطاع الصحي إلى تحسين معالجة حالات الإصابة بالالتهاب الرئوي وخفض معدل وفيات المواليد. دمج آليات الجودة في مؤسسات الرعاية الصحية إن العناصر التأسيسية الخمسة الحاسمة في تقديم خدمات الرعاية الصحية الجيدة هي: العاملون في مجال الرعاية الصحية، ومرافق الرعاية الصحية، والأدوية والأجهزة وغيرها من التقنيات، ونظم المعلومات، والتمويل. وللتأكد من أن الجودة جزء لا يتجزأ من أسس الأنظمة؛ يجب على الحكومات وواضعي السياسات وقادة النظام الصحي والمرضى والأطباء التعاون مًعا على: 01 • ضمان وجود قوى عاملة صحية مؤهلة. • ضمان تحقيق التميز في جميع مرافق الرعاية الصحية. • ضمان الاستخدام الآمن والفعال للأدوية والأجهزة والتقنيات الأخرى. • ضمان الاستخدام الفعال لنظم المعلومات الصحية. • استحداث آليات تمويل تدعم التحسين المستمر للجودة. تدخلات لتحسين جودة الرعاية الجودة مفهوم معقد ومتعدد الأوجه، يتطلب تصميم مجموعات من التدخلات المنفصلة ونشرها بشكل متزامن؛ فإعداد سياسة الجودة الوطنية واستراتيجيتها وصياغتها وتنفيذها له أولوية متزايدة مع سعي البلدان لتحسين أداء النظام الصحي بشكل منهجي. وتتضمن معظم أساليب تطوير استراتيجية الجودة الوطنية واحدة أو أكثر من العمليات التالية: • سياسة الجودة واستراتيجية التنفيذ كجزء من الخطة الوطنية الرسمية للقطاع الصحي. • إعداد وثيقة سياسة الجودة كوثيقة وطنية قائمة بذاتها، تكون عادة في إطار عملية تتضمن العديد من أصحاب المصلحة، تقودها أو تدعمها وزارة الصحة. • استراتيجية تطبيق الجودة الوطنية - مع جدول أعمال مفصل - يتضمن أيًضا قسًما عن المجالات الأساسية للسياسة. • تمكين التشريعات واللوائح التنظيمية من دعم السياسة والاستراتيجية. وتظهر بوضوح سبع فئات من التدخلات ويتم النظر فيها بشكل روتيني من قبل أصحاب المصلحة في النظام الصحي - بما في ذلك مقدمي الخدمات والمديرين وواضعي السياسات - عند محاولة تحسين جودة نظام الرعاية الصحية. وهذه التدخلات هي: • تغيير الممارسة السريرية في الخط الأمامي. • وضع المعايير. • إشراك وتمكين المرضى والأسر والمجتمعات. • إتاحة المعلومات والتعليم للعاملين في مجال الرعاية الصحية والمديرين وواضعي السياسات. • استخدام برامج وطرق تحسين الجودة المستمرة. • وضع حوافز على أساس الأداء (مالية وغير مالية). • التشريعات واللوائح التنظيمية. واختيار الحكومات لمجموعة من التدخلات المعنية بالجودة يجب أن يتم من خلال فحص دقيق لتدخلات تحسين الجودة المستندة إلى الأدلة فيما يتعلق ببيئة النظام، وتقليل الضرر، وتحسين الرعاية السريرية، والمشاركة والتمكين للمريض والأسرة والمجتمع. تبادل الدروس المستفادة بهدف توسيع نطاق التدخلات الناجحة تقوم عدة دول بتطوير ابتكارات لتحسين الجودة من مختلف الجوانب. وكما هو موضح في هذا التقرير؛ فإن العديد من البلدان ذات الدخل المنخفض والمتوسط قد أجرت تدخلات ناجحة، ولكنها تتطلب منصة عالمية لتبادل المعرفة. وهذا سيسمح للدول بالتعلم من التدخلات الناجحة وتكييفها لتتلاءم مع سكانها المحليين، كما سيسمح للدول بتجنب توجيه الجهود نحو التدخلات غير الناجحة. وقد ثبت أن تحسين جودة الرعاية يمثل تحديًا لجميع الدول. ومع ذلك؛ فإن توفير الرعاية الجيدة للناس في كل مكان يبقى أهم مسؤولية مشتركة وفرصة لتحسين صحة الناس على مستوى العالم. ومع التركيز المتعمد على الجودة؛ ستتمكن الدول من إحراز تقدم كبير نحو تحقيق أهداف التنمية المستدامة وتحقيق التغطية الصحية الشاملة. تقديم خدمة صحية عالية الجودة: ضرورة عالمية للتغطية الصحية الشاملة 11 دعوة إلى العمل هذا التقرير من منظور ثلاث مؤسسات عالمية معنية بالصحة - منظمة التعاون الاقتصادي والتنمية، البنك الدولي، ومنظمة الصحة العالمية - يقترح سبيًلا للمضي قدًما لصانعي السياسة الصحية الذين يسعون إلى تحقيق هدف إتاحة خدمات صحية عالية الجودة - تتمحور حول الفرد - للجميع. إن ثمة حاجة ملحة إلى اتخاذ إجراءات رفيعة المستوى من كل دائرة من الدوائر الرئيسية التي تحتاج إلى العمل جنبًا إلى جنب، مع الشعور بالحاجة الملحة للتمكن من تحقيق أهداف التنمية المستدامة لتحقيق رعاية صحية أفضل وأكثر أمانًا. وبالتالي يتعين على جميع الحكومات ما يلي: • أن يكون لديها سياسة واستراتيجية وطنية للجودة. • إثبات مسئوليتها عن تقديم خدمة آمنة عالية الجودة. • التأكد من أن الإصلاحات المدفوعة بهدف التغطية الصحية الشاملة، تدمج الجودة ضمن أساس أنظمة الرعاية الخاصة بها. • ضمان أن النظم الصحية لديها بنية تحتية للمعلومات وتكنولوجيا معلومات قادرة على قياس جودة الرعاية والإبلاغ عنها. • سد الفجوة بين الأداء الفعلي في الجودة والأداء القابل للتحقيق. • تعزيز الشراكات بين مقدمي الخدمات الصحية ومستخدمي الخدمات الصحية مما يحث على الجودة في الرعاية. • إنشاء قوى عاملة صحية مؤهلة ذات قدرة على تلبية متطلبات واحتياجات السكان ودعمها للحصول على رعاية صحية عالية الجودة. • عمليات الشراء والتمويل والعمولات تكون على أساس مبدأ القيمة. • تمويل البحوث الخاصة بتحسين جودة التمويل. ويجب على جميع الأنظمة الصحية: • تنفيذ التدخلات القائمة على الأدلة التي تظهر التحسن في الأداء. • وضع معيار مرجعي للمقارنة بالأنظمة المماثلة التي تحقق أفضل أداء. • ضمان تمكين جميع المصابين بالأمراض المزمنة من تقليل تأثير تلك الأمراض على نوعية حياتهم. • تعزيز نظم الثقافة والممارسات التي من شأنها تقليل الضرر للمرضى. • بناء القدرة على الوقاية من التهديدات التي تواجه الأمن الصحي، وكشفها، والاستجابة لها من خلال تركيز الاهتمام على الجودة. • وضع البنية التحتية للتعلم. • تقديم المساعدة الفنية وإدارة المعرفة الهادفة إلى التحسين في الجودة. ويجب على جميع المواطنين والمرضى: • تمكينهم من المشاركة النشطة في الرعاية لتحسين وضعهم الصحي. • لعب دور قيادي في تصميم نماذج جديدة للرعاية لتلبية احتياجات المجتمع المحلي. • إبلاغهم بأن من حقهم الحصول على الرعاية التي تلبي معايير الجودة الحديثة القابلة للتحقيق. • تلقي الدعم والمعلومات والمهارات اللازمة للتعامل مع حالاتهم المزمنة. ويجب على جميع العاملين في مجال الرعاية الصحية: • المشاركة مع مرضاهم في قياس الجودة وتحسينها. • تبني فلسفة ممارسة العمل الجماعي. 21 • رؤية المرضى كشركاء في تقديم الرعاية. • الالتزام بتوفير البيانات واستخدامها لإثبات فعالية الرعاية وسلامتها. وفي حين لم يتمكن أي طرف بمفرده من إجراء كل هذه التغييرات؛ فإن اتباع نهج متكامل - حيث تعمل الجهات الفاعلة المختلفة مًعا سعيًا لتحقيق دورها - سيكون له تأثير واضح على جودة خدمات الرعاية الصحية في جميع أنحاء العالم. تقديم خدمة صحية عالية الجودة: ضرورة عالمية للتغطية الصحية الشاملة 31 1الفصل خلفية: السعي لتحقيق الجودة في خدمات الرعاية الصحية 41 الفصل 1 خلفية: السعي لتحقيق الجودة في خدمات الرعاية الصحية التغطية الصحية الشاملة هدف مهم ونبيل. وتهدف التغطية الصحية الشاملة - وهي حٌق مكرس في أهداف التنمية المستدامة - إلى توفير الأمن الصحي وإمكانية الحصول على خدمات الرعاية الأساسية على نحو شامل دون التسبب في أي ضائقة مالية للأفراد والأسر والمجتمعات المحلية، مما يتيح التحول إلى مجتمعات واقتصادات أكثر إنتاجية وإنصافًا. ولكن لا ينبغي مناقشة التغطية الصحية الشاملة وتخطيطها - ناهيك عن تنفيذها - دون التركيز على الجودة. ومن الضروري ضمان أن تكون الرعاية فعالة وآمنة ومتوافقة مع تفضيلات واحتياجات الناس والمجتمعات المستفيدين من الخدمة. وعلاوة على ذلك؛ ينبغي تقديم الرعاية في حينها، وبإنصاف بين جميع الفئات السكانية، وتنسيقها في إطار سلسلة متواصلة من خدمات الرعاية الصحية مدى الحياة، مع الحد من إهدار الموارد. وبالتالي، فإن جودة الرعاية هي الأساس الذي تقوم عليه التغطية الصحية الشاملة؛ لأنه إذا لم يتم ضمان جودة الرعاية، فما الفائدة من توسيع نطاق الحصول عليها؟!، وأيًضا لأن الحصول على خدمات الرعاية بدون جودة يعتبر وعًدا فارًغا بالتغطية الصحية الشاملة. ولا ينبغي أن تقتصر الجودة على البلدان ذات الدخل المرتفع؛ فإذا كانت الدول قادرة على توفير أي نوع من الرعاية الصحية - حتى أفقر الدول يمكنهم؛ بل ويجب عليهم القيام بذلك - فإنه يجب عليهم توفير الرعاية الجيدة؛ لأن البديل - الرعاية رديئة الجودة - ليس ضاًرا فحسب؛ بل إنه يُهدر أيًضا الموارد الثمينة التي يمكن استثمارها في الدوافع المهمة الأخرى للتنمية الاجتماعية والاقتصادية بهدف تحسين حياة المواطنين، فهناك مليارات الدولارات التي تُنفق على عواقب الرعاية رديئة الجودة - الأموال التي يمكن أن تمول المدارس والخدمات الاجتماعية والبنية التحتية - كما يمكن أن يؤدي ضعف الجودة إلى تقويض ثقة السكان في فوائد الطب الحديث. وبهذه الطريقة؛ فإن التغطية الصحية الشاملة دون جودة الرعاية هي عمل لم يكتمل إنجازه. 1-1 أدلة كثيرة على ضعف الجودة في جميع البلدان لقد أُحِرَز تقدم كبير في تحسين بعض جوانب جودة الرعاية الصحية في جميع أنحاء العالم، على سبيل المثال فيما يتعلق بمعدلات النجاة من السرطان والوفيات الناجمة عن أمراض القلب والأوعية الدموية (1، 2). ولكن في مجالات أخرى، كان التقدم بطيئًا ومتفاوتًا، والأرقام خير دليل. • في البلدان مرتفعة الدخل، يتأثر واحد من كل عشرة مرضى سلبًا أثناء العلاج (3). • في البلدان مرتفعة الدخل، بالإمكان توقع إصابة سبعة من كل 001 مريض في المستشفى بعدوى مصاحبة للرعاية الصحية (واحد من كل 01 في البلدان النامية)، وبالالتهابات التي يمكن تجنبها بسهولة من خلال تحسين النظافة الصحية والاستخدام الذكي لمضادات الميكروبات (4). • لا تزال الاختلافات غير المبررة حول توفير الرعاية الصحية وإيصالها قائمة، ولا تحصل نسبة كبيرة من المرضى على الرعاية المناسبة القائمة على الأدلة (5، 6). • تتفاوت معدلات التطعيم ضد الأنفلونزا بين البلدان ذات الدخل المرتفع من 1٪ إلى أكثر من 87٪، على الرغم من أن الهدف الذي حددته جمعية الصحة العالمية في عام 3002 هو 57٪ بحلول عام 0102 (7). • أصبحت مقاومة الميكروبات للمضادات قضية عالمية رئيسية في مجال الصحة العامة، ويرجع ذلك جزئيًا إلى سوء استخدام الأدوية المضادة للميكروبات، والإفراط في استخدامها في الرعاية الصحية (8). • على الصعيد العالمي، قُدرت التكلفة المرتبطة بالأخطاء الدوائية بمبلغ 24 مليار دولار أمريكي سنويًا، دون احتساب الأجور المفقودة أو الإنتاجية المتوقفة أو تكاليف الرعاية الصحية (9). تقديم خدمة صحية عالية الجودة: ضرورة عالمية للتغطية الصحية الشاملة 51 • في الوقت الذي ارتفع فيه معدل حالات الولادة التي تتم بإشراف قابلات مهرة من 85٪ في عام 0991 إلى 37٪ في عام 3102، ويرجع ذلك أساًسا إلى الزيادة في حالات الولادة في المرافق الصحية، فلا يزال هناك العديد من النساء والأطفال الرضع الذين يموتون أو يصابون بإعاقات تستمر مدى الحياة حتى بعد الوصول إلى منشأة صحية بسبب سوء نوعية الرعاية. وتُقدر منظمة الصحة العالمية (OHW) أن 000303 أم و7.2 مليون رضيع حديث الولادة يموتون سنويًا في وقت الولادة، وأن هناك عدد أكبر بكثير يصابون بمرض يمكن الوقاية منه. علاوة على ذلك، هناك حوالي 6.2 مليون حالة إملاص كل عام (01 ، 11). • يفتقر ما يقرب من 04٪ من مرافق الرعاية الصحية في البلدان المنخفضة والمتوسطة الدخل إلى المياه المحسنة، بينما يفتقر نحو 02٪ منهم إلى الصرف الصحي - الآثار المترتبة على جودة الرعاية تتضح بجلاء - (21). • تبرز التقديرات الشاملة - لعدة بلدان - الخاصة بتوزيع التشخيص والسيطرة على ضغط الدم المرتفع في بلدان مختارة خارج منظمة التعاون الاقتصادي والتنمية أهمية خدمات الوقاية عالية الجودة. وفي معظم الحالات، لم يتم تشخيص نصف البالغين على الأقل الذين يعانون من ارتفاع ضغط الدم بإصابتهم بارتفاع ضغط الدم. وبالتالي؛ فإن التغطية العلاجية لارتفاع ضغط الدم منخفضة، حيث تتراوح من 7٪ إلى 16٪ بين الأشخاص الذين تعرضوا لضغط الدم المرتفع في الدراسات الاستقصائية للأسر المعيشية. ومع ذلك؛ فإن التغطية الفعالة أقل بكثير من التغطية ، حيث تتراوح من 1٪ إلى 13٪، مما يشير إلى وجود مشكلة في الجودة (31). 1-2 الحجج الاقتصادية بشأن الجودة وبالإضافة إلى آثار العناية الرديئة على حياة الناس، فإنها تهدر الوقت والمال. كما أن جعل الجودة جزًءا لا يتجزأ من التغطية الصحية الشاملة هو سعى إلى حياة أطول وأفضل إلى جانب كونه ضرورة اقتصادية. ودمج الجودة في الأنظمة الصحية ميسور التكلفة بالنسبة للبلدان على جميع مستويات التنمية الاقتصادية. وفي الواقع، الافتقار إلى الجودة هو تكلفة لا يمكن تحملها، خاصة بالنسبة للبلدان الأكثر فقرًا. إن الجودة المتدنية في الرعاية لا تسهم فقط في زيادة العبء المرضي على الصعيد العالمي والاحتياجات الصحية غير الملباة؛ بل إنها تؤثر أيًضا تأثيرًا اقتصاديًا كبيرًا، مع ما يترتب من تكاليف كبيرة على النظم والمجتمعات الصحية في جميع أنحاء العالم. تستخدم البلدان مرتفعة الدخل حوالي 51٪ من نفقات المستشفيات بها في معالجة التعقيدات الناتجة عن الرعاية وإيذاء المريض والتي يمكن الوقاية منها. وتؤثر الرعاية الرديئة بشكل غير متناسب على الفئات الأكثر ضعًفا في المجتمع، وتصل التكاليف الاقتصادية والاجتماعية الأوسع نطاقا ًإلى تريليونات الدولارات سنويا ً نظرًا لما تسبب للمرضى من أضرار ناجمة عن الإعاقة طويلة الأجل، والعاهات، وفقدان الإنتاجية (41). بالإضافة إلى ذلك، فالخدمات المكررة، والرعاية غير الفعالة، وحالات الدخول التي يمكن تجنبها في المستشفيات – وهي سمات في العديد من النظم الصحية – ينتج عنها هدر مقدر للموارد. ويتم توزيع ما يصل إلى ُخمس الموارد الصحية بطرق تولد القليل جًدا من التحسينات الصحية، في حين أن هذه الموارد النادرة يمكن توزيعها بشكل أكثر فاعلية (3). 1-3 الجودة كحتمية أساسية للتغطية الصحية الشاملة إن الجودة لا تأتي تلقائيًا؛ فهي تتطلب تخطيطًا، وينبغي تحديدها بوضوح كأولوية واضحة في التغطية الصحية الشاملة، إلى جانب إمكانية الوصول إليها والتغطية والحماية المالية. ويوضح هذا التقرير أن إدماج الجودة في النظم الصحية أمر ممكن إذا اتُبعت بعض الخطوات وطُبقت المبادئ، وهي الشفافية والاهتمام بالفرد وقياس المعلومات واستحداثها، والاستثمار في القوى العاملة، كل ذلك مدعوًما بالقيادة والثقافة الداعمة. ومع وجود هذه الأساسيات؛ يمكن تنفيذ التدخلات والممارسات المثبتة لضمان الجودة واستدامتها مثل نظافة الأيدي، وبروتوكولات العلاج، والقوائم المرجعية، والتعليم، وإعداد التقارير والتغذية الراجعة. 61 الفصل 1 خلفية: السعي لتحقيق الجودة في خدمات الرعاية الصحية وتعتبر الشفافية أمًرا بالغ الأهمية؛ لأنها الأساس المتين للتعليم المستمر والتحسين. وقد كان الاستنتاج العام الذي خلصت إليه 51 مراجعة للجودة على الأنظمة الصحية الوطنية التي أجرتها منظمة التعاون الاقتصادي والتنمية بين عامي 2102 و6102 هو الحاجة إلى مزيد من الشفافية فيما يتعلق بالأداء من حيث الجودة ونتائج الرعاية (51). ويتمثل أحد العناصر الرئيسية للشفافية في توخي الصدق والأمانة في النتائج، بما في ذلك الهفوات والأخطاء. وفي مثل هذه البيئة، يصبح ذلك فرصة للتعلم، كما هو الحال في القطاعات الأخرى، بما في ذلك النقل الجوي. ويجب الاحتفاء بالنتائج الناجحة ومشاركتها لنفس الأسباب. فقد تستغرق ثقافة الشفافية هذه بعض الوقت لبنائها، ولكن غرسها في جميع النظم الصحية ممكن وواجب، بغض النظر عن الموارد المتاحة. إن إشراك الأفراد والمجتمعات في رعايتهم الخاصة وفي تصميم خدماتهم الصحية يُعتبر عامًلا رئيسيًا لتحديد أفضل النتائج. إن الناس والمجتمعات التي يولدون فيها ويتربون ويعيشون ويعملون ويلعبون، هي في قلب تقديم الخدمات الصحية الجيدة. والأشخاص الذين يشاركون بشكل نشط في صحتهم والرعاية التي تخصهم يعانون من مضاعفات أقل ويتمتعون بصحة ورفاهية أفضل على المستوى السريري، مما يعني تمكين المرضى من المشاركة في الرعاية وفي القرارات السريرية، والتعامل مع حالاتهم الصحية بنشاط. فالاهتمام بالفرد هو "مدخل لجميع الصفات" (61). والواقع أن الخيط المشترك بين قصص النجاح التي تم تفصيلها لاحًقا في هذا التقرير هو وضع احتياجات وقيم المريض في مركزي الصدارة والقلب، وهذا يعني الاهتمام الممزوج بالرحمة والاحترام. لكن الاهتمام بالفرد يتجاوز الرعاية الفردية؛ إذ ينبغي إشراك الأشخاص والمرضى في تحديد الأولويات وفي تطوير السياسات، ولا يعد هذا الأمر أكثر أهمية من الرعاية الأولية والمجتمعية. كما يجب تصميم هذه الخدمات بمساهمة من المجتمعات التي تخدمها، بناًء على احتياجاتهم وتفضيلاتهم المتفردة، كما هو موضح في الفصل الرابع من هذا التقرير. إن الجودة تتطلب قياس المعلومات واستحداثها، ولأن الرعاية الصحية تتغير طوال الوقت؛ فإنه يجب مراقبة الجودة وتقييمها باستمرار لدفعها للتحسن. وهذا يعتمد على معلومات دقيقة وفي التوقيت السليم. وتخصص الصناعة المصرفية 31٪ من دخلها لنظم المعلومات، وتستثمر الرعاية الصحية أقل من 5٪، وهو مبلغ زهيد بالنسبة لقطاع قائم على الاستخدام الكثيف للمعلومات. فالبيانات التي تولدها النظم الصحية - في حال وجودها - غالبًا ما تتركز على المدخلات وحجم الأنشطة، ولابد إذن من تغيير هذا الأمر لتكون الجودة جزًءا روتينيًا من الرعاية الصحية. كما يجب تضمين مقاييس الجودة الموثوق بها في البنى التحتية للمعلومات الصحية المحلية والوطنية - وهذا الأمر أكثر أهمية من قياس المدخلات - واستلهاًما لروح الشفافية؛ يجب أن تكون المعلومات متاحة لجميع الجهات الفاعلة ذات الصلة، بما في ذلك المرضى، ومقدمي الخدمات، والمشرعين، والمشترين، وصانعي السياسات. ويجب قياس جميع أبعاد الجودة، فمن المهم معرفة مدى الالتزام بالبروتوكولات الأساسية وجودة العمليات والمسارات، على سبيل المثال: نظافة الأيدي، والقائمة التفقدية لفحص السلامة الجراحية، والالتزام بمبادئ الممارسة السريرية، والنتائج السريرية مثل: إعادة الإدخال، ومعدلات الوفيات، وردود الفعل السلبية للعقاقير، والبقاء على قيد الحياة بعد تشخيص السرطان، والسيطرة الكافية على سكر الدم خلال فترة الحمل. ولكن يجب أيًضا استقاء المعرفة حول نتائج الرعاية وخبراتها التي يتم تقييمها من قبل المرضى من خلال قياس مؤشرات الجودة المذكورة للمريض والمجتمع (71). ويجب القيام بكل ذلك مع تركيز واضح على الروابط الوثيقة بين القياس والتحسين؛ فالقياس وحده لن يحسن الجودة. القوى العاملة الصحية التي تتسم بالمهارة والحماسة والمدعومة بشكل كاف أمر بالغ الأهمية. إن مقدمي الرعاية الصحية يريدون تقديم أفضل رعاية ممكنة لمرضاهم. ومع ذلك؛ فالأنظمة والبيئات التي يعملون فيها غالبًا ما تصعب هذه المهمة؛ إذ تواجه العديد من البلدان أوجه قصور كبيرة في كل من كمية القوى العاملة الصحية ونوعيتها. وبالطبع، لا ينبغي أن يقتصر تقديم كل أوجه الرعاية على الأطباء، فالممرضات والعاملون في المهن الصحية والعاملون في مجال الصحة المجتمعية ومنسقو الرعاية ومديروها يلعبون دوًرا مهًما في تقديم رعاية عالية الجودة في القرن الحادي والعشرين. ومن الممكن تحقيق جودة عالية من خلال الاستفادة من مهاراتهم في جميع مراحل سلسلة الإنتاج الصحي (81). تقديم خدمة صحية عالية الجودة: ضرورة عالمية للتغطية الصحية الشاملة 71 وحتى تتوفر الرعاية عالية الجودة، يجب زيادة المعرفة التقنية من خلال القدرة على التواصل والعمل كفريق مع المهنيين الآخرين، ومشاركة المرضى ومقدمي الرعاية لهم. كما يتطلب الأمر وجود قوى عاملة مدربة على مبادئ التحسين المستمر للجودة وممارساته، بالإضافة إلى التعرف على "المنهج الخفي" الذي ينشأ عن ضعف الأنظمة التي يصممها البشر. وتتوقف الجودة أيًضا على كيفية تنظيم الجهود وتكاملها مع القطاعات الأخرى، مع مراعاة أنماط السلوك والتفاعل البشري والعلاقات الإنسانية. ويعتمد هذا بدوره على الحوافز القائمة، بما في ذلك التمويل والمكافآت، والتنظيم، وتقديم التقارير والتعليقات، والتي يجب تضمينها بعناية في جميع العمليات والمؤسسات. في النهاية، توفر الأنظمة التربة الخصبة التي يمكن أن تزدهر فيها التحسينات والممارسات عالية الجودة. لا شيء من المذكور أعلاه ممكن بدون قيادة وثقافة تمكينية. وقد تبين قدرة الثقافة المنفتحة - التي تتشجع فيها جميع الجهات الفاعلة على التعاون والتواصل والعمل مع مجتمعاتها لتقديم رعاية عالية الجودة، والتي تتمحور حول الفرد دون خوف أو ترهيب - على تحقيق نتائج أفضل (91). ولأن العديد من العوامل تؤثر على ثقافة التحسين المستمر للجودة؛ فلابد - أولاً وقبل كل شيء - من توفير بيئة شفافة، كما هو موضح أعلاه. ومن المهم أيًضا تدريب العمال وإدماجهم اجتماعيًا، ومراعاة التدابير الهادفة إلى التحسين، والملاحظات على الأداء، والتعلم المشترك، بالإضافة إلى العوامل التحضيرية مثل الحوافز المالية؛ لكن العنصر الرئيسي هو الاتساق في القيادة سواء من الحكومات أو صانعي السياسات والقادة السريريين ومديري النظم الصحية والمجتمع المدني. وهذا لا يتطلب مستوى عال من الموارد؛ بل يتطلب الاستثمار في إحداث تحول ثقافي نحو الشفافية من أجل التحسين المستمر. توفر هذه الأساسيات العمود الفقري للسياسات والممارسات للتحسين المستمر لجودة الرعاية الصحية؛ لكن الجودة يجب أن تكون مسؤولية جميع أصحاب المصلحة والمؤسسات. ويجب أن تكون مدعومة بتوجيه استراتيجي وطني واضح تمام الوضوح، ومصحوبًا بأهداف وغايات معرفة بدقة، ومشاركة قوية من جانب أصحاب المصلحة عبر النظام الصحي بأكمله، وكذلك عبر القطاعات الأخرى. 1-4 القدرة على تحمل تكاليف الجودة لجميع البلدان في حين أن تقديم رعاية صحية عالية الجودة للجميع قد يبدو فكرة طموحة؛ إلا أنه يمكن تحقيقها في جميع الظروف في ظل القيادة الجيدة والتخطيط المحكم والاستثمار الذكي. فعلى سبيل المثال، في أوغندا؛ قام نموذج يضم مواطنين ومجتمعات في تصميم خدمات الرعاية الصحية بتحقيق تحسن في مجموعة من المؤشرات، بما في ذلك انخفاض بنسبة 33٪ في معدل وفيات الأطفال (02). كما حققت كوستاريكا تحسينات ملحوظة في جودة الرعاية الأولية من خلال استراتيجية تحسين تم تخطيطها وتطبيقها ودراسة مواردها بعناية (12). وسوف تُقدم هذه الأمثلة وغيرها في وقت لاحق في هذا التقرير. وبالنسبة للبلدان المنخفضة والمتوسطة الدخل، فإن هناك فرصة ضخمة لمعالجة مسألة الجودة مع بناء التغطية الصحية الشاملة. ويمكن أن يتأثر النظام الصحي الذي ينضج ويصبح راسًخا، كما يمكن توجيهه ورعايته بالطريقة المرغوبة. كما يمكن تضمين الجودة في السياسات والعمليات والمؤسسات مع نمو النظام وتطوره. ويتمثل التحدي في كيفية التعلم من التجارب في النظم الصحية في البلدان ذات الدخل المرتفع، ليس فقط من التجارب الناجحة ولكن أيًضا من التجارب الغير ناجحة بصفة خاصة. والدرس الرئيسي هو أن دمج الجودة في النظم الصحية القائمة أمر ممكن بالتأكيد ولكن يمكن أن يكون شاقًا. وبدًلا من ذلك، يجب دمج الجودة منذ البداية، إلى جانب إمكانية الحصول على الخدمة والتغطية والحماية المالية. بطبيعة الحال، لا يمكن تصميم رعاية عالية الجودة بشكل كامل بالمجان؛ فهي تتطلب بعض الاستثمار في رأس المال والموارد الأخرى. وهذا الاستثمار ليس بعيد المنال، حتى بالنسبة لأفقر البلدان، فتكاليف الجودة الرديئة هائلة بالنسبة لحياة الناس وللنظم الصحية وللمجتمعات. والاستثمار في الجودة إذا طُبق بذكاء؛ سيحقق صحة أفضل للفرد وللسكان، كما سيحقق القيمة مقابل المال. و العائد على الاستثمار في ضمان رعاية عالية الجودة 81 الفصل 1 خلفية: السعي لتحقيق الجودة في خدمات الرعاية الصحية من المرجح أن يتفوق بكثير على التكاليف، وهناك نتائج أفضل تتمثل في زيادة التنمية الاقتصادية والاجتماعية؛ فعلى سبيل المثال، نجد أن الناس الأكثر صحة هم أكثر إنتاجية في العمل، والأطفال الأصحاء أداؤهم أفضل في المدرسة. لذا؛ فإن السعي إلى تحقيق التغطية الصحية الشاملة عالية الجودة ليس مجرد استثمار في صحة أفضل؛ بل هو التزام ببناء مجتمع أكثر صحة وعالم أكثر صحة. تقديم خدمة صحية عالية الجودة: ضرورة عالمية للتغطية الصحية الشاملة 91 تعريفي للجودة السيدة سيسيليا رودريغيز، المدير التنفيذي لمؤسسة "oveuM eM" 1. gro.sitirhtradiotamuehr.www. قبل ثماني سنوات، كانت سيسيليا رودريغيز مديرة لمرفق الرعاية الصحية الأولية عندما تم تشخيص إصابتها بالتهاب المفاصل الروماتويدي، وهو أحد أمراض المناعة الذاتية التي تسبب الالتهاب والتورم والألم الحاد في المفاصل. تقول رودريغيز، التي كانت في الثلاثينات من عمرها عندما عانت من الأعراض المؤلمة: "كان لدّي التهاب مفصلي روماتويدي سيئ وقضيت الكثير من الوقت في الفراش". "أدركت أن ما كنت أرّوج له كمدير بمجال الصحة كان مختلًفا تماما ًعما أحتاجه كمريضة." التهاب المفاصل الروماتويدي يصيب الناس من جميع الأعمار. وأسبابه الدقيقة غير معروفة، لكن العوامل الوراثية والبيئية قد تلعب دورا ً في ذلك؛ حيث يتأثر 1٪ من سكان العالم به. في تشيلي مثًلا، حيث تعيش رودريغيز - يعيش 000 001 شخص بهذا الوضع مدى الحياة. وفًقا لرودريغيز، يمكن تعريف الرعاية الصحية الجيدة بالنسبة للأشخاص المصابين بأمراض مزمنة بأنها: "توازن دقيق بين أفضل الممارسات السريرية وما هو الأفضل للمريض، مصّمم وفًقا للمريض"، وتستطرد: "نحن لسنا في حاجة دائمة إلى الأطباء الذين لديهم جميع الإجابات؛ نحن بحاجة إلى أشخاص يفهمون كيف نتعامل مع حالتنا." وقبل كل شيء، فهي تعتقد أن المرضى المصابين بأمراض مزمنة - تؤثر تأثيرًا كبيرًا على الحياة اليومية - بحاجة إلى الشعور بالتحكم في علاجهم. تقول: "كمريضة؛ أعرف ما أريد تحقيقه. يمكن للأطباء مساعدتي في فهم ما إذا كان بوسعي تحقيق ذلك ومساعدتي على القيام به. وبالنسبة لي، هذا أفضل مستوى لجودة الرعاية الصحية". سيسيليا رودريغيز وشقيقتها لورينا، اللتان تم تشخيص إصابتهما بالتهاب المفاصل الروماتويدي قبل بضع سنوات، أسستا منظمة غير ربحية لدعم الأشخاص المتضررين من نفس الحالة، وللدعوة لتحسين رعاية المرضى. تقول رودريغيز: "لقد أطلقنا على المنظمة غير الربحية اسم ‘oveuM eM’ أي (أنا أتحرك) لأننا علمنا أنه في هذه الحالة يجب أن تُبِقي جسمك يتحرك، ولكن أيًضا لأن ‘أتحرك’ يعني ‘أن أتخذ إجراء’." 02 "oveuM eM" هي جزء من حركة متنامية من المنظمات التي يقودها مرضى في تشيلي. وقد عملت رودريغيز كمتحدث باسم تحالف من الجمعيات التي نجحت في الضغط لجعل الأدوية الموصوفة أقل تكلفة. وفي عام 6102، اعتمدت شيلي "قانون otoS etraciR" الخاص بالعلاجات عالية التكلفة. تقول رودريغيز: "الآن لا أدفع إلا 002 دولاًرا أمريكيًا سنويًا لجميع أدويتي، بدًلا من 0051 دولار شهريًا". وتوضح رودريغيز قائلة: "أنظمة الرعاية الصحية تكون موجهة في العادة نحو علاج الأمراض الحادة، ونادًرا ما يتم تصميمها لمساعدة المرضى الذين يعانون من الأمراض مدى الحياة في التغلب على العقبات في الحياة اليومية". وتستشهد رودريغيز بمثال شقيقتها التي تضطر بجانب عملها إلى السفر إلى ثلاثة مواقع - وهي عملية تستغرق ما لا يقل عن خمس ساعات - لجمع العقاقير الموصوفة بالوصفة الطبية الشهرية. تقول: "في هذه الحالة؛ فإن جودة الرعاية تعني القدرة على الحصول على جميع أدويتها من مرفق الرعاية الصحية الأولية بالقرب من منزلها، في صباح يوم سبت". وتروج رودريغيز أيًضا لتمكين المرضى من إدخال الملاحظات في سجلاتهم الطبية بين المواعيد الطبية لمساعدة الأطباء على ضبط العلاج، وتقول: "إذا تمكنت من كتابة أنني قد أصابني مرض، وذكرت كيف تعاملت معه، فسيكون لدى طبيبتي تلك المعلومة عندما أراها بعد ثلاثة أو أربعة أشهر". بعد أن حضرت رودريغيز دورة تدريبية حول الإدارة الذاتية للأمراض المزمنة في الولايات المتحدة - مما ساعدها على التعامل بشكل أفضل مع آثار مرضها - عملت منظمتها على إتاحة البرنامج للمرضى في بلدها. تقول رودريغيز: "إن الاستثمار في تدريس الإدارة الذاتية يمكن أن يقلل التكاليف الإجمالية، ولهذا السبب نأتي بهذا البرنامج إلى تشيلي". ونتيجة لذلك، استفاد سبعمائة شخص في العام الماضي من هذا التدريب من خلال النظام العام. kcotSi / lexipwaR © :egap suoiverp no egamI تقديم خدمة صحية عالية الجودة: ضرورة عالمية للتغطية الصحية الشاملة 12 حول هذا التقريرالفصل2 22 حول هذا التقرير الفصل 2 إدراكا ً للفجوة العالمية في فهم جودة خدمات الرعاية الصحية وقياسها وتحسينها، تضافرت جهود كل من منظمة الصحة العالمية ومنظمة التعاون الاقتصادي والتنمية والبنك الدولي لإخراج هذا التقرير - تقديم خدمات صحية عالية الجودة: ضرورة عالمية من أجل تحقيق التغطية الصحية الشاملة. 2-1 الأهداف تم إعداد هذا التقرير لتحقيق الأهداف التالية: • تزويد الحكومات بوصف لجودة الخدمات الصحية وأهميتها من أجل تحقيق أهداف واسعة للصحة العامة، في سياق التغطية الصحية الشاملة. • تزويد الحكومات بصورة للُنُهج القائمة على الأدلة التي يمكنها ضمان جودة الخدمات الصحية وتحسينها. • الدعوة لاتخاذ إجراءات على المستويين الوطني والدولي. 2-2 النطاق هذا التقرير موجه إلى صانعي السياسات الذين يرغبون في توخي أساسيات تحسين جودة الرعاية الصحية في أنظمتهم الصحية. لذلك، ينظر التقرير في أسس جودة خدمات الرعاية الصحية، ولا يهدف إلى تقديم إرشادات تقنية للمهنيين في مجال الرعاية الصحية العاملين في الصفوف الأمامية، على الرغم من أنهم قد يجدون معلومات مفيدة فيه. كما أنه لا يدرس الآثار المترتبة على الجودة في مجالات تقنية محددة. 2-3 المحتوى يبدأ التقرير بفصل حول المعلومات الأساسية عن الجودة في خدمات الرعاية الصحية (الفصل الأول)، يتبعه وصف موجز للتقرير (الفصل 2). ويتكون الجزء الرئيسي من المنشور من ثلاثة فصول بشأن موضوعات الجودة الرئيسية (الفصول 3-5)، يليها دعوة لاتخاذ الإجراءات في مجال الجودة في الفصل السادس. • الفصل الثالث: الحالة العالمية لجودة الرعاية الصحية. وفي هذا الفصل، يتم تقديم صورة عالمية للجودة في خدمات الرعاية الصحية. ويعرض بيانات لإظهار أن جودة الرعاية في معظم البلدان - ولا سيما البلدان منخفضة ومتوسطة الدخل - دون المستوى الأمثل، وإظهار ارتباط تحسن الجودة بتحقيق نتائج صحية أفضل. • الفصل الرابع: دمج الجودة في أسس النظم الصحية. ويصف هذا الفصل كيف يجب وضع آليات لضمان الجودة ورصدها وتحسينها باستمرار في أسس النظم الصحية، ومعالجة القضايا الرئيسية التي تتطلب الاهتمام لتحسين جودة الرعاية الصحية على المستوى القطري. • الفصل الخامس: فهم أدوات تحسين الجودة. إذ الجودة مفهوم معقد ومتعدد الأوجه ويتطلب تصميم وتنفيذ مجموعات من التدخلات المنفصلة في وقت واحد. ويسلط هذا الفصل الضوء على أهمية تحسين الجودة من خلال السياسات والاستراتيجيات الوطنية ويقدم مجموعة من أدوات تحسين الجودة. • الفصل السادس: دعوة للعمل على تحقيق الجودة. ويوجه هذا الفصل دعوة للعمل على تحقيق الجودة إلى صانعي السياسات الصحية الذين يسعون إلى تحقيق هدف إتاحة خدمات صحية للجميع عالية الجودة وتتمحور حول الفرد. ويتم تقديم ذلك على نحو يتسم بالاستعجال، لأنه إذا لم نتحرك الآن؛ فإن تحقيق أهداف الصحة العامة سيكون في غاية الصعوبة. تقديم خدمة صحية عالية الجودة: ضرورة عالمية للتغطية الصحية الشاملة 32 ويلي هذه الفصول ملحق، يقدم مجموعة من التدخلات المتعلقة بالتحسين والتي تم اختيارها لتأثيرها المحتمل على الجودة من خلال الحد من الضرر، وتحسين تقديم خدمات الرعاية الصحية في الصفوف الأمامية، وبناء القدرات على مستوى الأنظمة من أجل تحسين الجودة. وتشير التدخلات التوضيحية إلى بعض الخيارات والإمكانيات المتاحة للقادة في الأنظمة الصحية أو المديرين أو الممارسين أو صانعي السياسات الذين يعتزمون النهوض بجودة الرعاية.

