- Email: [email protected]
Quality, quality, quality: gaps in the continuum of care
Comment
Quality, quality, quality: gaps in the continuum of care Albert Einstein
Albert Einstein’s words have often been used to signal the need to do things differently. Such a need was the opening message in the recent Partners’ Forum1 in New Delhi, India, to translate the pledges of the UN Secretary-General’s new Global Strategy for Women’s and Children’s Health2 into actions. Cynics of global health initiatives might argue that actions following pledges would indeed be something different. A more constructive response is to seize this opportunity to address a global insanity—continuing over and over again to deliver poor-quality health services for women and children and yet expecting positive results. High and equitable coverage of services for reproductive, maternal, newborn, and child health is a necessary but not sufficient condition for saving 16 million lives by 2015, a goal of the Global Strategy. These services must also provide good-quality care—care that is “effective, safe and a good experience for the patient”.3 Yet this essential requirement has not featured prominently in earlier initiatives or in national plans for reproductive, maternal, newborn, and child health in most of the world’s poorest countries, despite evidence about the perils of ignoring quality.4 There is indeed a need to do things differently: to reposition quality on the pathway to achieving mortality reduction goals. This repositioning requires something else to be done differently: to routinely and robustly monitor quality along the continuum of care, including users’ perspectives as well as providers’. “What you count is what you do” is a reality that helps to explain the national and international neglect of quality targets.5 There is a danger of presuming sustained reductions in mortality on the basis of increased coverage of services but without intelligence about the content and quality of care. Take, for example, maternal mortality and the coverage of delivery care by skilled health personnel. Although analyses show a relation between these two variables, there are marked exceptions.6 In sub-Saharan Africa, high levels of coverage of so-called skilled care at delivery often coincide with very high maternal and newborn mortality,7 which prompts questions about who receives care and whether it is of sufficient quality. National survey programmes typically provide data for coverage, but not for the quality of care; an oversight that can also be found in major governmental initiatives, such www.thelancet.com Vol 379 January 14, 2012
as in India’s Janani Suraksha Yojana scheme. This conditional cash-transfer programme provides incentives to mothers and community workers for institutional birth, and has led to unprecedented increases in coverage.8 However, this increase has not been matched by equivalent efforts to monitor and improve the quality of delivery care, and thus the impact of the scheme on the survival of mothers and babies is unclear.9 Other evidence shows the negative feedback loop of poorquality care causing coverage levels to plateau or decline.10 There are many reasons for the inadequate measurement of quality of care. These reasons include the multiple dimensions to quality, which defy capture in single or simple indicators, the weakness of routine systems for health information, and the over-reliance on household surveys, which limit data acquisition for technical aspects of quality. Although confidential methods of inquiry and death audits have enabled some countries such as South Africa11 and Mexico12 to assess the contribution of poorquality care, for many others this data gap has remained much the same for the past 20–25 years. A real opportunity to address this gap now lies in the emphasis in the Global Strategy on results and accountability, and on universal access to essential services. Indicators of the quality of care must be included in the agreed set of core markers for judging progress and for keeping promises, particularly to those who are most vulnerable. The decision will fall to the new WHO-led Commission2 for identifying the most effective arrangements for oversight and reporting of women’s and children’s health. A balance
Published Online April 6, 2011 DOI:10.1016/S01406736(10)62267-2
Corbis
Insanity: doing the same thing over and over again and expecting different results.
e5
Comment
will need to be struck between business-as-usual attitudes— namely, a reliance on indicators that are captured by current mechanisms (eg, Countdown to 201513), and the agreed need to do things differently—to develop, test, and roll out a minimum set of indicators for quality of care that use the latest innovations in data capture.14 These indicators should play an integral part in tracking progress towards universal access to essential health services.15 Meeting the entitlement of women and children to care of acceptable quality could, for example, be achieved through incentives at all levels of the health system, or by linking demand-side financial schemes with quality, and not just with coverage targets. Although the 2010 Delhi Declaration1 from the Partners’ Forum misses the opportunity to explicitly refer to quality of care, it does speak to an action agenda and the need to move beyond rhetoric. Acknowledging the importance of quality along the continuum of care is an important first step but, in the words of Jawaharlal Nehru, the global-health community must overcome one of its chief defects: “We are more given to talking about things than to doing them.”16
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*Wendy J Graham, Beena Varghese School of Medicine and Dentistry, University of Aberdeen, Aberdeen AB25 2ZD, UK (WJG); and Public Health Foundation of India, Vasant Kunj, New Delhi, India (BV) [email protected] We thank Jacqui Bell, Sanghita Bhattacharyya, Alec Cumming, and Julia Hussein for helpful comments. WJG’s institution has received grant support from the Norwegian Ministry of Foreign Affairs for research on quality of care, and WJG has a part-time secondment to the UK’s Department for International Development. BV sits on the Independent Review Committee of the GAVI Alliance.
