Crossing the Global Health Care Quality Chasm
A Key Component of Universal Health Coverage
Despite years of investment and research, the quality
of health care in every country is much worse than it
should be. Problems range from disrespect of people
when they are interacting with the health care system,
to preventable mistakes and harm, to high rates of incorrect and ineffective treatment.
Among low- and middle-income countries (LMICs)
the exact burden of poor quality is difficult to quantify
because of a dearth of data, lack of standardmetrics, and
insufficient research on quality interventions. But new
estimates suggest that globally between 5.7 and 8.4million people die every year from poor-quality care in
LMICs.1 These deaths, plus disabilities from poorquality care, account for lost productivity totaling an estimated $1.4 trillion to $1.6 trillion dollars annually.1
Wealthier countries have similar experiences in
terms of death, disability, and needless cost due to fragmented care, waste, and care organized around facilities instead of patients. One estimate suggests that
15% of all hospital costs in Organisation for Economic
Co-operation and Development (OECD) countries can
be attributed to patient harms from adverse events.2
In 2001, the Institute of Medicine published a landmark report on the quality ofUS health care:Crossing the
Quality Chasm: A New Health System for the 21st Century. The report starkly documented major defects in 6
dimensions of quality: safety, effectiveness, patientcenteredness, timeliness, efficiency, and equity. In the
nearly 2 decades since, reports have demonstrated that
manydefectspersistand that the “qualitychasm”isglobal.
TheNationalAcademiesofSciences,Engineering,and
Medicine (NASEM) has issued another report on global
healthcare quality,withanemphasis on low-resource settings:Crossing theGlobalQualityChasm:ImprovingHealth
CareWorldwide.Thecommitteeincludedscholarsandleaders fromnationsacross thespectrumofwealth.1
This report
joins 2 recent analyses of problems in global health care
quality.3
Thereportstatesthatwithoutcorrectionofdefects
in health care quality,especially inLMICs, universal health
coverage, a key component of WHO’s Sustainable Development Goals,4will give many people access to care that
will not help them and may even be harmful.
Yet there is reason for hope: momentum and commitment by the global community to achieve universal
health coverage offer an opportunity for nations to improve the quality of care while they broaden access. But
this will not happen automatically; so far, many nations
seem to be focused onexpanding access only. Equity and
quality of care will arrive together, or not at all.
Embracing Systems Design in Health Care
The report espouses an emerging, idealized vision of
health care that reflects systems thinking and adopts
fundamental principles of design and human factors. The
route to improvement places the “user”—patient, individual, community—at the center. This report recommendsdesignprinciples thatinclude full transparency;codesign with users, staff, and communities; care that is
anticipatory, not merely reactive; care reflective of societal values; and care that bases decisions on clear evidence, continuous feedback, and learning (Box).
Redesign like this is evident, for example, in Kenya’s
Clinical Information Network, which was developed in
2013 as a mechanism to promote continuing improvement. Their leaders understand that health care is a complexadaptive system that requiresmultidisciplinarywork,
soft skills, and flexibility for ongoing change.5
The NASEM report’s idealized system empowers
health care workers to solve problems at the front lines
of careand integratesand coordinates careacross the patient’s “journey.” Adherence to these principles supports
a “learninghealthcare system”—one thatlearns fromboth
successes and failures and encourages innovation. This
culture of continuous learning demands strong leadership, commitment, cooperation, and feedback to continually update policies, protocols, and systems.
Leveraging Universal Health Coverage
The path to achieving effective universal health coveragewillbedifferent foreverycountry,butexistinglevers
can be used in almost any setting to ensure and improve
quality. Common levers include financial mechanisms
(such as accreditation, strategic purchasing, and pay-forperformance schemes), policymechanisms (suchas public reportingandastrongcommitment toinvolvingpatients
andcommunitiesinhealthsystemdesignandgovernance),
andtechnicalmechanisms(suchasclinicaldecisionsupport,
health literacy outreach, and workforce training).
