Interview with Dr. Margaret E. Kruk

October 25, 2019

"This Is a Moment to Reinvent the Health System."

Dr. Margaret E. Kruk is Harvard University global health professor and chair of The Lancet Global Health Commission on High Quality Health Systems in the SDG Era

As more countries make universal health coverage a national goal, there’s been a focus on figuring out how to improve people’s access to care. But on its own, this won’t necessarily translate into better health. Harvard University associate professor Margaret Kruk, who chaired The Lancet Global Health Commission’s study on health care quality in low- and middle-income countries, says fundamental changes are required to ensure that when people do access care, they’re getting the right care.

A year on since publication of The Lancet Commission’s study on health care quality, what has been the response?

There has been a substantial reaction, both at the global and country level. Health systems typically are not something people get excited about, so it has been very encouraging to see the level of debate and discussion the study provoked. Some people were shocked that there was so much mortality in health systems. We identified 8.6 million excess deaths in low- and middle-income countries from illnesses for which cures are available. The study is helping people to reframe how they think about health care. Before, they thought that the problem was access, without thinking about what happens once they get through the clinic door. Now it is very clear that poor quality care is this other killer. For example, we found that fewer than half of the recommended basic clinical assessment and treatment items are being done for a sick child in a high-mortality country during a visit.

What has been the follow-up?

The Commission is not a standing committee, so it has officially concluded. However, we are in the middle of planning a research network to support countries that are following up on some of the key recommendations. We held consultations on the report findings with five countries: Argentina, Ethiopia, India, Kenya, and Nepal. Governments are leading these discussions; this isn’t something limited to the academic community. Many countries are at a crossroads. They see plateauing health metrics for their populations and so are facing increasing pressure from their populations to drastically improve the health system.

The area of quality of care suffers from a lack of rigorous studies and evidence because we have been preoccupied with measuring access and health, which of course are important too don’t tell us what we need to know about performance. We also don’t know enough about the structural changes that are required to improve the whole system. We absolutely need research and development efforts to support new health system models and approaches so that we are not recycling failure.

What are the biggest misconceptions out there on how to achieve higher-quality care?

Until now, the way that improvement has been conceived is that all we need to do is equip and staff clinics and that that will somehow be enough to provide good quality. The second misconception is that where quality is not so great, we can take models from wealthy countries whose systems work relatively well and apply them to low-income countries. In a country where staff are already extremely well trained and generally motivated it helps to remind them to wash their hands or give them a 10-point checklist of things that they already know. But [it’s a problem when] we try to apply these models to low-income countries without first questioning if they have the basic structures and foundations for high quality care. We tend to apply last-mile solutions when the problem is much more upstream, with training, with the way staff are motivated and even how entire systems are governed.

What surprised you most from the study’s research and findings?

Probably the consistent level of poor performance when you start to look below the surface. Even in clinics that are relatively well equipped, you can have very poor provider practices. Equipment and supplies are essential but do not provide good care on their own. We were also surprised to see some countries adopt models from other countries wholesale without understanding if they are appropriate. Putting all our eggs into the basket of one idea, or a small set of ideas developed in countries with largely different health systems seemed to us very problematic.

In what area we are failing the most?

Primary health care is the one that comes to mind. Globally, there has been a failure to advance service models that meet the needs of people as they are today, not in some idealized world. The world is rapidly urbanizing, people need care today, not in two weeks when their family doctor will see them. They also have the choice of many more clinics and hospitals and are voting with their feet, bypassing inadequate quality primary care.

We need new models that prove their worth to the population. In low and middle-income countries, primary care providers see people for six minutes or less when they come in with a health complaint. That’s just not enough. We see people very often having to wait to see a provider and struggling to have their records understood by the next provider. And the respectful, responsive element is also missing in many cases.

What is the private sector’s role in quality improvement?

There is a blind spot in health systems analysis in that many of the quality measures we saw in global surveys were not available for the private sector. If the health system’s main job is to improve health, which we contend it is, you can’t ignore the private sector. The question is how do you involve the private sector constructively? How do you tap into its best parts―the innovation, the responsiveness, the user focus? These are elements that every single facility, public or private, should value. Particularly at this moment of universal health coverage, we have every reason to think that well-performing, wealth-motivated, ethical private sector providers could and should be part of the service delivery models in many countries.

Do you see a danger of emerging markets repeating the mistakes of advanced economies?

Everyone is taking a very hard look at financing and payment and trying to learn from experience. There is a fair amount of good scholarship and evidence on what works―mixed payment models that combine some degree of fixed payments and prospective payments linked to population, together with some service-based payments. In my experience, low- and middle-income countries are very attuned to these issues and are willing to experiment, whereas more established legacy systems in high-income countries often have less scope for experimentation.

What gives you hope moving forward that systems will be designed with quality at their core?

The energy that I see from national governments on this issue. At the global level, there is still a lot of discussion on what we mean about quality, how do we fund it. What I see happening in countries, though, in particular those embracing universal health coverage, is a reassessing of their financing systems. This requires major reforms as many countries have high out-of-pocket cost and very minimal pooling. What we are arguing is that this is also a moment to reinvent the health system: how we deliver the service, how we train the providers. Universal health coverage will only be a health-improving approach if it tackles financing together with quality―and I think countries get that.

Published in October 2019


Dr. Margaret E. Kruk is Associate Professor of Global Health at the Harvard T.H. Chan School of Public Health. Dr. Kruk’s research generates evidence on how health systems can improve health in low-income and middle-income countries. She recently chaired The Lancet Global Health Commission on High Quality Health Systems in the SDG Era (HQSS Commission), a global initiative to redefine and measure quality in the health systems of lower-income countries. Follow her on twitter: @mkruk


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