Systemic Change and the Path to Quality Universal Health Coverage

Lessons from the Lancet Global Health Commission Launch of the Kenya-Specific Report on High-Quality Health Systems in the Sustainable Development Goal Era.

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By Alexander Wowra and the Jacaranda Health Team

On April 11, 2019, representatives of the Jacaranda Health team attended the launch of the Lancet Global Health Commission on High-Quality Health Systems Report in the Sustainable Development Goal Era in Kenya. The purpose of the event was to demonstrate Kenya’s commitment to quality -- not just making universal health coverage (UHC) a reality in the country, but to introduce systematic changes to ensure that coverage consists of quality healthcare for everyone. Kenya’s First Lady, Her Excellency Margaret Kenyatta, officially launched the report, of which she was a commissioner.

The Lancet report makes the point that staying on the current trajectory will not suffice to meet the demands associated with changing health needs, growing public expectations, and ambitious new health goals in low-income and middle-income countries (LMICs).

The report’s authors argue that “what is needed are high-quality health systems that optimize 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.”

In March 2019, Kenya joined the Network for Improving Quality of Care for Maternal, Newborn and Child Health during the Quality of Care Network’s second meeting on demonstrating accountability and learning, thus becoming the 11th country committed to rapid progress in improving quality of care.

Margaret E. Kruk, Associate Professor for Global Health at Harvard University, commended Kenya for taking the momentous step of declaring its demand for universal health care, but in the same breath went on to challenge all participants of the Lancet event to work actively towards a systematic change that would allow the country to implement truly meaningful, effective quality care.

Kruk demanded an overarching systemic change and called for a redefinition towards a more ambitious target than universal healthcare. She outlined three components that are vital to transforming the Kenyan system into what she coined “Quality Universal Health Coverage,” or “Q-UHC.”

1.     Competent providers

2.     Competent system

3.     Positive user experience

Our team, just like many other organizations’ representatives in attendance, felt inspired by Kruk’s words.

Hopefully, the same can be said of Kenya’s First Lady, who later tweeted: “It is my belief that quality healthcare should center on the basic principle that patients are whole, integrated people who need a holistic approach to their medical treatment.”

At the event, she had emphasized the need to strengthen health professionals’ education and training as recent health workforce graduates are often lacking adequate clinical skills in Kenya.

Organizations in attendance saw their role as potential change-makers in focusing on whole persons and improvements in health workforce education. At Jacaranda Health, for instance, we are directly addressing issues of quality in the Kenyan healthcare system through our flagship programs: our SMS service PROMPTS and Nurse Mentors.

PROMPTS serves to fill in the information gap and creates trust between providers and mothers, while our Nurse Mentors program trains providers in a on-going, sustainable way to pass on the critical skills necessary to successfully provide high-quality maternity care.

"Users are one of the best sources for improvement," Margaret Kruk commented. Jacaranda Health Innovation Fellow Jay Patel delivered credence to that statement through his presentation on how the continuously growing reach of PROMPTS is igniting demand for quality care by getting feedback from women via a simple SMS question: “Were you treated with respect at your last visit?”

With increasingly growing numbers of subscribers and a continuous expansion across Kenyan counties, PROMPTS keeps moms informed throughout their pregnancy and postpartum journey and allows for questions and comments to be sent back to the platform, which are summarized and shared with their health providers on a monthly basis, keeping providers engaged. This specific approach sets us apart from other programs.

To date, 20,000+ questions and counting have been asked and answered via our SMS platform, and we are addressing the full spectrum from general pregnancy inquiries to medically serious issues.

Margaret Kruk also highlighted the need of organizations to directly connect with their customers, as well as the government’s need to engage with its citizens when making healthcare decisions. She highlighted the efforts made by MomConnect, a program in South Africa with wide reach, which, similar to PROMPTs, directly engages and communicates with women.

However, these responses to specific elements of the healthcare quality gap are only part of the solution. We agree with the conference members that emphasized the importance of developing quality in healthcare over mere quantity and we believe there is more that organizations such as Jacaranda Health can contribute.

This is why we also presented our efforts in improving the very structures of organizational approaches to healthcare. Program Manager Meghan Munson’s presentation on our QI efforts echoed Kruk’s prior calls for reforming and updating existing structures, and highlighted the opportunities to do this even at the facility level. Meghan stressed the urgent necessity of incorporating low- and  no-cost interventions to improve healthcare systems. She explained how our Quality Improvement (QI) work helps government hospital frontline staff to effectively identify and solve problems in their services and systems.

Even though healthcare organizations often cannot directly redefine government health systems, we work hand-in-hand with governments to ensure positive change and impact. While applying the same scrutiny to their own processes that Margaret Kruk demanded of the government, we see this as a promising global moment to strengthen a focus on quality in healthcare.