A System of the Future
Billions of people already have access to cell phones and
the internet. Forty-seven of the least-developed countries have launched 3G services and are on track tomeet
Sustainable Development Goal 9 of universal and affordable internet access by 2020.6 The speed at which
digital capacity is increasing offers unprecedented opportunities to usher in a transformation.
This proliferation of infrastructure, coupled with advances in software and the capacity of the digital “cloud,”
allows users of care to become more actively involved in
thedecision-making thataffects their health. Theycanaccess their health care records from their phone and communicatewith clinicians through avariety ofvirtual channels, such as telemedicine, email, and social media. As of
2017, theWeChat app in China had been enabled inmore
than 38 000 medical facilities, allowing patients to view
VIEWPOINT
Donald Berwick, MD
Institute for Healthcare
Improvement (IHI),
Editorial Affairs,
Boston, Massachusetts.
Megan Snair, MPH
Center for Populations
Health Research,
Cleveland Clinic,
Cleveland, Ohio.
Sania Nishtar, PhD,
FRCP
Heartfile, Islamabad,
Pakistan.
Corresponding
Author: Donald
Berwick, MD, Institute
for Healthcare
Improvement (IHI),
Editorial Affairs, 53
State St, 19th Floor,
Boston, MA 02109
(donberwick@gmail
.com).
Opinion
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© 2018 American Medical Association. All rights reserved.
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theirmedical records, scheduleappointments,and pay bills from their
phones, positively affecting national challenges of fragmentation and
wait times.7These technological changes, as well as the expansion of
the roles of trained community health workers, can help care become more anticipatory, person-centered, and preventive. Primary
care services can be delivered in the community, and the system can
be far more responsive to the substantial global increase in noncommunicable diseases.
But this promising technological future is not without peril and
cannot be guaranteed everywhere. Many countries lack the regulatoryenvironment toensure patient safety,achieveequity,andavoid
institutional bias in the digital era. Governments and organizational leaders need to initiate new educational curricula to better
equip the workforce for this emerging surge of digital care.
Formidable Problems in the Current System
Compounding the typical challenges of the current complex health
care systems in many countries are 3 additional, formidable issues.
First, informal health workers (ie, those without formal training,
licensing, or supervision) provide care to large proportions of the
world’spopulation,insomenationsexceeding75%ofallcare.8Though
the informal health sector provides many benefits in areas where
healthcare is difficult toaccess, italso brings risks. Theseworkers typically operate outside formaland regulated health care systems, so the
care they give is usually not measured, accountable, or coordinated
with other providers. To raise overall quality of care, governments
should acknowledge the numerous interactions of informal health
workers and work actively to assess and improve their care.
Second, people living in fragile states and contexts of humanitarian crisis may lack health care entirely. The austerity of the settings makes it difficult, if not impossible, to provide continuity,
needed referrals, or even basic treatment.Nearly 2 billion people live
in these environments of extreme adversity, but little research has
been done to elucidate the state of quality or the interventions that
work best in these settings. Efforts to understand and improve quality under extreme adversity should become a priority worldwide.
Third, corruption and institutionalized collusion plague the
health care sector across the world, with estimates that $455 billion of the $7.35 trillion spent annually on health care is lost to fraud
or abuse.9 The NASEM report states that integrity, if not a dimension of quality, is an essential precondition of health care quality. In
the pursuit of universal quality care it is critical for governments and
societies to create better governance structures that are accountable and transparent, and to fund health systems well enough to decrease reliance on and tolerance of corruption.
Research Needs
Enormous gapsexist in the needed research base foraddressing quality improvement, especially with respect to LMIC settings, making
it difficult to recommend prioritized approaches. A broad research
agenda is needed, including rigorous clinical trials and primary research and also implementation research. The diversity of environments in low-resource settings, and across countries of all income
levels, demands that interventions be contextualized and validated locally before they are deployed at a larger scale.
