It is now more imperative than ever that the provision and experience of sexual and reproductive health must be of quality if we are to achieve the International Conference on Population and Development Programme of Work (ICPD PoA) and Sustainable Development Goals (SDG). Quality care will enable people to live independent and fulfilling lives; having the power to take decisions over their own bodies and make personal and professional life choices. The lancet commission has reminded us that quality of care should not be the purview of only the elite or an aspiration for the distant future of the poor but it should be in the DNA of all health systems. The right to health is meaningless without good quality care because health systems cannot improve health without it.
In some way, it is easier to define or recognize when we do not have or provide quality care than when we do. Sadly though, many of our health facilities and providers have become immune to poor health care. They do not even recognize quality care now. Research about mistreatment of women in labour in four countries; Ghana, Nigeria, Myanmar and Guinea was shocking and a sad example of poor quality care. The study led by Meghan Bohren indicates that 1 in 3 women had experienced mistreatment during childbirth. The Guardian highlighted this mistreatment as a global human right issue. Research have shown that whatever the woman’s class, race or location is, she has a chance of experiencing mistreatment in childbirth or poor quality care. The problem is so prevalent that you will see it in the findings of ‘What Women Want’ survey. Overwhelmingly, women wanted to be treated with respect and compassion whilst seeking and receiving health care. This need for respect and compassion is not just during pregnancy, labour and birth; it cuts across the full spectrum of Sexual and Reproductive Health – access to contraception, safe abortion, testing and treatment for STIs and HIV, services addressing menstruation, fertility, cervical screening, chronic health conditions like endometriosis and menopause.
Consequences of poor quality care
The lancet commission has shown that more than 80 million people per year in Lower and Middle Income Countries (LMIC) die from conditions that should be treatable by the health system. Poor health care is now a bigger barrier to reducing mortality and insufficient access. We know that 60 percent of deaths from conditions amenable to health care are due to poor health care, whilst the remaining deaths are from poor utilization or non-utilization of the health system. There are systematic deficit in quality of care. In LMIC, mothers and children receive half the recommended clinical action in a typical preventive or curative visit. One (1) in three (3) people in LMIC cited negative experiences with their health system in the areas of attention, respect, communication and the length of their visit. Quality of care is poorest for the most vulnerable including the poor, the less educated, adolescents, those with stigmatized conditions and those at the edge of the health system such as people in prisons and the homeless.
The experiences of poor quality care result in women and families avoiding health services or bypassing the ones they know will refer them to other facilities; sometimes with disastrous consequences. Poor quality care also means the inability of people to access the contraceptives they need and want. This inevitably results in the usage of traditional or other methods of contraceptive with limited effectiveness leading to unplanned pregnancies. They in turn seek unsafe abortion, often with tragic consequences; they do not seek for treatment for STIs leading to long term infertility and other issues. Poor quality care means that people are scared to be tested or treated for HIV due to the way the health system treats them. This means the opportunity to receive treatment and support is absent. Poor quality care and lack of patient safety are the greatest killers and challenges health systems face across the world. Patients now receive little care at the last hour and also too much care too soon as over medicalization is seen as quality improvement of health care and therefore must be quality of care. In the last decade, a lot of emphasis have been placed on increasing coverage and not enough emphasis on quality. The challenge for all of us with regard to quality care is determining what is the right care, what is the right way, what is the right time and making sure health delivery is done with kindness and respect.
WHO has identified quality of care as a key component of the right to health and the path to equity and dignity for women and children. In other to receive UHC, it is essential to deliver health services that meet quality criteria. The WHO criteria of quality health care is the extent to which health care services provided to individuals and patient populations improve desired health outcomes. In order to achieve this, health care must be safe, effective, truly efficient, equitable and people centred.
The health system must work in partnership with women, communities, civil society, private sector, academia, etc to ensure that the services provided are what people want and need and are provided in a way that is affordable, accessible and acceptable. Governments must design systems and services in a way that women and girls know they will be treated with kindness by compassionate and competent staff working in a system with zero tolerance for disrespect. There is the need to educate and support more health workers, especially midwives who provide the majority of maternal and newborn health services. We must also take into account the status of midwives. We must educate and train other health care professional; nurses, doctors and community health workers to ensure the full spectrum of care is provided and of quality. It is not enough to just get more health workers, more health facilities, more policies and more guidelines; the health workers must have pre-service education that is of quality, evidence based, grounded in practice with supportive supervision and mentoring and training that is long enough that they can get the skills they need in practice. They must have quality in-service education that keeps them up to date and connected. The health facilities that they are assigned to must be equipped, welcoming, clean, have water, sanitation and power, commodities and drugs, telephone for communication and transport for referrals.
We have to keep doing research, fund and support generation of evidence to better understand how to deliver quality care. We need research to work out what is needed, where, how, what works, why did it work, why did it not work, provide change, monitor progress and hold people accountable.
There are still challenges to overcome which will ensure that all people receive quality care. We must keep highlighting the importance of quality care in the global and national agenda. Recognizing the problem is a first start and deciding that poor quality care cannot continue is the next. Recognizing that quality care includes respectful care and kindness are essential.
The bright future of women and girls from every corner of the globe depends on our collective action. And for us at ARHR, that collective action must include a focus on quality of care i.e. the provision of the right care, in the right way and at the right time in a way that benefits women, families and communities.