Article

Why access to healthcare is not enough

Dr Pedro Saturno

While providing access to healthcare globally to as many people as possible is widely recognized as a priority, improving the quality of healthcare, especially in low and middle-income countries, should be seen as equally as important. Indeed, it is currently is bluntly acknowledged than access without quality is an empty vessel. Professor Pedro Saturno is the holder of the AXA Chair for the Improvement of Healthcare Quality at the National Institute of Public Health in Mexico, where he directs an ambitious research and formation programme designed to address the multiple aspects of healthcare quality improvement. He aims to improve the accessibility, quality and equity of health systems with a strong focus on vulnerable populations, like women, children or the elderly.

Healthcare quality relies on numerous factors: contrary to a widespread idea, monetary investment in health systems alone is insufficient to ensure quality of care. Prof. Saturno works on designing low-cost, simple integrated solutions to improve quality of care that are highly accepted by local communities and services providers alike. It is widely recognized that there are actually at least six aims for a population-centered healthcare system. While some are obvious, all are important to ensure quality for all: the provided services should be safe and effective, not harming patients and providing care based on scientific evidence. But it should also be patient- centered, respecting each patient’s preferences and values: for example, it is important that patients understand well their conditions, treatments and procedures so they can accept and be partners in their own healthcare. Care should also be timely, avoiding harmful delays, as well as efficient, in order to cut waste of resources, supplies, time and energy. Lastly, healthcare should be equitable, providing equal access and quality regardless of gender, ethnicity, geographic location or socioeconomic status.

Thus, improving healthcare quality, especially with limited resources, is more complex than it looks.

Prof. Saturno is working on three intertwined areas: first, he is looking to improve the quality throughout the health system. Then, he aims at achieving universal and equitable, effective access. Finally, he wants to find better ways to measure vulnerability, both in individuals and in groups. Vulnerability, defined by the OECD as a product of risk exposure and the capacity to confront negative events, is an important tool for policy makers to identify issues and know where to focus their efforts.

To tackle these very wide topics with limited resources, Prof. Saturno and his team conduct a lot of implementation research. Implementation research aims at understanding and overcoming the obstacles to the systemic application of scientific research findings in practice. For example, why does a hospital have better results that its counterpart in a different municipality, with equivalent human and monetary resources? Why are science-based findings not always put in place, with well-wishing guidelines ending up collecting dust in a cupboard?

 Working directly with municipalities and districts, Prof. Saturno’s goal is to understand the way that care is offered in practice, in order to bridge the gap with what should theoretically be done.  For example, the infant mortality rate is relatively high in Mexico, with a national average of 16.76 deaths per 1000 infants. But this average data covers strong disparities both among and within different Mexican states. To better understand which strategies work and why, Prof Saturno’s team is looking at communities in different states, each representing the national average or the most extreme situations regarding health indicators.

Indeed, comparatively small actions may have a lot of impact regarding quality improvement. For example, Prof. Saturno’s team is leading research projects focusing on maternal and child health, which is implemented in the states of Puebla and Chiapas. This research programme applies simple methods to data that was already collected by hospitals and care providers to offer new insights on perinatal deaths and how to prevent them. For instance, by creating a simple matrix that compares the moment of death of the fetus or baby, from conception until birth, and its weight or size, they were able to put to light important issues that were “hidden” in the overall infant mortality rate. Notably, they found that in some areas, there were many stillborn babies in the third trimester of pregnancies. Weighting over 1.5 kilos, these babies are theoretically viable. This high rate of preventable deaths indicated issues in the care provided during the pregnancy and around delivery.  Prof. Saturno’s team is working to implement this simple statistical matrix as a routine tool in many hospitals, in order to focus efforts and resources where there are most needed and to uncover previously unseen problem areas. In the same project, the process of care for childbirth and postpatum and neonatal care, is designed and standardized using integrated clinical pathways, which translate scientific evidence to the local context, with the participation of the mothers and all the health practitioners involved.

 The idea that simple tools and practices may have big impacts is found throughout all the research and formation programmes developed by Prof. Saturno, in conjunction with community involvement. Indeed, community involvement, through communication activities, workshops, etc.  plays an important role to improve acceptance and use of new tools or protocols on the healthcare providers’ side. On the side of patients, it helps strengthen care-seeking and knowledge of healthcare rights, as well as the adoption of risk-prevention measures.

In the Chair research programme, this care to involve communities in order to best suit their needs can be found in the bottom-up design of the different training programmes created and offered by the Chair. For example, Prof. Saturno and his team have designed and implemented in the state of Guerrero a ‘Diploma on Improvement of Healthcare Quality’ focused on human rights, in collaboration with the National Commission of Human Rights and the University Loyola del Pacífico, and the support of “Acción Ciudadana Frente a la Pobreza” (Citizens’ Action Against Poverty), a coalition of over fifty NGO´s advocating for universal and equitable access to health services. This diploma, aimed at managers and health professionals of the public healthcare system, was designed to help tackle the issues that the human rights practitioners have identified in the field, such as insuring informed consent for all medical procedures, in particular those related to women´s reproductive health, or preventing the mistreatment of marginalized groups.

In the future, Prof. Saturno wishes to deploy the tools and processes that were proven effective from his pilot tests in many more health facilities and networks, while involving local authorities, the civil society and the patients to ensure the durability of the projects.

Four methodological manuals, created by Prof. Saturno, are available for download [in Spanish]. These manuals cover three key areas for the improvement of quality in health services: