Revisiting the Lancet paper: Mortality due to low-quality health systems

9 November, 2019

In November last year we reported an important study in The Lancet. Its central finding was that

'15·6 million excess deaths from 61 conditions occurred in LMICs in 2016. After excluding deaths that could be prevented through public health measures, 8·6 million excess deaths were amenable to health care of which 5·0 million were estimated to be due to receipt of poor-quality care and 3·6 million were due to non-utilisation of health care. Poor quality of health care was a major driver of excess mortality across conditions, from cardiovascular disease and injuries to neonatal and communicable disorders.'

This kind of paper is rare and vital. We need to know not only the medical causes of death but also the healthcare-related causes. We need to know how many deaths might have been avoided with a reasonable basic level of care. And if the care is poor, we need to know why. Specifically from a HIFA perspective, we need to know the contribution of lack of availability and use of reliable, relevant healthcare information.

We don't have answers to these questions and I invite you to comment and suggest ways forward.

One first step is to clarify the findings of existing studies. The above study did not explain how they defined 'poor quality care' (5m deaths) and 'non-utilisation of care' (3.6m deaths). The response:

I contacted the correspnding author of the above study (Prof Margaret Kruk, Harvard University) to say: "I was interested to read your paper 'Mortality due to low-quality health systems in the universal health coverage era: a systematic analysis of amenable deaths in 137 countries', and would like to ask how you defined the term 'non-utilisation of healthcare services'. Would this include, for example, people who had been seen by a community health worker? If such primary care is not included in the figures, this would suggest the proportion of those dying from low quality of care (versus non-utilisation) is even higher than you estimate."

Her answer confirmed that CHWs were not included in the definition of 'utilisation of health care': "We define utilization as someone using a health facility."

Their definition is understandable. It is much more difficult if not impossible to estimate utilisation of CHWs and other community-based primary health workers (let alone private and traditional health workers) than it is to estimate visits to health facilities (which presumably includes primary health centres, although here again there is a wide range of facility types, from a CHW's home through to fully staffed centres with beds and basic surgical facilities).

It is clear that poor quality care - including care in the community - causes considerably more than 5 million avoidable deaths. Of course, care is a continuum from home through the different levels of the health system. A broader definition of 'quality of care' needs to include the care given in the home (or on the road), which is partly determined by the level of basic healthcare knowledge of families (or bystanders).

We still have a lot to learn about the prevalence and causes of poor quality care, and therefore a lot to learn about how to improve care and reduce avoidable deaths and suffering.

CITATION: Mortality due to low-quality health systems in the universal health coverage era: a systematic analysis of amenable deaths in 137 countries

Margaret E Kruk et al.

The Lancet - Articles| volume 392, issue 10160, p2203-2212, november 17, 2018

Published: September 05, 2018


Best wishes, Neil

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HIFA profile: Neil Pakenham-Walsh is coordinator of the HIFA global health campaign (Healthcare Information For All - ), a global community with more than 19,000 members in 177 countries, interacting on six global forums in four languages. Twitter: @hifa_org FB: