Evaluating and Improving Cardiovascular Health System Management in Low- and Middle-Income Countries

HomeCirculation: Cardiovascular Quality and OutcomesVol. 10, No. 11Evaluating and Improving Cardiovascular Health System Management in Low- and Middle-Income Countries Free AccessArticle CommentaryPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessArticle CommentaryPDF/EPUBEvaluating and Improving Cardiovascular Health System Management in Low- and Middle-Income Countries Sang Gune K. Yoo, BA;, Dorairaj Prabhakaran, MD, DM, MSc; and Mark D. Huffman, MD, MPH Sang Gune K. YooSang Gune K. Yoo From the Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.G.K.Y., M.D.H.); Public Health Foundation of India, Gurgaon (D.P.); Centre for Chronic Disease Control, New Delhi, India (D.P.); and London School of Hygiene and Tropical Medicine, United Kingdom (D.P.). , Dorairaj PrabhakaranDorairaj Prabhakaran From the Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.G.K.Y., M.D.H.); Public Health Foundation of India, Gurgaon (D.P.); Centre for Chronic Disease Control, New Delhi, India (D.P.); and London School of Hygiene and Tropical Medicine, United Kingdom (D.P.). and Mark D. HuffmanMark D. Huffman From the Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.G.K.Y., M.D.H.); Public Health Foundation of India, Gurgaon (D.P.); Centre for Chronic Disease Control, New Delhi, India (D.P.); and London School of Hygiene and Tropical Medicine, United Kingdom (D.P.). Originally published13 Nov 2017https://doi.org/10.1161/CIRCOUTCOMES.117.004292Circulation: Cardiovascular Quality and Outcomes. 2017;10:e004292Cardiovascular diseases represent an urgent global health burden and priority. A 2017 report from the Global Burden of Disease Study estimates that there were 422.7 million prevalent cases of cardiovascular disease and 17.9 million cardiovascular disease–related mortalities in 2015.1 The World Health Organization (WHO) established ambitious, voluntary global health targets in 2013 to reduce premature mortality (30–69 years) from noncommunicable diseases by 25% by 2025 (25×25).2 These targets include reductions in the national prevalence of key population-level risk factors (tobacco use, sodium intake, blood pressure, diabetes mellitus, overweight and obesity, and physical inactivity), increasing availability of drug therapies and technologies, and strengthening health systems to improve medication delivery and counseling. Despite the efforts, these targets will not be met in most low- and middle-income countries if current trends continue.3The 25×25 targets inadequately address many elements of health system management identified by the WHO health system framework. The framework consists of 6 building blocks: (1) service delivery, (2) health workforce, (3) health information systems, (4) access to essential medicines, (5) financing, and (6) leadership governance.4 Although the WHO's health system framework is largely descriptive, it underscores the complexity and importance associated with healthcare management as systems decentralize from central government to local entities. Health system stewardship was highlighted in 2014 Ebola epidemic in West Africa during which the co-ordination of clinical and nonclinical processes was essential to resource allocation, disease control, and quality of care.5 In this Perspective, we discuss the importance of health system management and review emerging methods to evaluate and improve health systems for better, safer global cardiovascular care with emphasis on low- and middle-income country settings.Health System ManagementHealth system management, which may be led by senior clinicians without formal management training in low- and middle-income country settings, includes a variety of activities: (1) organizing and co-ordinating clinical and nonclinical services and staff, including physicians, nurses, nonmedical staff, and medical information technology, (2) overseeing hospital and outpatient department logistics, (3) promoting patient safety, (4) maintaining work culture, (5) cultivating leadership and talent, and (6) developing and implementing policies that influence health and financial outcomes.4,5 However, managers both in public and private sectors may have variable training, experience, and performance.Favorable hospital management is associated with higher quality patient care. For example, adopting hospital management practices, such as monthly case reviews of acute myocardial infarction with clinicians and patient transporters or having a cardiologist always present on site, is associated with lower risk-standardized mortality rate from acute myocardial infarction based on a 2008 to 2009 survey of 537 US hospitals.6 Better management is also associated with increased revenue and productivity. For example, in the 2009 Management Matters project led by McKinsey & Company in partnership with academic investigators, United Kingdom hospitals with higher management ratings related to operations, performance, and human resources had higher income per hospital bed and patient satisfaction.7 Although there is wide within-country variability in management performance, cross-country analyses suggest that strong management practices were not dependent on high healthcare expenditures although these analyses were restricted to high-income countries.7Methods to Evaluate Health System ManagementTo better understand the role of management in health systems, instruments for management assessment have been developed. For example, the World Management Survey (http://worldmanagementsurvey.org/) addresses major management practice themes, including lean operations, performance, goals, and people management (Table).7 The survey was developed by economists to quantify the quality of management practices and is conducted through a semistructured interview that allows designation of numeric scores based on the interviewee's responses. McConnell et al8 adapted the World Management Survey in 2010 to assess management practices across 597 United States cardiac care units based on principles originating from the manufacturing sector. The authors reported a wide distribution of management practices among hospitals and the associations between high performing management practices and process outcomes, such as aspirin within 24 hours of arrival and prescription of aspirin and β-blocker at discharge.8 However, only 23% of hospitals scored a 4 or a 5 (5 being the highest performing practice) on more than half of the management practices evaluated, which stresses the need to improve the quality of management and nonclinical processes in US cardiac units.Table. Management Practice Dimensions From the World Management Survey7OperationsLayout of patient pathwayRationale for improving patient managementStandardization and protocolsContinuous improvementUse of human resourcesPerformancePerformance trackingPerformance reviewPerformance dialogueConsequence managementTargetsTarget balanceTarget interconnectionTime horizon of targetsTarget stretchClearly defined accountability for cliniciansClarity and comparability of targetsTalentRewarding high performersRemoving poor performersPromoting high performersInstilling a talent mindset/managing talentRetaining talentAttracting talentThe World Management Survey has been adapted and validated in 4 industry sectors, including healthcare, across 35 countries, including low- and middle-income countries, such as Brazil and India. Despite its use to inform hospitals and policymakers about their absolute and relative performance, this instrument does not prescribe specific interventions to improve management practices in lower-performing hospitals.Other methods to assess management-related topics, such as organizational and patient safety cultures, have been developed.9 However, these instruments, like the World Management Survey, are prone to recall and social desirability bias and may underestimate the true associations between management practices and patient outcomes. Interviewees may hide true management practices if they know the survey methodology. Conversely, interviewers' scoring may be skewed if interviewers are not blinded to hospital performance data.Improving ManagementStudies describing and evaluating interventions to improve general and cardiovascular-specific hospital management practices in low- and middle-income countries are limited. For example, a 2008 case study in Ethiopia describes a collaborative mentoring model for cultivating general management skills and professional development for hospital managers to improve hospital management. The Ethiopian Regional Health Bureaus and the Federal Ministry of Health under Tedros Adhanom, now Director-General of the WHO, partnered with The Clinton HIV/AIDS Initiative to design, implement, and evaluate a mentoring program with Yale University's School of Public Health to work directly with Ethiopian medical directors for a year through close mentorship, professional development opportunities, quality improvement projects, and longitudinal collaboration with key partners and staff.10 The subsequent master's level training of chief executive officers in health administration in Ethiopia was associated with higher adherence to composite hospital performance standards from 27% to 51% at 1-year follow-up.10 Although scalability, sustainability, and long-term effects of these programs warrant further study, adaptation, implementation, and spread of similar management-level interventions in low- and middle-income country settings could represent innovative approaches that complement ongoing efforts to improve cardiovascular quality and safety.A Path ForwardSince the Institute of Medicine's