A recent study in the Lancet showed that it was more dangerous to have access to poor quality health care than to have no access to health care. That is particularly true in Emerging Markets where quality varies dramatically. Julia Khalimova, Healthcare Quality and Patient Safety Specialist at IFC, the arm of the World Bank that invests in the private sectors of emerging markets, has been studying the field for ten years and IFC has recently launched a tool to enable operators to measure and improve. We talk to her about the problem. What progress has been made? And what is the best solution?
HBI: So many accreditation agencies all competing to sell their products on health quality! Does the world need another?
JK: This is different. We are not offering an accreditation tool but an action plan to improve processes and create a safe environment. It was developed as a self-assessment tool but we found a calling for an advisory service around it. Costs vary but for a 100-bed hospital it would be not more than $20,000.
HBI: There is the problem, isn’t there, of operators buying tech bling in to order to get accreditation?
JK: Maybe, we are not saying you have to have a piece of kit but we can suggest ways to work around that with processes or team up with someone who does. We are very pragmatic.
HBI: So how bad is the problem and why?
JK: A recent study showed that it was more dangerous to have access to poor quality health care than to have no access to health care.
There has been a sea change in a decade. Ten years ago medical staff had low awareness of basic stuff like hand-washing programmes. Now you find these programmes in remote mountain hospitals.
Infection control remains a huge problem. Unfortunately, patients too routinely go in with one problem and come out with another.
And we find that different countries have different regulations on say fire safety. A big issue is that often the standards and regulations are not enforced.
There is typically a big difference between some low-income African countries where there isn’t even clean water or 24-hour electricity and the situation in middle-income countries, but standards vary enormously between facilities.
HBI What is the determining factor?
JK: Every time and everywhere, it is the attitude of top management. Quality has to be something they enforce and care about. I often see quality delegated to a care quality team who are expected to achieve results within say 3-4 years. No matter how many quality managers you have that never works unless you have buy-in and emotional engagement from the top.
HBI: How does the private sector compare to the public sector?
JK: There are likely bigger differences within each sector than between. There are excellent and bad facilities in the public and private sector. What distinguishes the good from the bad is having top management or government officials focussed on the issue.
HBI: Are some countries ahead and why?
JK: Latin America has seen a lot of improvements and is really quite advanced now. Colombia made quality improvement obligatory in its legislation—and has made big progress both in the public and private sectors. Mexico is also making steps.
But one of the emerging markets which has made the largest gains over the last two decades is certainly Turkey. There are a lot of countries where there is a big potential and which are developing national quality control systems.
HBI: All well and good. But corruption can undermine all this.
JK: Absolutely. It remains a huge problem in many places. But there is also a clear solution. Oversight has to be at multiple levels to make corruption harder. You want a series of different and independent agencies checking different indicators.
HBI: And transparency? Giving the data to the patient?
JK: That really helps. The most effective treatment is making the data public. That is a much harder to game. Colombia has a web page where you can check all the data on the hospital and what it reports.
Data which compares hospitals is also very motivating. Of course, it must be done properly—for example you don’t want to incentivize hospitals to treat only the less complex patients.
HBI: Private insurers should play a role here. So you’ve been in the field for a decade. How many times have you seen payors close or penalise hospitals for non-compliance?
JK: A good question. And it is a great thing when it happens. I have seen only three cases where international private insurers did not prolong a contract and the last was 4-5 years ago.
I have never seen an insurer cancel a contract due to a serious incident.
I think in some countries there is more serious oversight from insurers. In lower-income countries such as in much of Africa, this is not the case at all. In the Middle East, more so, and, in India, insurers can play an important role. But often insurers pay attention only on the grounds of excess cost. It is not about creating a safe environment but about money. It would be good to foster some positive models—for example, hospitals wishing to develop a medical tourism business could be required by international insurers to raise quality standards.
It’s worth pointing out that in general, health insurance still plays a relatively small role in most of our markets. There are some exceptions such as Brazil. And the sector is starting to grow as emerging economies grow and formal employment increases. So, there is increasing potential for insurers to play a role in improving healthcare quality. For example, they can insist of minimum quality assurance standards and reporting requirements, or even demand accreditations—particularly for ‘premium’ plans.
HBI: So going back to your tool. How much has it been used?
JK: We’ve had a lot of interest! Already we have been asked to assess more than 20 very diverse healthcare organizations on 5 continents. Our clients like the approach because it is easy to understand, action-oriented, and good value for money. At least one organization has used it to progress to JCI accreditation
We would welcome your thoughts on this story. Email your views to Max Hotopf or call 0207 183 3779.