تقديم خدمة صحية عالية الجودة: ضرورة عالمية للتغطية الصحية الشاملة 52 الرعاية الصحيةالحالة العالمية لجودة الفصل3 62 الفصل 3 الحالة العالمية لجودة الرعاية الصحية "ما جدوى توفير رعاية الأمومة المجانية وتحقيق نسبة عالية من الولادات في المرافق الصحية إذا كانت جودة الرعاية دون المستوى أو حتى خطرة؟" مارغريت تشان، المديرة العامة السابقة لمنظمة الصحة العالمية، جمعية الصحة العالمية، أيار/ مايو 2102 3-1 الجودة المطلوبة من أجل تحقيق التغطية الصحية الشاملة سرعت الأهداف الإنمائية للألفية بين عامي 0002 و 5102 من إحراز تقدم عالمي نحو تحقيق الأهداف الصحية للسكان في البلدان المنخفضة والمتوسطة الدخل، فعلى الصعيد العالمي، انخفض معدل وفيات الأطفال بنسبة 35٪، وانخفض معدل وفيات الأمهات بنسبة 34٪، وانخفض معدل الإصابات الجديدة بفيروس نقص المناعة البشرية بنسبة تزيد على 83٪ (22). ومع ذلك، كان التقدم المحرز يفتقر كثيرًا إلى الإنصاف، ففي المجتمعات الفقيرة والريفية وبالنسبة إلى السكان الذين يصعب الوصول إليهم، ظلت معدلات الوفيات التي يمكن الوقاية منها مرتفعة. على سبيل المثال، بالنسبة للأطفال الذين تقل أعمارهم عن 5 سنوات في البلدان ذات الدخل المنخفض والمتوسط، ثمة اختلافات كبيرة في معدل الوفيات بين أولئك الذين يعيشون في الأسر المعيشية الأكثر فقرًا مقارنة مع أولئك الذين يعيشون في أغنى الأسر المعيشية، وبين أولئك الذين كانت أمهاتهم الأقل تعليًما مقارنة مع الذين كانت أمهاتهم الأكثر تعليًما، وبين أولئك الذين يعيشون في المناطق الحضرية مقارنة مع أولئك الذين يعيشون في المناطق الريفية (شكل 3-1). كشفت التقييمات المنهجية للخدمات الصحية الأساسية في البلدان ذات معدلات الوفيات المرتفعة عن وجود أوجه قصور رئيسية في جودة الرعاية المتلقاة. وفي أحد هذه التقييمات في ثمانية بلدان في أفريقيا في منطقة جنوب الصحراء الكبرى، بلغ متوسط التغطية (الفعالة) محسنة الجودة ٪82 فيما يتعلق بالرعاية السابقة للولادة، و62٪ لتنظيم الأسرة، و12٪ لرعاية الأطفال المرضى، وكان أقل بكثير من تغطية الخدمات الأولية (32). وفي خمسة بلدان شكل 3-1 متوسط معدل وفيات الأطفال دون سن الخامسة عبر حالات عدم المساواة، 5002-2102* النوع الاجتماعي محل الإقامة تعليم الأم** الوفيات لكل 0001 مولود حي الوضع الاقتصادي ث ثال ال س خم ال بع لرا س ا خم ال ى) غن الأ س ( ام لخ س ا خم ال ي ثان ال س خم ال قر) لأف (ا ول الأ س خم ال يم عل ن ت دو ب ي يف ر ي ضر ح ور ك ذ ث إنا ي دائ لابت م ا علي الت ي نو لثا م ا علي الت * متوسط القيمة في 94 دولة مختارة ** لا تتوفر بيانات في 01 دول المصدر: منظمة الصحة العالمية (22). تقديم خدمة صحية عالية الجودة: ضرورة عالمية للتغطية الصحية الشاملة 72 في منطقة جنوب الصحراء الكبرى في أفريقيا، أكثر من 04٪ من حالات الولادات في مرافق صحية تمت في مرافق الرعاية الأولية مع وجود فجوات كبيرة في الموارد والخبرة الفنية (42). ولم تتضمن الأهداف الإنمائية للألفية تركيزًا محدًدا على قياس جودة الرعاية وتحسينها، إلا أن هذه العيوب في جودة الرعاية كان لها آثار سلبية على تحويل زيادات التغطية إلى صحة سكانية أفضل. وقد تبين أن الخدمات ذات النوعية الرديئة تُنبئ بوجود خطر أكبر يتمثل في وفيات المواليد في أفريقيا (52). كما أن الزيادة في الولادات في المؤسسات الصحية بنسبة من 41٪ إلى 08٪ في الهند لم تقلل من وفيات الأمهات والأطفال بسبب سوء نوعية الرعاية المقدمة في المرافق الصحية (62). وقد تبين في الأساس أن سوء نوعية الرعاية مسؤول عن استمرار ارتفاع معدلات وفيات الأمهات والأطفال في البلدان ذات الدخل المنخفض والمتوسط ، على الرغم من الزيادات الكبيرة في نسبة الحصول على الخدمات الصحية الأساسية التي تحققت خلال عصر الأهداف الإنمائية للألفية. وفي عام 5102، اعتمدت الجمعية العامة للأمم المتحدة جدول عمل جديد للتنمية: "تحويل عالمنا : خطة التنمية المستدامة لعام 0302". وتضم أهداف التنمية المستدامة مجموعة واسعة من الأهداف الاقتصادية والاجتماعية والبيئية أكثر من الأهداف الإنمائية للألفية وتضع هدفًا صحيًا جديًدا، هو "ضمان حياة صحية وتعزيز الرفاهية للجميع في جميع الأعمار". وتعتبر التغطية الصحية الشاملة أساسية لأهداف التنمية المستدامة. التغطية الصحية الشاملة المحددة تعني ببساطة ضمان قدرة جميع الأفراد والمجتمعات على استخدام الخدمات الصحية التعزيزية والوقائية والعلاجية والتأهيلية والملطفة التي يحتاجونها، والتي تتسم بجودة كافية لتكون فعالة، مع ضمان عدم تعرض مستخدمي هذه الخدمات للمشقة المالية. وبالتركيز بصورة واضحة على جودة خدمات الرعاية الصحية؛ فإن خطة التنمية المستدامة لعام 0302 تسلم بالحاجة الملحة لوضع جودة الرعاية ضمن نسيج العمل الوطني والإقليمي والعالمي من أجل تعزيز الرفاهية للجميع. وفي حين ركز الاهتمام العالمي على التغطية الصحية الشاملة؛ فإنه على المستوى المحلي قد عزز تفشي فيروس الإيبولا المدمر في غرب أفريقيا القضية القوية المتمثلة في تحقيق جودة الرعاية، ففي غينيا وليبيريا وسيراليون، مثلت الفجوات في تقديم الخدمات وما صاحبها من انهيار للثقة العامة في الُنظُم الصحية تحديات هائلة أمام جهود الاستجابة والتعافي أثناء تفشي فيروس الإيبولا. على سبيل المثال، كشفت تقييمات النظام الصحي في سيراليون عن انخفاض كثافة الموارد البشرية في قطاع الصحة، وانخفاض القدرة على رصد الأمراض في المجتمع، وعجز البنية التحتية في المرافق الصحية، وضعف سلاسل الإمداد بالأدوية الأساسية (72). ومنذ ذلك الحين، شددت البلدان الثلاثة على حصول الجميع على خدمات صحية جيدة لتعزيز قدرتهم على منع تفشي الأمراض على نطاق واسع في المستقبل، ووضع الوقاية من العدوى ومكافحتها وسلامة المرضى كأولويات رئيسية. وعقب تفشي المرض، وضعت ليبريا خطة استثمارية لبناء قدرة النظام الصحي على الصمود، كما تعمل على إنشاء صندوق للأسهم الصحية يضع الجودة في صميمه (إطار 3-1). وتُظهر استجابة الغرب الإفريقي لتفشي فيروس الإيبولا الارتباط الحقيقي والوثيق بين مرونة النظام الصحي وجودة الرعاية والأمن الصحي العالمي. وسيتطلب تحقيق أهداف الصحة التابعة لأهداف التنمية المستدامة استثمارات مالية جديدة بمرور الوقت من مبلغ أولي قدره 431 مليار دولار أمريكي إلى 173 مليار دولار أمريكي سنويًا بحلول عام 0302 (82). فالرعاية ذات النوعية الرديئة غير فعالة، حيث تهدر الموارد النادرة وتزيد من تكلفة توسيع نطاق التغطية الصحية. وتتضح أوجه القصور من خلال الرعاية غير الضرورية التي لا تؤثر على النتائج الصحية. على سبيل المثال، في البلدان ذات الدخل المنخفض والمتوسط ، يؤدي الاستخدام المفرط للمضادات الحيوية لعلاج الحالات الحادة من عدوى الجهاز التنفسي إلى زيادة تبلغ في المتوسط ٪63 من تكلفة الرعاية (92). وقد تؤدي الأخطاء في تقديم الخدمات أيًضا إلى إلحاق ضرر مباشر بالصحة، بتكلفة إضافية على النظام الصحي. ويشير تحليل حديث لبلدان منظمة التعاون الاقتصادي والتنمية إلى أن أكثر من 01٪ من نفقات المستشفيات تذهب إلى تصحيح الأخطاء الطبية التي يمكن تجنبها، أو معالجة العدوى التي يصاب بها الأشخاص في المستشفيات (3). 82 الفصل 3 الحالة العالمية لجودة الرعاية الصحية إطار 3-1 ليبيريا: تضمين الجودة في خطة العمل الصحية بعد تفشي فيروس إيبولا قبل تفشي فيروس الإيبولا في عام 4102، أحرزت ليبريا - وهي بلد يتعافى منذ سنوات من عدم الاستقرار السياسي والاقتصادي - تقدًما في تحسين النتائج الصحية لسكانها. ومع ذلك، سلط تفشي الوباء الضوء على العقبات المستمرة التي يواجهها النظام الصحي في هذه الدولة الصغيرة الواقعة في غرب أفريقيا، حيث كان يوجد نقص في القوى العاملة الصحية الماهرة بشكل كاف في المرافق الصحية وفي المجتمعات، ولم تكن هناك آليات تمويل مستدامة، وكان هناك غياب لهياكل سلاسل الإمداد الضرورية ونظم المعلومات الصحية المتكاملة؛ بالإضافة إلى ذلك، كانت الوقاية من العدوى ومكافحتها غائبة إلى حد كبير في معظم الأحيان، وكانت الروابط بين الخدمات الصحية والمجتمع غير كافية. وأدت نقاط الضعف هذه إلى الإخلال بتوفير خدمات عالية الجودة وسمحت للوباء بالانتشار بسرعة. واستجابة لتفشي الوباء، تم وضع خطة استثمار لبناء نظام صحي قوي في ليبيريا للفترة 5102-1202. وتهدف الخطة إلى استعادة المكاسب المفقودة بسبب تفشي الوباء، ومعالجة نقاط الضعف الموجودة مسبًقا، وتعزيز ثقة المجتمع في الأنظمة الصحية، وتوفير الأمن الصحي. ويتمثل أحد الأهداف الاستراتيجية الرئيسية لخطة الاستثمار في تسريع إمكانية الحصول الشامل على الخدمات الآمنة وذات الجودة من خلال تحسين قدرة الشبكة الصحية على توفير الخدمات الأساسية. وتعترف حكومة ليبيريا بأن التنفيذ الناجح لخطة الاستثمار – بما في ذلك التركيز القوي على جودة الرعاية – أمر ضروري لمنع تفشي الأمراض السارية في المستقبل والكشف عنها والتصدي لها. في اجتماع عام 7102 لوزراء الصحة بالبلدان التابعة لمنظمة التعاون الاقتصادي والتنمية، أقر الوزراء تقاطع خطط عمل الجودة والكفاءة، ووافقوا على أن قياس الجودة وتحسينها يجب أن يشكلا محور الجهود المبذولة لتحقيق النتائج الصحية بقيمة عالية مقابل المال (03). وللاستثمار في الأنظمة الصحية عالية الجودة من أجل تحقيق التغطية الصحية الشاملة القدرة على تسريع إحراز تقدم في تعزيز الصحة، إلى جانب تعزيز الأمن الصحي العالمي، وتحقيق أقصى قدر من القيمة مقابل المال. 3-2 تعريف جودة الرعاية جودة الرعاية هي الدرجة التي تُزيد بها الخدمات الصحية للأفراد والسكان من احتمالية النتائج الصحية المنشودة وتتوافق مع المعرفة المهنية الحالية (13). ويعني هذا التعريف أن جودة الرعاية يمكن قياسها، وأنها تستهدف في نهاية المطاف التحسينات الصحية بدًلا من مجرد زيادة مدخلات الخدمة أو تحسين عمليات النظم، وينبغي أن تعكس رغبات أصحاب المصلحة الرئيسيين، بما في ذلك مستخدمي الخدمة والمجتمعات المحلية. ومن خلال تضمين الخدمات الصحية بشكل عام، يمتد هذا التعريف لجودة الرعاية إلى كٍل من الرعاية العلاجية والوقائية والرعاية المجتمعية للأفراد والسكان. وهذا النطاق يكتسب أهمية خاصة في البلدان التي تواجه عبئًا متزايًدا من الأمراض غير السارية، والتي يجب على أنظمتها الصحية توفير الخدمات مدى الحياة، بما في ذلك الحد من المخاطر والتشخيص وإدارة الأمراض وإعادة التأهيل والرعاية الملطفة. ونظرا ًلوجود قاعدة أدلة متزايدة باطراد بشأن فعالية الطرائق المختلفة للوقاية من الأمراض ومكافحتها، فإن هذا التعريف لجودة الرعاية يعترف أيًضا بالحاجة إلى وجود آليات لإدراج أدلة جديدة في تقديم الخدمات بشكل منهجي. ماهي خصائص الخدمات الصحية التي تدل على الجودة؟ يحدد هذا التقرير سبع خصائص قابلة للقياس للخدمات الصحية التي تزيد من احتمالية تحقيق النتائج الصحية المنشودة وتتسق مع المعرفة المهنية الحالية. تقديم خدمة صحية عالية الجودة: ضرورة عالمية للتغطية الصحية الشاملة 92 المصدر: enicideM fo etutitsnI (23). شكل 3-2 عناصر جودة الرعاية الصحية الفعالية الإنصافدقة التوقيت الأمان الكفاءة التمحور حول السكان التكامل وفي حين تم وصف العديد من عناصر الجودة على مدى عقود، نجد ثمة اعتراف متزايد بأن الخدمات الصحية الجيدة في جميع أنحاء العالم يجب أن تكون فعالة وآمنة ومتمحورة حول الفرد. بالإضافة إلى ذلك، من أجل تحقيق فوائد الرعاية الصحية ذات الجودة؛ يجب أن تكون الخدمات الصحية وقتية ومنصفة ومتكاملة وذات كفاءة (شكل 3-2) (23 ، 33). ولننظر إلى فاطمة، وهي امرأة تبلغ من العمر 08 عاما ًعاشت بمفردها منذ تقاعدها قبل 51 عاما.ً تعاني فاطمة من داء السكري من النوع الثاني منذ فترة طويلة، وكذلك ارتفاع كوليسترول الدم وارتفاع ضغط الدم الأساسي. وهي تظل في المنزل غالبًا وتخرج لتتجول فقط من حين إلى آخر بسبب ضعف بصرها وآلام الظهر التي تعاني منها حديثًا. وخلال العامين الماضيين، تم إدخالها مرتين إلى المستشفى بسبب فشل عضلة القلب الاحتقاني. وهي لا تراقب ضغط الدم أو نسبة سكر جلوكوز الدم كما تم نصحها، وتأكل الوجبات السريعة، وقد فاتها العديد من مواعيد المتابعة منذ خروجها من المستشفى. واليوم، أتت فاطمة إلى العيادة تشتكي من صعوبة في التنفس، وتشعر بضيق في صدرها بشكل غير عادي، وتجد صعوبة في الاستلقاء. وقد ذكرت أيًضا وجود صعوبة في متابعة علاجها الشهري. وتلاحظ الممرضة أن فاطمة تكرر الكلام وتجد صعوبة في العثور على الكلمات المناسبة لوصف أعراضها. وعلى مدى الأسابيع الأربعة القادمة، ستتلقى فاطمة الرعاية من عدد لا يحصى من مقدمي الخدمات الصحية، بما في ذلك أخصائي التغذية، ومقدم الرعاية الأولية، وأخصائي أمراض القلب والأخصائي الاجتماعي. وتوضح النقاط التالية ما قد تبدو عليه الرعاية الصحية عالية الجودة لفاطمة من خلال منظور عناصر الجودة السبعة. • الرعاية عالية الجودة لفاطمة فعالة، وبالتالي؛ سيتم تقديمها بناًء على المعرفة العلمية والمبادئ التوجيهية القائمة على الأدلة. وسوف يلتزم فريق الرعاية بالمسارات السريرية للمرضى الأكبر سًنا المصابين بفشل في القلب والأمراض المصاحبة المتعددة، بناًء على الأدلة والخبرة في إدارة الحالات المماثلة. وسوف يُطمئن الفريق فاطمة بأنها سوف تتلقى رعاية قائمة على الأدلة وأنه سيتم اتباع عملية منهجية للتوصل إلى خطة إدارة متكاملة عبر مختلف مقدمي الرعاية الذين يعتنون بها. • الرعاية عالية الجودة لفاطمة آمنة، أي أنها تقلل من إلحاق الضرر بالمريض، بما في ذلك الإصابات التي يمكن الوقاية منها والأخطاء الطبية. وفي كل مرفق، سيكون هناك مبادئ توجيهية واضحة لمنع العدوى المكتسبة من المستشفيات والأخطاء الطبية. على سبيل المثال، تم إجراء مراجعة شاملة لعلاجها الخارجي عند الدخول لمنع التفاعلات مع الأدوية المستخدمة أثناء رعايتها داخليًا. الجودة 03 الفصل 3 الحالة العالمية لجودة الرعاية الصحية • الرعاية عالية الجودة لفاطمة تتمحور حول الفرد، أي أنها تحترم تفضيلاتها واحتياجاتها وقيمها وتستجيب لها. وقد تكون فاطمة قلقة وتطرح أسئلة كثيرة، وهذا أمر مفهوم؛ لذا سيقوم فريق الرعاية متعدد التخصصات بالاستماع إلى أسئلتها ومخاوفها، والإجابة بصبر، وسيتعاونون في وضع خطة لإدارة الرعاية بمشاركتها النشطة. • الرعاية عالية الجودة لفاطمة دقيقة التوقيت، أي أن التأخير في تقديم الخدمات وتلقيها سيكون إلى أدنى حد ممكن. على سبيل المثال، سيتم إدارة الاتصال بكل مقدم خدمات مشارك في رعايتها من خلال نظام كفء لتدفق المرضى من أجل تحديد مواعيد الزيارات أو تعديلها وإخطار العملاء بأوقات الانتظار المتوقعة. وسيتم التعرف على الحالات التي تتطلب تدخًلا عاجًلا ويتم التصرف بشأنها في أسرع وقت ممكن. ومع التخطيط السليم؛ لن تواجه فاطمة أوقات انتظار طويلة أثناء زيارات المتابعة. • الرعاية عالية الجودة بالنسبة لفاطمة منصفة، وبالتالي؛ فإن نوعية الرعاية التي تتلقاها لن تختلف باختلاف الخصائص الشخصية مثل النوع الاجتماعي والعرق والإثنية والموقع الجغرافي والحالة الاجتماعية والاقتصادية. وستعكس الخدمات التي تلقتها فاطمة الدليل على الفوائد الصحية المحتملة للعلاج فقط، ولا شيء آخر. • الرعاية عالية الجودة لفاطمة متكاملة، وبالتالي؛ سيتم تنسيق الرعاية التي تتلقاها عبر المرافق ومقدمي الخدمات. وبعد تقديم الرعاية، سيقوم الأخصائي الاجتماعي بتقييم الخيارات لدعم خطة الرعاية الخاصة بها، وربطها بالجهات التي تقدم الرعاية المتعلقة بالخرف وخدمات أخرى حسب الحاجة. • الرعاية عالية الجودة لفاطمة تتسم بالكفاءة، وبالتالي؛ تتجنب إهدار الموارد، بما في ذلك المعدات والأدوية والطاقة والأفكار. وسيكون بمقدور كل من مقدمي الخدمات الطبية لديها متابعة الاختبارات والإجراءات السابقة التي أجرتها عبر نظام السجلات الطبية الإلكترونية القابل للتشغيل المتبادل، مما يَُحول دون تكرار الموارد وإهدارها. وسيكون استخدام الأدوية الجنيسة منصوًصا عليه في المبادئ التوجيهية السريرية. وسيتم توفير الرعاية لها من قبل فريق مترابط، يعمل كل من أفراده وفًقا لنقاط قوته ويأخذ على عاتقه المهام التي تتناسب مع كفاءاته. وباختصار؛ فإن الرعاية الصحية عالية الجودة هي الرعاية المناسبة، في الوقت المناسب، بطريقة منسقة، والتي تستجيب لاحتياجات وتفضيلات مستخدمي الخدمات، مع التقليل إلى أدنى حد من الأضرار وإهدار الموارد. وتهدف الرعاية الصحية عالية الجودة في نهاية المطاف إلى زيادة احتمالية النتائج الصحية المنشودة. ويدرك السعي للحصول على رعاية صحية عالية الجودة أن هذا التحسين هو عملية مستمرة أو ديناميكية وليست ثابتة. وبغض النظر عن مستوى دخل البلد؛ إذا كان هناك مجال لتحسين النتائج الصحية، يمكن أيًضا زيادة جودة الرعاية. 3-3 الصورة العالمية لجودة الرعاية الصحية يتطلب تقييم الاتجاهات في الحالة العالمية لجودة الرعاية الصحية التوافق في الآراء بشأن تعريف الجودة وقياس مؤشراتها، التي يمكن مقارنتها بين البلدان. ومع ذلك، لا توجد مجموعة بيانات ذات مؤشرات نوعية محددة بشكل موحد يتم جمعها عالميًا. كما لا يوجد اتفاق على مجموعة دنيا من المؤشرات الموحدة لجودة الرعاية لرصد التقدم نحو تحقيق أهداف التنمية المستدامة المتعلقة بالصحة عبر البلدان. ومع ذلك، هناك كم متزايد من العمل الذي يهدف إلى تحديد المؤشرات لدعم جهود تحسين الجودة الوطنية والإقليمية والدولية، بما في ذلك مشروع مؤشرات جودة الرعاية الصحية التابع لمنظمة التعاون الاقتصادي والتنمية، ومؤشرات تقديم الخدمات الخاصة بالبنك الدولي والمرصد الصحي العالمي التابع لمنظمة الصحة العالمية والمسوحات السكانية والصحية (43–73). وباستخدام بيانات من هذه المصادر، ومن الدراسات الاستقصائية للأسر المعيشية الممثلة وطنيًا، والبحوث التجريبية، يرد وصف لحالة جودة الخدمات الصحية على الصعيد العالمي أدناه. تقديم خدمة صحية عالية الجودة: ضرورة عالمية للتغطية الصحية الشاملة 13 ويركز هذا الوصف تركيزًا كبيرًا على مقاييس العمليات والنتائج لجودة الرعاية - أي الإجراءات في مجال الرعاية الصحية وتأثيرات هذه الإجراءات على النتائج الصحية المنشودة - ويتم فحص هذه التدابير فيما يتعلق بالمجالات السبعة لجودة الرعاية: الفعالية، والسلامة، والتمحور حول الفرد، ودقة التوقيت، وتكامل الرعاية، والإنصاف، والكفاءة. كما تتناول المؤلفات العلمية والسياساتية التدابير الهيكلية لجودة الرعاية التي تشكل سياق تقديم الخدمات، بما في ذلك المعدات والموارد البشرية والحوافز والهيكل التنظيمي (83). ويعتبر هذا التقرير أن العوامل البنيوية هي أسس عمليات ونتائج الرعاية عالية الجودة. ويتناول الفصل الرابع أسس الرعاية عالية الجودة. 3-3-1 هل الخدمات الصحية فعالة؟ عندما تكون الرعاية غير فعالة، أي عندما لا يلتزم مقدمو الخدمات بالإرشادات المبنية على الأدلة، قد يعكس هذا نقًصا في المعرفة بالمبادئ التوجيهية أو عدم الامتثال بغض النظر عن المعرفة. ويمكن تقييم فعالية الرعاية باستخدام فحص السجلات الطبية، ومقابلات المرضى عند الخروج، والرصد المباشر للتفاعل بين مقدم الخدمة والعميل، والمرضى المعياريين أو بطاقات الاختبار الإكلينيكية. وفي حين تقيس بطاقات الاختبار الإكلينيكية مدى معرفة مقدم الخدمة بالبروتوكولات القائمة على الأدلة لحالات طبية محددة؛ هناك أشكال أخرى للقياس تتابع في الغالب مدى الامتثال لهذه المبادئ التوجيهية. على وجه الخصوص، يقدم المرضى المعياريون حالات مرضية متسقة لمقدمي الرعاية ويسمحون بإجراء مقارنة جودة الرعاية بين مقدمي الخدمات. وهذه الطريقة من قياس الفعالية تخلو من الملاحظة والانحياز للتذكر (93). إن الاختلافات في الأمراض السائدة عبر البلدان والتغيرات في الأعراض السريرية للأمراض تعيق المقارنة المنهجية لفعالية الرعاية عبر مقدمي الخدمات والبلدان. ومع ذلك؛ فإن هناك مجموعة متزايدة من الأدلة تشير إلى وجود فجوات في فهم مقدمي الخدمات للمبادئ التوجيهية القائمة على الأدلة في البلدان ذات الدخل المرتفع والمتوسط والمنخفض والامتثال لها. على سبيل المثال، في كينيا، ٪61 فقط من مقدمي خدمات الرعایة شخصوا بشكل صحيح جميع الحالات المرضية الخمسة التي عرضت في بطاقات الاختبار الإكلينيكية لتقييم معرفة مقدم الخدمة (الشكل 3-3) (04). وفي دراسة أجراها أطباء في جمهورية مقدونيا اليوغوسلافية السابقة وفي الولايات ا لمتحدة الأمريكية، كانت النسبة المئوية المتوسطة للتشخيص الصحيح بالنسبة إلى أربعة بطاقات اختبار إكلينيكية 84٪ و76٪ على التوالي (14). وبغض النظر عن طريقة القياس، هناك أيًضا فجوة كبيرة بين معرفة مقدم الخدمة والممارسة الفعلية في نطاق تقديم الخدمات. وتوجد هذه النتيجة عبر البلدان، بما في ذلك الدنمارك والهند وكينيا وهولندا وجمهورية تنزانيا المتحدة (24-54). شكل 3-3 عدد بطاقات الاختبار السريرية التي يتم تشخيصها تشخيًصا صحيًحا من جانب مقدمي الخدمات الكينيين (العدد الإجمالي لبطاقات الاختبار: خمسة) المصدر: iazdihmiP dna nitraM (14) 4 حالات 5 حالات عدد بطاقات الاختبار السريرية حالة واحدة 3 حالات حالتان 23 الفصل 3 الحالة العالمية لجودة الرعاية الصحية 3-3-2 هل الخدمات الصحية آمنة؟ إن إلحاق ضرر بالمريض هو المساهم الرئيسي الرابع عشر في العبء العالمي للأمراض. ويقع القسم الأعظم من هذا العبء على عاتق البلدان المنخفضة والمتوسطة الدخل (شكل 3-4) (41). وتختلف الأسباب الرئيسية لإلحاق الضرر بين الأوضاع، بما في ذلك أخطاء المداواة والأخطاء التشخيصية في الرعاية الأولية، والإصابات جراء الضغط والأحداث الضائرة في الرعاية طويلة الأجل، والعدوى المكتسبة من المستشفيات والجراحات في الموقع الخاطئ في الجسم في المستشفيات (64-84). إن حجم الأحداث غير الآمنة في الخدمات الصحية كبير (41). وبالإضافة إلى التكلفة المباشرة لمعالجة الأحداث الضائرة، هناك تكاليف إضافية تنتج عن فقدان الإنتاجية وتقلص الثقة في النظام الصحي. ويعزى حوالي 51٪ من نفقات المستشفيات وأنشطتها في دول منظمة التعاون الاقتصادي والتنمية إلى الإخفاق في تحقيق السلامة. ومع ذلك، يمكن منع العديد من الأحداث الضائرة. وتشير الدلائل إلى أن أكثر من حدث من كل ثلاثة أحداث ضائرة في البلدان المنخفضة والمتوسطة الدخل يحدث في حالات غير معقدة وما يصل إلى 38٪ منها يمكن منعه (94). كما تتجاوز تكاليف الفشل في تحقيق السلامة تكلفة الوقاية. ويُقّدر أن تحسين سلامة المرضى في مستشفيات ميديكير في الولايات المتحدة قد وفر 82 مليار دولار أمريكي بين عامي 0102 و 5102. شكل 3-4 عبء الأمراض الناجم عن الأحداث الضائرة، 5102 ملاحظة: النسبة المئوية لمتوسط سنوات العمر المعدلة باحتساب مدد العجز / البلد. المصدر: noitaulavE dna scirteM htlaeH fo etutitsnI، 5102. %81 دخل مرتفع دخل منخفض دخل متوسط اعلى دخل متوسط ادنى %91 %52 %83 3-3-3 هل تتمحور الخدمات الصحية حول الفرد؟ تختلف الدرجة التي تدمج بها احتياجات وتفضيلات مستخدمي الخدمات بشكل منهجي في الخدمات الصحية بين البلدان ذات الدخل المرتفع والمتوسط والمنخفض. وقد استحدثت النظم الصحية في البلدان ذات الدخل المرتفع تدابير ومؤسسات لرصد تجارب المرضى وتصوراتهم بشأن حالاتهم الطبية المحددة وصحتهم العامة. وفي حين تتباين التوقعات والنُُّهج المتعلقة بالرعاية التي تتمحور حول الفرد بين البلدان، فإن معظم مستخدمي الخدمات في البلدان التابعة لمنظمة التعاون الاقتصادي والتنمية يبلغون عن تجربة إيجابية فيما يتعلق بالوقت الذي يتم قضاؤه مع مقدم الخدمة، والتفسيرات سهلة الفهم، والفرص للتعبير عن الاهتمام، والمشاركة في رعايتهم (شكل 3-5) (05). والاهتمام بتقديم رعاية محترمة ورحيمة ومتمحورة حول الفرد ليس سائدا ً في البلدان منخفضة ومتوسطة الدخل. على سبيل المثال، تشير مجموعة متنامية من الأبحاث بشأن تقديم رعاية تتسم بالاحترام للأمهات إلى معاناة النساء من تفاعلات ضعيفة مع مقدمي الرعاية الصحية ومن استبعادهن من اتخاذ القرار في مجال الرعاية، وغالبًا لا يتم إبلاغهن بتفاصيل رعايتهن (15، 25). تقديم خدمة صحية عالية الجودة: ضرورة عالمية للتغطية الصحية الشاملة 33 شكل 3-5 تقديم الطبيب لتفسيرات سهلة الفهم (3102 أو أقرب عام) 3-3-4 هل يتسم تقديم الخدمات الصحية بدقة التوقيت؟ لقد تبين أن أوقات الانتظار للإجراءات الاختيارية والطوارئ تنبئ بالرضا بين مستخدمي الخدمات (35-55)؛ ففي حالات الطوارئ، قد يؤدي التأخير في تلقي العلاج المناسب إلى حدوث وفيات يمكن منعها (65). ومع ذلك، تختلف أوقات الانتظار لمختلف الخدمات الصحية باختلاف بلدان منظمة التعاون الاقتصادي والتنمية. على سبيل المثال، في عام 5102، كان متوسط وقت الانتظار لاستبدال مفصل الورك حوالي 24 يوًما في هولندا، ولكنه 092 يوًما في إستونيا، وأكثر من 004 يوم في تشيلي وبولندا. وتبين الاتجاهات الزمنية أنه حدث تخفيض في وقت الانتظار في فنلندا ونيوزيلندا في حين أن هذا الاتجاه قد تقارَب في السنوات الأخيرة، مع استقرار نسبي في المعدلات منذ عام 8002 في العديد من البلدان، مثل الدنمارك والمملكة المتحدة لبريطانيا العظمى وأيرلندا الشمالية (شكل 3-6) (2). وتم القيام بعمل أقل بكثير لمقارنة التأخيرات في تقديم الخدمات في البلدان منخفضة ومتوسطة الدخل. وتشير الأبحاث التجريبية من فرادى البلدان إلى أن فترات الانتظار طويلة نسبيًا. على سبيل المثال، في دراسة لدائرة الطوارئ في بربادوس، كان مطلوبًا عشر دقائق في المتوسط لفرز المرضى، و312 دقيقة للنتائج المخبرية، و871 دقيقة ليتم رؤيتها من جانب أحد الأطباء (75). وأيًضا في قسم العيادات الخارجية في نيجيريا، انتظر 47٪ من مستخدمي الخدمات بين 06 و021 دقيقة ليتم تسجيلهم، وانتظروا وقتًا إضافيًا لرؤية أحد مقدمي خدمات الرعاية (85). لوكسمبورج1 بلجيكا1 البرتغال1 نيوزيلاندا1 المملكة المتحدة2 ألمانيا2 أستراليا2 الولايات المتحدة2 هولندا2 النرويج2 كندا2 جمهورية التشيك1 سويسرا2 السويد2 إسرائيل1 فرنسا2 إستونيا1و2 أسبانيا1و2 بولندا1و2 منظمة التعاون الاقتصادي والتنمية 91 المعدلات حسب العمر لكل 001 مريض المصدر: yevruS yciloP htlaeH lanoitanretnI dnuF htlaewnommoC لعام 3102 ومصادر وطنية أخرى. ملحوظة: %59 فواصل ثقة يمثلها حرف (H) 1. الموارد الوطنية 2. تشير البيانات إلى تجارب المرضى مع الطبيب المعتاد. 001 08 06 04 02 0 9.74 1.26 4.76 8.87 7.97 5.08 3.18 4.18 8.18 0.38 3.38 9.38 9.38 0.68 7.78 0.88 2.88 9.09 1.59 5.59 43 الفصل 3 الحالة العالمية لجودة الرعاية الصحية 3-3-5 هل الخدمات الصحية منصفة؟ توجد فجوات في جودة الرعاية الصحية في كل مكان في العالم، ولكنها أكثر خطورة بالنسبة للسكان المحرومين، فقد تتبعت تقارير التفاوتات في الرعاية الصحية الوطنية في الولايات المتحدة جودة الرعاية منذ عام 0102. وفي عام 5102، لم تظهر نصف معايير الجودة أي تغيير، أو أظهرت انخفاًضا في مستوى الجودة بين السكان ذوي الدخل المنخفض. ولم يظهر أكثر من نصف حجم الجودة المقاسة أي تغيير أو تفاقم بالنسبة لسكان الريف (95). وفي كندا، كان المرضى الذين يعانون من احتشاء عضلة القلب من مجموعات السكان الأصليين أقل تلقيًا للعلاج الموصى به، بما في ذلك تصوير الأوعية القلبية وإجراءات إعادة التوعي (06). وفي كينيا، تعد جودة الخدمات الصحية المقدمة للأمهات في أدنى مستوياتها في المقاطعات الفقيرة، حيث لم تحصل سوى 71٪ من النساء على الحد الأدنى الكافي من الرعایة عند الولادة (شکل3-7) (16). وأيًضا؛ في الهند فإن الأشخاص الذين يعيشون في أسر ذات وضع اجتماعي اقتصادي منخفض في المجتمعات الفقيرة يقل احتمال استخدامهم لمقدمي خدمات الرعاية الصحية المطلعين (26). المصدر: 7102 ecnalg a ta htlaeH (2). المصدر: la te amrahS (36). شكل 3-6 الاتجاهات في متوسط أوقات الانتظار لاستبدال مفصل الورك شكل 3-7 الجودة الهيكلية وجودة عملية خدمات الأمومة حسب مستوى الفقر في المقاطعات في كينيا درجة جودة البنية الجودة الأساسية لرعاية الأمومة جودة الرعاية السابقة للولادة جودة الرعاية عند الولادة الفقر الفقر الفقر الفقر الفقر الأيام فنلندا المملكة المتحدة الدنمارك نيوزيلاندا تقديم خدمة صحية عالية الجودة: ضرورة عالمية للتغطية الصحية الشاملة 53 3-3-6 هل الخدمات الصحية متكاملة؟ مع ظهور الأمراض المزمنة وغير السارية، يعيش المزيد من الأشخاص في ظل العديد من الظروف المزمنة والمعقدة والتي تتطلب تنسيق الرعاية على جميع المستويات وطوال جميع مراحل حياتهم. ويمكن لاستمرارية الرعاية وتنسيقها أن يحسنا من تجربة رعاية الأشخاص الذين يعيشون مع هذه الظروف ويدعما احتياجاتهم. ومع ذلك، توجد فجوات كبيرة في تنسيق الرعاية الصحية، حتى في البلدان مرتفعة الدخل، فقد وجدت دراسة استقصائية للمرضى ذوي احتياجات الرعاية المعقدة في 11 دولة من الدول مرتفعة الدخل مشاكل في التنسيق، مثل نتائج الاختبارات أو السجلات غير المتوفرة في المواعيد أو اختبارات مكررة تم طلبها، وعدم قيام مقدمي الخدمات بمشاركة معلومات مهمة معهم، وعدم توافر معلومات للمتخصصين عن التاريخ الطبي أو عدم إبلاغ الأطباء المعتادين عن تلقي رعاية اختصاصية (36). وقد أفاد تحليل لبيانات الرعاية الأولية والرعاية الثانوية بشأن الأشخاص كبار السن (الذين تتراوح أعمارهم بين 26 و28 سنة) من 002 من الممارسات العامة في إنجلترا أن المرضى الذين رأوا نفس الممارس العام نسبة أكبر من الوقت يشكلون عدًدا أقل من حالات الدخول إلى المستشفى للرعاية الإسعافية للحالات الحساسة (46). 3-3-7 هل الخدمات الصحية ذات كفاءة؟ لقد قدر تقرير الصحة العالمي عام 0102 أن حوالي ٪04-02 من جميع موارد القطاع الصحي ُمهدر (56). وتشمل الأسباب الرئيسية لعدم الكفاءة في تقديم الخدمات الاستخدام غير الملائم للأدوية، ومزيج الموارد البشرية دون المستوى الأمثل، والإفراط في استخدام المعدات أو زيادة المعروض منها، والفساد، وعدم استخدام البنية التحتية استخداًما كافيًا. ويوفر التباين الجغرافي غير المبرر في انتشار الإجراءات وكثافة الرعاية تقديرًا غير مباشر للإفراط في الاستخدام وبالتالي عدم الكفاءة. على سبيل المثال، تبلغ نسبة استخدام المضادات الحيوية للإسهال الحاد في الهند في المرافق الصحية العامة 34٪ ولكنها ترتفع إلى 96٪ في المرافق الخاصة. أيًضا، هناك تباين يبلغ تسعة أضعاف في استخدام التدخلات لرأب الشريان التاجي بطريق الجلد على المستوى الدولي، وتباين يبلغ خمسة أضعاف في استخدام طُْعم َمجازَة الشريان التَّاجي عبر بلدان منظمة التعاون الاقتصادي والتنمية (66). ولا يتم تفسير هذه الاختلافات من خلال التباين في عبء الأمراض القلبية الوعائية. والرعاية الصحية غير الفعالة بسبب الاستخدام المفرط وغيره من الأسباب لها آثار سلبية على النتائج الصحية للسكان. ويمكن زيادة متوسط العمر المتوقع عند الولادة بأكثر من عامين في المتوسط في بلدان منظمة التعاون الاقتصادي والتنمية مع الحفاظ على الإنفاق على الرعاية الصحية ثابتًا إذا اتسمت جميع البلدان بالكفاءة كالبلدان التي حققت أفضل النتائج (76). 3-4 الخلاصة على الرغم من الزيادة الكبيرة في إمكانية الحصول على الخدمات الصحية الأساسية التي تحققت خلال عصر الأهداف الإنمائية للألفية؛ فإن هناك مستويات عالية من الوفيات والمرض مما يمكن مكافحته ومعالجته من خلال بذل الجهود في مجال الجودة. على سبيل المثال، العبء المتبقي لوفيات الأمهات والأطفال في البلدان المنخفضة والمتوسطة الدخل يعزى إلى حد كبير إلى سوء نوعية الخدمات الصحية. وتدرج أهداف التنمية المستدامة بشكل واضح التركيز على جودة الخدمات الصحية في تحقيق التغطية الصحية الشاملة في جميع البلدان. وتشمل الخدمات الصحية عالية الجودة الرعاية المناسبة، في الوقت المناسب، والاستجابة لاحتياجات وتفضيلات مستخدمي الخدمات، إلى جانب التقليل إلى أدنى حد من إلحاق الضرر أو إهدار الموارد. وتزيد الرعاية الصحية النوعية من احتمالية النتائج الصحية المنشودة وتتسق مع السبع خصائص القابلة للقياس: الفعالية، والسلامة، والتمحور حول الفرد، ودقة التوقيت، والإنصاف، وتكامل الرعاية، والكفاءة. وبغض النظر عن مستوى دخل البلد، إذا كان هناك مجال لتحسين النتائج الصحية، يمكن أيًضا زيادة جودة الرعاية. وستكون الجهود المبذولة لرصد الاتجاهات في جودة الرعاية الصحية بجدول أعمال التنمية المستدامة غير فعالة في غياب توافق الآراء بشأن المؤشرات الرئيسية التي يمكن مقارنتها بين الدول وجمعها على أساس منتظم. وتشير الأدلة التجريبية من مجموعة العمل المتزايدة بشأن قياس الجودة إلى وجود ثغرات على مستوى العالم في جميع مجالات الخدمات الصحية ذات الجودة، وتوفر هذه الفجوات فرًصا لتحسين جودة الرعاية وصحة السكان. 63 السيد بافانا مسيبي، المدير التنفيذي لفحص الامتثال، مكتب الامتثال للمعايير الصحية جنوب أفريقيا "في أي نظام صحي، التمريض هو العمود الفقري للنظام"، كما يقول بافانا مسيبي، المدير التنفيذي لفحص الامتثال في مكتب الامتثال للمعايير الصحية في جنوب أفريقيا. "في بلدنا على وجه الخصوص، وفي بلدان أخرى في أفريقيا، التمريض هو المحرك للرعاية الصحية الأولية". وبصفته مسئوًلا تنفيذيًا في مجال الرعاية الصحية يتمتع بخبرة تزيد عن 51 عاًما، ويعمل لدى جهة مستقلة تتمثل مهمتها في ضمان جودة الرعاية والامتثال للمعايير الصحية في كل من مرافق الرعاية الصحية العامة والخاصة، فإن بافانا مسيبي في وضع جيد لتقييم الإسهامات المهمة التي يقدمها التمريض لجودة الرعاية الصحية. وهو يعرّف جودة الرعاية باختصار بأنها: "الاستفادة من الموارد المتاحة لتقديم أفضل رعاية للمستخدمين"، ويقر مسيبي بأن الرعاية الجيدة للمرضى تتطلب اتباع نهج شامل يتجاوز أحيانًا العلاج السريري. ويقول: "قد ترى مريضة تعاني من أعراض، وأثناء محاولتك علاجها، قد تجد أن هذه الأعراض ناتجة عن الإجهاد". ولأن طاقم التمريض يقضي وقتًا أطول مع المرضى أكثر من أي أطباء آخرين، فإن دورهم مهم للغاية. بالإضافة إلى ذلك، فهم يشاركون مشاركة مباشرة في تنفيذ التدابير الاحترازية التي تعزز بيئة طبية آمنة في عملهم اليومي. وفي جنوب أفريقيا، يتعين على جميع أفراد طاقم التمريض المسجلين أن يقضوا سنة من الخدمة المجتمعية بعد إكمالهم دراستهم لمدة أربع سنوات. وبعملهم تحت إشراف المهنيين من ذوي الخبرة الذين يقومون بإرشادهم، يتعرض الخريجون الجدد لمجموعة واسعة من القضايا الطبية. كما يطورون فهًما راسًخا للمجتمعات التي يخدمونها. والمعرفة والمهارات التي يكتسبها أفراد التمريض الصغار خلال هذه الفترة تعدهم جيًدا لتلبية متطلبات مهنتهم. ويقول مسيبي: "عندما كنت صغيرًا، كنت أعمل في عيادة في منطقة ريفية. وإذا جاء المرضى الذين يعانون من مشكلة تتطلب المستوى التالي من الرعاية، فإننا نحيلهم إلى الطبيب أو نستدعي سيارة إسعاف لنقلهم إلى المستشفى. وهناك عيادات في معظم المناطق، وحيث لا توجد عيادات، تقوم العيادات المتنقلة بإجراء زيارات. ومعظم هذه العيادات يديرها التمريض". تعريفي للجودة تقديم خدمة صحية عالية الجودة: ضرورة عالمية للتغطية الصحية الشاملة 73 ويشغل بعض أفراد التمريض في جنوب أفريقيا وظائف رفيعة المستوى كرؤساء تنفيذيين في المستشفيات أو مديري مقاطعات - حسب قول مسيبي -؛ لكن هناك حاجة إلى المزيد منهم في المناصب القيادية. ويضيف: "إن مهنة التمريض تحتاج إلى إنتاج قادة لنظام الرعاية الصحية. ويجب إنتاجهم من خلال النظام، ومعرفتهم به بحذافيره، ويجب عليهم أيًضا فهم عمليات تطوير السياسات داخل النظام". بافانا مسيبي، الذي كان قادًرا على إجراء دراسة في مستشفى حكومي عندما كان يدرس للحصول على درجة الماجستير في الصحة العامة، يود أن يتمتع المزيد من أفراد التمريض بفرص مماثلة لإجراء الأبحاث، ويعتقد أنه بوجود عدد أكبر من أفراد التمريض الذين يشاركون في صنع السياسات كأعضاء في اللجان الاستشارية؛ فإن اللجان والمجالس سوف تسهم أيًضا في إجراء المزيد من التحسينات في جودة الرعاية. ويتفاوض حاليًا مكتب مسيبي للامتثال للمعايير الصحية بشأن مذكرة تفاهم مع مجلس التمريض الجنوب أفريقي وجهات أخرى تمثل المهن الطبية لتعزيز التعاون في الخدمات الصحية. ويمكن لإجراء عمليات تفتيش مشتركة على المستشفيات، على سبيل المثال، أن يزيد من الكفاءة ويساعد على دعم مستويات مرتفعة من الرعاية، يقول مسيبي: "عندما نطور نماذج وأطر لتحسين الجودة، يجب أن نتأكد من أنها تتضمن كل شخص وتضع قيم المهنة في المقدمة". ويضيف: "في النهاية؛ نحن مهتمون جميًعا بتقديم الرعاية ذات الجودة، وإذا كنت ترغب في الحصول على الجودة، عليك التأكد من وجود فريق عمل جيد". kcotSi / ttelpnar © :egap suoiverp no egamI

تقديم خدمة صحية عالية الجودة: ضرورة عالمية للتغطية الصحية الشاملة 93 النظم الصحيةدمج الجودة في أسس الفصل4 04 دمج الجودة في أسس النظم الصحية الفصل 4 4-1 المقدمة تشكل الخدمات رديئة الجودة عائًقا أمام تحقيق تغطية صحية شاملة فعالة حتى لو أتيحت بتكلفة معقولة؛ وذلك لأن المجتمعات لن تستخدم الخدمات التي لا تثق بها والتي لا تعود بالنفع عليهم؛ لذا يجب تضمين آليات لضمان الجودة ورصدها وتحسينها باستمرار في أسس أنظمة الرعاية الصحية. يتناول هذا الفصل خمسة أسس ضرورية لأية خدمة صحية: العاملون بالرعاية الصحية، وخدمات الرعاية الصحية، والأدوية والأجهزة وغيرها من التقنيات، ونظم المعلومات، والتمويل. ومجرد توافر الموارد لا يكفي؛ بل يلزم بذل جهود واعية ومتواصلة لضمان استخدامها بطرق فعالة وآمنة إلى جانب تصميمها بما يناسب احتياجات كل مريض على حدة. وسوف يستعرض الفصل التالي تصريف الشؤون، فضًلا عن الأدوات والتقنيات والاقتصاد السياسي للإصلاح. وجود نظام شامل للرعاية يتيح للناس الحصول على رعاية مستمرة طوال حياتهم تشمل تعزيز الصحة، والوقاية من الأمراض، والتشخيص، والعلاج، وإدارة المرض، وإعادة التأهيل، والدعم العاطفي والروحاني، والرعاية الملطفة. وهناك ثلاثة اعتبارات مهمة ينبغي أن يستند إليها تصميم أي نظام للرعاية الصحية: يجب بناء الخدمات على نحو يلبي الاحتياجات المحلية؛ ويجب أن تكون الرعاية الأولية عالية الجودة والتي يسهل الحصول عليها هي حجر الأساس لجميع الخدمات الأخرى؛ كما ينبغي إشراك الأفراد والمجتمعات في تصميم كل خدمة وأسلوب تقديمها وتقييمها وتحسينها (86). ويجب أن تكون مبادئ تحسين الجودة ركيزة لجميع الأنشطة بدًءا من الخط الأمامي وصوًلا إلى مستوى النظام. 4-2 أسس لرعاية عالية الجودة 4-2-1 العاملون في مجال الرعاية الصحية الذين لديهم الدافع والدعم لتوفير الرعاية الجيدة إن الأطباء المهرة والممرضات وغيرهم من العاملين في مجال الرعاية الصحية ضروريون لتقديم رعاية صحية عالية الجودة للأفراد والعائلات والمجتمعات. إذ يوجد حاليًا عجز عالمي يقدر بنحو 5.2 مليون طبيب، و9ملايين ممرضة وقابلة، و6ملايين من المهنيين الصحيين ذوي الصلة. ونتيجة لذلك، غالبًا ما تكون الرعاية الأساسية غائبة أو لا تُقدم على نحو سليم (96). وتشتد المشكلة في الدول الأكثر فقرًا (الشكل 4-1). وحتى في الاقتصادات المتقدمة، غالبًا ما يتركز العاملون بالمجال الصحي في المدن، مما يؤدي في الغالب إلى تدني نوعية الرعاية في المناطق الريفية والنائية. وحتى داخل المدن، تعاني بعض المواقع - مثل الأحياء الفقيرة - من نقص خاص في العاملين بالمجال الصحي. يمكن للعاملين في مجال الصحة المجتمعية المساعدة في تخفيف النقص في القوى العاملة. فهم أفراد تم تدريبهم على تقديم خدمات رعاية صحية محددة، أو للقيام بمراقبة الأمراض السارية أو غير السارية وعلاجها. وعادة ما يأتون من المجتمعات التي يخدمونها، وبالتالي يقدمون حلقة وصل محتملة لجهود المشاركة المجتمعية. ويستطيع العاملون في مجال الصحة المجتمعية التغلب على الحواجز الثقافية واللغوية، مع التوسع في الحصول على الرعاية وتوفير أشكال جديدة من العمالة. وتظهر الأدلة أن العاملين في مجال الصحة المجتمعية قادرون على توفير رعاية آمنة وفعالة لأمراض الطفولة، والحد من انتشار الأمراض السارية وغير السارية، وتعزيز التغذية، وتوفير خدمات تنظيم الأسرة، بتكلفة منخفضة (07). وفي الأماكن منخفضة الموارد، خفض العاملون في مجال الصحة المجتمعية وفيات الأمهات والأطفال حديثي الولادة (17). وتبين أكثر من 05 سنة من الخبرة في البرامج أن هذه الوظائف يجب أن تكون مقابل أجر، وليست تطوعية، وأن تكون المسؤوليات محددة وليست واسعة النطاق، وأن توفر التدريب والتعليم والإشراف المستمر، وأن يتم دمجها في فرق الرعاية الصحية الأولية؛ وأن تكون جزًءا من حلقات التغذية الراجعة (27). تقديم خدمة صحية عالية الجودة: ضرورة عالمية للتغطية الصحية الشاملة 14 الشكل 4-1 التوزيع العالمي للأخصائيين الصحيين المهرة وكثافتهم وفًقا للإقليم بمنظمة الصحة العالمية، 5002-6102 المصدر: yrotavresbO htlaeH labolG (43) إن توافر الموظفين في حد ذاته لا يضمن رعاية جيدة؛ فقد يقضى العاملون في مجال الصحة القليل من الوقت مع المرضى، أو لا يمتلكون المقدرة على إجراء التشخيص الصحيح، أو يصفون العلاج غير المناسب (37). وقد قضى الأطباء في المناطق الريفية في جنوب الصين ما يعادل 6.1 دقيقة فقط من التشاور مع المرضى وألقوا عليهم ٪81 فقط من الأسئلة الأساسية. كما تم تقديم التشخيص الصحيح تماًما في واحدة فقط من كل أربع استشارات (44). بالإضافة إلى عدد العاملين في المجال الصحي، هناك جوانب مهمة أخرى تشمل ما يلي: • إمكانية الحصول على الخدمة، أو مدى سهولة مقابلة أخصائي الرعاية الصحية ذا المهارات المناسبة أو التحدث إليه، سواًء شخصيًا أو عبر روابط الفيديو أو الهاتف. • القبول، أو ما إذا كان الناس يشعرون أنهم عوملوا باحترام وأن وجهات نظرهم قد أُخذت بعين الاعتبار عندما يتعلق الأمر بالقرارات المتعلقة بصحتهم. • الجودة، أو المعرفة والمهارات وسلوك العاملين بالمجال الصحي وفقا للقواعد المقبولة، وكما يراها المستخدمون. • مزيج المهارات والعمل الجماعي، أو ما إذا كانت مجموعة الأخصائيين الصحيين (وفي بعض الأحوال، العمال العاديين) لديهم المعرفة والمهارات اللازمة للتعامل مع أنماط الوفيات والمراضة المحلية. • تهيئة البيئات المواتية، أو الظروف المادية والقانونية والمالية والتنظيمية والسياسية والثقافية التي تدعم تقديم رعاية ذات جودة عالية. أفريقيا أوروبا ي ند ور ب مر لق ر ا جز ريا ريت إ ية وائ ست الا يا غين تو سو لي ان ود س ال ب نو ج ي سيب رين وب ي وم و ت سا جر لني ا بيا يو إث قيا فري ط أ س و ية ور مه ج ون الي سير ي لاو ما اد ش ت قر ش دغ م جو تو زر ج ال نغ س ال نيا غي نيا نزا ة ت وري مه ج ق مبي وز م ريا يبي ل ي مال ون مير كا ال اج لع ل ا اح س سو فا نا كي ور ب او س بي يا غين دا غن أو ين بين نيا يتا ور م دا وان ر بيا ام ز انا غ غو ون ك ال ية ور مه ج غو ون ك ال ي بو مبا زي ند لا ازي سو ولا نج أ بيا ام غ نيا كي ريا جي ني ضر لأخ س ا لرأ ا انا سو وت ب ائر جز ال بيا مي نا ون جاب ال س يو ش وري م شل سي قيا فري ب أ نو ج التوزيع حسب البلد (في منطقة منظمة الصحة العالمية المختارة) الكثافة لكل 000 01 نسمة كثافة الأخصائيين الصحيين المهرة المتوسط العالمي 8.25 شرق البحر المتوسط غرب المحيط الهادئ الأميركتان جنوب شرق آسيا الكثافة لكل 000 01 نسمة 24 دمج الجودة في أسس النظم الصحية الفصل 4 إطار 4-1 دراسة حالة: تدريب العاملين في مجال الرعاية الصحية واستبقائهم في المناطق المحرومة من الخدمة في الفلبين تركز كليتا طب في الفلبين بشكل أساسي على اختيار الطلاب في المناطق المحرومة من الخدمات في البلاد وتدريبهم وتوظيفهم. كلية الطب في جامعة أتينيو دي زامبوانغا وكلية مانيلا للعلوم الصحية فى جامعة الفلبين هما جزء من شبكة التدريب من أجل العدالة في الصحة (teNEHT). وتنص هذه الشبكة الدولية من كليات الطب على ضرورة دمج احتياجات المجتمعات المحرومة من الخدمات في جميع مراحل التعليم الطبي وجوانبه، من الموقع الفعلي للكلية إلى المشاكل الصحية التي توجه المناهج الدراسية. أيًضا، يجب أن يكون هناك اعتماد على الممارسين الصحيين المجتمعيين في التدريس والإرشاد. افتُِتَحت كلية الطب في جامعة أتينيو دي زامبوانغا في عام 4991 في مدينة زامبوانغا، على الطرف الجنوبي الغربي من أقصى جنوب الجزر الفلبينية، حاملًة معها الأمل في زيادة فرص الحصول على الرعاية الصحية إلى عدد سكان يبلغ 2.3 مليون نسمة. وكانت أقرب كلية طب تبعد بمسافة 004 كيلومتر. وفي ذلك الوقت، لم يكن لدى 08٪ من 001 بلدية في المنطقة أي طبيب. وقد ابتُلِيَت المنطقة بارتفاع معدلات وفيات الرضع والأمراض المعدية. وفي عام 1102، أظهر استعراض للخريجين البالغ عددهم 461 خريج أن 58٪ منهم كانوا يزاولون نشاطهم في المنطقة، وأن نصفهم كان في المناطق الريفية والنائية. وبشكل عام، ظل 09٪ منهم يمارسون العمل في الفلبين مقابل 23٪ من الخريجين على المستوى الوطني. وبين عامي 4991 و8002، انخفض معدل وفيات الرضع في زامبوانغا بحوالي 09٪، وهي نسبة تتجاوز بكثير الانخفاض في المتوسط الوطني البالغ 05٪. وتواصل الكلية اختيار طلاب من المنطقة وتتبع منهًجا يتكامل تكامًلا وطيًدا مع الاحتياجات الصحية للمجتمع المحلي. المصدر: منظمة الصحة العالمية (67)؛ yelroW dna labotsirC (77). إن الخطوة الأولى نحو بناء قوى عاملة صحية عالية الجودة تتمتع بالمزيج المناسب من المهارات يجب أن تكون وضع استراتيجية وطنية شاملة للقوى العاملة الصحية لمعالجة الثغرات في الأرقام والتوزيع والاستبقاء؛ سواء في الأجل القصير أو الطويل. ويجب ألا تحرم استراتيجيات القوى العاملة الصحية الاختصاصية الأنظمة الصحية الأخرى عن طريق جذب الموظفين المؤهلين بعيًدا عن الأنظمة الصحية في بلدانهم الأصلية. ويمكن لسياسات القوى العاملة أن تستغرق سنوات حتى تؤتي ثمارها. ويكمن الحل الأكثر فعالية واستدامة لنقص اليد العاملة في المناطق الريفية في تدريب الطلاب الذين هم أنفسهم من المجتمعات الريفية، بما في ذلك إنشاء مدارس طبية في المناطق النائية. إن تحديث مناهج التدريب السابق للخدمة المقدم للعاملين في مجال الرعاية الصحية لضمان اكتسابهم الكفاءات الأساسية الطبية والتمريضية هو نقطة بداية واضحة؛ وما زال يمثل تحديًا في العديد من البلدان (الإطار4-1) (47). ومن الأولويات الأخرى التطوير المهني المستمر- يغطى مجموعة واسعة من الكفاءات - لضمان حفاظ الاختصاصيون الصحيون على معارفهم ومهاراتهم وتحسينها طوال حياتهم العملية. وتعمل النظم الصحية بشكل متزايد على جعل التطوير المهني المستمر - بل وحتى إعادة التسجيل - إلزاميًا. وحتى في حالات عدم وجود تطوير مهني مستمر، يمكن لصانعي السياسة العمل مع الجمعيات المهنية لتشجيع التطوير وتقييم تأثيره (57). وأخيرًا؛ فإن دمج مبادئ الجودة وتحسينها في مناهج وبرامج التعليم والتدريب قبل وأثناء الخدمة هو أمٌر حيوٌي في بناء قوى عاملة مؤهلة وقادرة على تقديم خدمات صحية عالية الجودة. تقديم خدمة صحية عالية الجودة: ضرورة عالمية للتغطية الصحية الشاملة 34 شكل 4-2 الاختلافات في توافر المعدات الأساسية عبر مرافق الرعاية الصحية في أفريقيا جنوب الصحراء الكبرى المصدر: evitaitinI ecnamrofreP eraC htlaeH yramirP (97) الحكم على جودة مرافق الرعاية الصحية يكون في المقام الأول حول مدى توافر الأساسيات، مثل المياه النظيفة، والكهرباء التي يعتمد عليها، والصرف الصحي الجيد، والتخلص الآمن من النفايات. وفي دراسة استقصائية أجريت في عام 4102، كان أقل من ربع المرافق في نيجيريا يتمتع بمياه موثوق بها وصرف صحي وكهرباء. وفي الواقع، تشير تقديرات منظمة الصحة العالمية إلى أن 04٪ من مرافق الرعاية الصحية في البلدان المنخفضة والمتوسطة الدخل تفتقر إلى المياه المحسنة وأن ٪02 تقريبًا يفتقر إلى الصرف الصحي. هناك حاجة ماسة لهذه الركائز الأساسية لجودة الرعاية؛ ومع ذلك، فإن البنية التحتية الكافية لا تعادل بالضرورة الرعاية عالية الجودة. فيجب إذن وضع معايير دنيا وإنفاذها، بالإضافة إلى تشجيع التحسين المستمر. ويستخدم الاعتماد والتفتيش وغيرهم من أشكال التقييم الخارجي والتصديق على نطاق واسع لتقييم مرافق الرعاية الصحية وفًقا لمعايير واضحة؛ ومع ذلك، فإن قوة الأدلة التي تدعم التقييمات الخارجية لمرة واحدة محدودة (08، 18). وبناًء على ذلك، تنتقل نظم الرعاية الصحية بشكل متزايد إلى عمليات تقييم أكثر استمرارية وتشكيًلا لأداء مقدمي الخدمات، بما في ذلك قياس نتائج المريض وتجاربه (51). 