Crossing the Quality Chasm and To Err is Human reports, healthcare quality and safety have gained greater attention in the United States. To address healthcare quality and safety in low- and middle-income countries, the National Academy of Medicine convened a workshop with global experts in 2015. The workshop's experts noted the need to expand research in nonclinical processes, such as cost-effectiveness and management, as strategies to improve healthcare quality.5 The WHO also recognizes the potential of stronger health systems to incentivize the use of evidence-based medicine, eliminate inefficient practice, and increase collaborations among healthcare professionals,4 and this emphasis may increase further under the leadership of its new Director-General.In low- and middle-income countries—where the burden of cardiovascular disease is greater and quality of care is frequently (though not always) poorer than that in the United States—the evaluation of health system management practices is understudied to an even greater degree. The lack of research into nonclinical processes limits the global effort to achieve global health targets, including 25×25. However, health system management research offers an important avenue for evaluations but also and more importantly could be coupled with developing and implementing novel interventions. Interventions to improve management practices in health systems across the WHO's 6 building blocks are myriad and may range from education and team training using simulation, organizational and information system redesign to improve transparency, and financial and other incentives based on local conditions, needs, expertise, and priorities. Linking health system management evaluations with targeted interventions seems to be a logical starting point. Health system management and its research will need longitudinal investment from local, regional, national, and global stakeholders to implement, evaluate, scale, and sustain interventions that meet the needs of local populations and systems to improve the quality and safety of cardiovascular care.AcknowledgmentsWe acknowledge the academic support from Drs Alex Haynes and Rafaella Sadun (the Ariadne Labs at Brigham and Women's Hospital and the Harvard T. H. Chan School of Public Health), Lisa Hirschhorn (Northwestern University Feinberg School of Medicine), Prakash Charles and Mark Schumacher (Northwestern Medicine), Mohammed Ali (Emory University), and P.P. Mohanan (Westfort Hi-Tech Hospital, Ltd. and Cardiological Society of India, Kerala chapter) for the development of the concepts outlined above.DisclosuresS.G.K. Yoo has received support from the Fogarty International Center (FIC) and National Institute of Mental Health of the National Institutes of Health under Award Number D43 TW010543. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Dr Prabhakaran has received support from the National Heart Lung and Blood Institute (NHLBI), FIC, National Cancer Institute (NCI), Wellcome Trust, Indian Council of Medical Research, and research support from several pharmaceutical companies. Dr Huffman has received support from the NHLBI for work related to this Perspective (award R00HL107749) that led to the article's conceptualization. Dr Huffman has also received support from the World Heart Federation to serve as senior program advisor for the World Heart Federation's Emerging Leaders program, which is supported by unrestricted educational grants from Boehringer Ingelheim and Novartis with previous support by AstraZeneca and BUPA.FootnotesCorrespondence to Mark D. Huffman, MD, MPH, Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, 680 N Lake Shore Dr, Suite 1400, Chicago, IL 60611. E-mail [email protected]References1. Roth GA, Johnson C, Abajobir A, Abd-Allah F, Abera SF, Abyu G, Ahmed M, Aksut B, Alam T, Alam K, Alla F, Alvis-Guzman N, Amrock S, Ansari H, Ärnlöv J, Asayesh H, Atey TM, Avila-Burgos L, Awasthi A, Banerjee A, Barac A, Bärnighausen T, Barregard L, Bedi N, Belay Ketema E, Bennett D, Berhe G, Bhutta Z, Bitew S, Carapetis J, Carrero JJ, Malta DC, Castañeda-Orjuela CA, Castillo-Rivas J, Catalá-López F, Choi JY, Christensen H, Cirillo M, Cooper L, Criqui M, Cundiff D, Damasceno A, Dandona L, Dandona R, Davletov K, Dharmaratne S, Dorairaj P, Dubey M, Ehrenkranz R, El Sayed Zaki M, Faraon EJA, Esteghamati A, Farid T, Farvid M, Feigin V, Ding EL, Fowkes G, Gebrehiwot T, Gillum R, Gold A, Gona P, Gupta R, Habtewold TD, Hafezi-Nejad N, Hailu T, Hailu GB, Hankey G, Hassen HY, Abate KH, Havmoeller R, Hay SI, Horino M, Hotez PJ, Jacobsen K, James S, Javanbakht M, Jeemon P, John D, Jonas J, Kalkonde Y, Karimkhani C, Kasaeian A, Khader Y, Khan A, Khang YH, Khera S, Khoja AT, Khubchandani J, Kim D, Kolte D, Kosen S, Krohn KJ, Kumar GA, Kwan GF, Lal DK, Larsson A, Linn S, Lopez A, Lotufo PA, El Razek HMA, Malekzadeh