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The Partnership for Maternal, Newborn, and Child Health. Partners’ forum 2010: from pledges to action—inauguration. Nov 13, 2010. http://www. who.int/pmnch/events/partners_forum/20101113_pf_inauguration/en/ index.html (accessed Nov 29, 2010). UN. The global strategy for women’s and children’s health. Sept 22, 2010. http://www.un.org/sg/globalstrategy.shtml (accessed Nov 29, 2010). Godlee F. Effective, safe and a good patient experience. BMJ 2009; 339: b4346. Institute of Medicine. Crossing the quality chasm. March, 2001. http://www. nap.edu/html/quality_chasm/reportbrief.pdf (accessed Dec 15, 2010). van den Broek NR, Graham WJ. Quality of care for maternal and newborn health: the neglected agenda. BJOG 2009; 116 (suppl 1): 18–21. WHO. Factsheet: skilled attendants. 2008. http://www.who.int/making_ pregnancy_safer/events/2008/mdg5/factsheet_sba.pdf (accessed Nov 29, 2010). Neal S, McConville B, Bell J, Matthews Z, Woods K, Graham WJ. The White Ribbon Alliance: atlas of birth. November, 2010. http://www. whiteribbonalliance.org/aob/docs/The-Atlas-of-Birth-book.pdf (accessed Dec 15, 2010). Lim SS, Dandona L, Hoisington JA, James SL, Hogan MC, Gakidou E. India’s Janani Suraksha Yojana, a conditional cash transfer programme to increase births in health facilities: an impact evaluation. Lancet 2010; 375: 2009–23. UN Population Fund. Concurrent assessment of Janani Suraksha Yojana (JSY) scheme in selected states of India, 2008. May, 2009. http://mohfw. nic.in/NRHM/Documents/JSY_Study_UNFPA.pdf (accessed Dec 15, 2010). Bell J, Curtis SL, Alayón S. Trends in delivery care in six countries. September, 2003. http://www.measuredhs.com/pubs/pdf/AS7/AS7.pdf (accessed Nov 29, 2010). Bradshaw D, Chopra M, Kerber K, et al, for the South Africa Every Death Counts Writing Group. Every death counts: use of mortality audit data for decision making to save the lives of mothers, babies, and children in South Africa. Lancet 2008; 371: 1294–304. Pan American Health Organization/WHO. Monitoring the reduction of maternal morbidity and mortality. June 23–27, 2003. http://www.paho. org/english/gov/ce/ce132-19-e.pdf (accessed Nov 29. 2010). Countdown to 2015: maternal, newborn and child health. http://www. countdown2015mnch.org (accessed Dec 15, 2010). The Earth Institute, Columbia University. Barriers and gaps affecting mHealth in low and middle income countries: a policy white paper. March, 2010. www. mhealthalliance.org/sites/default/files/OurWork.ThoughtLeadership.Reports. mHealth%20Policy%20Barriers.pdf (accessed Nov 29, 2010). WHO. The world health report. Health systems financing: the path to universal coverage. 2010. http://www.who.int/whr/2010/en/index.html (accessed Nov 29, 2010). Nehru J. Glimpses of world history. USA: Penguin Books, 2004.
