Quality of care : what are effective policy options for governments in low and middle income countries to improve and regulate the quality of ambulatory care?

Overview

Quality of Care (QoC) has been recognized as a key objective of health systems performance necessary to strengthen health systems in low- and middle-countries (LMICs). However, there is increasing evidence of very poor quality of ambulatory care in LMICs.

The problem with QOC is that quality is difficult to define and measure. There are multiple perspectives on the definition of quality — quality from the perspective of provider (effectiveness), the payer (efficiency), and the patient (responsiveness). At least six elements of quality have been identified by the Institute of Medicine in the United States. Common aspects measured for quality are — inputs (facility, staff, equipment, and supplies), process (adherence to protocols and standards of care), and outcomes (relief of symptoms, extension of life, complications or poor outcomes). Measuring outcomes in terms of health status is costly and considered more complex due to the intervention of patient-specific factors. As a result, quality (especially effectiveness and safety) tends to be neglected, and focus of programmes and performance evaluation is typically on the more measurable aspects — utilization, efficiency, and responsiveness to patient expectations.

However, neglect of quality aspects in terms of effectiveness and safety has resulted in overall poor quality of ambulatory care in LMICs which has largely manifested as (i) overtreatment (provision of unnecessary treatment, ineffective treatment, or more expensive treatment than required such as overprescribing antibiotics or diagnostic tests), and (ii) undertreatment ( failure to provide required treatment or misdiagnosis leading to poor outcomes, longer duration of illness, and occasionally complications).

The introduction of universal health coverage (UHC) reform in many LMICs of the Asia Pacific region has directed attention to the problem of low-quality care, and the need for strategies to improve and regulate QOC. The implementation of the number of discrete strategies to improve the provision of ambulatory is growing in these countries. However, the question is whether these strategies are working to improve quality, whether they can be implemented to scale, and how applicable they are in the context of mixed healthcare provision and UHC reforms.

This Policy Brief examines the problem of QOC in ambulatory care services; reviews evidence on strategies to address QOC at the ambulatory care level and provides guidance for policy-makers in LMICs in the Asia Pacific region on actions that governments can take to improve and regulate QOC in ambulatory care services.