R, Mazidi M, Meier T, Meles KG, Mensah G, Meretoja A, Mezgebe H, Miller T, Mirrakhimov E, Mohammed S, Moran AE, Musa KI, Narula J, Neal B, Ngalesoni F, Nguyen G, Obermeyer CM, Owolabi M, Patton G, Pedro J, Qato D, Qorbani M, Rahimi K, Rai RK, Rawaf S, Ribeiro A, Safiri S, Salomon JA, Santos I, Santric Milicevic M, Sartorius B, Schutte A, Sepanlou S, Shaikh MA, Shin MJ, Shishehbor M, Shore H, Silva DAS, Sobngwi E, Stranges S, Swaminathan S, Tabarés-Seisdedos R, Tadele Atnafu N, Tesfay F, Thakur JS, Thrift A, Topor-Madry R, Truelsen T, Tyrovolas S, Ukwaja KN, Uthman O, Vasankari T, Vlassov V, Vollset SE, Wakayo T, Watkins D, Weintraub R, Werdecker A, Westerman R, Wiysonge CS, Wolfe C, Workicho A, Xu G, Yano Y, Yip P, Yonemoto N, Younis M, Yu C, Vos T, Naghavi M, Murray C. Global, regional, and national burden of cardiovascular diseases for 10 causes, 1990 to 2015.J Am Coll Cardiol. 2017; 70:1–25. doi: 10.1016/j.jacc.2017.04.052.CrossrefMedlineGoogle Scholar2. World Health Organization. Global Action Plan for the Prevention and Control of Noncommunicable Diseases 2013–2020. Geneva, Switzerland: World Health Organization; 2013.Google Scholar3. Sacco RL, Roth GA, Reddy KS, Arnett DK, Bonita R, Gaziano TA, Heidenreich PA, Huffman MD, Mayosi BM, Mendis S, Murray CJ, Perel P, Pineiro DJ, Smith SC, Taubert KA, Wood DA, Zhao D, Zoghbi WA. The heart of 25 by 25: achieving the goal of reducing global and regional premature deaths from cardiovascular diseases and stroke: a modeling study from the American Heart Association and World Heart Federation.Circulation. 2016; 133:e674–e690. doi: 10.1161/CIR.0000000000000395.LinkGoogle Scholar4. World Health Organization. Everybody's Business: Strengthening Health Systems to Improve Health Outcomes: WHO's Framework for Action. Geneva, Switzerland: World Health Organization; 2007.Google Scholar5. National Academies of Sciences, Engineering, and Medicine. Improving Quality of Care in Low- and Middle-Income Countries: Workshop Summary. Washington, DC: The National Academies Press; 2015.Google Scholar6. Bradley EH, Sipsma H, Brewster AL, Krumholz HM, Curry L. Strategies to reduce hospital 30-day risk-standardized mortality rates for patients with acute myocardial infarction: a cross-sectional and longitudinal survey.Ann Intern Med. 2012; 156: 618–626.CrossrefMedlineGoogle Scholar7. Dorgan S, Layton D, Bloom N, Homkes R, Sadun R, Van Reene J. Management in Healthcare: Why Good Practice Really Matters. London, United Kingdom: McKinsey & Company; 2010.Google Scholar8. McConnell KJ, Lindrooth RC, Wholey DR, Maddox TM, Bloom N. Management practices and the quality of care in cardiac units.JAMA Intern Med. 2013; 173:684–692. doi: 10.1001/jamainternmed.2013.3577.CrossrefMedlineGoogle Scholar9. Bradley EH, Brewster AL, Fosburgh H, Cherlin EJ, Curry LA. Development and psychometric properties of a scale to measure hospital organizational culture for cardiovascular care.Circ Cardiovasc Qual Outcomes. 2017; 10:e003422.LinkGoogle Scholar10. Kebede S, Mantopoulos J, Ramanadhan S, Cherlin E, Gebeyehu M, Lawson R, Bradley EH. Educating leaders in hospital management: a pre-post study in Ethiopian hospitals.Glob Public Health. 2012; 7:164–174. doi: 10.1080/17441692.2010.542171.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Heller D, Kumar A, Kishore S, Horowitz C, Joshi R and Vedanthan R (2019) Assessment of Barriers and Facilitators to the Delivery of Care for Noncommunicable Diseases by Nonphysician Health Workers in Low- and Middle-Income Countries, JAMA Network Open, 10.1001/jamanetworkopen.2019.16545, 2:12, (e1916545) Singh K, Devarajan R, Mohanan P, Baldridge A, Kondal D, Victorson D, Karmali K, Zhao L, Lloyd-Jones D, Prabhakaran D, Goenka S and Huffman M (2019) Implementation and acceptability of a heart attack quality improvement intervention in India: a mixed methods analysis of the ACS QUIK trial, Implementation Science, 10.1186/s13012-019-0857-7, 14:1, Online publication date: 1-Dec-2019. Sérvio T, Britto R, de Melo Ghisi G, da Silva L, Silva L, Lima M, Pereira D and Grace S (2019) Barriers to cardiac rehabilitation delivery in a low-resource setting from the perspective of healthcare administrators, rehabilitation providers, and cardiac patients, BMC Health Services Research, 10.1186/s12913-019-4463-9, 19:1, Online publication date: 1-Dec-2019. Nallamothu B (2017) Global Health and Circulation: Cardiovascular Quality & Outcomes, Circulation: Cardiovascular Quality and Outcomes, 10:11, Online publication date: 1-Nov-2017. November 2017Vol 10, Issue 11 Advertisement Article InformationMetrics © 2017 American Heart Association, Inc.https://doi.org/10.1161/CIRCOUTCOMES.117.004292PMID: 29133473 Originally publishedNovember 13, 2017 Keywordsleadershipglobal healthmortality, prematurecardiovascular diseasesPDF download Advertisement SubjectsHealth ServicesQuality and Outcomes