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Achieving a high percentage of universal health coverage often does not translate into a high quality of health systems, according to speakers at the opening of the Geneva Health Forum. While in developed countries people are demanding better quality, the expectations of people living in low and middle-income countries need to be raised, they said. Another panel looked at the use of big data and mathematical modelling as ways to improve health systems, including Facebook monitoring.

The 2018 edition of the Geneva Health Forum is taking place from 10-12 April. The general 2018 theme is the impact of the digital revolution in health practices.

According to the GHF, it is the largest event in Europe gathering academic leaders, practitioners, policy makers, diplomats, representatives of donor agencies, and healthcare providers.

The schedule shows five plenary sessions, 25 parallel sessions, some lunch sessions, and some workshops.

The first plenary session focused on the quality of health systems: the missing piece between better access and improved health.

Access Important but High Quality Key

Prof. Margaret Kruk, chair of the Lancet Global Health Commission on High-Quality Health Systems, and associate professor of Global Health at Harvard University, talked about the work and the findings of the commission. The commission is expected to published its report in the Fall.

Its main aims are to define health system quality; to describe the quality of care for sentinel Sustainable Development Goals conditions in low-and middle-income countries (LMICs) and its equity; to propose tractable measures of quality; and to identify structural approaches to improve quality.

According to Kruk, achieving 90 percent of universal health coverage does not always equate to the equivalent survival rates, for example in maternal mortality. The commission gives a fresh look at how to define high quality health systems, she said.

Several factors contribute to this high quality of health systems, she explained. The systems have to: consistently deliver care that improves or maintains health, be valued and trusted by all people, and respond to changing population needs. The foundations of quality health systems have to be context-specific, she said.

Among the findings of the commission is that people get less than half of basic medical content in clinic visits. The average length of a medical visit for a child who is very sick in African or South East Asia is about 8 minutes, she said.

She also underlined the weakness of care platforms, with 12 days on average for people in LMICs from the moment of admission to surgery, for example for a hip fracture. Timeliness of care is key in health quality, she added.

High quality health systems could help save 7.8 million lives each year in LMICs, according to Kruk.

Improving care must go beyond quick fixes and “silver bullets”, she said, adding there is a need for structural reform in health systems. Service delivery should be redesigned, so that patients are steered toward the adequate services. Many women in LMICs go to primary care clinics for childbirth, which are not equipped for such service, she explained.

Demand for quality has to be instilled in the population, as in many countries people are passive recipients of healthcare. In wealthy countries, more and more people are demanding better care, however in LMICs, many say they are satisfied with the system because they have such low expectations that they are convinced that they can expect very little from health care, she said.

Answering a question from the audience, Kruk said in a lot of countries which have 100 percent coverage, there is still a lot of unhappiness and a lot of discrepancies. She cited Thailand as a model where quality of services and access have been brought together. Universal health coverage needs to be reframed as quality universal health coverage, “otherwise those services will not be used,” she said.

She told Intellectual Property Watch later that the commission is looking at access issues, including the price of medicines, but it was not a focus of its work.

WHO: Quality of Health Systems Part of General Programme of Work

Edward Kelley, commissioner and director of the Department of Service Delivery and Safety at the World Health Organization also confirmed the importance of high quality health systems. In LMICs, diagnostic accuracy can be as low as 34 percent, he said, adding that in high-income countries 1 in 10 patients is harmed while receiving health care.

He mentioned the WHO General Programme of Work 2019-2023, to be formally adopted at the upcoming World Health Assembly in May, and its triple billion target, one of which is to have 1 more billion people benefitting from universal health coverage (IPW, WHO, 29 January 2018).

Among what is needed to reach high quality health care are: a health workforce ready to deliver quality services; the necessary infrastructure to enable quality; the safe and effective use of medicines; devices and other technologies; the use of accurate data and information for quality improvement; and clear linkages with financing at all levels, according to Kelley.

Pockets of Excellence in LMICs to be Explored

Yogan Pillay, deputy director of the General of National Department of Health, South Africa, joined by phone and said there are pockets of excellence in LMICs. The questions are how to train the right people, how to deal with the supply side, and how systems can provide the best quality of care.

The demand side is often underestimated, he said, echoing Kruk, and adding that health systems should be designed around people.

Big Data, Facebook, Mathematical Modelling, Privacy and Ethics

Another panel on 10 April dealt with big data and mathematical modelling to improve health systems.

Devika Nadkarni, research associate at Boston University, talked about the interest of using mathematical modelling to improve health care systems. She illustrated the point with a case study on maternal health in Mnazi Mmoja hospital in Zanzibar.

Mnazi Mmoja hospital experiences essential medicines and consumable stock outs, has insufficiently trained medical personal and suffers from a lack of documentation and access to data, she said.

Students from the State University of Zanzibar and students from Boston University formed a Partnership for Global Health Technologies (PGHT), according to a 2017 joint presentation document [pdf].

One of the goals of the PGHT is to devise a model allowing the hospital administrators to identify what impact human and material resources are having on maternal mortality, and identify possible bottlenecks, the document says.

Nadkarni said mathematical modelling can be applied to many different health areas, including surgery, blood transfusion, and non-communicable diseases.

Szocska Miklos of the Semmelweis University in Budapest, Hungary, former Hungarian health minister, and former candidate in the 2017 WHO director general election, presented the use in big data for health in his country.

Hungary, he said, is a data-rich country, which made it easy to map a number of events, like the movement of patients from one place to the other in the country, seeking treatment.

The use of big data allowed the Hungarian government to save money, including by allowing management control, and for example establishing joint procurement services.

He gave an example of how the government was able to assess the rate of resistance to the introduction of a new vaccination. The Hungarian population is very compliant towards vaccination, he said. By monitoring Facebook, the government was able to determine that two Facebook users were delivering anti-vaccination messages, and could establish, by looking at who was following those two users, that the anti-vaccination movement had minimal impact, and the new vaccination would not encounter resistance, saving the government a public communication campaign.

Asked about data protection and ethics by someone in the audience, Miklos said the government only uses depersonalised data and the country is mobilising “huge resources” to find legal solutions through which large amounts of data can be used for the benefit of patients. Hungary uses the negative consent principle, he said, adding that Hungarians have no problem with their data being used for health purposes but the country still needs to invest in data protection.

Last year, Margaret Chan, then WHO director general, speaking at a summit on artificial intelligence, called for caution in “the midst of all this exciting potential.” She said medical decisions are complex, and they depend on context and values, such as care and compassion (IPW, WHO, 7 June 2017).

Background

The Geneva Health Forum is a biennial event launched in 2006. It is organised by Geneva University Hospitals, and the Faculty of Medicine of the University of Geneva, with the collaboration of the Genève Internationale, the World Health Organization, and the World Economic Forum. The Geneva Health Forum also has a number of partners, including the Swiss Agency for Development and Cooperation, the International Committee of the Red Cross, Médecins Sans Frontières (Doctors Without Borders), the Ecole Polytechnique Fédérale de Lausanne, and the Graduate Institute.