We cannot End TB by focusing on just coverage: quality also matters!

The newly released Lancet Global Health Commission on High Quality Health Systems provides a compelling case for the TB community to think beyond coverage and focus on quality of care
We cannot End TB by focusing on just coverage: quality also matters!

Today, The Lancet Global Health published a landmark report entitled High-quality health systems in the Sustainable Development Goals era: time for a revolution. In this Commission, the authors assert that providing health services (i.e. coverage) without guaranteeing a minimum level of quality is ineffective, wasteful, and unethical. What is needed, the Commission argues, are high-quality health systems that optimise health care in each given context by consistently delivering care that improves or maintains health, by being valued and trusted by all people, and by responding to changing population needs. The graphic below shows the HQSS framework for a high quality health system.

Throughout the report, tuberculosis is used as a key example, to illustrate the need to go beyond coverage and focus on quality of care. According to the HQSS report and a linked analysis published in The Lancet, more than 8 million people per year in LMICs die from conditions that should be treatable by the health system. 60% of deaths from conditions amenable to health care are due to poor-quality care, whereas the remaining deaths result from non-utilisation of the health system.

The HQSS report provides a detailed analysis on TB deaths. Of the 946,003 TB deaths amendable to healthcare, the authors estimate that 469,956 (50%) are due to poor quality TB care. The remaining 476,047 deaths are due to non-utilisation of healthcare services (graphic below).

Source: The Lancet

The report suggests that high-quality health systems could prevent 900000 deaths from tuberculosis each year. In other words, by using already existing tools and improving quality of care, we can avert 50% of all TB deaths.

As a tuberculosis researcher working on quality of TB care, I am not shocked by the findings of the HQSS report. But I find their analysis helpful for advocacy. The fact that 50% of TB patients are dying despite seeking medical care is a sad reflection on the state of affairs. How is it acceptable that we cannot save patients with a curable, bacterial infection for which we have tools and technologies?

As highlighted in the HQSS report and our own work on this topic (available at https://www.qutubproject.org), studies show show large gaps in cascades of care, across types of TB and countries. Patient pathways analyses show long, complex pathways to health care, private or informal sectors being the preferred first point of contact, and lack of adequate TB services at the primary care level. Simulated patient studies, using a methodology developed by our team, in 4 countries (IndiaKenyaChina and South Africa) confirm gaps in cascades of care, and show poor quality of care in both public and private sectors, with private sector faring worse. TB patients suffer high costs and long wait times while seeking TB care and receiving treatment. In short, we need nothing short of a quality revolution in TB (please see this video, from my plenary talk on this subject).

As I have argued earlier, the TB field urgently needs to adopt and implement the science of quality improvement. But QI alone is not sufficient, since even the foundations of TB care are weak. Countries need to invest adequate funds to control TB, and make sure TB services are of high quality and patient-centric.

With the UN High Level Meeting on TB coming up this month, the time has arrived for the TB community to think beyond coverage and demand high quality care for all patients in all countries. If we are serious about ending TB, we must put quality on the agenda, in addition to expanding coverage of critical interventions.

Photo credit: Centre for Health Solutions, Kenya (photographer: Nyawira Gikandi)

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