[OPINION] Bringing care back to health care

A month ago, my grandfather was hospitalized due to a sudden bout of pneumonia. For a week, he was bedridden, subjected to battery of medical procedures, and given several treatments. As a doctor, it was a bit bizarre to be witnessing the day-to-day clinical operations from the caregiver's perspective, but overall, I was pleased with the care that he received.

Yet, as a public health practitioner, I knew that this is not the same level of care enjoyed by many of our fellow Filipinos, so I felt both grateful and bothered at the same time.

My grandpa may have passed on, but this episode made me reflect about those who are not given the chance to access good quality health care.

Medical supplies in public health facilities remain inadequate, if not totally missing. Long waiting times either for a doctor's consult or a laboratory test can be agonizing. Overworked health providers without enough sleep may lead to an emotional and even distasteful clinical encounter. Hasty execution of surgical tasks may result in a gauze left inside the abdomen, if not a pair of scissors.

These behaviors do not only lead to poor health, but also diminish confidence and trust among patients to the health system.

Early this month, a global commission launched its new report that addressed why gaps in health care quality exist and how they lead to poor health outcomes. Led by Professor Margaret Kruk, whose course on health care quality I was privileged to attend in Harvard, the Lancet Commission on High Quality Health Systems calls on national governments and global health agencies to start a "quality revolution" in health care.

Go beyond access

Currently, many countries, including the Philippines, are embarking on reform policies to achieve universal health coverage. However, Prof. Kruk's group urges governments to go beyond access, because "providing health services without guaranteeing a minimum level of quality is ineffective, wasteful, and unethical."

The report even went on by reiterating that quality health care is a fundamental human right, and therefore it has nothing to do with anyone's capacity to pay. This means that even poor Filipinos are deserving of quality health care too. As said by the report: "Quality should not be the purview of the elite or an aspiration for some distant future; it should be the DNA of all health systems."

Paraphrasing the commission's report, a high quality health system is defined as one that consistently delivers positive health outcomes, is valued and trusted by all people, and can immediately respond to changing population needs. What are some of the quality traits in concrete terms? Health care should be competent, safe, complete, continuous, preventive, timely, respectful, and patient-centered.

The 57-page commission report analyzed the state of health care quality globally, and the results are shocking. More than 8 million people die each year in developing countries due to diseases that are treatable by health care. In 2015 alone, these deaths resulted in US$6 trillion in economic losses. And from these deaths, 3 out of 5 are due to poor-quality care. While estimates do not exist for the Philippines, one can surmise that the situation is the same as well.

Based on data from 18 countries, providers were shown to fully implement recommended guidelines in only 47% of patient visits. Meanwhile, one in 3 patients experience disrespectful care, inadequately short consultations, poor communication or long wait times. For a host of essential health services, even in places where good quality exists, the poor always gets poor quality nonetheless.

In one study from Tanzania, nearly 1 out of 2 mothers choose to bypass closer public facilities and instead travel longer distances for private facilities which they perceive as providing better quality care. People seek for quality, and they are willing to take the extra mile, more so pay more from out of their pockets just to receive good quality care.

So what can the Philippines learn from the report?


Challenge for DOH

One key message from the commission is that improving quality cannot be done in piecemeal, as lack of quality is merely a symptom of defects in the broader system. A doctor or nurse cannot be solely blamed for a medical error – institutions too must be held accountable, and they should ensure the root cause of poor quality is remedied.

How can the Philippines begin the health care quality revolution?

First, the Department of Health should set the policy, standards, and vision for quality in health care – and must implement, build capacity for, and monitor it. In short, the commitment to quality must not end with paying lip service.

The commission recommends that a national guarantee for quality health care be established, which will ensure that health care providers and the government are held accountable. The revitalized Universal Health Care Bill currently deliberated in Congress provides a window of opportunity, as the draft bill highlights the need for health care to be "people-centered" – another way of saying that health care should be of high quality.

Setting the policy framework is not enough – money should be put where the mouth is. Substantial investments especially in public health facilities should be allocated to ensure that health workers are equipped with needed supplies and conducive environments.

Corrupt practices that siphon scarce resources away from quality improvement should be reported and reprimanded too. PhilHealth, as the main purchaser of health care, must pay hospitals not just based on volume but also quality indicators, so that health facilities are incentivized to do better in their provision of care.

We doctors and health professionals do play an important role too in building a culture of quality. Quality in health care should be mandatory in health professions curriculum, and universities must conduct implementation research focusing on quality-related questions.

I am elated to learn that my alma mater, the University of the Philippines Manila College of Medicine, has made health care quality and patient safety a priority in its research agenda.

Since health care is most effectively delivered by teams and not individuals, doctors, nurses, and other health professionals must learn on how to work collaboratively, with the patient's welfare and not personal egos in mind.

Patient satisfaction

Providers must also educate their patients on what quality health care provision looks like. In addition to monitoring technical quality measures such as rates of post-surgical infection or re-hospitalization, hospitals must regularly conduct patient satisfaction surveys and set up complaint desks, since like restaurants, health care is a customer-oriented service too.

And hospitals must create a positive and enabling environment with less hierarchy – where open learning is encouraged and care improvement can be done immediately when medical errors are discovered without a culture of blaming.

Finally, the general public, with the aid of civil society groups, must demand for better health care quality.

The rise in incidents of "doctor-shaming" that go viral in social media platforms is indicative that patients and the public today are becoming more empowered and increasingly dissatisfied with health care quality.

For sure, health professionals do have the utmost duty to provide high quality and respectful service to avoid such expressions of distrust and anger from patients. However, there are also appropriate ways of providing feedback that encourages learning and builds mutual confidence between health workers and the public.

For instance, the first step is actively advocating for laws and guidelines that enshrine quality in health care. Providing honest feedback about the care experience to health care providers and hospital administrators is another.

Raising complaints to the DOH and other higher authorities will help document, flag, and remedy incompetent care and corrupt practices. And when high quality care is provided, despite resource limitations, a simple expression of gratitude can encourage an underpaid health worker to do better.

The message is simple: it's time to bring care back to health care. Quality health care is a right, and making sure it is realized is everyone's responsibility. – Rappler.com


Renzo Guinto (@RenzoGuinto) is a physician and currently a Doctor of Public Health candidate at the Harvard T.H. Chan School of Public Health. He is also currently establishing PH Lab, a "glocal think-and-do tank" for generating innovative solutions for Philippine health, public health, and planetary health. He can be reached at https://scholar.harvard.edu/renzoguinto.