4-2-3 الأدوية والأجهزة والتقنيات الآمنة في التصميم والاستخدام إن الحصول على الأدوية، والأجهزة، والتقنيات على نحو مأمون وفعال، بما في ذلك نقل الدم، شرٌط أساٌسي للحصول على خدمات الرعاية الصحية الفعالة؛ ووضع قيود على المنتجات غير الآمنة أو غير الفعالة أمر بالغ الأهمية لسلامة المرضى. وقد حدث تحسن في الحصول على الأدوية والتقنيات الأخرى وفي تحقيق الحد الأدنى من معايير الجودة فيها؛ ولكن لا تزال هناك فجوات كبيرة في توفير الرعاية الأساسية؛ وهناك مشاكل معقدة وخطيرة مع المنتجات المزيفة مما يزيد من تعقيد هذه القضية. 4-2-2 مرافق رعاية صحية يسهل الوصول إليها، وجيدة التجهيز لا يزال هناك اختلاف كبير في توافر الخدمة ومدى استعدادها؛ وتختلف كثافة المستشفيات والعيادات اختلافًا كبيرًا داخل البلاد وعبرها؛ وقد تبعد مرافق الرعاية الصحية الأساسية مسافة ساعات طويلة عن المجتمعات الريفية الفقيرة. ففي إفريقيا جنوب الصحراء الكبرى، تتوفر المعدات الأساسية مثل ميزان الحرارة وسماعة الطبيب في أكثر بقليل من نصف المرافق في إثيوبيا، ولكنها توجد في جميع المرافق تقريبًا في بوركينا فاسو (الشكل 4-2). إن توافر الخدمات واستعدادها للتشغيل شرط ضروري لتقديم الرعاية الجيدة. ومع ذلك، هذا لا يكفي لتقديم خدمات عالية الجودة، كما نوقش في جميع أجزاء هذا التقرير (87). ين بن سو فا نا كي ور ب غو ون ك ال بيا يو إث نيا غي نيا كي قر ش دغ م نيا يتا ور م ي لاو ما جر لني ا ال نغ س ال ون الي جو سير تو نيا نزا ت دا غن أو بيا ام ز 001 09 08 07 06 05 04 03 02 01 0 % 2.98 2.68 5.47 3.36 8.27 0.76 2.38 9.48 5.07 0.28 0.78 3.18 0.78 2.86 5.87 3.58 44 دمج الجودة في أسس النظم الصحية الفصل 4 وتختلف معايير التنظيم اختلافًا كبيرًا؛ فعلى سبيل المثال، في بعض البلدان، يمكن شراء المضادات الحيوية بدون وصفة طبية، مما يشجع الاستخدام غير الرشيد، ويزيد من خطر مقاومة مضادات الميكروبات (28). حتى في الحالات التي يتم فيها تنظيم استخدام الدواء بشكل صحيح، تؤثر الأخطاء على واحد من كل 01 وصفات طبية، معظمها متعلق بالجرعة (38). ووفًقا لأحد التقارير، فإن 03-04٪ فقط من المرضى في البلدان ذات الاقتصادات النامية أو التي تمر بمرحلة انتقالية يعالجون بالأدوية وفًقا للمبادئ التوجيهية السريرية (48)؛ كما أن دور المرضى في جعل الأدوية والأجهزة فعالة وآمنة هو أمر بالغ الأهمية. إن الأنظمة الصحية عادة لا تولي اهتماًما كافيًا لإعلام المرضى ودعمهم في استخدامهم للأدوية.؛ ولذا تم إطلاق التحدي العالمي الثالث بشأن سلامة المرضى في منظمة الصحة العالمية - التطبيب بدون ضرر - في مؤتمر القمة الوزاري العالمي الثاني بشأن سلامة المرضى، بون، ألمانيا، في مارس/آذار 7102 بهدف الحد من الأضرار الشديدة المتعلقة بالأدوية والتي يمكن تلافيها بنسبة 05٪ على مستوى العالم في خمس سنوات. تتطلب المعدات الطبية الصيانة، وتدريب المستخدمين، ودعم النسخ الاحتياطي، وفي النهاية، إيقاف التشغيل. ويثير التبرع بالمعدات - وهو أمر مهم في بعض البلدان منخفضة الدخل - مخاوف معينة؛ فما لم تتوفر قطع الغيار والمواد المستهلكة وتدريب الموظفين، يمكن أن تكون هذه المعدات غير قابلة للاستخدام أو غير آمنة. كما تفتقر ثلاثة من كل عشرة بلدان إلى سلطة وطنية تنظم التقنية الطبية التي يمكن استخدامها وكيفية استخدامها (58). إن عمليات نقل الدم هي حالة خاصة؛ فالعديد من البلدان منخفضة الدخل غير قادرة على فحص الدم للكشف عن فيروس نقص المناعة البشرية، والتهاب الكبد B، والتهاب الكبد C، والزهري. وعندئذ يكون المرضى المتلقون لنقل الدم في خطر غير مقبول من الإصابة بالعدوى المنقولة. تساعد السياسات الوطنية المتعلقة بالأدوية والأجهزة على ضمان منتجات ذات جودة مضمونة، بكميات كافية وبأسعار معقولة؛ وسوف تتم مناقشة العمليات الموحدة لتقييم التقنية الصحية في الفصل التالي. إن القواعد التنظيمية القابلة للتنفيذ التي تتناول التصميم والتطوير، والبيع، والاستخدام، والتخلص من النفايات قد تكون فعالة في ضمان الجودة والسلامة في هذا المجال. والمبادئ التوجيهية وقوائم المراجعة يمكن أن تشجع الاستخدام المناسب بجوار سرير المريض؛ فهم يجب أن يكونوا مصحوبين بأنظمة مراقبة لمراقبة الاستخدام الصحيح، والتي يمكنها اكتشاف الحوادث والتفاعلات المضادة. إن التبرع التطوعي بالدم بدون أجر يحسن إمداد وسلامة الدم. وسيحُدث تحوٌل في السلامة إذا اعتمدت جميع الأنظمة الصحية هذه الطريقة من التبرع (68). كما يتم تقليص مخاطر نقل الدم عن طريق تقييم الجودة الخارجية لجمع مشتقات الدم، وإعدادها وإدارتها. 4-2-4 نظم المعلومات التي ترصد بشكل مستمر و تقود إلى رعاية أفضل لا يزال استحداث مقاييس الجودة الدقيقة والجيدة التوقيت لخدمات الرعاية الصحية وتجارب المستخدمين والنتائج المحققة أمرًا صعبًا؛ بالنظر إلى قلة ما تنفقه الحكومات والجهات المانحة على أنظمة المعلومات الصحية. وتستثمر معظم النظم الصحية لمنظمة التعاون الاقتصادي والتنمية ما بين ٪2 و٪4 فقط من إجمالي الإنفاق الصحي في نظم المعلومات؛ بينما في معظم البلدان ذات الدخل المنخفض والمتوسط، يكون الرقم أقل من 1٪ (78). ونتيجة لذلك، لا يتم في الغالب الكشف عن البيانات المتعلقة بالنتائج والجودة على الإطلاق، أو يتم تجميعها بطرق لا يمكن تحليلها أو قياسها بسبب الافتقار إلى المصطلحات الموحدة. حتى عندما يتم جمع البيانات؛ تظل ترجمة هذه البيانات إلى معلومات قابلة للتنفيذ لتحسين الجودة تحديًا أساسيًا. ومع ذلك، فإن معلومات الأداء الجيد مهمة لتحسين جودة الرعاية؛ فقد وجد مشروع الرعاية الصحية الأوروبي، الأداء والكفاءة (EPOHoruE) أن معدل الباقين على قيد الحياة بعد النوبة القلبية تباين بقدر الضعف في نظام صحي وطني واحد (88). ولتمكين المستشفيات والعيادات من تقديم نفس المستوى من الرعاية الممتازة؛ يجب جمع بيانات مقارنة أكثر ثراًء حول التنوع في الجودة والنتائج، وتفسيرها واستخدامها فى نشر أفضل الممارسات ودعم ذوي الأداء الضعيف. بالإضافة إلى مشروع الرعاية الصحية الأوروبي، فإن التعاون الأوروبي من أجل تحسين الرعاية الصحية (98) ومشروع مؤشرات جودة الرعاية الصحية لمنظمة التعاون الاقتصادي والتنمية (53) يمثلان اتجاًها لوضع أنظمة لجودة البيانات على الصعيد العالمي (الإطار 4-2). تقديم خدمة صحية عالية الجودة: ضرورة عالمية للتغطية الصحية الشاملة 54 إطار 4-2 دراسة حالة: مشروع مؤشرات جودة الرعاية الصحية لمنظمة التعاون الاقتصادي والتنمية بدأ مشروع مؤشرات جودة الرعاية الصحية لمنظمة التعاون الاقتصادي والتنمية في عام 1002 بهدف إعداد مقارنات دولية لجودة الرعاية الصحية، وبالتالي تحديد أفضل الممارسات ومشاركتها لرصد وضمان الجودة وتحسينها. يتم اختيار الخبراء المشاركين في المشروع من الدول الأعضاء بمنظمة التعاون الاقتصادي والتنمية، والدول غير الأعضاء في المنظمة، والمنظمات الدولية بما في ذلك منظمة الصحة العالمية، والمفوضية الأوروبية، ومعاهد البحوث. تم الإبلاغ عن حوالي 05 مؤًشرا (تغطي الرعاية الأولية، والرعاية في المستشفيات، وخدمات الصحة النفسية، وسلامة المرضى وتجاربهم) من حوالي 04 دولة. تُنشر مؤشرات جودة الرعاية الصحية المقارنة إلى جانب إحصاءات صحية أخرى لمنظمة التعاون الاقتصادي والتنمية حول النفقات والموارد والاستخدام بغية تيسير تفسيرها. إلى جانب جمع البيانات العادية، هناك بحث وتطوير مستمر لتحسين مصداقية مؤشرات جودة الرعاية الصحية ومدى فائدتها وقابليتها للمقارنة. الهدف الآخر للمشروع هو تعزيز البنى التحتية للمعلومات الوطنية لإنتاج مؤشرات أكثر تعقيًدا وموثوقية في عدد متزايد من البلدان، بما في ذلك الدول غير الأعضاء في منظمة التعاون الاقتصادي والتنمية. المصدر : منظمة التعاون الاقتصادي والتنمية (53). في كثير من الأحيان، تُترك البيانات ضحية للإهمال في أنظمة ورقية سيئة التنظيم، أو تكون عالقة في مخازن رقمية غير متوافقة مع بعضها البعض. والاستخدام المناسب للمعلومات في الوقت المناسب والعمل عليها هو أمٌر بالغ الأهمية. ويقوم البرنامج التعاوني للبيانات الصحية، وهو مبادرة عالمية تقودها منظمة الصحة العالمية والبنك الدولي والوكالة الأمريكية للتنمية الدولية (DIASU)، بالتصدي لهذا التحدي؛ فمن خلال العمل مع الوكالات الدولية وفرادى البلدان، يسعى البرنامج التعاوني للبيانات الصحية إلى تنسيق كيفية جمع بيانات الأنظمة الصحية والإبلاغ عنها على الصعيد العالمي، ويهدف إلى تمكين تتبع أفضل لأداء النظام الصحي وتقدمه نحو الأهداف المتعلقة بالصحة في أهداف التنمية المستدامة (09). وبالمثل، تهدف مبادرة أداء الرعاية الصحية الأولية (97) إلى تقاسم النتائج القابلة للمقارنة الدولية حول أداء أنظمة الرعاية الصحية الأولية على الصعيد العالمي، وتمكين تحسين الأداء من خلال مشاركة النتائج وأفضل ممارسات تحسين الأداء. يجب تسجيل المعلومات الأساسية عن جميع الولادات والوفيات بشكل موثوق؛ فالتسجيل المدني الفعال هو العمود الفقري للبنية التحتية للمعلومات في النظام الصحي. ومن هذا يمكن إعداد السجلات التي تراقب الاحتياجات والتدخلات والنتائج لمجموعات المرضى (مثل المصابين بفيروس نقص المناعة البشرية أو السرطان أو الأمراض العقلية). يخصص السجل المدني ُمعرفًا فريًدا لهوية أي شخص؛ وهذا يسمح بربط البيانات من مزودين مختلفين بمرور الوقت وتمكين تتبع خدمات الرعاية الصحية. وإذا كان تشريع حماية الخصوصية يمنع ربط البيانات المجهولة بعناصر تجربة الفرد الصحية في أماكن مختلفة وفي أوقات مختلفة، فلن تكون هناك طريقة لتقييم مسار الرعاية بأكمله (الإطار 4-3). تظل الإدارة الفعالة للمعلومات ضعيفة في العديد من النظم الصحية. إن استخدام البيانات الصحية الشخصية لمراقبة أداء الخدمات الصحية وتحسينها يخدم غرًضا عاًما مهًما، ولكن يجب أن يتم دائمًا بطرق تحمي الخصوصية؛ وإذن هناك حاجة إلى تشريعات وطنية تحمي خصوصية المريض مع تمكين استخدام البيانات والتواصل الجيد مع الجمهور حول استخدام البيانات، بالإضافة إلى وضع معايير لتحسين جودة البيانات وقابليتها للمقارنة على المستوى العالمي (19). 64 دمج الجودة في أسس النظم الصحية الفصل 4 إطار 4-3 دراسة حالة: تطوير التسجيل المدني والإحصاءات الحيوية في أوغندا كان يتم تسجيل واحد فقط من كل خمسة من المواليد السنوية البالغ عددهم 5.1 مليون في نظام التسجيل المدني الوطني والإحصاءات الحيوية في أوغندا. وغالبًا ما كان على العائلات أن تسافر لمسافات طويلة للتسجيل شخصيًا، وهو الأمر الذي يتطلب رسوًما. وقد تسبب النظام القائم على الورق في التأخير المتكرر في إصدار شهادات الميلاد، حتى بين الولادات المسجلة؛ لم يحصل أكثر من نصفهم على شهادة ميلاد. نفذت منظمة الأمم المتحدة للطفولة (اليونيسيف) وأوغندا تيليكوم نظام السجلات الحيوية المتنقلة، الذي يربط مستخدمي الهاتف المحمول وحواسيب المستشفيات بخادم حكومي مركزي. وبالنسبة للولادات التي تحدث خارج المرافق الصحية، يقوم المتطوعون - وهم عادة قادة القرى - بجمع معلومات الولادة وإرسالها إلى قاعدة بيانات حكومية من خلال خدمة مجانية من هواتفهم المحمولة. ويقوم مسؤول بمراجعة المعلومات وإذا تم اعتبارها ذات مصداقية، يتم إصدار شهادة ميلاد؛ ويتم إخطار متطوع المجتمع المحلي عبر رسالة نصية. وقد أدى بدء تطبيق نظام السجلات الحيوية المتنقلة إلى زيادة تسجيل المواليد بشكل كبير، مما أدى إلى زيادة التوسع في البرنامج. والآن يتم تنفيذه أيًضا في المدارس للوصول إلى الأطفال الذين لم يتم تسجيلهم سابًقا. المصدر : منظمة الأمم المتحدة للطفولة (اليونيسيف) (29). إن الانتقال من السجلات الورقية إلى السجلات الصحية الإلكترونية المنفردة، والتي يمكن استخدامها في العديد من مجالات الرعاية الصحية، سوف يساعد في مراقبة أداء خدمات الرعاية الصحية. كما أن دعم الأطباء والمديرين وواضعي السياسات في تفسير بيانات الخدمة واستخدامها لتحسين الجودة سيكون أمرًا حيويًا أيًضا. هناك حاجة إلى إجراء خاص لتحسين سلامة المرضى؛ وعليه فإن تشجيع الشفافية عندما تسوء الأمور، من خلال بناء ثقافة تعليمية خالية من إلقاء اللوم، يعد شرطًا مسبًقا. ويمكن دعم ذلك إذا ركزت التحليلات على فهم الأسباب الجذرية للأحداث الضائرة عن طريق استكشاف العوامل المسببة والعوامل المساهمة التي تثير الأخطاء، والتي ينتج عن بعضها ضرٌر كبٌير للمرضى. وسوف يعزز الاتفاق على مصطلحات موحدة دوليًا أيًضا القدرة على تصنيف الأحداث الضائرة ومقارنتها ومنع حدوثها عبر الأنظمة الصحية المختلفة. وأخيرًا؛ وافق وزراء الصحة في دول منظمة التعاون الاقتصادي والتنمية في عام 7102 على أن يتم قياس أنظمتهم الصحية باستخدام موجة جديدة من مؤشرات الأداء التي يبلغ عنها المريض (03). وتقوم نظم معلومات صحية أكثر تطوًرا بإجراء المسح على المرضى مباشرة؛ لرصد وجهات نظرهم حول جودة الرعاية التي يتلقونها ومقارنتها ومراقبة نتائجهم الصحية (39). وتعتبر هذه الاستراتيجية تطوًرا مهًما يدعم التحول النوعي من أنظمة القياس التي تركز على مقدمي الرعاية الصحية إلى الأنظمة المتمحورة حول الفرد، والتي يركز القياس فيها على الخبرات والنتائج التي يُنظر إليها من منظور المرضى (49). 4-2-5 آليات التمويل التي تمكن الرعاية الجيدة وتشجعها من غير المستغرب أن يكون للطريقة التي يتم بها تحصيل الأموال، وتجميعها واستخدامها لدفع تكاليف خدمات الرعاية الصحية، تأثيرات كبيرة على جودة الرعاية ونتائجها؛ أوًلا، هناك أدلة قوية على وجوب تحصيل الأموال وتجميعها قبل الحاجة إلى الرعاية، من خلال أنظمة تأمين إلزامية (مع اشتراكات مدعومة لغير القادرين على تحمل تكاليف التأمين). والبديل - الدفع من الأموال الخاصة في لحظة الحاجة - يعني عدم حصول الناس على رعاية عندما يحتاجون إليها وينتهي بهم الحال أكثر مرًضا نتيجة لذلك، أو معاناتهم من فقر مأساوي (56). تقديم خدمة صحية عالية الجودة: ضرورة عالمية للتغطية الصحية الشاملة 74 إن كيفية تدفق التمويل من وكالات التأمين إلى الخطوط الأمامية، لشراء الخدمات أو تسديدها، هي على نفس القدر من الأهمية. وهناك العديد من الآليات الممكنة، مثل الرسوم مقابل الخدمات، أو وضع حد أقصى، أو ميزانيات الحظر السنوية (تُحول إلى المستشفيات أو العيادات، بناًء على الإنفاق السابق أو المتوقع)؛ ولكل منها نقاط قوة ونقاط ضعف، في المدى الذي يتم فيه مكافأة النشاط على النتائج، أو تحفيز الرعاية الوقائية عن الرعاية التفاعلية؛ فلا توجد "عصا سحرية"، ومن الناحية العملية يتم في العادة استخدام مزيج من الآليات. إن ما هو مهم - من منظور جودة الرعاية - هو أن المزيج مصمم بذكاء، ومتوائم بأكبر قدر ممكن مع الاحتياجات المحلية، ويحفز تنسيق الرعاية المقدمة للأفراد ذوي الاحتياجات المعقدة، ويستثمر بشكل كاف في الرعاية الأولية والوقاية، ويكافئ الرعاية الجيدة ويعاقب على الرعاية التي لا تفي بالمعايير الكافية. وبناًء على ذلك، تصمم الأنظمة الصحية بشكل متزايد آليات تدفع مقابل حزم الرعاية أو مساراتها، وتختبر المدفوعات المتعلقة بالجودة. إن إحدى هذه الابتكارات، المطبقة في المناطق عالية الدخل وكذلك ذات الدخل المنخفض، هي الأجر مقابل الأداء (P4P)، أو التمويل القائم على النتائج؛ فالبرامج المصممة بحرص، والمحددة بوقت في كثير من الأحيان، تُدفع لمقدمي الرعاية الصحية مقابل تنفيذ تدخلات محددة وذات أولوية عالية. ولدى ما يقرب من ثلثي بلدان منظمة التعاون الاقتصادي والتنمية خطة واحدة على الأقل من أجل تنفيذ برنامج الأجر مقابل الأداء، في الغالب في الرعاية الأولية. وتشير الاستعراضات المنهجية بشكل مبدئي إلى التأثير الإيجابي للأجر مقابل الأداء وبرامج التمويل القائمة على النتائج على الجودة في بلدان منظمة التعاون الاقتصادي والتنمية (39). إن النتائج المتعلقة بالتمويل المعتمد على النتائج في البيئات منخفضة الدخل مختلطة، مع وجود نتائج متواضعة إلى حد ما حتى الآن فيما يتعلق بتحسين الجودة، خاصة بالنسبة للحالات غير المستهدفة. وبشكل عام؛ يمكن استخدام ابتكارات الدفع لتقديم مزايا جانبية مستمرة - مثل بروتوكولات رعاية محسنة، وتحسين التعاون بين مقدمي الخدمة، ونظم معلومات محسنة - حول احتياجات الرعاية الصحية، والأنشطة والنتائج والتكاليف. 4-3 جودة الرعاية كأساس لرعاية صحية محورها الناس هناك ثلاثة مبادئ أساسية للتصميم يجب أخذها بعين الاعتبار بينما تخطط الحكومات لتقديم تغطية صحية شاملة؛ أولاً: يجب تصميم الخدمات بطريقة تلبي احتياجات الرعاية الصحية المحلية. وعلى الرغم من أن ذلك يبدو واضًحا، فإن العديد من النظم الصحية تفتقر إلى التركيز الصحي على السكان. وبدلاً من ذلك، فإن شبكات الخدمات الصحية المتاحة هي نتاج تراث تاريخي، أو نتاج لضغط سياسي أو تمويل مانح مؤقت. وقد تأخذ المجتمعات المحلية مقاعد المتفرجين الأبرياء في تصميم الرعاية الموجهة لهم في نهاية المطاف. لقد عانت العديد من البلدان ذات الدخل المنخفض والمتوسط من عبٍء كبير ٍمن الأمراض السارية، وهذا يعني أن أنظمتها كانت بحاجة إلى وظائف صحية عامة قوية في مجالات مثل الرقابة والمختبرات والتحصين الروتيني. وقد يكونون قد تلقوا أيًضا مبالغ كبيرة من الجهات المانحة في شكل منح برامج لمكافحة أمراض معينة أو القضاء عليها. ومع ذلك، فإن العبء المتزايد للأمراض غير السارية في هذه البلدان نفسها يتطلب خدمات قادرة على دعم الناس مع مرور الوقت من خلال رعاية شخصية استباقية للتعامل مع حالتهم، ومنع المضاعفات، وتحسين نوعية الحياة (الإطار 4-4). 84 دمج الجودة في أسس النظم الصحية الفصل 4 إطار 4-4 دراسة حالة: الاحتياجات غير الملباة لرعاية الأمراض المزمنة يعد ضغط الدم أو ارتفاع ضغط الدم أحد عوامل الخطورة الأكثر انتشاًرا وأهمية في حالات الوفاة المبكرة والعجز على مستوى العالم. إن ارتفاع ضغط الدم دون تلقي علاج يؤدي إلى أمراض الكلى، وأمراض القلب الإقفارية والجلطة (وهذان الأخيران هما السببان الرئيسيان للوفاة في جميع أنحاء العالم). ويؤثر ارتفاع ضغط الدم على واحد من كل ثلاثة بالغين فوق سن العشرين في جميع أنحاء العالم، مع انتشار أعلى الآن في البلدان المنخفضة والمتوسطة الدخل منه في البلدان ذات الدخل المرتفع (معدل انتشار حسب العمر يبلغ 5.13٪ مقابل 5.82٪ على التوالي). ومن بين ما يقرب من 5.1 مليار شخص يعانون من ارتفاع ضغط الدم، سيكون أقل من نصفهم على علم بحالتهم؛ 9.63٪ فقط سيتلقون العلاج المناسب. ونسبة قليلة تبلغ 8.31٪ سيضعون مرضهم بضغط الدم تحت السيطرة بشكل فعال. وتوجد تفاوتات كبيرة في مستوى الوعي والعلاج حسب مستوى دخل الدولة: في البلدان ذات الدخل المرتفع مقابل البلدان ذات الدخل المنخفض والمتوسط ، تبلغ معدلات التشخيص والعلاج ضعف المعدل و4 أضعاف نسبة المرضى سيطروا على ضغط الدم لديهم. المصدر : la te slliM (96). لقد حللت دراسة حديثة 22 مبادرة لتعزيز الرعاية الصحية الأولية في 01 مقاطعات في الصين، وعلى المستويين الوطني ودون الوطني في 21 بلًدا. وقد تم استنباط ثمانية مبادئ من نظم الرعاية الصحية الأولية عالية الأداء: ضمان الرعاية الصحية الأولية كنقطة اتصال أولى لمعظم احتياجات الرعاية الصحية؛ وفرق رعاية مفعلة متعددة التخصصات؛ وتكامل رأسي للخدمات؛ وتكامل أفقي للخدمات؛ وتكنولوجيا معلومات واتصالات متقدمة؛ ومسارات سريرية متكاملة وأنظمة فعالة مزدوجة للإحالة؛ ومعايير القياس والتغذية الراجعة؛ والإشهاد (59). المبدأ الرئيسي الثاني للتصميم هو بناء خدمات رعاية أولية عالية الجودة (79). ويجب أن تكون الاتصالات الأولى مع الرعاية الصحية، ونقطة الدخول العادية للشخص في النظام الصحي، مستمرة وشاملة (الإطار 4-5). ولا ينبغي استبعاد أي مشكلة صحية جسدية أو عقلية من وظائف الرقابة والتنسيق في الرعاية الأولية. وإذا تم تسجيل الأفراد والعائلات في مجتمع جغرافي (أو معرَّف بطريقة أخرى) رسميًا لدى مقدم رعاية أولية محدد؛ فإن هذا يتيح إنشاء ملفات تعريف صحة المجتمع المحلى، بالإضافة إلى مراقبة الاحتياجات وتقديم الرعاية الوقائية. كما يخلق التسجيل أيًضا بنية للرعاية الاستباقية بين الناس الذين يعانون من الحالات المزمنة. إن الرعاية الأولية أيًضا أساسية لمرونة النظام الصحي، وهي محورية في مراقبة الأمراض المعدية أو الأخطار الأخرى، وفي تقديم الرعاية في خط المواجهة في حالة تفشي المرض. ثالثًا: يجب إدخال التواصل مع المرضى والعائلات والمجتمعات في تصميم الأنظمة الصحية، بدًلا من إلحاقه في مرحلة متأخرة. وقد أظهر استعراض للدراسات العشوائية ذات الشواهد لبرامج الرعاية المتكاملة للضعفاء من المسنين - على سبيل المثال - أن أكثر الفوائد استمدت من تلك التي شارك فيها الشخص المسن بشكل مباشر في تخطيط الرعاية (89، 99). إذا تم تشجيع مجموعات المرضى على المشاركة في العمل الجماعي، سيستفيد الناس بشكل كبير من دعم الآخرين الذين يعانون من مشاكل صحية مماثلة. ويقوم برنامج المرضى الملتزمين بسلامة المرضى التابع لمنظمة الصحة العالمية بتوضيح ذلك جيًدا. وقد قام البرنامج بتمكين شبكة عالمية من ممثلي المرضى تهدف إلى تعزيز التعاون بين المرضى والعائلات والمجتمعات ومقدمي الرعاية الصحية وواضعي السياسات لجعل الرعاية الصحية أكثر أمانًا من خلال رؤى وتجارب المرضى أنفسهم (001). تقديم خدمة صحية عالية الجودة: ضرورة عالمية للتغطية الصحية الشاملة 94 إطار 4-5 دراسة حالة: الرعاية الأولية في كوستاريكا في كوستاريكا، يشكل قطاع الرعاية الصحية الأولية المعاصر قاعدة صلبة لبقية نظام الرعاية الصحية. فالعيادات المجتمعية، أو فرق أساسية للرعاية الصحية المتكاملة (nóicneta ed socisáb sopiuqe SIABE ، dulas ed largetni) هي الوحدات الوظيفية لتقديم الرعاية الأولية. يخدم كل فريق حوالي 0001 أسرة. ويتكون كل منهم من طبيب واحد على الأقل وممرضة ومساعد رعاية صحية. كما يمكن أن يقوم العاملون الآخرون، مثل الأخصائيين الاجتماعيين وأطباء الأسنان وفنيي المختبرات والصيادلة وأخصائيين التغذية، بدعم العيادة. وفي إجراء مكمل لهذه الفرق، تم مؤخرًا إنشاء مراكز للرعاية الصحية المتكاملة (nóicneta ed sortnec SIAC ،dulas ne largetni). وهي تقدم نموذًجا موسًعا للرعاية الأولية، بما في ذلك خدمات الأمومة، وأسرّة الرعاية الوسيطة (لتجنب دخول المستشفى أو تسريع عملية الخروج المبكر من المستشفى)، والجراحة البسيطة، وإعادة التأهيل، والعيادات المتخصصة (مثل إدارة الألم)، وتشخيصات مثل التصوير الشعاعي. يقوم إطار عمل تفصيلي للرعاية الأولية بتقييم السلطات الصحية المحلية عبر 03 مؤًشرا في مجالات الحصول على الخدمة، والاستمرارية، والفعالية، والكفاءة، وإرضاء المرضى، والكفاءة التنظيمية. ويتم تعيين هدف وطني لكل مؤشر، ويتم نشر لوحات المعلومات الخاصة بالنتائج المحلية، مما يسمح لمقدمي الخدمات بمقارنة أدائهم مقارنة بالمقاييس المرجعية الوطنية والإقليمية والمحلية. تظهر البيانات الوطنية أن 08٪ من الحالات المعروضة على الرعاية الأولية يتم معالجتها عند هذا المستوى، دون الإحالة إلى الرعاية الثانوية. توجد مبادئ توجيهية للإحالة، ويتم إرجاع حالات الإحالة إلى المستشفيات إذا لم يتم إكمال الخطوات المناسبة في الرعاية الأولية. كما يقوم أطباء المستشفى بتدريب الزملاء العاملين في فرق الرعاية الصحية المتكاملة لتعزيز إدارة الرعاية الأولية. المصدر: منظمة التعاون الاقتصادي والتنمية (12). إطار 4-6 دراسة حالة: استخدام "صوت المواطن والعمل" لتمكين المجتمعات في أوغندا يعتبر تمكين المجتمعات من خلال التدريب والتعليم خطوة مهمة في تمكينهم من التعامل مع مقدمي الرعاية الصحية. على سبيل المثال، يسمح نموذج مشروع "صوت المواطن والعمل" (02) للمواطنين بالتعرف على عدد العاملين بالمجال الصحي، واللقاحات، والمعدات والمواد التي يجب أن تكون موجودة في المركز الصحي المحلي. ثم يعمل المقيمون مع العاملين بالمجال الصحي والحكومة المحلية على قياس …مدى التزام المنشأة بالمعايير الحكومية. وعلى نطاق أوسع، فإن التعاون مع المنظمات غير الحكومية وجماعات المجتمع المحلي والمنظمات الممثلة للمرضى يقدم أيًضا مكاسب هائلة محتملة. وقد أصبحت منظمات المجتمع المدني التي تركز على القضايا الصحية راسخة بشكل متزايد في العديد من البلدان المنخفضة والمتوسطة الدخل (الإطار4-6). وتقوم هذه المجموعات بعمل ما هو أكثر بكثير من مجرد تقديم المشورة والدعم؛ فهي تساعد أيًضا الأشخاص على تأكيد حقوقهم في الحصول على رعاية عالية الجودة. ويوضح استعراض الدراسات التي أعدها kcarevaL (101) الطرق المتعددة التي من خلالها تعزز المشاركة المجتمعية الأنظمة الصحية. وهذا يشمل تعزيز الشبكات الاجتماعية، وتطوير المهارات المحلية مثل القيادة وتعبئة الموارد، أو ببساطة طرح السؤال "لماذا؟". … 05 دمج الجودة في أسس النظم الصحية الفصل 4 كما يمكنهم أيًضا استخدام بطاقة النتائج المجتمعية لتقييم المرفق وفًقا للمعايير التي يضعونها بأنفسهم، وعقد اجتماعات مع المجتمع المدني والحكومة ومقدمي الخدمات حيث يمكن لجميع أصحاب المصلحة مراجعة الأدلة والالتزام بخطة عمل لتحسين الخدمات. وقد تم تنفيذ نموذج "صوت المواطن والعمل" بنجاح في أوغندا في عام 4002 للتصدي للرعاية الصحية الضعيفة المقدمة في مستوى الرعاية الأولية. وكان الهدف الرئيسي للتدخل هو تعزيز مساءلة مقدم الخدمة أمام عملائه من المواطنين من خلال استحداث عملية يمكن للمجتمعات المحلية إدارتها ودعم استمرارها بمفردها وباستخدام منظمات مجتمعية مدّربة كجهات ميسرة. وبعد مرور عام على التنفيذ، شهدت المرافق الصحية في قرى العلاج (مقارنة بقرى المقارنة) انخفاًضا لمدة 21 دقيقة في متوسط وقت الانتظار وانخفاًضا فى معدلات الغياب بنسبة 31٪. كما أظهرت المرافق الصحية في قرى العلاج انخفاًضا بنسبة 33٪ في معدل وفيات الأطفال دون الخامسة؛ وزيادة بنسبة 85٪ في استخدام القابلات الماهرات؛ و91٪ زيادة في عدد المرضى الساعين للحصول على الرعاية السابقة للولادة. وقد تم الحفاظ على التحسينات لمدة أربع سنوات من بدء المشروع. 