Improving Health Services: A Global Imperative Amidst COVID-19
Patricio V. Marquez and Lani Rice Marquez
"If you can't describe what you are doing as a process, you don't know what you're doing”
W. Edwards Deming, 1900-1993
Although “back to normal” in all spheres of life is still a distant aspiration worldwide after six months of relentless coronavirus (COVID-19) onslaught, restoring routine health services is a task that cannot wait. The diversion of health care resources to contain and mitigate the COVID-19 pandemic, coupled with a fear of health facilities among the population amid lockdowns, has disrupted the delivery and utilization of services in different parts of the world.
In the absence of a vaccine or effective treatment, the immediate priority is to halt the spread of the deadly coronavirus through public health action, including: testing and contact tracing to stop cases from becoming clusters and outbreaks; isolation of infected people from people who are not sick; quarantine to separate and restrict the movement of people believed to have been exposed to the coronavirus to monitor if they become sick; and social distancing measures and wearing face masks in public spaces for the general population. The restoration and strengthening of health system capacity, however, are equally essential tasks that should be planned and implemented to ensure that critically ill patients receive appropriate care and to reduce the overall impact of the pandemic. A false dichotomy between COVID-19 emergency response and health system strengthening priorities needs to be avoided.
The question that merits consideration, then, is how can quality improvement be at the core of restoring health services? Does improvement happen only by increasing providers’ knowledge and use of new tools, technologies, and medicines to prevent disease and diagnose and treat patients? Or is improvement a process that requires sustained effort and participation of all actors involved in the delivery of services?
To answer these questions, a new open-access book "Improving Health Care in Low-and Middle-Income Countries" offers an interesting perspective rooted in the work of W. Edwards Deming, who proposed in the 1950s that eliminating delays, duplications, and errors would result in higher quality products and services at lower unit costs. Deming’s ideas were initially embraced and applied with good results in Japan to manufacture automobiles, electronic appliances, and other consumer goods, and were later adapted by Don Berwick and others in the United States and other countries in the 1990s for improving health care.
“Improvement”, therefore, as suggested by the book authors, should be understood as “a directed effort to take what we know can improve health – proven, high-impact interventions like active management of the third stage of labor or keeping newborns warm – and ensure that those are implemented reliably, in different contexts, every time, for every patient who needs them.” The country case studies from Africa, Eastern Europe, South Asia, and Latin America and the Caribbean presented in the book illustrate how a persistent effort to identify gaps in care, propose changes to address those gaps, and test the effectiveness of the changes can measurably improve health processes and outcomes.
Overall, one can infer from the book that there is no “best way” to improve health care. Rather, it is clear that engagement of health workers is the critical element for improving care at different levels of the health system—community, health center, district hospital, and referral hospital and for a wide variety of health conditions--prevention of mother-to-child transmission of HIV, tuberculosis-HIV co-infection, nutrition and health promotion for pregnant women and children under two, maternal mortality, and antimicrobial resistance due to overuse of antibiotics.
Indeed, key to success in all country case studies is a dedicated focus of improvement teams on reaching explicit standards, identifying gaps in meeting standards and taking action to address the gaps, including brainstorming and thinking through new ways of improving adherence to standards. Some approaches introduced rewards for meeting standards, but similar improvements in care were achieved by simply informing health workers of gaps in care without explicit rewards for quality.
Measurement is a critical part of testing and implementing changes. The development of data analysis skills among health workers, therefore, is critical for the quality improvement process, particularly looking at changes in data in a simple or intuitive way to allow improvement teams to easily understand what worked—and what didn't.
Building in mechanisms to share learning across teams as they tested different approaches improved the impact of quality improvement efforts in many cases, as effective ways for improving care were shared among teams and scaled up to more sites.
Teams were able to achieve better improvement results with strong support structures around them, including management support, to help them address system-level problems that are beyond the reach of individual teams. Many of the cases also emphasize the value of coaching support to help teams to translate standards into practice and for intervening in the particular care area.
A pilot approach can be useful to demonstrate results on a small scale before scaling up to multiple sites. Results at pilot sites can help create buy-in and political support for the improvement at the political and administrative level of the health system, which in turn can strengthen the efforts at the service delivery level.
Benchmarking or comparing performance between facilities and districts, while providing facility-specific feedback, can stimulate efforts of teams to modify practices. Indeed, health workers can be motivated by evidence of how their practices deviate from the established practices or from the mean performance of other facilities in the same region.
It should be clear, however, that the medium- and long-term sustainability of quality improvement efforts and their achievements will depend on their institutionalization through policies, organizational and institutional arrangements, performance management processes, and adequate and predictable funding allocations. This will support the establishment of a “quality improvement culture” that is ingrained at all levels of the health system. The engagement of frontline teams, following clearly defined standards of work for the delivery of safe, effective, and efficient health care, that is monitored and adjusted as a team responsibility, would be key to sustain performance and contribute to improving the health conditions of the population. If this is done, it would help rebuild trust and confidence in health services after the COVID-19 crisis has ended.