Conclusions
The welcome commitment to universal health coverage needs a parallel and equally intense commitment around the world, from governments and the private sector alike, to the ambitious and continual improvement of the quality of care. This can be achieved, but
it will require the redesign of health care systems and new thinking, if humankind is to benefit not just from access to care, but access to care that can help and heal them.
ARTICLE INFORMATION
Published Online: August 31, 2018.
doi:10.1001/jama.2018.13696
Conflict of Interest Disclosures: All authors have
completed and submitted the ICMJE Form for
Disclosure of Potential Conflicts of Interest.
Drs Berwick and Nishtar served as co-chairs of the
NASEM committee whose work is summarized in
this article. No other disclosures were reported.
Additional Contributions: We thank the NASEM
committee for their invaluable input to this project:
Donald Berwick, Sania Nishtar, Sheila Leatherman,
Ashish Jha, Neeraj Sood, Pascale Carayon, Margaret
Amanua Chinbuah, Vincent Okungu, Marcel
Yotebieng, Tianjing Li, Mohammed K. Ali, Mario dal
Poz, Jeanette Vega, and Ann Aerts.
REFERENCES
1. National Academies of Sciences, Engineering,
and Medicine. Crossing the Global Quality Chasm:
Improving Health Care Worldwide. August 28, 2018.
doi:10.17226/25152
2. Slawomirski L, Auraaen A, Klazinga N.
The economics of patient safety. Paris, France:
OECD Publishing; 2017.
3. Berwick DM, Kelley E, Kruk ME, et al. Three
global health-care quality reports in 2018. Lancet.
2018;392(10143):194-195.
4. SDG3: Ensure healthy lives and promote
wellbeing for all at all ages. http://www.who.int/sdg
/targets/en/. Accessed August 17, 2018.
5. Irimu G, Ogero M, Mbevi G, et al. Approaching
quality improvement at scale: a learning health
system approach in Kenya. Arch Dis Child. 2018.
doi:10.1136/archdischild-2017-314348
6. ICTs, LDCs, and the SDGs: Achieving Universal
and Affordable Internet in the Least Developed
Countries. https://www.itu.int/en/ITU-D/LDCs
/Pages/ICTs-for-SDGs-in-LDCs-Report.aspx. 2018.
7. LewL.How Tencent’smedicalecosystem is shaping
the future of China’s healthcare.https://technode.com
/2018/02/11/tencent-medical-ecosystem/. 2018.
8. SudhinarasetM,IngramM,LofthouseHK,Montagu
D. What is the role of informal healthcare providers in
developing countries? PLoS One. 2013;8(2):e54978.
9. Gee J, Button M. The Financial Cost of Fraud.
London, UK: PKF Littlejohn; 2015.
Box. Design Principles From Crossing the Global Quality Chasm1
1. Systems thinking drives the transformation and continual
improvement of care delivery.
2. Care delivery prioritizes the needs of patients, health care
staff, and the larger community.
3. Decision making is evidence-based and context-specific.
4. Trade-offs in health care reflect societal values and priorities.
5. Care is integrated and coordinated across the patient journey.
6. Care makes optimal use of technologies to be anticipatory and
predictive at all system levels.
7. Leadership, policy, culture, and incentives are aligned at all
system levels to achieve quality aims and promote integrity,
stewardship, and accountability.
8. Navigating the care delivery system is transparent and easy.
9. Problems are addressed at the source, and patients and health
care staff are empowered to solve them.
10. Patients and health care staff co-design the transformation of
care delivery and engage together in continual improvement.
11. The transformation of care delivery is driven by continuous
feedback, learning, and improvement.
12. The transformation of care delivery is a multidisciplinary
process with adequate resources and support.
13. The transformationofcaredeliveryissupportedbyinvestedleaders.
Opinion Viewpoint
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