quality gaps

BOX 3.3 WHAT HAS TO CHANGE: DYSFUNCTIONAL GATEKEEPING AND QUALITY GAPS

Despite some gains in access to basic services, enormous gaps in the quality and comprehensiveness of primary care persist in many countries. Increasingly, individuals’ most pressing health challenges relate to noncommunicable diseases, mental health, nutritional disorders, and injuries, many of which lie outside the traditional remit of primary health care (PHC). In low- and middle-income countries (LMICs), over 75 percent of individuals with diabetes (Manne-Goehler et al. 2019) and 90 percent of individuals with hypertension (Mills et al. 2016) receive zero or inadequate care to control their conditions (Thornicroft etal. 2017). Sixty percent of health care-preventable deaths in these countries can be attributed to poor-quality care—substantially more than the total attributable to nonutilization of the health system (Kruk et al. 2018). Unqualified providers have proliferated in unregulated LMIC markets, and the adherence of PHC providers to clinical guidelines can be low. With limited ability to solve patients’ problems and perceived poor quality deterring care-seeking, PHC services can be inefficient and unproductive. Some PHC providers often see extremely low caseloads despite high burdens of disease—only 1.4 outpatient visits per day in Nigeria, 5.2 per day in Madagascar, and 6 per day in Ugandaa—while absentee rates frequently exceed 25 percent.b Low- and middle-income countries: In rural India, 76 percent of all primary care providers and 65 percent of self-identified “doctors” have no formal medical training (Centre for Policy Research 2011). In eight Sub-Saharan African countries, providers complete less than one-half of the relevant history and physical examination questions, given a patient’s symptomatic presentation,c and frequently misdiagnose common conditions.d Among women giving birth in facilities in rural Tanzania, more than 40 percent bypassed their local health clinic to seek care in hospitals, despite substantially higher costs. They were more likely to do so if they were relatively wealthy, the local facility was in poor physical condition, or if the perceived (and actual) quality of care was low (Kruk etal. 2014). Upper-middle-income countries: Although major depressive disorder should be treatable in a primary care setting, less than one in ten people with major depression receive minimally adequate treatment in Bulgaria, Lebanon, or Mexico (Thornicroft etal. 2017). High-income countries: In Riyadh, Saudi Arabia, 75 percent of survey respondents in a sample of PHC centers reported that they do “not make primary health care their first choice.” They most frequently cite the limited scope of services and mistrust to explain their preferences (Olasunbo etal. 2016).

a. Data from PHCPI, “Caseload per Provider (Daily),” accessed May 10, 2021, https://improvingphc .org/indicator/caseload-provider-daily#?loc=64,77,86,93,120,130,129&viz=0&ci=false. b. Data from PHCPI, “Provider Absence Rate,” accessed May 10, 2021, https://improvingphc.org /indicator/provider-absence-rate#?loc=&viz=0&ci=false. c. Data from PHCPI, “Adherence to Clinical Guidelines | PHCPI,” accessed May 10, 2021, https:// improvingphc.org/indicator/adherence-clinical-guidelines#?loc=&viz=0&ci=false. d. Data from PHCPI, “Diagnostic Accuracy | PHCPI,” accessed May 10, 2021, https://improvingphc .org/indicator/diagnostic-accuracy#?loc=&viz=0&ci=false.

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What is meant by high-quality comprehensive care?

Health care quality can be succinctly defined as “the degree to which health care services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” (Larson 1991). As such, care quality encompasses two key domains: (1) ensuring effectiveness, that is, providing appropriate care based on scientific knowledge and safety, and (2) avoiding harm through inappropriate or inadequate care. Beyond these core features, some authors have broadened the concept of care quality to include criteria such as timeliness, efficiency, equity, and patient centeredness, among many others (Agency for Healthcare Research and Quality, n.d.). Some have recommended including quality of inputs as well as patient outcomes as proxy indicators, in addition to measuring quality at the service/output level (Donabedian 1988; Joyce, Moore, and Christie 2018).

A classic definition of comprehensiveness evokes “the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs,” within the broader context of primary care (IOM 1996). PHC is the appropriate level to marry the two concepts of quality and comprehensiveness of care. Doing this moves the discussion away from focusing on gatekeeping to envisioning a platform to provide a comprehensive set of essential services (Watkins et al. 2017).

What are the drivers of quality, comprehensive care?

Fundamental to building high-quality, comprehensive primary health care is a systems approach (Bargawi and Rea 2015). WHO experts note that quality improvement efforts often tend to focus on the micro level of local facilities and staff performance. Although crucial, this approach needs to be supported by systemic action, since the quality of local primary health care is deeply affected by the prevailing culture and environment of the health system. System-level interventions to improve quality of care include the following: national workforce strategies; registration and licensing mechanisms; service delivery and care platform redesigns; external evaluation or accreditation; public reporting and benchmarking mechanisms; and national regulatory bodies for medicines, medical devices, and other health products. Health information systems to measure and drive quality of care, as well as financing methods to support provision of high-quality care, are also essential (Bargawi and Rea 2015).

Recent WHO technical guidance on quality in PHC notes that the organization of PHC providers in cohesive multidisciplinary teams is increasingly