By Sola Ogundipe
A total of 376,039 deaths occurred in Nigeria in 2016 as a result of insufficient access to qualitative healthcare systems.
With a mortality rate of 67 per 100,000 lives due to poor quality care, no less than 122,664 deaths were recorded from effects of poor quality healthcare in the country, while 253,375 persons died from non-utilisation of available health systems.
These and other findings are the outcome of a new Lancet Global Health Commission Report that states that improved access to care is not sufficient to improve health in the face of an epidemic of poor quality care.
l report tagged: “High-Quality Health Systems in the Sustainable Development Era: Time for a Revolution” identified systematic deficits in quality of care across a range of health conditions and in both primary and hospital care.”
The analysis is part of The Lancet Global Health Commission on High Quality Health Systems – a two-year project bringing together 30 academics, policy-makers and health systems experts from Nigeria and 17 other countries who examined how to measure and improve health system quality worldwide.
The findings which reveal the state of health systems worldwide and outline steps to address health system quality, is the first to quantify the global burden of poor quality health systems, by measuring public accountability and transparency on health system performance.
According to the Health System Quality Country Profile for Nigeria provided by the report, there were 545,898 deaths preventable from public health measures in 2016.
A breakdown according to process of care and user experience shows that 30 percent of users of the health system believe it works pretty well and that only minor changes are needed, however 46 percent thinks government should improve basic health services well while 94 per cent were confident they could get effective care if needed.
Over the years, health commentators have expressed concerns over failed efforts to achieve effective health coverage for all Nigerians especially the poor.
Among factors contributing to underperformance of the health system, are weak public financial management and utilisation of policies built around a federal system which breeds unintended dysfunction and complexities that make it hard to achieve intended benefits.
Others include absence of an institutionalised function of evidence-based planning, research, and dynamics of development assistance for health, among others.
The World Health Organisation, WHO describes a good health system as one that delivers quality services to all people, when and where they need them.
Such system, WHO notes, requires a robust financing mechanism; a well-trained and adequately paid workforce; reliable information on which to base decisions and policies; well maintained facilities and logistics to deliver quality medicines and technologies.
Lamenting the epidemic of poor-quality care in low and middle income countries like Nigeria, the Commission noted that some of the systematic deficits observed in quality of care across a range of health conditions include approximately one million deaths from neonatal conditions and tuberculosis that occurred in people who used the health system, but received poor care.
The Commission established that while many low and middle income countries have made significant progress in improving access to care, poor quality care in the health system is now responsible for a greater number of deaths than insufficient access to care.
“The total number of deaths from poor-quality care per year is estimated to be five times higher than annual global deaths from HIV/AIDS (1 million), and over three times more than deaths from diabetes (1.4 million), the Commission noted.
Data from over 81,000 consultations in the 18 countries surveyed found that, on average, mothers and children receive less than half of the recommended clinical actions in a typical visit, including failures to do postpartum check-ups, incorrect management of diarrhoea or tuberculosis, and failures to monitor blood pressure during labour.
Complaints of poor user experience, citing lack of respect, long wait times, and short consultations and low confidence and trust in health systems were recorded.
Among those affected are people with stigmatised health conditions, such as HIV/AIDS, mental health and substance abuse disorders, as well as other vulnerable groups such as refugees, prisoners and migrants are less likely to receive high quality care.
The Lancet Global Health noted that an estimated 5 million deaths per year in low- and middle-income countries are the result of poor quality care, with a further 3.6 million the result of insufficient access to care.
“While many low- and middle-income countries have made significant progress in improving access to care, a new reality is at hand: poor quality care in the health system is now responsible for a greater number of deaths than insufficient access to care.
In a comment, Chair of the Commission, Dr. Margaret E Kruk, of Harvard T. H. Chan School of Public Health, Boston, USA, said: “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.
“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. Countries will know they are on the way towards high-quality, accountable health systems when health workers and policymakers choose to receive health care in their own public institutions.
“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. 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,” Kruk stated.
In his own comment, former Minister of State for Health in Nigeria and Co-Chair of the Commission, Dr. Muhammad Pate, stated: “The vast epidemic of low quality care suggests there is no quick fix, and policy makers must commit to reforming the foundations of health care systems.
“This includes adopting a clear quality strategy, organizing services to maximise outcomes not access alone, modernizing health worker education, and enlisting the public in demanding better quality care.”
Further, Pate, who is the Chief Executive of Big Win Philanthropy, said: “For too long, the global health discourse has been focused on improving access to care, without sufficient emphasis on high quality care. Providing health services without guaranteeing a minimum level of quality is ineffective, wasteful and unethical.”
In a linked Comment, Director General of the WHO, Dr. Tedros Adhanom Ghebreyesus, said: “Quality is not a given. It takes vision, planning, investment, compassion, meticulous execution, and rigorous monitoring, from the national level to the smallest, remotest clinic.
“The strength of a country’s core capacities under the International Health Regulations depends on the quality of its health services. The same nurse who vaccinates children and cares for new mothers will also need to detect an unusual communicable disease. Similarly, people and communities are at the heart of quality health service delivery.
“We cannot talk about quality without placing them at the centre. When people are actively engaged in their own health and care, they suffer fewer complications and enjoy better health and wellbeing.”
Noting that many current improvement approaches have limited effectiveness, the Commission proposes several ways to address health system quality, starting with public accountability for and transparency on health system performance.
Additionally, commonly used health system metrics such as availability of medicines, equipment or the proportion of births with skilled attendants do not reflect quality of care and might lead to false complacency about progress.
The Commission calls for fewer, but better measures of health systems quality, and proposes a dashboard of metrics that should be implemented by counties by 2021 to enable transparent measurement and reporting of quality care.