I remember very vividly two of the hospitals I visited in Vietnam, during my first field trip as a global health advisor on the iDSI. In a central hospital in Hanoi, I saw an acute stroke centre that was spotlessly clean and gleaming with the latest equipment, with specialised stroke clinicians offering a range evidence-based treatments matching Western standards. In contrast, in a district hospital a mere two hours away from the capital city, I saw an elderly woman with suspected stroke who had been hospitalised for two weeks, seemingly not getting any better and not receiving any meaningful treatment (and there was no way to confirm the diagnosis as no brain imaging could be done). There was no question as to which hospital I would choose, if I could, if a relative or I were unfortunate to have a stroke.

The reality is that for most people, there is no choice – those who have the means to access the better hospitals, perhaps simply because they live closer to the city, likely get better treatment. This is unfair. Universal health coverage (UHC) is only truly universal if everyone has fair access to good quality health services, irrespective of where they live, what facilities they have access to, their education, income, religion or ethnic background.

Variation in quality is not a phenomenon unique to Vietnam, but is a reality in health systems across the world – even in relatively well-resourced and well-performing UHC systems such as the UK National Health Service. Some variation in quality may be acceptable, but one reason why unacceptable variation occurs is that there is a lack of clarity across the system about what is best practice.

Quality standards

In a bid to address this variation, NICE in the UK introduced Quality Standards (QS). QS are concise sets of statements that describe what is best practice in a given disease area (drawn from existing evidence based guidelines). For instance, what kinds of and how many antenatal checks a pregnant woman should ideally receive; sets out the practical steps required to achieve improvement, *and* most importantly quantifies the improvement. In essence, QS brings everyone together to identify the top 5 or 10 things that need improving nationally, and focus efforts towards raising standards in those areas.

Since 2012, iDSI has been working with India, China, Vietnam and recently Thailand, to develop and implement QS as ways of tackling inequalities in healthcare quality, and to raise overall standards in key areas such as antenatal and maternal health, non-communicable diseases (stroke, hypertension, and diabetes), and antimicrobial resistance. We have drawn on our UK and international experience to create resources section of the site and on our new iDSI Knowledge Gateway.

Thailand, long seen as a success story of UHC, also recognises unacceptable variation in quality among public healthcare providers. In particular, there is now a push to raise and standardise quality in health promotion and disease prevention, beginning with QS in antenatal care. I was privileged to be invited as an international expert to observe and advise on this process. The discussions I heard among policymakers, clinicians and grassroots health volunteers were so rich that I can already anticipate insights and lessons that will go into the next version of the QS guide.

The enthusiasm and expertise of the stroke clinicians I met in the central hospital in Vietnam was unquestionable; the challenge is to sustain those excellent standards of practice and to ensure that all healthcare services across a country can reach those standards. iDSI’s vision is that everyone has fair access to quality healthcare, and we hope that our efforts in introducing and localising the QS model is a small step in the right direction.

However, universal access to RRT is a challenge for low- and middle-income countries due to their high cost. Of the three types, kidney transplantation is the most expensive, given that transplantation services are not widely available in resource-limited settings and as such will require high, intensive capital investment, human resource development, and organ supply, storage, and other related costs. Haemodialysis comes in second for similar reasons – capital investment in machines and human resource development are costly. In addition, physicians have financial incentives to promote this treatment since it will ensure that patients return to clinics or hospitals for treatments several times a week, which may drive up costs if implemented in government-supported facilities.

The last type of RRT, Peritoneal dialysis, has been found cost-effective and has better health outcomes for resource-limited settings (Teerawattananon et al 2016). It also answers unique healthcare challenges in these settings – for example, peritoneal dialysis units can be sent to remote areas that have limited access to healthcare facilities. Thailand has implemented peritoneal dialysis as the first-line treatment to ESRD. This means that patients covered under the universal healthcare scheme will receive peritoneal dialysis as their treatment under public hospitals, with haemodialysis as the secondary treatment in case of contraindications. The country significantly invested and promoted this policy, providing capital investment for PD providers, free training for health professionals, infrastructure development, and a professional fee for health professionals in providing PD services.

On October 13-14 during the International Conference: PD First Policy-Onsite Study, other countries considering their policy for RRT visited Thailand to understand how this policy was enacted and the components of its implementation. The program of activities included a forum that explained the economic and clinical evidence to support peritoneal dialysis for Thailand, the implementation, and the continued management and evaluation of the program. Participants also visited peritoneal dialysis patients and clinics to see first-hand the patient experience on the program. This is particularly important for countries that will be using this information to inform policy on broader level such as Indonesia, which is already implementing pilot programs for RRT and considering scaling them up to the national level.

Reference: Economic Evaluation of Palliative Management versus Peritoneal Dialysis and Hemodialysis for End-Stage Renal Disease: Evidence for Coverage Decisions in Thailand

Link: http://www.valueinhealthjournal.com/article/S1098-3015(10)60455-X/abstract?_returnURL=http%3A%2F%2Flinkinghub.elsevier.com%2Fretrieve%2Fpii%2FS109830151060455X%3Fshowall%3Dtrue

Dr Suwit spoke about the Thai experience of achieving universal access to affordable quality healthcare, outlining some of the challenges faced by policy makers and offering his own advice and experience of how to ‘move the mountain’ towards sustainable UHC.

A video recording of the lecture is now available to view online.

The theme for this year’s conference was Priority Setting for Universal Health Coverage (UHC). Discussion focused on how countries can make “better decisions about priorities in the context of UHC, regardless of how rich or poor a country may be, or how much progress it has made in its UHC journey”.

PMAC 2016 was co-hosted by iDSI core partner NICE International and our global funders the Bill and Melinda Gates Foundation, DFID and Rockefeller Foundation, along with a number of other international partners, and forms part of a “longer-term, collaborative international effort to articulate priority-setting as a necessary (if not sufficient) condition for attaining and sustaining UHC”.

The conference also formally  launched Phase 2 of iDSI, which sees our demand-driven practical support to low- and middle-income country governments being scaled up, with the aim of embedding evidence-informed priority-setting mechanisms in health systems around the world.

“up to 68 percent of out of pocket health costs in resource-limited countries is for medication… inclusion of off-label drugs in the UHC benefit package, as shown in the use of bevacizumab in Thailand, serves as an example of how to offer high-cost NCD treatment in a safe and effective way”

The blog also emphasises the importance of evidence-based decision making and use of HTA in considerations about access to medicines.

“No matter what measures are adopted, the decision-making should be an evidence-based process participated in by multiple stakeholders and supported by health technology assessment (HTA), which takes into account human rights, cost-effectiveness, safety, and intellectual property rights“