4-4 الرؤية: الأنظمة الصحية التي تلتزم بالتمركز حول الناس إن الأم الحامل التي تعاني من ارتفاع ضغط الدم، أو الرجل المسن المصاب بالسكري، والتهاب المفاصل وفقدان السمع، كلاهما في حاجة لمجموعة من الخدمات التي يجب تقديمها بشكل فعال - ليس فقط داخل النظام الصحي الرسمي؛ ولكن في المجتمع الذي سيعودون إليه للحياة والعمل. يحتاج الشاب المصاب بالفصام إلى رعاية منسقة بعناية ليس للتعامل مع مشاكل صحته العقلية فحسب؛ ولكن أيًضا للتعامل مع مجموعة من المشاكل الصحية البدنية المزمنة التي تقلل العمر المتوقع بما يصل إلى 52 سنة للأشخاص المصابين بمرض عقلي شديد. وتتطلب الرعاية الصحية المعقدة أنظمة قادرة على تقديم مسار كامل للرعاية (تعزيز الصحة، والوقاية من الأمراض، والتشخيص، والعلاج، وإدارة الأمراض، وإعادة التأهيل، وخدمات الرعاية الملطفة) على نحو مستمر وآمن، وبطرق يقدرها المرضى وعائلاتهم. وتشمل الإدارة الفعالة للنظم الصحية عدة مهام، بما في ذلك الاستمرار في الإشراف الاستراتيجي على الأهداف والأولويات، وتوليد المعلومات والتحليلات اللازمة لتتبع مدى استيفاء تلك الأهداف، وتصميم القواعد والسياسات والعمليات لتوجيه النظام في الاتجاه المطلوب، وخلق التعاون داخل وخارج النظام الصحي ورعايته. إن ترسيخ الحق في الرعاية الصحية في التشريع الوطني، وفًقا للحاجة، خطوة قيّمة في إحراز تقدم نحو التغطية الصحية الشاملة. وتظهر التجربة أن الالتزامات القانونية كثيرًا ما يفشل ترجمتها، بحكم الأمر الواقع، إلى الحصول على رعاية عالية الجودة. كما أن إنشاء وكالة وطنية مسؤولة عن مراقبة الجودة وتحسينها يُعد خطوة مهمة. ومن الناحية المثالية، ينبغي أن تكون تلك الوكالة مستقلة عن شركات التأمين ومقدمي الرعاية الصحية، ولديها سلطات تنظيمية لجمع بيانات الجودة والنتائج وتحليلها ونشرها. كما يمكن أن يشمل دورها تقاسم الدروس المستفادة من الجهات عالية الأداء ودعم الخدمات ذات الأداء الضعيف في معالجة فجوات الأداء. تعني الرعاية التي تتمحور حول الفرد أن الأنظمة الصحية يجب أن تضمن: • الاستمرارية من الوقاية من المرض إلى التخفيف، بين الخدمات (على سبيل المثال الرعاية المكثفة والأشعة) وبين مستويات الرعاية (الأولية إلى التخصصية)، طوال دورة الحياة. • التنسيق عبر مختلف أماكن الرعاية، بطرق تلبي الاحتياجات الخاصة للأفراد ومقدمي الرعاية لهم. تقديم خدمة صحية عالية الجودة: ضرورة عالمية للتغطية الصحية الشاملة 15 الشكل 4-3 الرعاية الأولية كمركز للتنسيق التواصل داخل المجتمع المتلقي للخدمة ومع الشركاء الخارجيين المصدر : منظمة الصحة العالمية (201). دعم استشاري الإحالة بسبب المقاومة للأدوية المتعددة مجموعة المساعدة الذاتية العامل الصحي المختص بالاتصال المجتمعي خدمات اجتماعية أخرى أخرى الإحالة لحدوث مضاعفات مراقبة التخلص تصوير الثدي بالآشعة من النفايات العنف القائم على نوع الجنس إدمان الكحول المشيمة المنزاحة أمراض الدم حادث مرور دعم دعم تشخيصي تدريبي لطاخة بابانيكولاو فريق الرعاية الأولية: رعاية مستمرة، وشاملة، وتتمحور حول الفرد مستشفى المنظمات غير الحكومية خدمات وقائية متخصصة خدمات تشخيصية الرعاية المتخصصة مجتمع المحلي ال وحدات الصحة النفسية في المجتمع المحلي مختبر الصحة البيئية مركز تدريب تجمعات مدمني الكحول مأوى للنساءالمجهولين مركز فحص السرطان قسم الطوارئ الأمومة جراحة مركز مكافحة السل عيادة السكري مختبر تحليل الخلايا تصوير مقطعي محوسب • الشمولية التي توسع مجموعة خدمات الرعاية - من تعزيز الصحة إلى الرعاية الملطفة - التي يمكن للأفراد والمجتمعات استخدامها. عندما تكافح النظم الصحية لتوفير رعاية تتمحور حول الفرد، فغالبًا ما يُعزى ذلك إلى أن الخدمات لا تزال تركز بشكل كبير على علاج الأمراض بعينها، بدًلا من الوقاية من المرض أو تعزيز الصحة والرفاهية بشكل أفضل. ويعطي النظام الأولوية للرعاية المتخصصة للاستثمار فيه وتركيز الموارد. ويمكن تصميم الرعاية الأولية بحيث تكون الوسيط بين احتياجات المجتمع ومجموعة من الأحكام في النظام الصحي. ويمكنه بعد ذلك أداء الدور التنسيقي المَُحسن الذي تتطلبه الرعاية التي تتمحور حول الفرد (الشكل 4-3). وتتمثل إحدى الطرق المهمة للحفاظ على رعاية متمحورة حول الفرد على الطريق الصحيح، وضمان التوازن الصحيح بين خدمات الرعاية الأولية والثانوية، في نشر تقارير منتظمة تحلل أداء النظام الصحي ككل. 25 دمج الجودة في أسس النظم الصحية الفصل 4 الشكل 4-4 خمس استراتيجيات لخدمات محورها الفرد إن الرعاية التي تتمحور حول الناس هي مدخٌل بالغ الأهمية يمكن من خلاله تحسين الجودة. وهي تشرك المرضى في اتخاذ القرارات بشأن رعايتهم، وتسألهم عن نتائج الرعاية، وتشكك في الاختلافات في نتائج المرضى عبر مقدمي الخدمة المختلفين، كما أنها تدفع إلى المزيد من الاستثمار في السجلات الإلكترونية التي تعمل عبر سياقات متعددة، وتضمن الشفافية والتعلم عندما تسوء الأمور، وتشجع عدًدا لا يحصى من الإجراءات الأخرى لتحسين جودة الرعاية الصحية. وكما قال ’دونالد بيرويك’ خبيرجودة الرعاية الصحية العالمي: "إن التمحور حول الناس ليس مجرد واحد من أبعاد جودة الرعاية الصحية؛ بل هو مدخل لجميع الصفات" (61). إن إطار منظمة الصحة العالمية للخدمات الصحية المتكاملة المتمركزة حول الناس، والذي تم تبنيه بدعم كامل من الدول الأعضاء في جمعية الصحة العالمية في مايو 6102، يحدد رؤية قاطعة حيث "يتمتع جميع الناس بإمكانية الحصول المتكافئ على خدمات صحية جيدة يتم إنتاجها بشكل مشترك، وبطريقة تلبي احتياجاتهم مدى الحياة". ويدعو الإطار إلى تنسيق الخدمات عبر نطاق الرعاية المتواصل وإلى بيئة مساندة تساعد مقدمي الرعاية على ممارسة مهامهم باستخدام المهارات والموارد التي يحتاجون إليها. يقترح هذا الإطار خمس مناطق استراتيجية مترابطة (الشكل 4-4) لكيفية إعادة توجيه الخدمات والنظم الصحية لإنجاز هذه الرؤية (301). 4-5 خاتمة يمكن دمج الجودة في أسس أنظمة الرعاية الصحية، بغض النظر عن مدى طول الطريق حتى يصل النظام الصحي إلى التغطية الصحية الشاملة. إن قيام العاملين في الرعاية الصحية، ومرافق الرعاية الصحية، والأدوية، والأجهزة، وغيرها من التقنيات، ونظم المعلومات، والتمويل باتباع نهج موجه نحو الجودة هو أمر حيوي في جميع مراحل التنمية. ويجب أن يكون بناء أسس أنظمة الصحة عالية الجودة في طليعة التفكير والتخطيط وصنع السياسات؛ لكن هناك حاجة ملحة لمزيد من الإجراءات لإنشاء أنظمة صحية جيدة. كما يجب أن تتبادل الأنظمة الصحية تسلسًلا هرميًا من أعلى إلى أسفل للمسارات والشبكات يقوم على التعاون والتآزر، مع إيلاء الاهتمام بالرعاية الأولية بصفتها حجرالأساس ووضع الناس في بؤرة الاهتمام. يجب أن يقترن هذا التحول في العلاقات بآليات جديدة لمساءلة الحكومات وقادة النظام الصحي وبناء ثقة المواطنين. ويحدد الإطار 4-7 الإجراءات الرئيسية التي يمكن اتخاذها لضمان دمج الجودة في أسس أنظمة الرعاية الصحية. ويقدم الفصل التالي مزيًدا من التفاصيل حول أنواع التدخلات التي يمكن جمعها وتنفيذها على المستويات الكلية والوسطى والجزئية لتحسين جودة الرعاية. تمكين الناس وإشراكهم تنسيق الخدمات تعزيز تصريف الشؤون والمساءلة إعادة توجيه نموذج الرعاية تهيئة بيئة مواتية تقديم خدمة صحية عالية الجودة: ضرورة عالمية للتغطية الصحية الشاملة 35 إطار 4-7 الإجراءات الرئيسية: دمج الجودة في أسس الأنظمة الصحية لضمان دمج الجودة في أسس الأنظمة لتحقيق تغطية الرعاية الصحية الشاملة، يجب على الحكومات وصانعي السياسات وقادة النظام الصحي والمرضى والأطباء التعاون مًعا من أجل: 1. ضمان وجود قوى عاملة عالية الجودة في مجال الرعاية الصحية، من خلال: • وضع استراتيجية وطنية لمعالجة الفجوات في أعداد الاختصاصيين الصحيين وتوزيعهم واستبقائهم، على المدى القصير والمدى الطويل. • تحديث مناهج التدريب للعاملين في مجال الرعاية الصحية ودمج مبادئ الجودة وأساليب تحسينها في مناهج التدريب. • تشجيع برامج التطوير المهني المستمر وتقييم أثرها. 2. ضمان التميز في جميع مرافق الرعاية الصحية، من خلال: • ضمان جاهزية الخدمة وتوافرها كشرط ضروري ولكن غير كاٍف لجودة الرعاية. • تشجيع عمليات التقييم المستمرة والتصميمية لجودة مرافق الرعاية. • جمع وتحليل البيانات الأكثر ثراًء عن التغيرات في الجودة والنتائج عبر المرافق، وتحويل الأفكار إلى إجراءات لنشر أفضل الممارسات ودعم أصحاب الأداء الضعيف. 3. ضمان الاستخدام الآمن والفعال للأدوية، والأجهزة، والتقنيات الأخرى عن طريق: • وضع سياسات وطنية بشأن الأدوية والأجهزة مع التركيز على الجودة المضمونة، والإمداد الكافي والأسعار المناسبة، مدعومة بتقييم معياري للتقنية الدوائية. • وضع مبادئ توجيهية، وقوائم مرجعية وأنظمة مراقبة لدعم الاستخدام الصحيح للتكنولوجيا الطبية، ومراقبة الأخطاء والحوادث وردود الفعل السلبية. • إقرار التبرع التطوعي بدون مقابل بالدم وإدخال تقييم جودة خارجي لعمليات جمع مشتقات الدم وتحضيرها وإدارتها. 4. ضمان الاستخدام الفعال لأنظمة المعلومات الصحية، وذلك من خلال: • إنشاء أنظمة يعتمد عليها لتسجيل المواليد والوفيات؛ ومن ثم إنشاء نظام وطني للمعرفات المنفردة للمريض لدعم مراقبة الجودة عبر مسارات الرعاية. • التحول من الاعتماد على التسجيل الورقي إلى التسجيلات الصحية الإلكترونية المتفردة، والتي يمكن استخدامها في العديد من أماكن تقديم الرعاية الصحية. • وضع تشريع وطني يحمي الخصوصية الفردية ويسمح في نفس الوقت باستخدام المعلومات الصحية الشخصية لأغراض البحث وتحسين الجودة. • دعم الأطباء السريريين، والمديرين، وواضعي السياسات في جمع بيانات الخدمة وتحليلها بغية تحسين الجودة، والتواصل الفعال مع الجمهور حول كيفية استخدام تلك البيانات. • التشجيع على الشفافية عندما تسوء الأمور، عن طريق خلق ثقافة تعليمية تركز على فهم الأسباب الأصلية بدًلا من إلقاء اللوم بشكل فردي. • الموافقة على معايير لرفع جودة البيانات وقابليتها للمقارنة على المستوى العالمي، وخاصة المصطلحات القياسية لتصنيف الأحداث الضائرة وتحليلها والحيلولة دون وقوعها. • تضمين قياس لنتائج وخبرات المرضى كعنصر قياسي في تقييم جودة المرافق. … 45 دمج الجودة في أسس النظم الصحية الفصل 4 5. استحداث آليات تمويل تدعم التحسين المستمر للجودة، بواسطة: • الحد من الاعتماد على الأموال الخاصة في التمويل، والتحول إلى أموال سابقة الدفع والتجميع لتمويل غالبية الأنظمة الصحية من خلال مخططات التأمين الإلزامية، مع تقديم دعم مالي لغير القادرين على الاشتراك. • ربط تمويل مقدمي خدمات الرعاية باحتياجات الرعاية الصحية المحلية، وتحفيز تنسيق الرعاية المقدمة للأفراد ذوي الاحتياجات المعقدة، والاستثمار في الرعاية الأولية على نحو كاف. • الاستفادة الكاملة من إمكانات خطط الدفع لتقديم مزايا إضافية مستدامة مثل تحسين بروتوكولات الرعاية، وتحسين التعاون بين مقدمي الخدمات، وتحسين نظم المعلومات عن احتياجات الرعاية الصحية، والأنشطة، والتكاليف، والنتائج. تقديم خدمة صحية عالية الجودة: ضرورة عالمية للتغطية الصحية الشاملة 55 تحسين الجودةفهم وسائل الفصل5 65 الفصل 5 فهم وسائل تحسين الجودة 5-1 مقدمة الجودة هي مفهوم معقد ومتعدد الأوجه، والسعي لتحقيقها يتطلب تصميم توليفة من التدخلات المنفصلة واستخدامها في آن واحد. وفهم هذا الترابط أمر بالغ الأهمية في تصميم النظم الصحية في المستقبل؛ فعلى سبيل المثال، يشكل وضع معايير الرعاية جزًءا من تحسين الجودة؛ ولكن لكي يتم تنفيذ المعايير بشكل موثوق به، يلزم اتخاذ إجراءات إضافية؛ مثل تدريب مقدمي الرعاية الصحية والإشراف عليهم ومراقبة امتثالهم، وإبداء الملاحظات بشأنهم؛ فعملية وضع المعايير وحدها، دون هذه الإجراءات الداعمة والمتبادلة الأخرى، ذات قيمة محدودة (401، 501). يصف هذا الفصل مجموعة من وسائل تحسين جودة الخدمات الصحية ويناقش مبررات تطوير السياسات والاستراتيجيات الوطنية المتعلقة بالجودة. ويلقي الضوء على الأهداف المشتركة التي تعالج الجودة من خلال مجموعة واسعة من التدخلات، عبر جميع مستويات نظام الرعاية الصحية - من السياسة والتنظيم على المستوى الوطني إلى توفير الرعاية للمريض الواحد بشكل مباشر -. كما يفسر الترابط بين الوسائل المتنوعة للتغيير وتجنب نهج المسار الواحد. ويجب أيًضا تصميم الوسائل حسب الحاجة داخل البلدان؛ حيث يمكن اتخاذ القرارات المتعلقة بالصحة على المستوى دون الوطني والمجتمعي، كما يجب أن تكون حساسة للعوامل الفريدة المرتبطة بالظروف. 5-2 تحقيق التحسين من خلال سياسة الجودة والاستراتيجية الوطنية يعد وضع سياسة واستراتيجية الجودة الوطنية وصياغتها وتنفيذها ذا أولوية متنامية مع سعي البلدان للنهوض بأداء النظام الصحي بشكل منهجي. ومن المرجح أن تكون سياسة واستراتيجية الجودة الوطنية المصممة بعناية – مع تطبيق نهج مستنير للتنفيذ - أحد الاعتبارات المحورية للبلدان حيث تعمل على زيادة إمكانية الحصول على الخدمات الصحية التي تحقق أفضل ما يمكن تحقيقه من نتائج. ولكن لماذا تركز الدول على تحقيق الجودة من خلال الجهود الوطنية؟ إن لكل بلد ثقافته الخاصة، واحتياجات سكانه، والتراث التاريخي الذي يشكل نظام الرعاية الصحية الخاص بها؛ ومع ذلك، تشترك معظم البلدان في مجموعة من الأهداف وفي إدراكهم للسياق الاستراتيجي للرعاية الصحية. وهناك ستة مجالات رئيسية للأرضية المشتركة: • الإيمان بأن الرعاية الصحية عالية الجودة، والمأمونة، والتي تتمحور حول الفرد هي سلعة عامة ينبغي تأمينها لجميع المواطنين. • القبول بأن تحسين فرص الحصول على الرعاية دون الاهتمام بنوعيتها لن تؤدي إلى النتائج الصحية المرجوة للسكان. • الاعتراف بأن الاستراتيجيات الرامية إلى تحسين كفاءة النظم الصحية يجب أن تحقق وضع مالي متزايد التقييد. • الحاجة إلى تحقيق الاتساق بين أداء تقديم الرعاية الصحية العامة والخاصة في الأسواق الصحية المجزأة والمختلطة. • إدراك أن تصريف الشؤون يعني تلبية الطلب العام لشفافية أكبر فيما يتعلق بمعايير الرعاية وخيارات العلاج والأداء والنتائج المتغيرة. تواجه البلدان تحدي تطوير أو تحسين سياساتها واستراتيجياتها المتعلقة بالجودة من خلال الإجماع الوطني. ويجب أن تدرك أيًضا أن تحقيق التغيير نحو رؤية مستقبلية لأداء أفضل سيظل دائمًا مقيًدا بالواقع العملي لكيفية تقديم الرعاية الصحية ومكانها. توضع السياسات الوطنية المعنية بجودة الرعاية الصحية من خلال مختلف الهياكل الحكومية. وذلك ينطوي - في بعض البلدان - على وضع تشريع يتيح إنشاء هياكل جديدة للإدارة وتصريف الشؤون أو خلق أشكال جديدة من الإجراءات الإلزامية (على سبيل المثال، تسجيل الأطباء وترخيصهم)، أو صياغة آليات تنظيمية جديدة (مثل التفتيش والاعتماد)، مما قد يفضي إلى الحاجة إلى وثيقة واضحة لسياسة وطنية للجودة. وفي تقديم خدمة صحية عالية الجودة: ضرورة عالمية للتغطية الصحية الشاملة 75 إطار 5-1 دراسة حالة: إثيوبيا – استراتيجية جودة الرعاية الصحية الوطنية 6102-0202 إثيوبيا هي ثاني أكبر دولة من حيث عدد السكان في أفريقيا، ويبلغ عدد سكانها حوالي 001 مليون نسمة. وقد شهد القطاع الصحي في البلد منذ عام 5991 إصلاحات كبيرة من خلال تنفيذ استراتيجية تمويل الرعاية الصحية. وتحدد خطة التحول في قطاع الصحة أربعة جداول أعمال ذات أولوية للتحول: ضمان تقديم خدمات صحية عالية الجودة بطريقة عادلة؛ والتركيز على التحول على مستوى المقاطعة؛ وتعزيز نظم المعلومات الصحية؛ وخلق قوى عاملة صحية رحيمة ومحترمة ومهتمة. وقد تم إطلاق الاستراتيجية الوطنية لجودة الرعاية الصحية الإثيوبية في مارس 6102. ومن أجل تفعيل الاستراتيجية؛ قامت مديرية جودة الخدمات الصحية باستحداث أداة لتحسين الجودة للمراجعة السريرية لبعض خدمات الرعاية الصحية ذات الأولوية العالية في المستشفيات. كما تم إجراء تدريب على مستوى الدولة على جودة الرعاية وطرق المراجعة مع كوادر رعاية صحية مختارة من جميع المستشفيات. ويتيح نظام بيانات الجودة الآن دمج مؤشرات الأداء الرئيسية مع نظام معلومات الإدارة الصحية الحالي (601). وهناك عدد من الأولويات المهمة في تنفيذ الاستراتيجية، بما في ذلك تعزيز اللجنة الوطنية التوجيهية المعنية بالجودة برئاسة وزير الدولة، وهى: دعم إنشاء وحدات للجودة في مكاتب الصحة الإقليمية والمرافق الصحية؛ وبناء القدرات من خلال تدريب الكوادر والإرشاد المتخصص؛ ودمج تحسين الجودة في منهج الصحة قبل المدرسة؛ وتعزيز آليات الرصد والتقييم؛ وخلق الطلب على الجودة داخل المجتمع، مع التركيز على الرعاية المتسمة بالاحترام. حالات أخرى، قد يكون تنفيذ سياسة أو استراتيجية وطنية للجودة ببساطة جزًءا من الخطة الخمسية الروتينية لقطاع الصحة أو وثيقة داخلية بوزارة الصحة. ولا توجد طريقة واحدة صحيحة للقيام بذلك؛ ولكن معظم الأساليب تتضمن واحدة أو أكثر من العمليات التالية: • سياسة الجودة واستراتيجية التنفيذ بوصفها جزًءا من الخطة الوطنية الرسمية طويلة الأجل للقطاع الصحي. • إعداد وثيقة سياسة الجودة كوثيقة وطنية قائمة بذاتها، تكون عادة في إطار عملية تضم العديد من الجهات أصحاب المصلحة، وتقودها أو تدعمها وزارة الصحة. • استراتيجية تنفيذ وطنية للجودة - مع جدول أعمال مفصل - يتضمن أيًضا قسًما عن مجالات السياسة الأساسية. • تمكين التشريعات واللوائح التنظيمية لدعم السياسة والاستراتيجية. يقدم الإطاران 5-1 و5-2 دراسات حالة قطرية حول تنفيذ سياسة الجودة الوطنية واستراتيجيتها في القطاع الصحي في إثيوبيا والسودان. 85 الفصل 5 فهم وسائل تحسين الجودة إطار 5-2 دراسة حالة: السودان – سياسة جودة الرعاية الصحية الوطنية واستراتيجيتها يوجد في السودان نظام صحي لامركزي، حيث تكون الحكومة الفيدرالية مسؤولة عن وضع السياسات الوطنية للصحة واستراتيجيتها وتنسيقها؛ بينما حكومات الولايات هي المسؤولة عن التخطيط والتنفيذ على مستوى الولاية؛ والكيانات المحلية هي المعنية بتقديم الخدمات على الأرض؛ والجهة الإدارية الرئيسية هي المجلس الوطني لتنسيق قطاع الصحة المتعدد القطاعات. إن الوعي بجودة الرعاية بين العامة وأخصائيي الرعاية الصحية متقطّع. وعلى الرغم من وجود بحوث متعلقة بالجودة فإنه لا يوجد آلية كافية لنشر النتائج فيما بين المنظمات، لذلك لا يتم دائمًا اتخاذ القرارات على أساس البيانات والأدلة ذات الصلة. ومع ذلك، يجري اتخاذ تدابير لتصحيح أوجه القصور المذكورة؛ وتماشيًا مع الخطة الاستراتيجية الوطنية الثالثة لقطاع الصحة، تم صياغة سياسة جودة الرعاية الصحية الوطنية واستراتيجيتها في عام 7102، والتي سيتم تنفيذها خلال الفترة 7102-0202. وتتناول السياسة أربعة مجالات رئيسية ذات أولوية: تعزيز تصريف الشؤون والمساءلة، والامتثال لمعايير الجودة الوطنية، وتعزيز نهج يركز على الفرد، والحد من الأذى الذي يمكن تجنبه للمرضى. وقد تم التركيز بشكل خاص على القوى العاملة الصحية من خلال التدريب المعتمد، والمسارات الوظيفية، ومعايير التوظيف، والموارد البشرية لنظم إدارة الصحة، ونظم تقييم الأداء والمراجعة للمساعدة في بناء القدرات. ويأتي تأسيس شراكة رسمية مع المرضى والمجتمع في صدارة جدول أعمال سياسة واستراتيجية الجودة الوطنية. وتشمل الخطوات التالية تعزيز آليات التنسيق لنظام الصحة الوطني؛ ووضع مخطط للاحتفاظ بالموارد البشرية؛ وتعزيز نظام معلومات إدارة الصحة؛ وإضفاء الطابع المؤسسي على الجودة على جميع المستويات؛ وتحسين سلامة المرضى ومكافحة العدوى على مستوى الولاية؛ وتعزيز القدرة على الإدارة والتنفيذ على جميع المستويات. تعمل استراتيجية الجودة - وبأقصى قدر من الفعالية - كجسر بين النقطة التي يقف عندها النظام الصحي الحالي ومستوى الجودة الذي يهدف البلد إلى تحقيقه. ويمكنها تسريع وتيرة تحقيق الأهداف والأولويات الصحية؛ باستخدام مبادئ إدارة الجودة التي تتضمن عمليات التخطيط والمراقبة والتحسين (701). وعلى الرغم من اختلاف شكل ومحتوى السياسة والاستراتيجية الوطنية لكل بلد؛ فمن المرجح أن تحظى العناصر الثمانية التالية باهتمام عالمي: • الأهداف والأولويات الصحية الوطنية؛ وستساعد هذه الموارد على توجيه الموارد لتلبية مطالب السكان الأكثر إلحاًحا؛ ثم يتم مواءمة جدول أعمال الجودة معهم. • تعريف الجودة؛ فيجب أن يكون تعريف الجودة المستخدم مقبوًلا في السياق المحلي داخل البلد، ويجب أن يدعم النهج الوطني. كما أن استخدام اللغة المحلية والفهم المشترك أمران ضروريان. • تحديد أصحاب المصلحة ومشاركاتهم؛ فالجودة هي مجموعة المكونات الفردية للنظام الصحي بأكمله. ويتيح إشراك أصحاب المصلحة الرئيسيين في تطوير السياسات والاستراتيجيات مجموعة شاملة من العوامل التي تعزز الخدمات الصحية ذات النوعية الجيدة والتي ينبغي معالجتها. • تحليل الموقف: حالة الجودة؛ حيث تشمل الحالة الراهنة للجودة في أي نظام صحي الأولويات والمشاكل ذات الصلة؛ والبرامج والسياسات ذات الصلة؛ والقدرات والكفاءة التنظيمية؛ والقيادة وتصريف الشؤون؛ والموارد ذات الصلة. وتقييم الحالة الراهنة للجودة يحدد الفجوات الرئيسية التي تتطلب الاهتمام ومجالات خدمات الرعاية الصحية التي يمكن تعزيزها. تقديم خدمة صحية عالية الجودة: ضرورة عالمية للتغطية الصحية الشاملة 95 إطار 5-3 دراسة حالة: المكسيك – الاستراتيجية الوطنية لتوحيد الجودة في مرافق وخدمات الرعاية الصحية المكسيك، التي يبلغ تعداد سكانها حوالي 021 مليون نسمة، لديها نظام رعاية صحية مختلط يشمل اثنين من مقدمي الخدمات من القطاعين العام والخاص. وعلى الرغم من الإصلاحات الرئيسية، بما في ذلك إدخال نظام التغطية الصحية المجانية في عام 3002؛ لا تزال التحولات السكانية والوبائية - مثل شيخوخة السكان وزيادة انتشار الأمراض غير السارية - تضع ضغوطًا هائلة على نظام الرعاية الصحية. وقد أُطلقت في كانون الثاني/ يناير 1002 استراتيجية شاملة لتحسين الجودة على نطاق المنظومة. وكانت الأهداف الرئيسية هي تعزيز جودة الرعاية كقيمة أساسية في ثقافة منظمات الرعاية الصحية - العامة والخاصة على حد سواء - ولتحسين نوعية خدمات الرعاية المقدمة على نطاق نظام الصحة. وفي عام 2102، تم إطلاق الاستراتيجية الوطنية لتوحيد الجودة في مرافق وخدمات الرعاية الصحية، والتي سيتم تنفيذها من خلال المديرية العامة للجودة والتعليم في الرعاية الصحية في وزارة الصحة. وتهدف الاستراتيجية إلى تحسين الجودة في المجالات التالية: سلامة المرضى، والابتكار والتحسين المستمر، وإدارة المخاطر، واعتماد مرافق الرعاية الصحية، والتنظيم الصحي، والتعليم الصحي. إن تنفيذ الاستراتيجية يدعمه إطار إدارة الجودة الذي يوفر الهيكل الإداري لتحسين الجودة على جميع المستويات. ويستهدف الإطار تحقيق خمس نتائج قيمة: صحة السكان، والحصول الفعال على الخدمة، والمنظمات الموثوقة والآمنة، والتجارب المرضية للسكان مع الرعاية الصحية، والتكاليف المعقولة. ومشاركة المواطنين محل تشجيع، وقد تم وضع نظام مراقبة مع مؤشرات. وتشمل الحوافز جائزة وطنية للجودة، وحوافز مالية لشبكات الوحدات من أجل إقامة مشاريع مشتركة محددة لتحسين الجودة. المصدر: وزارة الصحة (801)، وla te zeláznoG-aibaraS. (901)، و la te saleuR. (011). • طرق التحسين والتدخلات؛ إن الاختيار الحكيم للتدخلات المترابطة التي سيتم تنفيذها على جميع مستويات نظام الرعاية الصحية سيحسن النتائج الصحية. وهذه المهمة معقدة بسبب الموارد المحدودة، والدليل على أثرها، والجدوى، والمقبولية. • تصريف الشؤون والهيكل التنظيمي للجودة؛ فتصريف الشؤون، والقيادة، والقدرات التقنية كلها عوامل ضرورية لتحسين الجودة، ويجب تحديدها بوضوح. وفي عدد متناٍم من البلدان، تم إنشاء وحدة على المستوى الوطني - عادة في وزارة الصحة - تعمل مع هيئات الجودة الوطنية الأخرى جنبًا إلى جنب. • نظم معلومات إدارة الصحة ونظم البيانات؛ ويعتمد تحسين الجودة على بيانات أداء واضحة ودقيقة. ومن الضروري وجود نظام معلومات لدعم جهود الجودة على المستوى الوطني للقياس، وإبداء الملاحظات على الأداء، وإعداد التقارير. • تدابير الجودة؛ فوجود مجموعة أساسية من مؤشرات الجودة له أهمية حاسمة للحكم على ما إذا كان ينتج عن التدابير المتخذة جودة أعلى للرعاية، مما يؤدي إلى تغير كبير في النتائج الصحية؛ ولتقديم الملاحظات لمقدمي الخدمات وإدارة المرافق؛ ولتعزيز الشفافية تجاه الجمهور؛ وللمقارنة المرجعية لتحديد أفضل الممارسات للتعلم منها. ويقدم الإطار 5-3 دراسة حالة عن تطبيق استراتيجية الجودة الوطنية من خلال إطار تنسيقي لإدارة الجودة في المكسيك. 