The Region of the Americas made significant progress in terms of health during the last decade. However, access, coverage and quality of health care still present substantial deficits that reflect unfair differences in the health status of people and communities. On one hand, the demographic transition and epidemiological changes (the increment of chronic diseases, emerging and re-emerging diseases) challenge the capacity of health systems to provide quality health services. Added to this, there is the segmentation of health systems, the fragmentation of services, the absence of regulatory and normative frameworks (or the weakness to enforce existing regulations), and the weak development and implementation of any system of accountability.

In this context, quality in healthcare services is of the highest importance and is a high priority issue for healthcare systems in the region. Every country has legislations, regulations, and national standards regarding the quality of healthcare and patient safety, or has created specific entities (undersecretaries, Directorate-Generals, or commissions) within the organisational structures of healthcare systems with the overall mission of improving the quality of healthcare. However, despite this institutionalisation of quality management, a lack of integrality and integration of strategies in order to guarantee and improve the quality of care in healthcare systems is prevalent in most countries.[1]

The technical cooperation provided to countries in the area by the Pan American Health Organization (PAHO) and other international institutions have for some time focused its work on the implementation of projects aimed at improving quality of care with vertical proposals which have achieved some success in some cases and made isolated progress. Such is the case with programmes such as the Patient Safety programme and its various projects (hand hygiene, safe surgery, adverse events, etc.). However, complaints made by patients and their families about quality issues within health services subsist and in many countries these have worsened so much that dissatisfaction among users of and workers within health services has now reached alarming levels.

In an attempt to discover why these projects have experienced only limited results in health services and why the lack of quality continues to be a great challenge for healthcare systems,a regional forum took place on 4th and 5th November 2015 at the central offices of PAHO in Washington DC to discuss ‘Universal Health: Healthcare Systems and Quality of Care’. Present at this forum were executive officials responsible for healthcare quality in over 30 countries across the Americas, as well as PAHO experts, the World Health Organization (WHO), the Institute for Health Improvement (IHI), organisations and foundations which work on issues of healthcare quality, and the Mexican Medical Arbitration Commission (CONAMED: ‘Comisión de Arbitraje Médico de México’), among others.

This debate was part of the efforts made by the Member States of PAHO to implement the Strategy for Universal Access to Health and Universal Health Coverage (Universal Health)[2]approved by the Governing Board of PAHO in September 2014. This strategy defines universal access as the absence of any kind of barrier that could prevent people from using comprehensive, appropriate, timely, quality health services whenever needed, and states that universal health cover implies the existence of organizational and financing mechanisms capable of covering the whole population.

Three challenging ideas formed the basis of discussion at the forum. The first of these raised the need to agree unanimously on an up-to-date, operative and clarifying definition of quality health services. The second idea proposed that quality of care and the guarantee of this quality cannot be seen as issues exclusive to health services, but are rather issues that also require the involvement of management, financing and the generation of resources within the health system. Therefore, any debate on the quality of healthcare services must include plans, strategies and changes to be simultaneously implemented in the four sections of the health system and must include people and communities who use these services, taking into account their particular ideas, their individual needs and their expectations about the quality of healthcare services. The third idea dealt with the subject of how to evaluate quality and how to guarantee sustainability of the policies, strategies and interventions that it requires.

Listed in brief below is a general overview of the main ideas generated during the debate:

  • Universal Health (cover and access for all) and quality health services form a comprehensive and unbreakable unit. This approach aims to reduce inequality in access to quality health services and to increase health cover with quality interventions in order to attain health and well-being for all.
  • Strengthening of the government and regulation of the healthcare system is fundamental in order to offer better quality health services. This implies a strengthening of the governing role of the national health authority so that it may effectively synchronise the operation of all areas of the healthcare system.
  • Thus it is considered that responsibility for quality at national health authority level and in the services cannot be limited to only one department, one unit, or one ‘focal point’ but constitutes a priority across all programmes, departments, and health disciplines forming the central axis of an organisational culture of excellence.
  • Regulation, in every sense, is indispensable for consolidating and protecting a culture of quality. A clear regulatory framework provides the security that the population and health workers need.
  • The most solid and sustainable results with regards to quality are achieved when health system interventions are carried out comprehensibly across all health services via an integrated support network approach.
  • There is no method of accreditation that can effectively improves quality without incentives to stimulate health workers, hence the importance of pay mechanisms. The theory behind allocation of resources in healthcare shows that mixed pay systems contribute towards an improvement in quality.
  • Frequent and timely evaluation of the role of health services is indispensable for generating information useful in the making of decisions which aim to continue improvement.
  • The quality of services is very closely linked with the training and skill development of human resources in an institutional culture of discipline, commitment, and excellence.
  • Communities and people must be actively involved in efforts to improve the quality of health services. Quality is intrinsically linked to a right to health, and its sustainability demands guaranteed participation.

These statements will form the base of a wider discussion involving participants from each member country of PAHO, with the objective of arriving at an agreed proposal intended for discussion and approval by the Governing Bodies of PAHO and which may guide further development of thismatter in the context of the Strategy for Universal Health.

Dr. Reynaldo Holder

Regional Advisor – Hospitals and Integrated Health Care Delivery Systems, Area of Health Systems based on Primary Health Care, Pan American Health Organization/ World Health Organization.

Specialist in organization and management of health systems and services both at the national and local levels.

Doctor in Medicine (1982), Specialist in Pediatric Medicine (1988), Master in Science in Health Services Management (2002).

Associate Editor of the International Journal of Integrated Care and a Founding Board Member of the International Foundation for Integrated Care.

[1]Sebastian García Saiso et al. Quality – the core of healthcare systems. Quality of healthcare in Mexico as seen through its institutions: 12 years of experience. Secretary of Health. Mexico. December 2012.
(Original reference in Spanish: La calidad como eje transversal de los sistemas de salud. La calidad de la atención a la salud en México a través de sus instituciones: 12 años de experiencia. Secretaria de Salud. México. Diciembre, 2012)

[2]PAHO, Strategy for Universal Access to Health and Universal Health Coverage.Resolution CD53.R14, 2014. Note: “Universal Health” is used to abbreviate the title of the resolution.(Original in Spanish: OPS, Estrategia para el Acceso Universal a la Salud y la Cobertura Universal de Salud. Resolución CD53.R14, 2014. Nota: Se utiliza “Salud Universal” como abreviatura al título de la resolución.)