A call for coordinated and evidence-based action to protect children outside of family care Published Online December 12, 2011 DOI:10.1016/S01406736(11)61821-7
e6
A caring and protective family, immediate and extended, is central to effective child protection. Children in the most dire straits, however, live without protective family care. These children may be found living on the streets or in institutions, trafficked, participating in armed groups, or exploited for their labour. Children in such circumstances often experience abuse, neglect, lack of stimulation, and extreme and toxic stress, all of which have a profoundly negative effect on a child’s development and adult outcomes.1 Children living outside of family care have largely fallen off the statistical map. There are only limited
data about how many children live in such precarious circumstances, except for scattered estimates from some specific countries. Such children are often not covered in household-based surveys. Some international data collection activities provide useful information about these children, including USAID’s Demographic and Health Surveys,2 UNICEF’s Multiple Indicator Cluster Surveys,3 the Statistical Information and Monitoring Program on Child Labor surveys sponsored by the International Labour Organization,4 and the US Centers for Disease Control and Prevention’s Violence Against Children surveys.5 Although there is a www.thelancet.com Vol 379 January 14, 2012
Quality, quality, quality: gaps in the continuum of care Albert Einstein
Albert Einstein’s words have often been used to signal the need to do things differently. Such a need was the opening message in the recent Partners’ Forum1 in New Delhi, India, to translate the pledges of the UN Secretary-General’s new Global Strategy for Women’s and Children’s Health2 into actions. Cynics of global health initiatives might argue that actions following pledges would indeed be something different. A more constructive response is to seize this opportunity to address a global insanity—continuing over and over again to deliver poor-quality health services for women and children and yet expecting positive results. High and equitable coverage of services for reproductive, maternal, newborn, and child health is a necessary but not sufficient condition for saving 16 million lives by 2015, a goal of the Global Strategy. These services must also provide good-quality care—care that is “effective, safe and a good experience for the patient”.3 Yet this essential requirement has not featured prominently in earlier initiatives or in national plans for reproductive, maternal, newborn, and child health in most of the world’s poorest countries, despite evidence about the perils of ignoring quality.4 There is indeed a need to do things differently: to reposition quality on the pathway to achieving mortality reduction goals. This repositioning requires something else to be done differently: to routinely and robustly monitor quality along the continuum of care, including users’ perspectives as well as providers’. “What you count is what you do” is a reality that helps to explain the national and international neglect of quality targets.5 There is a danger of presuming sustained reductions in mortality on the basis of increased coverage of services but without intelligence about the content and quality of care. Take, for example, maternal mortality and the coverage of delivery care by skilled health personnel. Although analyses show a relation between these two variables, there are marked exceptions.6 In sub-Saharan Africa, high levels of coverage of so-called skilled care at delivery often coincide with very high maternal and newborn mortality,7 which prompts questions about who receives care and whether it is of sufficient quality. National survey programmes typically provide data for coverage, but not for the quality of care; an oversight that can also be found in major governmental initiatives, such www.thelancet.com Vol 379 January 14, 2012
as in India’s Janani Suraksha Yojana scheme. This conditional cash-transfer programme provides incentives to mothers and community workers for institutional birth, and has led to unprecedented increases in coverage.8 However, this increase has not been matched by equivalent efforts to monitor and improve the quality of delivery care, and thus the impact of the scheme on the survival of mothers and babies is unclear.9 Other evidence shows the negative feedback loop of poorquality care causing coverage levels to plateau or decline.10 There are many reasons for the inadequate measurement of quality of care. These reasons include the multiple dimensions to quality, which defy capture in single or simple indicators, the weakness of routine systems for health information, and the over-reliance on household surveys, which limit data acquisition for technical aspects of quality. Although confidential methods of inquiry and death audits have enabled some countries such as South Africa11 and Mexico12 to assess the contribution of poorquality care, for many others this data gap has remained much the same for the past 20–25 years. A real opportunity to address this gap now lies in the emphasis in the Global Strategy on results and accountability, and on universal access to essential services. Indicators of the quality of care must be included in the agreed set of core markers for judging progress and for keeping promises, particularly to those who are most vulnerable. The decision will fall to the new WHO-led Commission2 for identifying the most effective arrangements for oversight and reporting of women’s and children’s health. A balance
Published Online April 6, 2011 DOI:10.1016/S01406736(10)62267-2
Corbis
Insanity: doing the same thing over and over again and expecting different results.
e5
Comment
will need to be struck between business-as-usual attitudes— namely, a reliance on indicators that are captured by current mechanisms (eg, Countdown to 201513), and the agreed need to do things differently—to develop, test, and roll out a minimum set of indicators for quality of care that use the latest innovations in data capture.14 These indicators should play an integral part in tracking progress towards universal access to essential health services.15 Meeting the entitlement of women and children to care of acceptable quality could, for example, be achieved through incentives at all levels of the health system, or by linking demand-side financial schemes with quality, and not just with coverage targets. Although the 2010 Delhi Declaration1 from the Partners’ Forum misses the opportunity to explicitly refer to quality of care, it does speak to an action agenda and the need to move beyond rhetoric. Acknowledging the importance of quality along the continuum of care is an important first step but, in the words of Jawaharlal Nehru, the global-health community must overcome one of its chief defects: “We are more given to talking about things than to doing them.”16
1
2 3 4 5 6
7
8
9
10
11
12
*Wendy J Graham, Beena Varghese School of Medicine and Dentistry, University of Aberdeen, Aberdeen AB25 2ZD, UK (WJG); and Public Health Foundation of India, Vasant Kunj, New Delhi, India (BV) [email protected] We thank Jacqui Bell, Sanghita Bhattacharyya, Alec Cumming, and Julia Hussein for helpful comments. WJG’s institution has received grant support from the Norwegian Ministry of Foreign Affairs for research on quality of care, and WJG has a part-time secondment to the UK’s Department for International Development. BV sits on the Independent Review Committee of the GAVI Alliance.