06 الفصل 5 فهم وسائل تحسين الجودة 5-3 تدخلات لتحسين الجودة يمكن للتدخلات الرامية لتحسين الجودة أن يكون لها تأثير كبير على خدمات صحية محددة وعلى النظام الصحي بشكل عام. ويمكن لفهم أنواع التدخلات المستخدمة بشكل شائع، ومعرفة الأدلة المتعلقة باستخدامها وفعاليتها، إتاحة خيارات أكثر استنارة حول ماهية التدخلات التي ينبغي اختيارها في البلدان. وتتشابه طبيعة تحديات الرعاية الصحية في مختلف النظم الصحية في جميع أنحاء العالم تشابًها كبيرًا، على الرغم من اختلاف سياقات احتياجات السكان الصحية، والتمويل، وقدرة القوى العاملة. وفي حين أن الأولويات قد تختلف - الأمراض السارية مقابل الأمراض غير السارية، واحتياجات الرعاية في وقت لاحق من الحياة مقابل علاج الأمهات والأطفال - ؛ فالسعي لتحقيق أهداف الجودة متواجد في كل مكان، وهي: • تقليل الضرر على المرضى. • تحسين الفعالية السريرية للخدمات الصحية المقدمة. • إشراك وتمكين المرضى والأسر والمجتمعات. • بناء القدرة النظامية لأنشطة تحسين الجودة المستمرة. • تعزيز تصريف الشؤون والمساءلة. لكن ماذا يحدث بعد ذلك للعمل؟ إن الاتفاق على قائمة الأهداف أسهل من تحديد الاستراتيجيات لتحقيقها. وفي هذا السياق، تبرز سبع فئات من العمل، وينظر فيها بشكل روتيني أصحاب المصلحة المعنيين بالجودة - مقدمو الخدمات، والمديرون، وصانعو السياسات - عند محاولة تحسين أداء نظام الرعاية الصحية. ويتم النظر فيها في الأقسام الفرعية التالية. 5-3-1 تغيير الممارسة السريرية في الخطوط الأمامية إن الفجوة بين ما هو معروف بالرعاية الفعالة "المعرفة" وما يوفره مقدمو الرعاية بشكل روتيني "الفعل" موثقة بشكل جيد في جميع أنحاء العالم. ويتطلب سد هذه الفجوة بين "المعرفة" و"الفعل" إجراء تغييرات متعددة الوسائط في الممارسة السريرية على كل مستوى من مستويات النظام الصحي، بدًءا من المقابلة الفردية بين المريض وعامل الرعاية الصحية إلى إعادة تصميم أسلوب تقديم الرعاية الصحية. إن مهارات العاملين في مجال الرعاية الصحية، ومعارفهم، وسلوكياتهم تشكل عوامل أساسية. كما أن التدابير الرامية إلى دعم مقدمي الرعاية الصحية بغية تحقيق الرعاية الأكثر فعالية تشمل أنظمة دعم اتخاذ القرارات السريرية التي تتراوح من البروتوكولات المكتوبة إلى الوسائل المدعومة إلكترونيًا. وإن الحد من الضرر الذي يلحق بالمرضى هو هدف رئيسي؛ فمن المقدر أنه من كل 001 مريض في المستشفى في أي وقت، سيلتقط 7 مرضى في البلدان المتقدمة و01 في البلدان النامية عدوى واحدة على الأقل من العدوى المرتبطة بالرعاية الصحية (111). وبعيًدا عن المريض ومقدم الخدمة، يجري تصميم وتنفيذ نماذج جديدة للرعاية لمعالجة الأبعاد المتعددة للجودة. وتحدد النماذج أفضل الممارسات الحالية لتقديم الرعاية الصحية بشكل عام وأيًضا فيما يتعلق بمجموعات خاصة من السكان (على سبيل المثال، الأشخاص المصابون بمرض مزمن أو حالات الصحة الذهنية) أو ذوي الخصائص المشتركة (على سبيل المثال، الأطفال أو كبار السن). وغالبًا ما تكون نماذج الرعاية الجديدة مبنية على المجتمع، وتمتد إلى ما وراء جدران المستشفيات وتدمج مساهمات منظمات الرعاية الأولية والمتخصصة والاجتماعية (401). 5-3-2 وضع المعايير إن وضع المعايير، مع البروتوكولات القائمة على البراهين، يتيح إيجاد الاتساق في تقديم الرعاية عالية الجودة عبر مختلف النظم الصحية على الصعيد العالمي. وعلى الرغم من أن الكيانات الحكومية غالبًا ما تقودها؛ فإن وضع المعايير هو مجال لتحسين الجودة حيث يجب أن تلعب الهيئات المتخصصة دوًرا رئيسيًا، إما بالعمل بشكل مستقل أو بالشراكة مع الحكومات. وتركز بعض المعايير السريرية على مجموعات سكانية محددة، والبعض الآخر على حالات المرض أو بروتوكولات العلاج؛ على سبيل المثال، تم وضع معايير الرعاية السريرية العالمية لتحسين رعاية الأم والوليد في المرافق الصحية (211). كما أنه غالبًا ما يتم تحقيق دمج السياسة السريرية تقديم خدمة صحية عالية الجودة: ضرورة عالمية للتغطية الصحية الشاملة 16 والرعاية المستندة إلى المعايير من خلال بروتوكولات رعاية المرضى والمسارات السريرية. وفي حين أن المعايير السريرية غالبًا ما تكون خطوة مبكرة في استراتيجيات الجودة الوطنية؛ فإن وضع المعايير دون اتباع نهج شامل للجودة قد لا يسفر عن النتائج المتوقعة والتقدم المستهدف. 5-3-3 إشراك وتمكين المرضى والأسر والمجتمعات يجب أن تذهب الأنظمة الصحية إلى ما هو أبعد من برامج محو الأمية الصحية للاستفادة الكاملة من إمكانات التركيز على الفرد كمدخل إلى رعاية ذات جودة أعلى. وهناك أدلة قوية - في جميع السياقات القطرية - على أن التدخلات التي تهدف إلى إشراك وتمكين المرضى ومقدمي الرعاية والعائلات يمكن أن تشجع على توفير مستوى أفضل من الرعاية؛ بما في ذلك السلوكيات الصحية، وتحسين تجربة المريض، واستخدام الخدمات الصحية على نحو أكثر فعالية، وتخفيض التكاليف، وتحسين النتائج (001). ففي نيبال، على سبيل المثال، أدى إشراك المجموعات النسائية في تحديد المشاكل والاستراتيجيات الرئيسية لتحسين وضع الأمهات والمواليد إلى انخفاض عدد وفيات حديثي الولادة بنسبة 03٪ وانخفاض وفيات الأمهات بنسبة 08٪ (311). إن تقديم المعلومات، والمشورة، والدعم، للمرضى يمكن أن يساعدهم على إدارة حالاتهم الصحية والمشاركة في وضع خطط العلاج والحفاظ على صحتهم. كما يمكن لآليات المشاركة المجتمعية المستمرة والمستدامة أن تدعم البرامج لتحسين جودة الرعاية؛ كما أن الحاجة لتأمين الثقة أو بنائها في المجتمعات هي أيًضا ذات أولوية؛ فبدونها سيكون هناك حاجز رئيسي يحول دون الرغبة في الحصول على الرعاية الصحية حتى عند تواجد الحاجة إليها. 5-3-4 المعلومات والتعليم للعاملين الصحيين، والمديرين، وواضعي السياسات لكي تكون أنظمة معلومات تحسين الجودة فعالة، يجب أن تفي باحتياجات مقدمي الرعاية، ومديري المرافق الصحية، وقادة النظام الصحي، وواضعي السياسات، والهيئات التنظيمية. وهذا يتطلب معلومات موجهة وطرق تعليمية لكل جمهور. ويحتاج العاملون في مجال الصحة إلى معلومات مقارنة حول أدائهم، خاصًة بالمقارنة مع أفضل الممارسات؛ كما يحتاج القادة، والمديرون، وواضعو السياسات، والهيئات التنظيمية، والمموِّ لون أيًضا إلى معلومات مقارنة. وسيختلف الشكل والتركيز حسب مجال الجودة التي يتم مراجعتها، سواء كانت خدمة (على سبيل المثال، رعاية الأمومة)، أو حالة مرضية (على سبيل المثال، رعاية الأشخاص المصابين بالسكري)، أو مجموعة ضمن السكان (على سبيل المثال، كبار السن)، أو تدخل (على سبيل المثال، الاستفادة من التحصين ضد الحصبة). وأحد الالتزامات المطلوبة من القادة يتمثل في ضمان الحفاظ على مستوى مناسب من الاستثمار في نظم المعلومات؛ ومع ذلك، لا يحتاج التقدم في الحصول على المعلومات واستخدامها إلى الاعتماد على حلول التقنيات المتقدمة؛ فعلى سبيل المثال، قد يكون دعم القرار السريري في شكل مطالبات محوسبة، أو في بساطة نماذج ورقية مع خانات لتحديد العمليات الأساسية المتعلقة بالرعاية الفعالة للطفل. 5-3-5 استخدام البرامج والطرق للتحسين المستمر في الجودة إن تحسين الجودة ليس مفهوًما ثابتًا؛ بل هو خاصية ديناميكية بنظام ناشئ باستمرار؛ ويُستخدم العديد من الطرق المختلفة لضمان استمرار جودة الرعاية الصحية وتحسينها، بما في ذلك آليات تصريف الشؤون السريرية الواسعة النطاق؛ واستعراض الأقران والمراجعة السريرية؛ والملاحظات الفردية؛ والإشراف والتدريب؛ وأدوات دعم اتخاذ القرار السريري على أساس المبادئ التوجيهية؛ والتعلم القائم على التعاون للتخصصات المتعددة. وأحد المبادئ الأساسية التي يستند إليها التحسين المستمر للجودة هو آليات التعلم النشطة باستخدام دورات التكرار المتغيرة. وعلاوة على ذلك، فإن تجنب "إلقاء اللوم والتوبيخ" أمر أساسي في تجنب مخاطر بث الخوف والمقاومة بدًلا من المشاركة الحماسية في السعي المشترك لتحسين الأداء. ولا توجد طريقة واحدة فعالة؛ بل يجب الجمع بين عدة تدخلات مع فهم للسياق المحدد. وقد أضحى دور الثقافة المؤسسية عنًصرا حاسًما في تحديد المزيج الملائم من طرق تحسين الجودة استناًدا إلى القدرات والإمكانات المتاحة. 5-3-6 تقديم حوافز على أساس الأداء (مالية وغير مالية) يمكن أن تكون الحوافز مالية، مثل صرف مبالغ نقدية، أو غير مالية، مثل الإشادة والجوائز. ويعتبر التمويل المرتكز على الأداء مصطلًحا عاًما لإثابة مقدمي الخدمات الصحية استناًدا إلى مجموعة من مقاييس الأداء؛ ويستخدم بشكل متزايد كأداة محفزة لرفع الجودة. وتشمل النماذج الشراء على أساس القيمة؛ وعقوبات إعادة القبول؛ وإيقاف المدفوعات عن الأخطاء الطبية؛ وبرامج الأداء التي تركز على تعزيز الرعاية الأولية. كما يمثل المبلغ المرتبط بالأداء مكونًا فرعيًا من إجمالي المدفوع، استناًدا إلى مجموعة من طرق التمويل. ولا تزال 26 الفصل 5 فهم وسائل تحسين الجودة الإطار 5-4 دراسة حالة: أونتاريو، كندا - الرعاية الممتازة لجميع القوانين والاستراتيجيات يمثل توفير فرص متساوية للحصول على رعاية عالية الجودة تحديًا في أونتاريو، مع مساحتها الكبيرة وتعداد سكانها غير المتجانس البالغ أكثر من 5.31 مليون نسمة، بما في ذلك الأمم الأولى. وكما هو الحال في جميع المقاطعات الكندية، تمتلك أونتاريو نظاًما صحيًا يقوم على جهة دفع منفردة؛ ويمول القطاع العام حوالي ثلثي نفقات الرعاية الصحية، في حين يسدد المرضى أو خطط التأمين الخاصة الثلث بشكل مباشر. وقد وجدت العديد من الدراسات أن العلاقة بين الجودة والتمويل ضعيفة بشكل عام في أونتاريو، والهدف الرئيسي للإصلاحات الحالية للنظام الصحي هو تعزيز ذلك الارتباط. وأصبح قانون الرعاية الممتازة للجميع قانونًا رسميًا في عام 0102، حيث شكلت استراتيجية الرعاية الممتازة للجميع أداة التنفيذ. ويفرض القانون تشكيل لجان للجودة في مجلس الإدارة في منظمات القطاع الصحي، كما يتطلب إجراء دراسات استقصائية عن مدى رضا المرضى والأسر والموظفين. بالإضافة إلى ذلك، يجب على منظمات الرعاية الصحية إعداد ونشر إعلان للمرضى عن الِقيَم وخطة تحسين الجودة؛ كما أنشأ "قانون الرعاية الممتازة للجميع" وكالة موسعة للجودة بالمقاطعة، هي "جودة الصحة في أونتاريو"؛ مع تكليف بإجراء رصد لأداء النظام الصحي وإعداد التقارير العامة، ودعم تحسين الجودة، وتعزيز توفير أفضل نوعية من الرعاية الصحية. وعلى المستوى التنظيمي، تحكم اللوائح التنظيمية ضمان الجودة والسلامة في المستشفيات ودور الرعاية، والمختبرات، وغير ذلك من أماكن الرعاية الصحية، وقد تم إنشاء كليات تنظيمية للصحة لضمان أن يقدم الأخصائيون الصحيون الخدمات بطريقة آمنة ومسؤولة وأخلاقية. وفي حين أن 56٪ من سكان أونتاريو يقدرون وضعهم الصحي كممتاز أو جيد جداً؛ فإن هذا المتوسط يخفي تباينات جغرافية وسكانية كبيرة؛ على سبيل المثال، يُحتمل أن يبلغ أفقر ُخمس عن وجود … الأدلة مختلطة حول قدرة برامج الدفع مقابل الأداء على تغيير النتائج الصحية من تلقاء نفسها؛ ومع ذلك، يمكن للحوافز - المالية والحوافز غير المالية المعترف بها بشكل متزايد - أن تؤدي وظيفة محفزة ومستدامة ذات أهمية عند استخدامها كجزء من برنامج قوي لتحسين الجودة. وفي الوقت نفسه، يجب الاهتمام بتجنب العوامل المثبطة (مثل أنظمة الدفع التي تشجع على الاستخدام الزائد للأدوية). 5-3-7 التشريعات واللوائح التنظيمية تستخدم الحكومات التشريعات واللوائح التنظيمية لتحقيق الأهداف الصحية الوطنية. وقد تتناول التشريعات الموجهة لتحسين جودة الخدمات الصحية مجموعة واسعة من القضايا، مثل التغطية والمزايا؛ وإنشاء هيئات وطنية جديدة (أو تمكين الحالية)؛ وإجراء إصلاحات على مدفوعات ترخيص المنشآت والموردين ؛ وتقارير الأداء العام. إن اللوائح التنظيمية هي مجموعة من العوامل خارج الممارسة السريرية أو إدارة الرعاية الصحية التي تؤثر على السلوك في تقديم الخدمات الصحية أو استخدامها (411). وتستهدف اللوائح عادة أنشطة مقدمي الخدمات من الأفراد والمؤسسات؛ ومنظمات التأمين الصحي؛ ومصنعي المستحضرات الصيدلية والأجهزة؛ والمستهلكين أو المرضى. وغالبًا ما تفشل التدخلات التنظيمية المختلفة في تحقيق أهدافها المنشودة، ويعود ذلك جزئيًا إلى افتقار الجهات المسؤولة إلى القدرة على الإنفاذ. كما تتزايد أهمية اللوائح المعنية بنشاط القطاع الخاص؛ بالنظر إلى النسبة الكبيرة من إجمالي الخدمات المقدمة. ويقدم الإطار 5-4 دراسة حالة توضح استخدام التشريعات واللوائح التنظيمية في دعم أهداف جودة الرعاية الصحية في أونتاريو، كندا. … تقديم خدمة صحية عالية الجودة: ضرورة عالمية للتغطية الصحية الشاملة 36 العديد من الحالات المزمنة أكثر من الُخْمس الأغنى. وردًّ ا على ذلك، سيظل التركيز المستمر على القيادة، والمساءلة، والمواءمة بين الحوافز والأهداف لتحسين الخدمة هو حجر الزاوية في استراتيجية أونتاريو لنظام رعاية صحية ذي جودة أعلى. المصدر : معهد علوم التقويم السريري (SECI) (511)، وزارة الصحة والرعاية طويلة الأجل (611) 5-4 النظر في نوعية التدخلات واختيارها في الوقت الذي توفر فيه فئات العمل السبعة خريطة واسعة لتحسين الأداء؛ هناك حاجة أخرى لتحديد التدخلات الرئيسية لتحسين الجودة. إن إمكانية اختيار التدخل "الصحيح" أمر نادر؛ فلا يوجد تدخل واحد يلبي جميع الاحتياجات. حتى التدخلات غير المثيرة للجدل - مثل بروتوكولات نظافة اليدين - غير فعالة إذا لم يتم تنفيذها من خلال مراعاة الثقافة التنظيمية ومواقف الموظفين ودوافعهم. والربط مع الأهداف الوطنية - المصمم لتحمل التغييرات السياسية - أمٌر أساٌسي لتحقيق الاستدامة على المدى الطويل. وسوف يتطلب أي طموح لتحسين الجودة اتباع نهج متعدد النماذج، باستخدام مزيج من التدخلات. وقد لا يكون لبعض الأساليب - مثل اعتماد المرافق الصحية - تأثير مباشر على النتائج الصحية ولكن يمكن أن تكون مهمة في بناء الثقة العامة وتعزيز ثقافة الجودة داخل نظام الرعاية الصحية. وقد فشلت البرامج التي تركز فقط على سلوك مقدمي الخدمة في إدراك أن البيئة الأوسع للرعاية الصحية تلعب دوًرا محوريًا في تسهيل أو عرقلة أفضل الممارسات؛ فعلى سبيل المثال، غالبًا ما يعتمد وصف المضادات الحيوية المناسبة على طبيب يمكن أن يتأثر سلوكه بالمبادئ التوجيهية للممارسة، وردود الفعل على الأداء، واستعراض الأقران، والتدريب والإشراف، والحوافز المالية، وتوافر مجموعة كافية من المضادات الحيوية، وتوقعات المرضى. ويصبح التغيير إذن أمرًا واضح التعقيد. لقد تم تحديد التدخلات التوضيحية الواردة في الجدول 5-1 للخصائص التالية: أنها ذات صلة في مجموعة واسعة من البلدان على مستوى العالم؛ وعادًة تؤخذ في الاعتبار كخيارات؛ ووجود بعض الأدلة لتوجيه اختيارها واستخدامها؛ ويمكن تنفيذها على مستويات متعددة، بدًءا من مستوى عيادات الرعاية الأولية الصغيرة إلى مستوى البرنامج الوطني. إن السياق الذي يتم تطبيق هذه التدخلات فيه محورٌي في الحفاظ على مصداقية مساعي تحسين الجودة. وعلى سبيل المثال، فإن وضع استراتيجية تدخل متعدد النماذج للجودة في مرفق صحي دون توفير إمدادات مياه كافية يقدم كشًفا واقعيًا وفوريًا للباحثين عن الجودة؛ فالبيانات المتعلقة بالمياه، والصرف الصحي، والنظافة المجمعة من المرافق الصحية في جميع أنحاء العالم، تقدم سياقًا واضًحا للعمل على الهياكل المطلوبة لتحقيق الجودة. والقائمة المقدمة ليست شاملة، ويمكن تضمينها تدخلات أخرى؛ وقد تم اختيار هذه المجموعة من التدخلات لتأثيرها المحتمل على الجودة من خلال الحد من الضرر، وتحسين تقديم خدمات الرعاية الصحية في الخطوط الأمامية، وبناء قدرة على مستوى النظام لتحسين الجودة. ولا يتم تصنيف التدخلات التوضيحية من حيث الفعالية؛ ولكنها تشير إلى بعض الخيارات والإمكانيات المتاحة لقادة النظام الصحي، أو المديرين، أو الممارسين، أو صانعي السياسات الذين يهدفون لتحسين جودة الرعاية. كما تُعرض التدخلات ببساطة قدر الإمكان، وتسلط الضوء على القضايا البارزة؛ ومع ذلك، فالتنفيذ ليس أمرًا بسيطًا؛ فالتدخلات المتعددة المجمعة في بيئة النظام تتداخل مع عدد من الفئات السبع المذكورة أعلاه. 46 الفصل 5 فهم وسائل تحسين الجودة جدول 5-1 تدخلات الجودة التوضيحية التدخلاتالفئة • غالبًا ما يعتبر تسجيل الأطباء وغيرهم من المهنيين الصحيين واعتمادهم، وكذلك بيئة النظام المنظمات الصحية، عاملاً محدًدا ومؤسًسا لنظام صحي جيد الأداء. • التقييم والاعتماد الخارجي هو اعتراف الجمهور بمستوى أداء المنظمة، من قبل هيئة خارجية (القطاع العام، ربحي أو غير ربحي)، وذلك عبر مجموعة أساسية من المعايير المحددة مسبًقا. • تصريف الشؤون السريرية هي مفهوم يستخدم لتحسين الإدارة والمساءلة وتوفير الرعاية الصحية الجيدة. ويشمل المراجعة السريرية؛ وإدارة المخاطر السريرية؛ ومشاركة المريض أو مستخدم الخدمة؛ والتعليم والتطوير المهني؛ والبحوث المعنية بالفعالية السريرية والتنمية؛ واستخدام نظم المعلومات؛ ولجان تصريف الشؤون السريرية المؤسسية. • تُعد التقارير العامة والمقاييس المرجعية المقارنة استراتيجية تستخدم غالبًا لزيادة الشفافية والمساءلة بشأن قضايا الجودة والتكلفة في نظام الرعاية الصحية من خلال تزويد المستهلكين والدافعين ومؤسسات الرعاية الصحية ومقدمي الرعاية بمعلومات مقارنة عن الأداء. • يعد التمويل والتعاقد على أساس الأداء مصطلًحا واسًعا لما يدفعه مقدمي الخدمات الصحية استناًدا إلى مجموعة من مقاييس الأداء ويستخدم بشكل متزايد كأداة لتحسين الجودة. وغالبًا ما يكون المبلغ المرتبط بالأداء عنًصرا فرعيًا من المبلغ بالكامل، والذي قد يستند إلى مجموعة من طرق التمويل. • يعد التدريب والإشراف على القوى العاملة من بين التدخلات الأكثر شيوًعا لتحسين جودة الرعاية الصحية في البلدان المنخفضة والمتوسطة الدخل. • تنظيم الأدوية لضمان جودة الأدوية والأدوية والفعاليات المضمونة والآمنة والفعالة هو أمر أساسي لنظام صحي فعال. هناك حاجة إلى التنظيم للتخلص من الأدوية المتدنية النوعية والمزيفة بناًء على القواعد والمعايير الدولية، بما في ذلك مراقبة ما بعد التسويق. • يمكن استخدام التفتيش على المؤسسات للتحقق من المعايير الدنيا للسلامة كآلية الحد من الأذى لضمان وجود القدرة الأساسية والموارد اللازمة للحفاظ على بيئة سريرية آمنة. • بروتوكولات السلامة، مثل تلك الخاصة بنظافة اليدين، تتصدى للعديد من المخاطر التي يمكن تجنبها والتي تهدد سلامة المرضى وتسبب المعاناة والأذى. • قوائم التحقق من السلامة، مثل قائمة التحقق من السلامة الجراحية الخاصة بمنظمة الصحة العالمية وقائمة التحقق الخاصة بالرعاية المتعلقة بالصدمات النفسية، يمكن أن تكون ذات تأثير إيجابي على الحد من المضاعفات السريرية والوفيات. • الإبلاغ عن الأحداث الضائرة يوثق حدوث حالة طبية غير مرغوب فيها لمريض ناتجة عن خدمات صحية محددة أو أثناء تعامل طبي مع مريض في أحد مرافق الرعاية الطبية ويجب ربط هذا التوثيق بنظام تعليمي. … تقديم خدمة صحية عالية الجودة: ضرورة عالمية للتغطية الصحية الشاملة 56 5-5 خاتمة يتطلب تحسين أداء النظام الصحي إجراء اختيارات وأحكام خلال وضع السياسة؛ وتحديد أولويات أهداف الجودة الوطنية؛ وإشراك أصحاب المصلحة الرئيسيين؛ واختيار التدخلات ذات الصلة بالجودة. وتعتبر البنية التحتية، والسياق، والثقافة والتقاليد الخاصة بالرعاية الصحية في بلد والمحلية، من العوامل المركزية في تحديد الأساليب التي يجب تطبيقها. التدخلاتالفئة التحسن في الرعاية السريرية • توفر أدوات دعم القرار السريري المعرفة والمعلومات الخاصة بالمريض (الآلية أو الورقية) في الأوقات المناسبة لتعزيز تقديم الرعاية الصحية في الخطوط الأمامية. • المعايير السريرية، والمسارات والبروتوكولات هي الأدوات المستخدمة لتوجيه الرعاية الصحية القائمة على الأدلة التي تم تنفيذها دوليًا لعقود من الزمن. ويتزايد استخدام المسارات السريرية لتحسين الرعاية في الظروف المتنوعة كبيرة الحجم. • المراجعة السريرية وإبداء الملاحظات هي استراتيجية لتحسين رعاية المرضى من خلال تتبع الالتزام بالمعايير والمبادئ التوجيهية الواضحة إلى جانب تقديم ملاحظات قابلة للتنفيذ على الممارسة السريرية. • توفر مراجعات المراضة والوفيات آلية تعلم قائمة على التعاون وعملية مراجعة شفافة للأطباء لفحص ممارساتهم وتحديد مجالات التحسين، مثل نتائج المرضى والأحداث الضائرة، دون خوف من اللوم. • دورات التحسين القائمة على التعاون وعلى العمل الجماعي هي طريقة رسمية للمستشفيات أو العيادات للعمل مًعا على التحسين المعني بالموضوع محل التركيز على مدى فترة زمنية محددة مع آليات التعلم المشتركة. مشاركة المرضى، والأسرة، والمجتمع المحلي وتمكينهم • تشير المشاركة الرسمية للمجتمع المحلي وتمكينه إلى المساهمة النشطة والمقصودة لأفراد المجتمع في صحة السكان وفي أداء نظام تقديم الخدمات الصحية، ويمكن أن تعمل كآلية إضافية للمساءلة. • محو الأمية الصحية هي القدرة المستمرة على الحصول على المعلومات الصحية الأساسية وفهمها اللازمين لاتخاذ القرارات الصحية المناسبة من جانب المرضى والأسر والمجتمعات الأوسع، وترتبط ارتباطًا وثيًقا بجودة الرعاية. • يتم استخدام عملية صنع القرار المشتركة في كثير من الأحيان لتصميم الرعاية الملائمة لاحتياجات المرضى وتفضيلاتهم، بهدف تحسين التزام المريض وتقليل الرعاية غير الضرورية إلى أدنى حد في المستقبل. • الدعم من النظراء ومجموعات المرضى ذوي الخبرة يربط بين الأشخاص الذين يعيشون في ظروف سريرية مماثلة من أجل تبادل المعرفة والخبرات؛ فهو يخلق الدعم العاطفي والاجتماعي والعملي لتحسين الرعاية السريرية. • حظيت خبرة المريض في الرعاية باهتمام كبير كأساس لتصميم التحسينات في الرعاية السريرية. والتدابير التي أبلغ عنها المريض مهمة في حد ذاتها؛ فالمرضى ذوي الخبرة الأفضل هم أكثر مشاركة برعاية أنفسهم، مما قد يسهم في تحقيق نتائج أفضل. • أدوات الإدارة الذاتية للمرضى هي تكنولوجيات وتقنيات يستخدمها المرضى والعائلات لإدارة المشاكل الصحية خارج المؤسسات الطبية الرسمية؛ ويتزايد النظر إليها كوسيلة لتحسين الرعاية السريرية. 66 الفصل 5 فهم وسائل تحسين الجودة جدول 5-2 التدخلات المعنية بالجودة: إشراك العناصر الفاعلة الرئيسية الدورالعنصر الفاعل • تعريف الأولويات الوطنية وأهداف الجودة.الحكومة • توفير بنية تحتية أساسية عالية الجودة، على سبيل المثال تكنولوجيا المعلومات والمرافق. • تحسين اللوائح التنظيمية. • تقديم البيانات من أجل الشفافية والتحفيز. • التفتيش على مقدمي الرعاية الصحية والترخيص لهم. مرافق الرعاية الصحية • تصريف الشؤون السريرية. • وضع بروتوكولات الرعاية والمسارات السريرية. • دعم القرار السريري. • استخدام بروتوكولات السلامة. • آليات التعلم بين المؤسسات. مقدمو الرعاية السريرية • المعايير السريرية ومسارات المرضى. • مراقبة الالتزام بمعايير الرعاية. • استعراض الأقران والمراجعة السريرية. • اتخاذ القرارات المشتركة. المرضى والجمهور • مشاركة المريض والأسرة والمجتمع. • تثقيف المريض والإدارة الذاتية. • المشاركة في تصريف الشؤون. • ملاحظات المريض من واقع تجربته في الرعاية. واحدة من أكبر العقبات التي تعترض تحسين الرعاية الصحية هي الإحجام عن الاعتراف بالمشاكل الموجودة (911-711)؛ وعقبة أخرى هي صعوبة اختيار التدخلات الفعالة وتنفيذها بكفاءة. وقد أصبحت أهمية القيادة أشبه بشعاٍر شائع في مجال تحسين جودة الرعاية الصحية؛ ولكن من دونها لا نطمح للاعتقاد بأن التحسن ممكن لتحفيز العمل الجماعي. والدافع الرئيسي الآخر للنجاح هو البرهان على أن التدخل يؤتي ثماره، وهنا لا غنى عن جمع البيانات وإبداء الملاحظات؛ ومع ذلك، قد تفتقر الفرق المحلية إلى الخبرة في جمع البيانات وتفسيرها؛ كما أنهم قد يعانون من أنظمة جمع البيانات التي تم تصميمها بشكل سيئ لمراقبة الجودة (021). ويمكن اعتبار التدابير التي تشكل عبئًا مفرطًا مضيعة للوقت، في حين يمكن أن يؤدي سوء اختيار التدابير إلى التلاعب والرشوة. ويعتبر تطبيق عنصر المراقبة من البداية أمرًا حيويًا، وهذا يعني دمج أنظمة القياس في التحسين والتأكد من أنها مزودة بالموارد الكافية (121، 221). وتتسم الاستراتيجية الوطنية الناجحة للجودة بتعدد الأوجه وباستخدام العديد من التدخلات المتضافرة (الجدول 2-5)؛ بدًءا من تلك التي تضع المريض في محور عملية الرعاية، إلى تلك التي تدعم العاملين في مجال الصحة في وضع المعايير والعمل في إطار الفرق بفعالية. ويلعب القادة، والمديرون، وصانعو السياسات دوًرا حاسًما في دعم وتمكين البيئات التي يمكن أن يزدهر فيها وضع المعايير؛ والحوافز القائمة على الأداء، واللوائح التنظيمية والتدخلات الأخرى. تقديم خدمة صحية عالية الجودة: ضرورة عالمية للتغطية الصحية الشاملة 76 الإطار 5-5 الإجراءات الرئيسية: فهم أدوات تحسين الجودة لضمان استخدام عدة أدوات لتحسين الجودة في الرعاية الصحية؛ يجب على الحكومات وواضعي السياسات وقادة النظام الصحي والمرضى والأطباء التعاون مًعا من أجل: 1. وضع سياسة واستراتيجية الجودة الوطنية وتنقيحها وتنفيذها، من خلال: • اعتماد تعريف للجودة، قابل للتطبيق في السياق المحلي. • إجراء تحليل وضع الحالة الراهنة للجودة. • إشراك أصحاب المصلحة الرئيسيين في تنقيحها. • تحديد (أو إنشاء) الهياكل التنظيمية التي يمكن أن توفر تصريف الشؤون، والقيادة، والقدرات الفنية في الجودة. • ضمان إدماج الجودة في وظائف وزارة الصحة. 2. اعتماد وتعزيز أهداف الجودة الشاملة، من خلال: • وضع أهداف واقعية وقابلة للقياس للحد من الضرر وتحسين الرعاية. • العمل مع الهيئات المتخصصة لإنشاء مجالات الرعاية لتحسين الفعالية السريرية. • إشراك وتمكين المرضى والأسر والمجتمعات. • بناء القدرة النظامية للأنشطة الجارية لتحسين الجودة. • إنشاء وتفعيل نظم التعلم للتحسين المستمر. 3. تصميم استراتيجية جودة تتضمن مجموعة من التدخلات لتحسين الجودة، من خلال: • دراسة تدخلات تحسين الجودة المستندة إلى الأدلة بعناية فيما يتعلق ببيئة الأنظمة، والحد من الضرر، وتحسين الرعاية السريرية، ومشاركة المريض والأسرة والمجتمع. 4. رصد و تقرير نتائج جودة الرعاية بغية استمرار جهود التحسين ويعد وضع سياسة الجودة الوطنية واستراتيجياتها من الأولويات إذا كان التحسن جزًءا لا يتجزأ من طريقة عمل نظام الرعاية الصحية. كما يلزم بذل جهود وطنية من أجل تصميم وتنفيذ نهج متماسك للجودة يستخدم أدوات متعددة بغية ضمان تحقيق التغيير الإيجابي الذي يدعو إليه السكان في جميع أنحاء العالم. ويوضح الإطار رقم 5-5 الإجراءات الرئيسية التي يمكن اتخاذها لضمان الاستفادة الكاملة من أدوات تحسين الجودة. 86 دكتور م. ر. راجاغوبال، أخصائي الرعاية الملطفة، تريفاندرم، الهند مستشفيات اليوم ليست مكانًا للموت؛ فهي غير مناسبة في الغالب لتوفير الرعاية في نهاية العمر ثقافيًا وسريريًا على حٍد سواء، وفًقا لما ذكره الدكتور م. ر. راجاغوبال، "الأب الروحي" للرعاية الملطفة في الهند. وقد أمضى أخصائي التخدير السابق أكثر من 02 عاًما في تطوير الرعاية للمرضى على فراش الموت في ولاية كيرالا الصغيرة الخصبة في جنوب غرب البلاد؛ واليوم - مع وجود 3٪ من سكان الهند بها - تمتلك كيرالا ثلثي خدمات الرعاية الملطفة بالبلاد. وتطور اهتمامه عندما كان يعمل كطبيب تخدير في كلية كاليكوت الطبية في شمال كيرالا في أوائل التسعينات؛ واعترف في وقت مبكر أن معالجة الألم ودعم المرضى على فراش الموت لا يمكن أن يتحقق من قبل الطاقم الطبي وحده - كانت الحاجة كبيرة جًدا - وسوف تعتمد على تسخير التزام المتطوعين. "الألم هو الجزء المرئي من جبل الجليد للمعاناة؛ وما يتم تجاهله هو الجزء تحت السطح - مشاعر اليأس والقنوط، والقلق بشأن الأطفال، أو بشأن المال - هو ما تهتم به الرعاية الملطفة." وقد نمت الحركة، ووفًقا لتقديراته فاليوم هناك 003 مجموعة تطوعية في جميع أنحاء الولاية (لا توجد أرقام رسمية)، يوفرون الرعاية للمرضى في منازلهم، ويحددون المحتاجين ويساعدون في توجيه الموارد الطبية المحدودة إلى حيث يمكنهم تحقيق أفضل استفادة؛ والآن، يجذب "نموذج كيرالا" الانتباه من جميع أنحاء العالم. وبعد انتقاله إلى تريفاندروم في الجنوب، أسس في عام 6002 شركة aidnI muillaP، التي تدعم 11مجموعة من المتطوعين وخمس فرق طبية متنقلة تقدم الرعاية الملطفة في المنطقة، بالإضافة إلى القيام بحملات لتحسين الرعاية الملطفة في جميع أنحاء الهند؛ وهو يبلغ من العمر الآن 96 عاًما، ولا يزال يزور المرضى في المنزل ويعلم الزملاء الأصغر سًنا كيفية التعامل معهم. "إذا لبست ربطة عنق، وتعاملت باستعلاء، وتحدثت فقط عن الألم، لن أكتشف الكثير؛ فباتباع نهج مختلف وألطف، ووضع يد على ذراع المريض، سيتحدثون عن مشاكل أعمق". وهو يحذر من أهمية اللغة قائلا: "يمكنك أن تلحق الضرر بسبب جرعة خاطئة من الدواء، وبسبب كلمة خاطئة على حٍد سواء". تعريفي للجودة تقديم خدمة صحية عالية الجودة: ضرورة عالمية للتغطية الصحية الشاملة 96 كما أن التشخيص والعلاج أصبحا يعتمدان بشكل متزايد على التقنية؛ كان هناك فقدان لشيء ما، كما يقول. وقد أدى نمو صناعة الرعاية الصحية التجارية - مدفوًعا بتحقيق الربح - إلى تفاقم الإحساس بالاغتراب؛ والنتيجة هي أن المرض أصبح أكثر أهمية من الشخص المصاب به. ويعتقد معظم الأطباء أن من واجبهم إطالة الحياة بدًلا من تخفيف وطأة الموت؛ لقد أضحى العلاج أهم من الرعاية. "لقد أصبح المريض شخًصا غريبًا وسط الآلات، يبدو أن نظام الرعاية الصحية قد نسي أن الصحة ليست مجرد غياب المرض؛ بل وجود الرفاه الجسدي والعقلي والاجتماعي." ويؤكد أن كل مستشفى يجب أن يدمج الرعاية الملطفة مع عملها الذي يركز على المرض؛ فمعظم الناس - إذا أُتيح لهم الاختيار والرعاية المناسبة - سيختارون الموت في منازلهم محاطين بأحبائهم؛ لكن البعض يشعرون بمزيد من الأمان في بيئة المستشفى، بالقرب من طبيبهم المألوف. ويقول: "يجب أن يكون اختياًرا شخصيًا". إن الحصول على مسكنات الألم أمر حيوي لهذا الاختيار؛ ولكن المورفين ليس من السهل الحصول عليه. وتشير الأرقام إلى أن الهند تستخدم 023 كيلوجراًما من المورفين سنويًا، أي ٪1 فقط من الكمية المطلوبة لتلبية الحاجة. ليست التكلفة هي التي تقيد الحصول عليه، ولكن القانون؛ فقد كان المورفين مقيًدا بشدة في الهند منذ عام 5891 بسبب المخاوف من تعاطي المخدرات. ونتيجة لذلك، نشأ جيلين من الأطباء غير ملمين به، حيث حكموا على الملايين من المرضى الميئوس من شفائهم بمواجهة الموت الأليم دون داع. هنا أيًضا، قادت كيرالا الطريق. فمنذ عام 5991، تم السماح لمراكز الرعاية الملطفة في ولاية كيرالا بإعطاء المورفين عن طريق الفم. وقد أصبحت مؤسسة الدكتور راج الآن مركزًا متعاونًا مع منظمة الصحة العالمية للتدريب والسياسة المتعلقة بالحصول على مسكنات الألم وتستضيف عدًدا كبيرًا من الزوار الدوليين. "يجب أن تكون الرعاية الصحية شراكة بين الطبيب والمريض والأسرة. ويجب ألا يعمل الأطباء بمفردهم ولكن مع الممرضات والمستشارين والمتطوعين من المجتمع والأخصائيين الاجتماعيين. واجبي هو بناء علاقة مع مرضاي وأسرهم ورعايتهم كبشر. الحياة ليست مجرد وجود - هناك ما هو أكثر من ذلك." kcotSi / TETTEPL © :egap suoiverp no egamI

الجودةدعوة للعمل على تحقيق الفصل6 تقديم خدمة صحية عالية الجودة: ضرورة عالمية للتغطية الصحية الشاملة 17 27 الفصل 6 دعوة للعمل على تحقيق الجودة 6-1 التنمية المستدامة والجودة والطريق إلى الأمام لا يمكن تحقيق أهداف التنمية المستدامة المتعلقة بالصحة من خلال الاعتماد على الإنجازات الخاصة بالأمراض أو الإصلاحات المالية وحدها؛ فالأمر يتطلب التزاًما قويًا بإنشاء خدمات صحية عالية الجودة تتمحور حول الفرد. إن تحقيق التغطية الصحية الشاملة المبنية على أساس ثابت من الرعاية الآمنة عالية الجودة، بالإضافة إلى كل ما هو ضروري للحفاظ عليها؛ هو الحتمية التي تواجه صناع السياسة اليوم. وقد اعتمدت معظم الجهود السابقة لتحسين الجودة على المنهجيات القائمة على المشاريع، ولم يظهروا شيئًا يذكر من التوسع والاستدامة؛ فهناك حاجة إلى مزيد من التركيز على أسس الخدمات الصحية عالية الجودة عبر سلسلة الرعاية المستمرة. إن تقديم خدمات صحية عالية الجودة يعني أيًضا ربط الإصلاحات المالية وإعادة توجيه نموذج التسليم بالأهداف المتعلقة بجودة الرعاية. وأخيرًا - وبناًء على أسس قوية - يجب على الأنظمة الصحية التي تقدم تحسينات مستدامة في الجودة استخدام أدوات سياسة واستراتيجية وطنية لضمان الجودة؛ بهدف خلق بيئة ُتمَِكن المناصرين على المستويات المحلية والإقليمية والوطنية من تمديد وتوسيع نطاق الأساليب التي ثبت نجاحها لتحسين الخدمات. وفي مثل هذه البيئة، ستقوم الحكومات ومقدمو الخدمات بخيارات مناسبة على الصعيد المحلي بشأن أي من التدخلات الرامية لتحسين الجودة، هي الأقوى تأثيرًا على تحسين بيئة النظام، والحد من الضرر، وتحسين الرعاية السريرية، وإشراك وتمكين المرضى والأسر والمجتمعات. إن المضي قدًما نحو تحسين الجودة، والتغطية الصحية الشاملة، والُنُهج التي تركز على الفرد ضمن مجموعة النظم الصحية المتشابكة يتطلب تفكيرًا نُظُميًا - فهًما متعمًقا وشامًلا لديناميكيات الأنظمة الصحية من أجل تغييرها نحو الأفضل - من خلال فك تشابك الأنظمة الصحية؛ وسوف يساعد التفكير النظمي في تعزيز تنفيذ النظام وتقييمه للتدخلات اللازمة لدعم تحقيق الأهداف الصحية؛ بشكل منصف ومستدام وفعال. 6-2 دعوة للعمل يقترح هذا التقرير من منظور ثلاث مؤسسات عالمية معنية بالصحة - منظمة التعاون الاقتصادي والتنمية، والبنك الدولي، ومنظمة الصحة العالمية - طريقة للمضي قدًما لصانعي السياسات الصحية الذين يسعون إلى تحقيق هدف إتاحة خدمات صحية عالية الجودة للجميع ومحورها الفرد. ويستدعي هذا الفصل سلسلة من الإجراءات رفيعة المستوى من كل جهة من الجهات الفاعلة الرئيسية التي تحتاج إلى العمل جنبًا إلى جنب مع مراعاة الحاجة الملحة بهدف التمكين من تحقيق ما وعدت به أهداف التنمية المستدامة بتحقيق رعاية صحية أفضل وأكثر أمانًا (الإطار 6-1). وبينما لن يتمكن أي طرف من تحقيق كل هذه التغييرات؛ فإن اتباع نهج متكامل حيث تعمل الجهات الفاعلة المختلفة مًعا لتحقيق دورها في الدعوة إلى العمل على تحقيق الجودة، سيكون له تأثير واضح على جودة الخدمات الصحية في جميع أنحاء العالم. تقديم خدمة صحية عالية الجودة: ضرورة عالمية للتغطية الصحية الشاملة 37 الإطار 6-1 الإجراءات رفيعة المستوى من قبل الجهات الفاعلة الرئيسية لتحقيق الجودة في مجال الرعاية الصحية ينبغي لجميع الحكومات القيام بالتالي: • إيجاد سياسة واستراتيجية وطنية للجودة. • إثبات المساءلة عن إتاحة خدمة آمنة وعالية الجودة. • ضمان أن الإصلاحات المدفوعة بهدف تحقيق التغطية الصحية الشاملة تدمج الجودة ضمن أساسيات نظم الرعاية. • ضمان وجود بنية أساسية من المعلومات بالأنظمة الصحية، إلى جانب وجود تكنولوجيا معلومات قادرة على قياس جودة الرعاية وتقديم التقارير عنها. • سد الفجوة بين الأداء الفعلي والأداء الذي يمكن تحقيقه فيما يتعلق بالجودة. • تعزيز الشراكة بين مقدمي الخدمة الصحية ومتلقيها؛ مما يحث على تحقق الجودة في الرعاية. • بناء ودعم قوى عاملة من الأخصائيين الصحيين ذوي القدرات والإمكانات لتلبية مطالب السكان واحتياجاتهم لرعاية عالية الجودة. • استناد عمليات الشراء، والتمويل، والتكليف على مبدأ القيمة. • تمويل الأبحاث المعنية بتحسين الجودة. ينبغي لكل الأنظمة الصحية القيام بما يلي: • إجراء تدخلات قائمة على براهين، والتي من شأنها إظهار التحسن في الأداء. • عقد المقارنات القياسية مع الأنظمة المشابهة صاحبة أفضل الممارسات. • ضمان تمكن كافة المصابين بأمراض مزمنة من تخفيف آثار تلك الأمراض على نوعية الحياة التي يحيونها. • الترويج للعادات والأنظمة الثقافية التي تحد من إلحاق الأذى بالمرضى. • بناء القدرة للتمكن من الوقاية من تهديدات الأمن الصحي، وكشفها، والاستجابة لها من خلال تركيز الاهتمام على الجودة. • إنشاء البنية التحتية للتعلم. • تقديم المساعدة الفنية، وإدارة المعرفة لتحسين الخدمة. ينبغي لكل المواطنين والمرضى القيام بما يلي: • التمكن من المشاركة النشطة في الرعاية لتحسين وضعهم الصحي. • لعب دوٍررائٍد في تصميم نماذج جديدة للرعاية؛ لتلبية احتياجات المجتمع المحلي. • درايتهم بحقهم في الحصول على الرعاية التي تلبي معايير الجودة الحديثة القابلة للتحقيق. • تلقي الدعم والمعلومات والمهارات اللازمة لإدارة حالاتهم الخاصة على المدى الطويل. ينبغي لكل العاملين بالقطاع الصحي القيام بما يلي: • مشاركة مرضاهم في قياس الجودة وتحسينها. • تبني فلسفة ممارسة العمل الجماعي. • رؤية المرضى كشركاء في تقديم الرعاية. • الالتزام بتوفير البيانات، واستخدامها لإثبات فعالية وسلامة الرعاية.

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تقديم خدمة صحية عالية الجودة: ضرورة عالمية للتغطية الصحية الشاملة 58 هذا الملحق يحدد ويعرض المزيد من المعلومات والبحوث حول مجموعة من التدخلات لتحسين الجودة. 1. يعتبر ترخيص مزودي الرعاية الصحية من المحددات الرئيسية لنظام صحي جيد الأداء. ومع ذلك، يشير العمل الناشئ الذي ينظر في الفروق في الأداء بين الممارسين المرخصين وغير المرخص لهم إلى أن الترخيص وحده لا يكفي لضمان توفير الرعاية الجيدة؛ فعلى سبيل المثال، في دراسة أجراها البنك الدولي حول منطقة ريفية في الهند - حيث عدد مقدمي الخدمات غير المؤهلين يبلغ 51 ضعًفا على أولئك الحاصلين على درجة علمية طبية - ُوِجد أن التدريب الرسمي ليس ضمانًا للجودة العالية. ولاحظت الدراسة فروقًا طفيفة بين الأطباء المدربين وغير المدربين في الالتزام بقوائم التحقق من السلامة، وعدم وجود اختلافات في احتمال قيام مقدمي الرعاية بإعطاء التشخيص أو توفير العلاج الصحيح (1). كما تشير هذه النتائج إلى أن الأطباء المدربين رسميًا قد يعرفون ما يجب عليهم القيام به سريريًا؛ ولكن هناك حاجة إلى المزيد من التدخلات لضمان الامتثال لمعايير الرعاية عالية الجودة (2). ويعتبر الرصد المنتظم للجودة والملاحظات الفردية لمقدمي الخدمة، وكذلك تثقيف المرضى حول كفاءة مقدمي الخدمة، وسائل أخرى لتحسين جودة الرعاية (3). 2. الاعتماد هو اعتراف عام - من جانب هيئة خارجية - بمستوى أداء المؤسسة وفًقا لمجموعة من المعايير المحددة سلًفا (4). ويمكن منح الاعتماد من قبل القطاع العام والجهات الربحية وغير الربحية. ومن الناحية التاريخية كانت المقاييس المستخدمة لتقييم الاعتماد هيكليّة ومرتكزة على العمليات؛ مثل وجود معدات طبية ملائمة، ونسب التوظيف، والتقيد بالمعايير البرنامجية. وقد تم إجراء بحوث محدودة على العلاقة بين الاعتماد والنتائج السريرية؛ ففي إحدى الدراسات في مصر، كانت درجات رضا المرضى أعلى بكثير بالنسبة للوحدات الصحية غير الحكومية المعتمدة عبر عدد قليل من المجالات، مثل النظافة، منطقة الانتظار، وقت الانتظار، طاقم الوحدة والرضا العام (5). كما يقدم الاعتماد بعض الفوائد - من الناحية النظرية على الأقل - مثل زيادة ثقة الجمهور واطمئنانه، وأسلوب التنظيم الذاتي من جانب مؤسسات الرعاية الصحية، كما يوفر الأساس اللازم للحوافز والعقوبات المتعلقة بإدارة الأداء. وقد يشكل الحفاظ على برنامج اعتماد فعال تحديًا لعدة أسباب، مثل الحاجة إلى موارد إضافية لمعالجة أوجه القصور في الهيكل وفي أداء المنشآت عند الإعداد للاعتماد، والتكيف المستمر لضمان مطابقة المعايير للأدلة، والتمويل المستدام أو الاعتماد الدولي (6، 7). وفي العديد من الظروف، ستكون هناك حاجة إلى فترة من المساعدة الفنية المستهدفة قبل تنفيذ أي برنامج اعتماد (6). 3. تصريف الشؤون السريرية يشمل التعزيز المنهجي لأنشطة مثل التدقيق السريري؛ وإدارة المخاطر السريرية؛ ومشاركة المريض أو مستخدم الخدمة؛ والتعليم والتطوير المهني؛ والبحث والتطوير السريري الفعال؛ واستخدام نظم المعلومات؛ ولجان تصريف الشؤون السريرية المؤسسية (8). والحوكمة السريرية هي مفهوم يستخدم للارتقاء بالإدارة والمساءلة وتوفير الرعاية الجيدة. وقد كانت هيئة الخدمات الصحية الوطنية في المملكة المتحدة رائدة في تنفيذ أنشطة تصريف الشؤون السريرية على نطاق واسع (9). وعلى الرغم من أن الكتابات من البلدان ذات الدخل المنخفض والمتوسط لا تزال محدودة؛ فقد أظهرت دراسة حالة من إندونيسيا أن تصريف الشؤون السريرية استُخِدم لتحسين صحة الأم والوليد في 22 مستشفى (01). وأكثر الآليات المقبولة لتحفيز تصريف الشؤون السريرية هي تلك التي تعترف بالقيادة المحترفة، والتي يُنظر إليها على أنها ذات صلة محليًا؛ كما أنها تسمح بالتفكير في الممارسة المهنية على المستوى الشخصي (11). 4. التقارير العلنية هي استراتيجية تستخدم لزيادة الشفافية والمساءلة في قضايا الجودة والتكلفة في نظام الرعاية الصحية من خلال تزويد المستهلكين والدافعين ومنظمات الرعاية الصحية ومقدمي الخدمات بمعلومات مقارنة عن الأداء. وهي تشمل مجموعة واسعة من المناهج، مثل بطاقات تقرير أداء المستشفى، والأسعار والتكاليف المقارنة في المجتمع، ومقارنة المؤشرات السريرية لمقدمي الخدمة. وقد نُِفذت التقارير العلنية في العديد من البلدان ذات الدخل المرتفع، بما في ذلك كندا والمملكة المتحدة والولايات المتحدة، حيث تشير الأدلة إلى أنها تسرع من وتيرة التحسن. وفي البلدان المنخفضة الموارد تم نشر عدد أقل؛ ولكن العديد من الحالات توضح التأثير المحتمل. وفي أفغانستان، أعدت وزارة الصحة العامة بطاقة أداء متوازن ونشرتها بشكل الملحق – تدخلات لتحسين الجودة 68 تدخلات لتحسين الجودة الملحق علني (21)، باستخدام الدراسات الاستقصائية للأسر المعيشية وبيانات المسح السنوي للمستشفيات، والتي أظهرت تحسًنا تدريجيًا في النتائج الوطنية بين عامي 4002 و8002 في جميع المجالات الستة، بما في ذلك رضا المرضى والمجتمع؛ والقدرة على توفير الخدمات؛ والجودة الشاملة للخدمات؛ وتخفيض رسوم الاستخدام (31). 5. التمويل القائم على الأداء هو مصطلح عريض للمكافأة المقدمة لمقدمي الرعاية الصحية بناًء على مقاييس الأداء. وفي كثير من الأحيان يكون المقدار المرتبط بالأداء مكونًا فرعيًا من المبلغ الكامل؛ والذي قد يعتمد على رسوم الخدمة أو الحد الأعلى أو أي حسابات أخرى. ويمكن تخصيص الدفع على المستوى الفردي أو على مستوى المجموعة (على سبيل المثال المستشفى أو الإدارة أو فريق الرعاية). وتظهر الأدلة نجاًحا متبايًنا اعتماًدا على عوامل مثل المشاركة الكبيرة من أصحاب المصلحة، والقدرات المؤسسية، وكفاءة مخطط التمويل أو المسئول عن الأموال (41-71). وتشير تجربة ميدانية من رواندا إلى أن التمويل المستند إلى الأداء قد يكون مجديًا (ويفضل على التمويل القائم على المدخلات) في أفريقيا جنوب الصحراء الكبرى (51). وقد وجدت الدراسة تحسًنا في عدد من مؤشرات إتاحة الخدمة والمعرفة؛ فعلى سبيل المثال، حدث انخفاض بنسبة 26٪ في التكاليف التي يتكبدها المريض من أمواله الخاصة، وزيادة بنسبة 441٪ في الولادات على أيدي أشخاص مهرة، وزيادة بنسبة 32٪ في المعرفة بمخاطر انتقال فيروس نقص المناعة البشرية من خلال الأشياء الخارقة للجلد؛ ولكن لم يُعثر على أي تأثير على النتائج السريرية (51). وبالمثل، وجدت نتائج من تجربة رائدة في نيجيريا زيادة في زيارات الرعاية السابقة للولادة، واللجوء لأشخاص مهرة عند الولادة (71). 6. يعد تدريب العاملين في مجال الصحة والإشراف عليهم من بين التدخلات الأكثر شيوًعا لتحسين جودة الرعاية الصحية في البلدان المنخفضة والمتوسطة الدخل. وعلى الرغم من الاستثمارات المكثفة من الجهات المانحة، فإن تقييمات الأثر طويل الأجل لهذين التدخلين نادرة. وقد وجدت إحدى الدراسات أن التدريب والإشراف لم يحسنا من جودة الرعاية المقدمة للنساء الحوامل أو الأطفال المرضى في أفريقيا جنوب الصحراء (81). كما وجدت دراسة أخرى من بنين أن العمال - الذين تلقوا تدريبًا على الإدارة المتكاملة لأمراض الطفولة بالإضافة إلى دعم دراسي - قدموا رعاية أفضل من أولئك الذين حصلوا على التدريب بالإضافة إلى الدعم المعتاد؛ وكان أداء المجموعتين أفضل من العمال غير المدربين (91). وفي أحد المشاريع ذات الصلة - في بنين - لتعزيز الإشراف على العاملين في مجال الصحة - وبعد إحراز نجاح مبدئي - واجه المشروع العديد من العقبات على مستويات متعددة من النظام الصحي أدت إلى انهيار الإشراف؛ بما في ذلك ضعف التنسيق، ومهارات الإدارة غير الكافية، وفرق الإدارة غير الفعالة، والافتقار إلى الحوافز، واللامركزية، ومقاومة العاملين في مجال الصحة، وإعطاء أولوية أقل للإشراف على البرامج المحددة، وعبء العمل على الإشراف، وأنشطة عدم الإشراف، والتنفيذ غير الكامل لتدخلات المشروع، والافتقار إلى القيادة والمشرفين الفعالين (02). وخلصت الدراسة إلى أن الدعم من القادة أمر حاسم؛ وبالتالي فإن المانحين والسياسيين بحاجة إلى جعل الإشراف أولوية (02). 7. تنظيم الأدوية يحسن جودة الأدوية، سواء المُنتجة أو المتاحة. وبينما تشير نسبة تتراوح بين 5٪ و51٪ من الدول الأعضاء في منظمة الصحة العالمية إلى حالات أدوية مزيفة؛ فربما يكون ذلك تقليًلا من الأمر الواقع؛ فقدرة تنظيم الدواء على الصعيد العالمي محدودة. وتقدر منظمة الصحة العالمية أن 03٪ من البلدان ليس لديها لائحة تنظيمية أو لديها كيان تنظيمي لا يعمل بشكل صحيح (12). وقد قيمت دراسة أجريت في أوغندا مدى فعالية المبادئ التوجيهية للمعايير الوطنية للعلاج في ترشيد وصف العقاقير، ووجدت تحسًنا ملحوظًا في علاج الحالات العامة والملاريا والإسهال (22). ونظرًا للقدر الكبير الذي تتطلبه الهيئات التنظيمية للأدوية من الموارد المالية والبشرية على حد سواء؛ فقد يكون من الصعب التأكد من اتباع المبادئ التوجيهية. ويلاحظ أن هذا هو الحال خاصة في البلدان الأكثر فقرًا (12). وقد قيل إن البلدان محدودة الموارد ينبغي أن تعتمد على تقييم السلطات التنظيمية الرئيسية للأدوية - مثل تلك الموجودة في الولايات المتحدة وأوروبا - عند تقييم فئات معينة من الأدوية (32)؛ وهذا لا يحل مشكلة الإنفاذ، وقد لا تتوافق المبادئ التوجيهية للبلدان ذات الدخل المرتفع مع السمات التي تحددها البلدان الأخرى على أنها الأكثر أهمية. وأفضل الممارسات في استراتيجيات وصف الدواء والتي أثبتت نجاحها في كل من البلدان النامية والصناعية تتضمن مبادئ توجيهية قياسية للعلاج، وقوائم الأدوية الأساسية، والصيدلة واللجان العلاجية، والتدريب المهني، والتعليم المستهدف أثناء الخدمة (42). 