Improved Access Not as Important as High-Quality Care in Preventing Deaths Globally

Access to care is not enough to improve health in low- and middle-income countries (LMICs). According to a new study in The Lancet, expansion of coverage has to be paired with investments to create high-quality health systems.

While research has shown that expanded insurance coverage in the United States has been associated with improved self-reported health status, evidence from low-income countries has shown that expanded coverage does not always result in better outcomes. For instance, a program in India that increased coverage for more than 50 million women to give birth in health facilities did not improve maternal or newborn survival.

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“The evidence of poor-quality health care challenges the assumption that increasing utilization of health services will be sufficient to reduce mortality in lower-income countries,” the authors wrote.

The researchers estimated excess mortality for 61 conditions targeted in the Sustainable Development Goals. To do so, they used data from the 2016 Global Burden of Disease study to compare mortality by age and sex in LMICs and compared them with corresponding mortality from a reference group of 23 high-income countries.

They found that approximately 15.6 million of the 19.3 million total deaths (80%) in 2016 in LMICs, from the 61 conditions, were avertable deaths. Of those deaths, 8.6 million were amenable to healthcare—3.6 million were the result of not utilizing healthcare services and 5 million were the result of poor quality care.

“Quality care should not be the purview of the elite, or an aspiration for some distant future; it should be the DNA of all health systems,” Margaret E. Kruk, MD, MPH, chair of the Lancet Global Health Commission on High Quality Health Systems and associate professor of global health at the Harvard T. H. Chan School of Public Health, said in a statement. “The human right to health is meaningless without good quality care. High-quality health systems put people first. They generate health, earn the public’s trust, and can adapt when health needs change.”

Central Europe (78.8%), Tropical Latin America (75%), and Southern Latin America (74%) had the highest percentage of amenable deaths due to use of poor-quality services. Meanwhile Western sub-Saharan Africa (56.4%), Eastern sub-Saharan Africa (51.5%), and East Asia (50.2%) had the highest percentage of avertable deaths resulting from nonutilization of services.

Cardiovascular diseases represented the largest number of deaths resulting from either poor-quality care or nonutilization of services, followed by neonatal death, tuberculosis, road injuries, and chronic respiratory conditions. Poor-quality care was a major driver of cardiovascular deaths (84%) and vaccine preventable diseases (81%), while insufficient access to care was a larger driver of deaths from cancer (89%), mental and neurological conditions (85%), and chronic respiratory conditions (76%).

“The impact of poor-quality care goes well beyond mortality, but can lead to unnecessary suffering, persistent symptoms, loss of function, and a lack of trust in the health system,” Kruk said. “Other side effects are wasted resources and catastrophic health expenditures. Given our findings, it is not surprising that only one quarter of people in low- and middle-income countries believe that their health systems work well.”

Reference

Kruk ME, Gage AD, Joseph NT, Danaei G, García-Saisó S, Salomon JA. Mortality due to low-quality health systems in the universal health coverage era: a systematic analysis of amenable deaths in 137 countries. [published September 5, 2018]. Lancet. doi: 10.1016/S0140-6736(18)31668-4.