The number of deaths due to poor-quality health care is estimated to be five times higher than the annual global deaths from HIV/AIDS — and three times more than deaths from diabetes.

That amounts to 5 million deaths per year in 137 low- and middle-income countries as a result of poor-quality care, with a further 3.6 million lives lost due to insufficient access to care, according to the first study to quantify the burden of poor-quality health systems worldwide.

The findings come from a new analysis published in The Lancet, as part of The Lancet Global Health Commission on High Quality Health Systems. The commission was a two-year project that brought together 30 academics, policymakers and health-systems experts from 18 countries who examined how to measure and improve health system quality worldwide. Its final report was published in The Lancet Global Health.

“As efforts to expand universal health coverage continue to drive the global health agenda, these numbers remind us that addressing the quality of health systems must be a top priority,” said Stanford Health Policy’s Joshua Salomon, a professor of medicine, member of the commission, and senior author on The Lancet study.

“Increasing access to health care continues to be critically important, but we find that there is also a tremendous opportunity to do a better job at caring for those who are already accessing the health system.”

To quantify the burden of poor-quality health care, the authors analysed data for 61 different health conditions and computed the "excess mortality" found among patients in low- and middle-income countries – that is, the additional risk of death in those countries compared to corresponding risks in high-income countries with strong health systems. Among the 5 million deaths attributed to receipt of poor-quality care, 1.9 million, or nearly 40 percent, occurred in the South Asia region, which includes India, Pakistan and Afghanistan.     

The commission, in an extensive report on its overall findings and recommendations, found systematic deficits in quality of care in multiple countries, across a range of health conditions and in both primary and hospital care. These include:

1. The over 8 million excess deaths due to poor-quality health systems lead to economic welfare losses of $6 trillion in 2015 alone.
2. Poor-quality is a major driver of deaths amenable to health care across all conditions in low- and middle-income countries, including 84 percent of cardiovascular deaths, 81 percent of vaccine preventable diseases, 61 percent of neonatal conditions — and half of maternal, road injury, tuberculosis, HIV and other infectious disease deaths.  
3. Approximately 1 million deaths from neonatal conditions and tuberculosis occurred in people who used the health system, but received poor care.

“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,” said Commission Chair Margaret E. Kruk of the Harvard T.H. Chan School of Public Health. 

“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,” Kruk said. “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.”

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The commissioners used data from more than 81,000 consultations in 18 countries and 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 labor.

And perhaps not surprising, poor-quality care is more common among the most vulnerable.

The wealthiest women attending antenatal care are four times more likely to report blood pressure measurements, and urine and blood tests compared to the poorest women; adolescent mothers are less likely to receive evidence-based care; and children from wealthier families are more likely to receive antibiotics. People with stigmatized 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. 

“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 said. 

The right to high quality care

In an accompanying editorial by The Lancet, the editors acknowledge that expansion of universal health coverage remains essential, but that without high quality health-care systems, universal care “will be an abstract and meaningless myth.”

The commission proposes several ways to address health system quality, starting with public accountability for and transparency on health system performance. 

It found many current improvement approaches have had limited effects. 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 measurements of health systems quality, and proposes a dashboard of metrics that should be implemented in counties by 2021 to enable transparent measurement and reporting of quality care.

“The vast epidemic of low-quality care suggests there is no quick fix, and policymakers must commit to reforming the foundations of health care systems,” said Muhammad Pate, co-chair of the commission and former minister of state for health in Nigeria.

“This includes adopting a clear quality strategy, organizing services to maximize outcomes, not access alone, modernizing health-worker education, and enlisting the public in demanding better quality care,” Pate said.

“For too long, the global health discourse has been focused on improving access to care, without sufficient emphasis on high quality care,” he said. “Providing health services without guaranteeing a minimum level of quality is ineffective, wasteful and unethical.”

The Walter H. Shorenstein Asia-Pacific Research Center (Shorenstein APARC) is excited to announce that its Corporate Affiliates Program has been renamed the Global Affiliates Program effective September 1, 2018.

The new name reflects the program’s evolution over the course of its history. In particular, it more accurately describes the increasingly diverse base of Asian organizations that partner with APARC as affiliate members. Our affiliates span a broad continuum including governmental agencies, nonprofit organizations, and for-profit establishments.

“The network of organizations supporting the affiliates program has expanded steadily since the program’s inception in 1982,” says Global Affiliates Program Manager Denise Masumoto. “The new name captures the breadth and depth of those partnerships, which was important for us to recognize.”