13 14
15
16
The Partnership for Maternal, Newborn, and Child Health. Partners’ forum 2010: from pledges to action—inauguration. Nov 13, 2010. http://www. who.int/pmnch/events/partners_forum/20101113_pf_inauguration/en/ index.html (accessed Nov 29, 2010). UN. The global strategy for women’s and children’s health. Sept 22, 2010. http://www.un.org/sg/globalstrategy.shtml (accessed Nov 29, 2010). Godlee F. Effective, safe and a good patient experience. BMJ 2009; 339: b4346. Institute of Medicine. Crossing the quality chasm. March, 2001. http://www. nap.edu/html/quality_chasm/reportbrief.pdf (accessed Dec 15, 2010). van den Broek NR, Graham WJ. Quality of care for maternal and newborn health: the neglected agenda. BJOG 2009; 116 (suppl 1): 18–21. WHO. Factsheet: skilled attendants. 2008. http://www.who.int/making_ pregnancy_safer/events/2008/mdg5/factsheet_sba.pdf (accessed Nov 29, 2010). Neal S, McConville B, Bell J, Matthews Z, Woods K, Graham WJ. The White Ribbon Alliance: atlas of birth. November, 2010. http://www. whiteribbonalliance.org/aob/docs/The-Atlas-of-Birth-book.pdf (accessed Dec 15, 2010). Lim SS, Dandona L, Hoisington JA, James SL, Hogan MC, Gakidou E. India’s Janani Suraksha Yojana, a conditional cash transfer programme to increase births in health facilities: an impact evaluation. Lancet 2010; 375: 2009–23. UN Population Fund. Concurrent assessment of Janani Suraksha Yojana (JSY) scheme in selected states of India, 2008. May, 2009. http://mohfw. nic.in/NRHM/Documents/JSY_Study_UNFPA.pdf (accessed Dec 15, 2010). Bell J, Curtis SL, Alayón S. Trends in delivery care in six countries. September, 2003. http://www.measuredhs.com/pubs/pdf/AS7/AS7.pdf (accessed Nov 29, 2010). Bradshaw D, Chopra M, Kerber K, et al, for the South Africa Every Death Counts Writing Group. Every death counts: use of mortality audit data for decision making to save the lives of mothers, babies, and children in South Africa. Lancet 2008; 371: 1294–304. Pan American Health Organization/WHO. Monitoring the reduction of maternal morbidity and mortality. June 23–27, 2003. http://www.paho. org/english/gov/ce/ce132-19-e.pdf (accessed Nov 29. 2010). Countdown to 2015: maternal, newborn and child health. http://www. countdown2015mnch.org (accessed Dec 15, 2010). The Earth Institute, Columbia University. Barriers and gaps affecting mHealth in low and middle income countries: a policy white paper. March, 2010. www. mhealthalliance.org/sites/default/files/OurWork.ThoughtLeadership.Reports. mHealth%20Policy%20Barriers.pdf (accessed Nov 29, 2010). WHO. The world health report. Health systems financing: the path to universal coverage. 2010. http://www.who.int/whr/2010/en/index.html (accessed Nov 29, 2010). Nehru J. Glimpses of world history. USA: Penguin Books, 2004.
A call for coordinated and evidence-based action to protect children outside of family care Published Online December 12, 2011 DOI:10.1016/S01406736(11)61821-7
e6
A caring and protective family, immediate and extended, is central to effective child protection. Children in the most dire straits, however, live without protective family care. These children may be found living on the streets or in institutions, trafficked, participating in armed groups, or exploited for their labour. Children in such circumstances often experience abuse, neglect, lack of stimulation, and extreme and toxic stress, all of which have a profoundly negative effect on a child’s development and adult outcomes.1 Children living outside of family care have largely fallen off the statistical map. There are only limited
data about how many children live in such precarious circumstances, except for scattered estimates from some specific countries. Such children are often not covered in household-based surveys. Some international data collection activities provide useful information about these children, including USAID’s Demographic and Health Surveys,2 UNICEF’s Multiple Indicator Cluster Surveys,3 the Statistical Information and Monitoring Program on Child Labor surveys sponsored by the International Labour Organization,4 and the US Centers for Disease Control and Prevention’s Violence Against Children surveys.5 Although there is a www.thelancet.com Vol 379 January 14, 2012