Disparities in access to quality health care remain prevalent in the U.S. health care system. So states the National Healthcare Disparities Report (NHDR) to Congress. The NHDR and its companion, the National Healthcare Quality Report (NHQR), both produced by the Agency for Healthcare Research and Quality (AHRQ), have served for years as critical gauges of how well the United States is doing in improving health care quality and how evenly (or not) quality gains are being distributed by race, ethnicity, and class. The most recent NHDR notes that while some gaps are diminishing, disparities in access to high-quality, evidence-based health care persist among different U.S. socioeconomic strata as well as racial and ethnic minorities.
Conventional and, in many ways, intuitive policy levers for redressing such gaps in quality, such as making greater volumes of health care available to affected subpopulations, have been shown by John Wennberg and his Dartmouth colleagues, among others, to be inadequate, given the persistence of inequities in quality in the face of ever-increasing national health care spending. The task of learning which remedial strategies work to address variations and disparities in quality remains a dynamic, evolving front for policy discourse and research.
Efforts to identify and address the drivers and exponents of disparities in health care quality and outcomes is hardly the exclusive province of the developed world’s policy communities, however. The Millennium Development Goals (MDGs), first articulated in 2000, reflect a global consensus of what progress should look like in the developing world by 2015. Three of the eight MDGs call for improvements in population health status, including diminution of maternal and child mortality and decreased prevalence of major diseases such as HIV/AIDS and malaria. Population health indicators in low-income countries continue to founder, despite recent empirical evidence showing that use of health care even in the poorest populations is often fairly high. This reality may indicate that the efficacy of the several-decades-old focus of global development strategy on increasing the availability of health care is approaching its limit. Evidence exists from the global plane to support the notion that merely increasing the volume of health care consumed does not necessarily translate to better health. It follows, then, that the next set of policy and research inquiries should focus on efforts to optimize available health resources, by identifying and eliminating disparities in quality and outcomes in developing countries.
Accordingly, as part of its global health initiative, Health Affairs presents a collection of seven papers reporting on variations in quality in five countries in three global regions reflecting differing stages of economic development: Mexico and Paraguay in Latin American, India and Indonesia in Asia, and Tanzania in sub-Saharan Africa. This set of papers advances the global quality policy discourse by moving us beyond assessments of “structural quality” — that is, tallies of the sheer number and physical condition of health care facilities and the like. Rather, they offer insight into the actual quality of the medical advice offered to patients by their providers — so-called process quality.
As Jishnu Das and Paul Gertler note in the overview paper, process quality in this case is assessed by divining what providers actually know, through the use of medical vignettes; what they do in practice, through examining household reports or direct clinical observation; and the effort that physicians expend, as measured by how much time they spend with each patient and the questions they ask. In so doing, these papers measure variations and disparities in the quality of care dispensed across socioeconomic strata, ethnic groups, and physician practice settings — be they private sector, public sector, or NGO.
The result is a new research base offering policymakers in these countries, and among global development institutions, empirical evidence documenting how effectively providers are able to leverage available resources to improve population health. It puts to the test, among other things, the public health sector’s historical promise in these countries to ameliorate inequities in health care quality flowing from socioeconomic or minority status. Although differences in sample sizes and methods prevent robust cross-national comparisons, the authors of these seven papers, much like the NHDR and NHQR, hope to point stakeholders within the various countries and among global institutions toward the most efficacious remedial policy solutions to improve populationwide health outcomes.