Each year, the Global Affiliates Program hosts at APARC a cohort of qualified personnel nominated by our affiliate members, who send their talent to Stanford as visiting fellows for a year of research and enrichment. Global Affiliate visiting fellows get involved in the many aspects of research and education at APARC and Stanford, and contribute to the intellectual exchange at the Center and the University at large. The Global Affiliates Program is looking forward to welcoming 21 visiting fellows for the 2018-19 academic year.

Coinciding with the announcement of the program’s new name, APARC has invited Global Affiliate alumni to join us for special receptions held in Tokyo, on September 5th, and in Beijing, on September 10th. Both events will provide an opportunity for former visiting fellows to gather with APARC faculty and friends for an evening of reconnecting, networking, and reminiscing on their shared experiences.

We invite you to check out our website for updates on both alumni receptions and on our 2018-19 Global Affiliate visiting fellows. For a monthly roundup of the latest research, publications, and insights from APARC experts sign up for our newsletter.
 

Colin H. Kahl will serve as co-director of the social sciences for Stanford’s Center for International Security and Cooperation (CISAC).

Kahl, a top international security expert and veteran White House advisor, is the Steven C. Házy Senior Fellow at Stanford’s Freeman Spogli Institute (FSI) for International Studies. He begins his new position on September 1, following Amy Zegart, the previous co-director for the social sciences. Rodney Ewing is the CISAC co-director for science and engineering.

Prior to Stanford, Kahl was an associate professor in the Security Studies Program at Georgetown University’s Edmund A. Walsh School of Foreign Service. From 2014 to 2017, he was deputy assistant to the U.S. president and national security advisor to the vice president. In that position, he served as a senior advisor to President Obama and Vice President Biden on all matters related to U.S. foreign policy and national security affairs, and represented the Office of the Vice President as a standing member of the National Security Council Deputies’ Committee.

Kahl’s research is focused on American grand strategy and a range of contemporary international security challenges, particularly digital and nuclear security, which are core CISAC research areas.  He also leads the Middle East Initiative at FSI. The Initiative seeks to improve understanding of how developments in the Middle East impact people in the region and security around the globe.

In the Winter Quarter, Kahl will teach a course, “Decision Making and U.S. Foreign Policy,” in the Ford Dorsey Master’s in International Policy program; he will also co-teach CISAC’s introductory class, “International Security in a Changing World.”

“For more than three decades, CISAC has been one of the nation’s premier centers for interdisciplinary research on international affairs,” Kahl said. “The Center has a long tradition of bringing together social scientists and hard scientists to conduct cutting edge, policy-relevant research on some of the most pressing security challenges we face,” Kahl said. “I look forward to working with Rod Ewing and my other CISAC colleagues to continue and expand upon this tradition of excellence.”

“Colin Kahl, who has both academic and extensive policy experience through his work in government and think tanks, will be a terrific co-director and asset to CISAC,” said Ewing.

“We are thrilled that Colin will be leading CISAC with Rod Ewing. Colin’s extensive experience in both theory and policy will enhance CISAC’s work in all areas,” said FSI Director and Senior Fellow Michael McFaul.

Kahl received his B.A. in political science from the University of Michigan (1993) and his Ph.D. in political science from Columbia University (2000).

MEDIA CONTACTS:

Colin H. Kahl, Center for International Security and Cooperation: ckahl@stanford.edu
Katy Gabel, Center for International Security and Cooperation: (650) 725-6488, kgabel@stanford.edu

Larry Diamond discussed the DPP government’s pursuit of transitional justice and its approach to cross-strait ties in an interview with ‘Taipei Times’ reporter Sean Lin in Taipei, arguing for a more arbitrational approach to party assets while warning against action that might provoke China. Read here. 

Hong Kong’s democrats need to focus on ‘prize’ of universal suffrage rather than independence, leading US academic Larry Diamond says. Read the article here.

In the summer of 2018, the Asia Health Policy Program (AHPP) at the Shorenstein Asia-Pacific Research Center (co)hosted two conferences in Beijing. From June 25-26, AHPP hosted “Healthy Aging and Chronic Disease Management in China and India in International Comparison” at the Stanford Center at Peking University in Beijing. Immediately following the event, June 26-27 AHPP cohosted, along with Professor Fang Hai, Peking University China Center for Health Development Studies, the “Fourth Annual Conference on Primary Care and China’s Health System Reform”, focused this year on China’s family doctor system.