8. يمكن استخدام التفتيش على المؤسسات لضمان تطبيق الحد الأدنى لمعايير السلامة كآلية لضمان وجود القدرات والموارد الأساسية اللازمة للحفاظ على بيئة سريرية آمنة. وعلى الرغم من وجود القليل من الكتابات الرسمية حول التفتيش على المؤسسات لضمان تطبيق الحد الأدنى من معايير السلامة على تقديم خدمة صحية عالية الجودة: ضرورة عالمية للتغطية الصحية الشاملة 78 مستوى المستشفى أو المركز الصحي (52)؛ فإن عناصرالتفتيش المعروفة لتحسين ممارسات السلامة تشمل الاتساق بين المعايير، واعتماد المعايير من قبل وزارة الدولة، والإشراف المناسب لتعميم المعايير ومساعدة الممارسين على استخدامها في الممارسة اليومية (62). ويمكن أن تحدد معايير التفتيش - على أقل تقدير - العناصر الهيكلية الأساسية للجودة، وهي: مصدر مياه نظيفة؛ طاقة يُعتمد عليها وقدرة احتياطية؛ تغطية كافية من قبل العاملين الماهرين في مجال الرعاية الصحية؛ مسؤولية إدارية واضحة؛ سجلات طبية كاملة؛ والمحاسبة. 9. بروتوكولات السلامة - مثل تلك الخاصة بنظافة الأيدي - تعالج العديد من المخاطر التي يمكن تجنبها والتي تهدد سلامة المرضى وتسبب المعاناة والأذى (72). والعدوى المرتبطة بالرعاية الصحية هي الحدث الضائر الأكثر شيوًعا في تقديم الرعاية الصحية في جميع أنحاء العالم (82)؛ وأكثرها شيوًعا هي عدوى الجروح الناتجة من الجراحة، ومجرى الدم، والمسالك البولية، والجهاز التنفسي السفلي (92). ومع ذلك، فإن نظافة الأيدي مشكلة عالمية؛ حيث تبلغ معدلات الامتثال أقل من 04٪ (03). وقد أظهرت دراسات معنية بالنظافة اليدوية تأثيرًا على معدلات نظافة الأيدي تتراوح من 01٪ إلى 05٪ تقريبًا (13، 23). وأظهرت عشرون دراسة أُجريت في المستشفيات، ونشرت بين عامي 7791 و8002 وجود ارتباط بين تحسين ممارسات نظافة الأيدي وانخفاض العدوى (33). وبالإضافة إلى ذلك، يمكن أن تكون برامج نظافة الأيدي فعالة من حيث التكلفة؛ فقد أوضحت إحدى الدراسات في فيتنام أنه مقابل كل إصابة مرتبطة بالرعاية الصحية تم تجنبها، تم توفير 0001 دولار أمريكي (23). ويتطلب تغيير السلوك وجود نُهج متعددة الأوجه تركز على تغيير النظام، والدعم الإداري، والدوافع، وتوافر المطهرات الكحولية، والمياه والصابون المأمونين، والتدريب والتعليم المكثف للعاملين في مجال الرعاية الصحية، والرسائل التذكيرية في مكان العمل (03، 43، 53). والامتثال هو مشكلة منتشرة تعتمد على العديد من العوامل الهيكلية، بما في ذلك الوضع المهني (طبيب، مساعد التمريض، فني علاج طبيعي)؛ وقسم أو نوع الرعاية المقدمة؛ ونسب الموظفين؛ ووجود معدات السلامة ذات الصلة مثل القفازات (33). وعلاوة على ذلك، يجب أن تراعي البرامج السياق (على سبيل المثال، يجب استخدام المطهرات الكحولية في الأماكن التي لا يتوفر فيها الماء الموثوق في نظافته) (13، 53). 01. يمكن لقوائم التحقق من السلامة - مثل قوائم التحقق من السلامة الجراحية - أن يكون لها تأثير إيجابي على الحد من كل من المضاعفات السريرية والوفيات على حٍد سواء. ففي إحدى الدراسات التي أجريت في ثمانية مستشفيات متنوعة في مزيج من أوضاع الدخل المرتفع والمنخفض؛ انخفضت معدلات حدوث مضاعفات بعد العمليات الجراحية بمعدل 63٪، وانخفضت معدلات الوفيات بمقدار مماثل بعد زيادة الالتزام بإجراءات السلامة الأساسية الست المشمولة بقائمة التحقق المقدمة (63). وعلاوة على ذلك، إذا تم منع حدوث مضاعفات كبيرة خلال السنة الأولى من إنشاء قائمة تحققيه؛ فسوف يحقق المستشفى عائًدا على استثماراته (73). ومع ذلك، تشير الأدلة إلى أن نجاح قوائم التحقق يتطلب تعليم الطاقم الطبي، والموارد المادية، والاندماج في الجهود المؤسسية الأوسع والسياق السريري (83-04). وقد ثبت أن هذه العوامل ذات أهمية خاصة في البلدان المنخفضة والمتوسطة الدخل (83). وقد لا يؤدي ضعف تنفيذ قائمة التحقق في أوضاع الدخل المنخفض إلى الحد من مخاطر سلامة المرضى فحسب؛ بل قد يؤدي أيًضا إلى مخاطر جديدة مثل التلاعب، وفك الارتباط، وغير ذلك من السلوكيات الضارة برعاية المرضى (83). ومن المرجح أن يتم تحسين تنفيذ قوائم التحقق الجراحية في برامج سلامة المرضى الراسخة والمتعددة الأوجه (83). 11. يوثق الإبلاغ عن الأحداث الضائرة أي حادث طبي ضار أو غير مرغوب فيه ينتج عن خدمات صحية محددة أو أثناء مقابلة المريض (14). والإبلاغ عن الأحداث الضائرة هو استراتيجية لرفع الوعي وزيادة الشفافية وتعزيز المساءلة فيما يتعلق بالرعاية غير الآمنة. وتمثل الأحداث الضائرة الناجمة عن الرعاية الطبية مصدًرا رئيسيًا للمراضة والوفيات على مستوى العالم. وقدرت دراسة تبحث العبء العالمي للرعاية الطبية غير الآمنة أن هناك 124 مليون حالة دخول إلى المستشفيات في العالم سنويًا، مع حدوث ما يقرب من 7.24 مليون حدث ضائر ينتج عنهم ضياع 32 مليون سنة من سنوات العمر المصححة باحتساب مدد العجز (sYLAD) في السنة (24). وقد وقع ما يقرب من ثلثي إجمالي الأحداث الضائرة في البلدان المنخفضة والمتوسطة الدخل. وقد تقود الرعاية الطبية غير الآمنة المرضى - خاصة في البلدان منخفضة الدخل - إلى عدم اللجوء لنظام الرعاية الصحية الرسمي؛ مما يجعل الرعاية غير الآمنة حاجزًا مهًما أمام العديد من فقراء العالم. إن استهلاك الموارد بسبب الإقامة لفترات طويلة في المستشفيات والرعاية الإضافية، وكذلك فقدان الأجور والإنتاجية؛ هو نتيجة أخرى للرعاية غير الآمنة. 88 تدخلات لتحسين الجودة الملحق 21. دعم القرار السريري (SDC) هو توفير المعرفة والمعلومات الخاصة بالمرضى وتقديمها في الأوقات المناسبة لتعزيز تقديم الرعاية الصحية في الخطوط الأمامية. ويشمل نظام دعم القرار مجموعة متنوعة من الأدوات لتعزيز عملية اتخاذ القرار، مثل الإرشادات السريرية، وإصدار الأوامر وفقا ًللحالة، والتنبيه والتذكير المحوسب، ونماذج التوثيق، والدعم التشخيصي. ويمكن دعم القرار السريري آليا (إدراجه في السجلات الصحية الإلكترونية أو الأجهزة المحمولة) أو بالاستناد إلى الورق. وعلى الرغم من أن نظام دعم القرار السريري الإلكتروني له العديد من المزايا؛ إلا أنه يتطلب مساعدة فنية مستمرة، وقد يكون عرضة لتحديات البنية التحتية السيئة، مثل القدرة المحدودة على الاتصال بالإنترنت، أو إمدادات الطاقة التي لا يمكن التعويل عليها (34). وقد بحث عدد من الدراسات جدوى تنفيذ دعم القرار السريري في البلدان المنخفضة والمتوسطة الدخل؛ ولكن لا يوجد سوى الحد الأدنى من الأدلة على تأثيرها على الصحة حتى الآن (34، 44). وتشير الدراسات إلى الحاجة إلى الموازنة بين مطالبات دعم القرار السريري الموجودة للتوحيد القياسي للرعاية لتحسين الجودة واستقلالية الطبيب في اتخاذ القرارات استناًدا إلى السياق والخبرة السريرية واحتياجات المريض الفريدة (34-54). 31. المعايير السريرية، والمسارات، والبروتوكولات هي أدوات لتوجيه الرعاية الصحية القائمة على الأدلة التي تم تنفيذها دوليًا منذ ثمانينات القرن الماضي (64). ففي الأماكن مرتفعة الدخل، استخدمت المسارات السريرية لتحسين الرعاية لحالات متنوعة، بما في ذلك احتشاء عضلة القلب الحاد واالجلطة؛ فعلى سبيل المثال، أظهرت دراسة من أستراليا أنه بعد إدخال برنامج المسار السريري مع قوائم التحقق ورسائل التذكير، حصل 84٪ إضافيين من مرضى احتشاء عضلة القلب الحاد على حاصرات المستقِبل ِبيتا خلال 42 ساعة من دخولهم المستشفيات (74). وبالمثل، بعد إدخال برنامج المسار السريري، تلقى 55٪ إضافيين من مرضى الجلطة الأسبرين أو كلوبيدوغرل خلال 42 ساعة من دخولهم المستشفيات (74). وشملت دراسة أخرى من الولايات المتحدة بروتوكولات "أفضل رعاية" السريرية في سير العمل السريري من خلال إدخال أمر مقدم الرعاية، وأظهرت أن أداة دعم القرار زادت بشكل ملحوظ من عدد المرضى الذين يتلقون الأسبرين لاحتشاء عضلة القلب الحاد (84). كما تستخدم المسارات والبروتوكولات السريرية في البيئات المنخفضة والمتوسطة الدخل؛ حيث تُنشر المبادئ التوجيهية الوطنية دوريًا، وتعمل كمصدر مرجعي مهم للأطباء ومسؤولي الصحة العامة، خاصة بالنسبة للبرامج الرأسية التي تركز على المرض مثل السل وفيروس نقص المناعة البشرية / الإيدز (94، 05). 41. التدقيق السريري والتعليقات هي استراتيجية لتحسين رعاية المرضى من خلال تتبع الالتزام بالمعايير والمبادئ التوجيهية الصريحة؛ إلى جانب تقديم تعليقات قابلة للتنفيذ. والاستخدام الشائع في جميع أنحاء العالم هو تعزيز تنفيذ المبادئ التوجيهية للممارسة السريرية؛ حيث يتم استخدام التدقيق والتعليق لتحديد التفاوتات غير المبررة ولزيادة الالتزام بالمبادئ التوجيهية. ويعتبر التدقيق على مستوى الفرد والمستشفى جزًءا أساسيًا من استراتيجية السرطان بكتالونيا (إسبانيا) لتعزيز الإنصاف (15). وحتى في المناطق الريفية محدودة الموارد؛ على سبيل المثال في جمهورية تنزانيا المتحدة، ارتبط التدقيق السريري بانخفاض في معدل وفيات الأمهات وحالات المراضة (25). وقد أثبتت الأبحاث في البلدان ذات الدخل المرتفع أن المرافق ذات الأداء الأعلى تميل إلى تقديم تعليقات في الوقت المناسب، وبشكل فردي وغير عقابي لمقدمي الخدمات مقارنة بالمرافق ذات الأداء المنخفض (35). وفي حين أن معظم الدراسات لا تحدد مدى تأثير التدقيق والتعليق بشكل ملموس على الالتزام بالمعايير؛ إلا أنها تسلط الضوء على مدى تكرار الأخطاء الطبية كما تعطي سرًدا وصفيًا لجودة الرعاية في مواقع معينة، مما يساعد الطاقم الطبي على تحديد المناطق التي تحتاج لتحسين الرعاية والتعامل معها. والتحديات الملحوظة التي تواجه النجاح في التنفيذ تشمل توافر الموارد؛ ومشاركة مقدمي الخدمات؛ والدعم القيادي للعملية؛ والاتساق في فهم المبادئ التوجيهية وتنفيذها؛ ودقة المعلومات في السجلات السريرية؛ وفاعلية آليات التغذية المرتدة المستمرة (15، 45). 51. توفر مراجعات المراضة والوفيات آلية تعلم تعاونية، وعملية مراجعة شفافة للأطباء لفحص ممارساتهم وتحديد مجالات التحسين، مثل نتائج المرضى والأحداث الضائرة، دون خوف من اللوم (55). وتستخدم مراجعات المراضة والوفيات لجميع الموظفين السريرين لإجراء مراجعة على ما ساهم في حدوث المضاعفات أو وفاة المريض، لأغراض التعلم (55). وهي - على هذا النحو - تعزز الاعتراف النشط بالأخطاء، وهي أيًضا فرصة للتعلم بالإضافة إلى تحديد التحسينات المطلوبة في العملية. وقد تبين أنها تعمل على تحسين التعاون والتواصل، والتعلم القائم على فرق المساعدة، وتؤدي إلى تغييرات في حفظ السجلات وتصريف الشؤون المعنية بسلامة المرضى (55-75)؛ وقد كانت شائعة في السابق في السياقات مرتفعة الموارد، ولكن الدراسات بدأت تظهر إمكانات في البلدان المنخفضة والمتوسطة الدخل. ويوحي العمل الوصفي من نيبال تقديم خدمة صحية عالية الجودة: ضرورة عالمية للتغطية الصحية الشاملة 98 بأنها قابلة للتنفيذ في السياقات الريفية منخفضة الموارد (65). كما تشير الأبحاث عبر السياقات الجغرافية والاقتصادية إلى أهمية مشاركة الإدارة العليا؛ ومشاركة كل من الموظفين السريريين وغير السريريين؛ وتحديد الأهداف بوضوح؛ واختيار الحالات بناًء على إمكانات تحسينها؛ والمتابعة المنسقة لأنشطة التحسينات بوصفها عوامل رئيسية للنجاح (55-75). 61. دورات التحسين التعاونية والقائمة على الفرق هي طريقة رسمية تجمع بين فرق متعددة من المستشفيات أو العيادات للعمل مًعا على تحسين متعلق بالمجال موضع التركيز على مدى فترة زمنية محددة. وهناك العديد من السمات المشتركة للتعاون، وهي: تبادل الأفكار المعنية بالتحسين؛ والاختبار التكراري للإجراءات التي تؤدي إلى التحسين؛ والتعلم المتبادل عبر مؤسسات الرعاية الصحية المتعددة. وقد أظهرت الدراسات التي أُجريت على الأماكن مرتفعة الدخل - مثل الجمعية الوطنية للوقاية من العدوى الجراحية، أو جمعية خفض معدلات الولادة القيصرية - أن الشراكات التعاونية يمكن أن تكون فعالة للغاية؛ مما يقلل من معدلات الإصابة بالعدوى من 72٪ إلى 7.1٪، وفي معدلات الولادة القيصرية بنسبة 03٪ خلال بضعة أشهر (85-06). كما استُخِدمت الشراكات التعاونية في الأماكن منخفضة الدخل؛ فعلى سبيل المثال، كان تحالف المستشفيات الإثيوبية للجودة شراكة تعاونية وطنية برعاية وزارة الصحة الاتحادية الإثيوبية؛ وكان يضم 86 مستشفى، وقد أظهر 44 منها تحسًنا بنسبة 01٪ في مقياس من 01 نقاط لمدى رضا المرضى من البداية وحتى نهاية فترة إجراء الدراسة (16). وقامت الوكالة الأمريكية للتنمية الدولية (DIASU) بتمويل 45 شراكة تعاونية في 41 بلد من ذوي الدخل المنخفض والمتوسط خلال الفترة 8991-8002. وقد أظهر استعواض التحليلات لـ 72 من هذه الشراكات في 21 بلد من ذوي الدخل المنخفض والمتوسط أنه تم الحفاظ على مستوى عاٍل من الأداء لمدة 31 شهرًا في المتوسط، وبلغ متوسط الوقت الذي بلغ فيه الأداء 08٪ هو 2.9 شهرًا؛ في حين بلغ متوسط الوقت اللازم لوصول الأداء إلى 09٪ ، 4.41 شهرا (26). 71. يشير إشراك المجتمع المحلي وتمكينه بشكل رسمي إلى المساهمة النشطة والمقصودة لأفراد المجتمع في صحة سكان المجتمع، وأداء نظام تقديم الخدمات الصحية. ومشاركة المجتمع في الصحة لها العديد من الأشكال والأساليب، بما في ذلك تبني سلوكيات معينة لمنع الأمراض وعلاجها؛ والمشاركة الفعالة في أنشطة مكافحة الأمراض؛ والمساهمة في تصميم البرامج الصحية وتنفيذها ورصدها؛ وتوفير الموارد للصحة. ويمكن إجراء المشاركة والمدخلات في النظم الصحية من خلال وسائل مختلفة، مثل تحليل الاحتياجات، وتحديد الأولويات عالية المستوى، أو المشاركة في مجالس الإدارة. ويمكن العثور على العديد من أمثلة لحالات - على سبيل المثال، في إريتريا والسنغال - أدت المشاركة المجتمعية المعززة في مكافحة الملاريا إلى انخفاض حالات الملاريا الحادة (36). ويشير التحليل الأولي لتفشي مرض الإيبولا إلى أن جهود المشاركة المجتمعية الأكثر رسمية أدت إلى تأثير كبير على عملية تحديد الحالات وتتبعها؛ وإلى ثقة أوسع في وحدات علاج الإيبولا المحلية (46). ولقد أدركت عمليات إصلاح النظام الصحي بشكل متزايد المساهمة الجوهرية للمجتمعات؛ ففي كينيا، تم اختبار الجدوى في التخطيط السنوي للقطاع الصحي على مستوى المقاطعة حيث أثرت المشاركة المجتمعية على تحديد الهدف والأولويات. والتحديات التي تواجه المشاركة المجتمعية الرسمية تشمل بناء القدرات لتمكين المجتمعات، وتوفير الأدوات والمنتجات لدعم مشاركة المجتمع المحلي، والمتابعة المناسبة والإشراف من قبل المهنيين الصحيين. 81. محو الأمية الصحية هي القدرة على الحصول على المعلومات الصحية الأساسية اللازمة لاتخاذ القرارات الصحية المناسبة وفهمها من جانب المرضى والأسر والمجتمعات الأوسع نطاقا ً (56). ويمثل ضعف محو الأمية الصحية تحديًا لجودة الرعاية الصحية؛ فعلى سبيل المثال، يواجه المرضى الذين يعانون من انخفاض نسبة الإلمام بالقراءة والكتابة صعوبة في اتباع التعليمات الطبية، والتفاعل مع نظام الرعاية الصحية، وقراءة الوصفات الطبية أو الالتزام بها (56). وبالإضافة إلى أن المرضى الذين يعانون من انخفاض المعرفة النوعية للأمراض أظهروا انخفاًضا في نوعية الحياة ونتائجهم المرتبطة بالصحة أقل (56)؛ تشير الدراسات إلى أن التدخلات التعليمية يمكن أن يكون لها تأثير على كل من تحسين المعرفة والبحث عن الرعاية السريرية؛ فعلى سبيل المثال، أدى التدخل في مالاوي إلى تحسن كبير في المعرفة المتعلقة بمجال الصحة الذهنية (66)، ووجدت دراسة في الهند وجود ارتباط إيجابي بين برامج محو الأمية الصحية ومعدلات تلقيح الأطفال (76). ومع ذلك، فإن مكاسب محو الأمية تقل مع مرور الوقت؛ لذا يعد وضع برنامج للمتابعة أمرًا أساسيًا. ويقترح البحث استهداف الأشخاص المؤثرين - مثل المعلمين - لنشر الوصول البرنامجي وضمان التأثير على المدى الطويل (66، 76). وتشمل الاعتبارات الأخرى دمج مناهج محو الأمية الصحية في التعليم المدرسي المطلوب، وهو أمر شائع خاصة مع التثقيف في مجال الصحة الجنسية (86). 09 تدخلات لتحسين الجودة الملحق 91. عادة ما يتم استخدام عملية صنع القرار المشترك بين مقدمي الرعاية والمرضى لملائمة الرعاية لاحتياجات المريض وتفضيلاته؛ بهدف تحقيق نتائج أفضل للمرضى. وهناك أدلة كثيرة على أن المرضى يريدون المزيد من المعلومات والمزيد من المشاركة (96)؛ لكن القليل من الدراسات قد قيّمت التأثير على النتائج السريرية، خاصة في البلدان منخفضة ومتوسطة الدخل. وقد يؤدي قصور الاتصال بين مقدمي الخدمات إلى نقص في الخدمات (07). ومع ذلك، توجد عوائق أمام تمكين المرضى في العديد من بيئات قطاع الصحة العامة - كما هو الحال في العيادات - والتي غالبًا ما تكون مزدحمة ومكتظة فوق طاقتها (17). وإحدى الدراسات التي أُجريت حول الالتزام بالعلاج المضاد للفيروسات الرجعية وصنع القرار المشترك، أو "تمكين المريض" توصلت إلى أنه بعد التشخيص، فضل المرضى في الواقع أن يقوم مقدم الخدمة باتخاذ القرار؛ ولكن بعد تشخيص فيروس نقص المناعة البشرية لديهم وتكيفهم معه، كانوا أكثر انفتاًحا على اتخاذ نهج القرار المشترك لعلاج فيروس نقص المناعة البشرية (17). ولا يوجد دليل على أن المشاركة في صنع القرار تؤثر سلبًا على الرعاية السريرية، على الرغم من أنه قد تكون هناك قيود على ما يمكن تناوله في زيارة سريرية واحدة، نظرًا لعوامل مثل المفاهيم المحلية للمرض أو عدم الثقة المتأصلة تاريخيًا في الطب "الغربي"، مما قد يدفع المرضى إلى طلب الأدوية التقليدية (07). 02. مجموعات الدعم المتبادل من الأقران والمرضى الخبراء تربط الأشخاص الذين يعيشون في ظروف سريرية مماثلة من أجل تبادل المعرفة والخبرات. ويكمل هذا النهج خدمات الرعاية الصحية الأخرى ويعززها من خلال خلق الدعم العاطفي والاجتماعي والعملي اللازم لإدارة المشاكل الصحية والحفاظ على صحة جيدة لأكبر قدر ممكن. والكتابات المكثفة التي تدعم فعالية مجموعات دعم الأقران ومجموعات المرضى في البالغين المصابين بفيروس نقص المناعة البشرية تلقي نظرة فاحصة على ما هو مجد وقابل للتحقيق كاستراتيجية لتحسين جودة الرعاية. وقد أظهرت مراجعة منهجية لتأثير مجموعات الدعم على الأشخاص المصابين بفيروس نقص المناعة البشرية أن مجموعات الدعم كانت مرتبطة بخفض معدل الوفيات والمراضة، وزيادة في الاستمرار في تلقي الرعاية وتحسين نوعية الحياة (27). كما أظهرت الزيارات الجماعية نتائج واعدة في إلحاق المرضى الفرادى بشبكة دعم الأقران لتحقيق أقصى قدر من الالتزام، وتحسين استمرار المريض في العلاج، وتوعية المرضى، ورصد الآثار الجانبية، وتحقيق مكاسب علاجية (37). وفي مجموعة دعم من جنوب أفريقيا، كان من المرجح بشكل كبير أن يكون المشاركون حاملون لفيروس غير قابل للكشف ولتعداد خلايا 4DC أكبر من 002 خلية/ مل في 21 شهرًا أكثرمن أولئك الذين لم يشاركوا في مجموعة الدعم (27). وبالنظر إلى التحديات الشديدة التي تواجه الموارد البشرية في جميع أنحاء العالم - وعلى وجه التحديد النقص في مقدمي الرعاية الصحية المدربين - يمكن أن تلعب مجموعات الدعم دوًرا أكبر في تحسين فعالية نماذج الرعاية (27). 12. لقد اتُِخذت تعليقات المريض وتجربته مع الرعاية كاستراتيجية لفهم وتحسين جودة الخدمات الصحية بشكل كبير، خاصة في الدول ذات الدخل المرتفع. وفي هذه السياقات، هناك مجموعة متزايدة من الأدلة على أن التجربة المبلغ عنها ذاتيًا ترتبط مع معايير أخرى - أكثر موضوعية - للجودة السريرية (47). وترتبط التدابير التي يُبلغ عنها المريض بتجربة أفضل للمرضى، والالتزام بالعلاج، وزيادة التفاعل مع الرعاية المقدمة لهم، ونتائج أفضل (57، 67). وقد أظهر عدد قليل من الدراسات في البلدان المنخفضة والمتوسطة الدخل أنه يمكن للمرضى الحكم بشكل كاٍف على جوانب معينة من الرعاية؛ فعلى سبيل المثال، وجدت دراسة أجريت في جمهورية تنزانيا المتحدة أن المرضى لجئوا بشكل استباقي إلى الرعاية بناًء على احتياجاتهم السريرية، وفًقا لحكم نوع وشدة الأعراض، بالإضافة إلى القيمة المتوقعة للرعاية التي تم تلقيها سابًقا (77). كما وجدت الأدلة المستندة إلى التدقيق لإعدادات الرعاية الأولية في الهند أن المرضى لديهم فكرة جيدة عما يريدونه ويحتاجونه من الأطباء وعلى استعداد لدفع ثمنه (87). ويشعر بعض النقاد بالقلق من أن العوامل الرئيسية المحددة لتجربة المريض قد تكون مدفوعة بعوامل مثل البيئة الجاذبة أو التعامل الودي للعاملين؛ ومع ذلك، فقد ثبت أن المرضى قادرون على تمييز وسائل الراحة السطحية من المشاركة الأكثر جدوى. 22. أدوات الإدارة الذاتية للمريض هي تكنولوجيات وتقنيات يستخدمها المرضى والعائلات لإدارة مشكلاتهم الصحية خارج المؤسسات الطبية الرسمية؛ ويتم دراستها بشكل متزايد كأدوات لتحسين الجودة في سياق التمكين المتزايد للمرضى في جميع أنحاء العالم. وبالنظر إلى الانتشار المتزايد للأمراض المزمنة على مستوى العالم؛ فإن الإدارة الذاتية لمرض السكري هي مثال جيد. وقد أظهر مرضى السكري المشتركون في برامج إدارة الذات التثقيفية انخفاًضا ملحوظًا في مستويات الهيموغلوبين الغليكوزيلاتي. وفي أوغندا، تضمنت نتائج المرضى انخفاًضا في نسبة c1AbH وضغط الدم الانبساطي؛ وفي هندوراس، أظهرت تقارير الرعاية الذاتية تحسينات في أكثر من 05٪ من المرضى في مستويات السكر في الدم، والنظام الغذائي والالتزام بالدواء (97). وقد وجد أحد التحليلات الاقتصادية للتدخلات لمرض السكري أن التدريب الذاتي لإدارة السكري يقلل من تقديم خدمة صحية عالية الجودة: ضرورة عالمية للتغطية الصحية الشاملة 19 التكاليف الطبية في البلدان النامية على المدى القصير (08). ولأن الهواتف المحمولة متاحة على نطاق واسع؛ يمكن أن تكون تدخلات الإدارة الذاتية (htlaeHm) القائمة على استخدام الهواتف المحمولة أداة فعالة من حيث التكلفة (97). وتشمل التحديات التي تواجه التنفيذ الواسع النطاق: سبل الوصول الجغرافي والمالي إلى برامج الإدارة الذاتية؛ والموارد البشرية المدربة على المستويين المركزي والطرفي؛ والحصول على التعليم (18). 32. يتم إجراء تقييم التقنية الصحية (ATH) لمعرفة كيف تساعد تقنيات الرعاية الصحية في الحفاظ على الصحة وتحسينها. ويستخدم التقييم لإعلام واضعي السياسة ومتخذي القرارات السريرية المعنيين بإدخال ونشر مجموعة واسعة من التقنيات الصحية (28، 38). إن الحكم على ما إذا كان التقييم يؤثر على الجودة يتضمن النظر في النتائج المحققة على المدى الطويل للسياسات التي تم تنفيذها وإثبات نجاحها. وتقييم التقنية الصحية لديه العديد من التطبيقات المختلفة، مثل وضع السياسات لتطعيم الإنفلونزا للأطفال، وتوفير المعلومات لتطوير خطط السداد في السويد (مما أدى إلى انخفاض التكاليف السنوية)، والتأثير على خصائص حزم المزايا الصحية في تايلاند أو تشيلي (48-68)، أو تحديد دور تقنيات جراحة المناظير في كازاخستان (78). ويعد التماسك بين الجهات المعنية أمرًا ضروريًا للتنفيذ الناجح للتقييم بمشاركة المتخصصين في الرعاية الصحية، ومجموعات مناصرة المرضى، والصناعة، مثل التقنية الطبية أو شركات الأدوية (88). إن الشفافية في التحليلات والتكاليف والنتائج (بيانات المريض الحقيقية) هي المفتاح لنجاح تقييم التقنية الصحية (38). نظرًا لأن الحصول على منتجات الرعاية الصحية، والإجراءات، والأدوية في الوقت المناسب وعلى النحو المناسب؛ يمكن أن يؤثر على نتائج المرضى. كما يمثل تقييم التقنية الصحية آلية مهمة لتحسين جودة الرعاية لكل من الأفراد والسكان. 92 ةدوجلا نيسحتل تلاخدت قحلملا 1. 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