The global crisis in health care quality

Providing access to health care worldwide has been a primary focus of the global health community. However, a recent study in The Lancet finds that a greater number of deaths in low-income and middle-income countries (LMICs) are due to poor-quality health care, rather than lack of access to health care. 

Researchers used the 2016 Global Burden of Disease study to estimate mortality in 137 LMICs for 61 conditions for which personal health care plays an important role in reducing mortality, such as vaccine-preventable diseases, asthma, heart disease, certain types of cancer, and more. After comparing mortality rates from these conditions in LMICs to rates in high-income reference countries in 2016, they found an excess of 8.6 million deaths in LMICs that could have been helped with health care services. Researchers estimate that 5 million of these deaths were due to receipt of poor-quality care and 3.6 million were due to inability to access health care. 

How can it be that poor quality causes more deaths than lack of access? Isn’t sub-par health care better than no health care at all? In fact, emerging research over the past few years suggests that expanding health coverage in LMICs does not necessarily lead to better outcomes, the authors point out. This is because not all clinics have enough resources or skills to treat all of those who come to the clinic in a timely and attentive manner.

“For a very long time in global health, we have been really mandating and supporting and pushing access to care, without really thinking about what happens when people get to the clinic,” said Dr. Margaret Kruk, co-commissioner of this study and professor at the Harvard T. H. Chan School of Public Health, in an NPR interview.

Some of the quality issues stem from lack of skilled practitioners in certain specialties; for example, many hospitals and clinics are not prepared to handle complications during birth. However, not all of the skills deficiency is clinical — much of it is interpersonal. 

“Many parents — 40 to 50 percent — leave the clinic without knowing the child’s diagnosis,” said Kruk, which points to a critical lack of communication between clinicians and patients. In regions where there aren’t many clinics, time is also a huge issue. Long waits are common and when patients do get in, they may spend just 6-8 minutes with the clinician. 

“Universal health coverage could avert 8.6 million deaths per year but only if expansion of service coverage is accompanied by investments into high-quality health systems,” the authors conclude. In other words, we need both access and quality to make the largest positive impact in health outcomes.