Healthy Aging and Chronic Disease

Day one of the Healthy Aging and Chronic Disease Management conference combined discussions of chronic disease control in India and China (part of an ongoing SCPKU Team Innovation faculty fellowship) with a workshop focused on assessing net value of diabetes management across Asia.

Research teams from Hong Kong, South Korea, India, Taiwan, and the United States convened to discuss research on net value analysis of diabetes in their respective countries. The Net Value in Diabetes Management project seeks to develop a method for measuring net value of diabetes internationally­–based on previous methods discussed in an 2009 study by Karen Eggleston and Joseph Newhouse with data from the Mayo Clinic for Type 2 Diabetes.

The research teams provided updates to their calculations from the gathering last year and explained the strengths and weaknesses of their data sets, the risk prediction model they employed or created for their specific population, and the cost effectiveness analyses conducted with their data.

Participants included Kavita Singh from the Public Health Foundation of India, Janet Lam from Hong Kong University, Hongsoo Kim and Wankyo Chung from Seoul National University, Rachel Lu and Ying Isabel Chen of Chang Gung University Taiwan, and Kyueun Lee and Karen Eggleston of Stanford University.

Non-communicable/Chronic Disease Control

The afternoon of day one featured presentations by various representatives from provincial and national-level Centers for Disease Control and Prevention (CDC) in China regarding non-communicable disease (NCD) control initiatives.

Dong Jianqun from the People’s Republic of China CDC presented the “Effect of Community-Based 5+1 staged diabetes management.” This research project–fielded in sites in three different provinces–involved staged diabetes targeting management. Results showed that examination rates for complications management increased. Fang Le from the Zhejiang Provincial CDC presented updates on community management of NCDs in Zhejiang, including the intensive follow-up system for high risk diabetes patients. Representatives from Shandong University and the Shandong CDC, including Dr. WANG Yan, presented “The Status, Problems, and Determinants of community management and control of diabetes in Shandong Province” while also discussing current policy and implementation.

The afternoon ended in a session comparing health care systems and ongoing initiatives for chronic disease control in China and India. Kavita Singh discussed issues in India’s health system, including high out of pocket expenditure, over-privatization, and large health inequities across states and between urban and rural areas. Singh introduced existing innovations being used, including smartphone-based decision support software in heart disease monitoring. Dong Jianqun and colleagues discussed NCD control in China, including the demonstration areas that have integrated initiatives including better surveillance and management of diabetes and hypertension, and prevention education.

The first conference closed the next morning by bringing together representatives from various Chinese organizations to discuss the current state of primary care, family doctor system, and health care reform within the country. During a highly immersive classroom session for the Diabetes Net Value Teams, Dr. Sanjay Basu shared insights regarding best practices in predictive risk modeling.

China’s Family Doctor System

Beginning the afternoon of June 26, the second conference was devoted to China’s family doctor system, primary care, and health care reforms.  The event opened with remarks from Zhuang Ning, Deputy Director of the State Department of Health, System Reform Department, about the importance of community health and greater recognition of primary health providers in China.

The director’s remarks were followed by an opening keynote address by Professor MENG Qingyue, Dean of the Peking University School of Public Health and Director of the China Center for Health Development Studies at Peking University. Professor Meng reflected on the role of primary care in the development of China’s health system. Qin Jiangmei, Director of the Community Health Research Center, National Health and Family Planning Commission Health Development Research Center, next introduced the necessity of comprehensive health reform in China as well as funding challenges.

Afterwards, representatives from the Beijing Dongcheng district, Shanghai Changning district,  Xiamen City, and Shenzhen Luohu Hospital Group shared their experiences constructing family doctor systems within their respective regions. Important points stressed by the presenters included consolidation, maintaining a good evaluation system, and establishing trust with their patients.

The day ended with a Primary Medical Care Roundtable Discussion featuring four directors of district-level community health centers. The panelists answered questions concerning the future model of primary care in China, as well as changes they would like to see at the community and policy levels. The district directors advocated that more funds be allocated to general practitioners, believing that they will be the dominant form of primary care in China. Participants also spoke of the additional need for clearer targets to ensure that primary care providers are better funded (so that, with enough time, patients will begin to recognize the importance of the family physician).

The second conference concluded on June 27 by way of a highly engaging classroom session on the continuing collaboration between the Zhejiang Provincial CDC and Stanford University Asia Health Policy Program.