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

Cardiovascular 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 to 69 years) from non-communicable 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, 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.³

The “25 × 25” targets inadequately address many elements of health system management identified by the WHO health system framework. The framework consists of six 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 de-centralize from central government to local entities. Health system stewardship was highlighted in 2014 Ebola epidemic in West Africa during which the coordination of clinical and non-clinical 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 management

Health 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 coordinating clinical and non-clinical services and staff including physicians, nurses, non-medical 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 2008-2009 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 While there is wide within-country variability in management performance, cross-country analyses suggest that strong management practices were not dependent upon high healthcare expenditures, though these analyses were restricted to high-income countries.⁷

Methods to evaluate health system management

To 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 1).⁷ The survey was developed by economists to quantify the quality of management practices and is conducted through a semi-structured interview that allows designation of numerical scores based on the interviewee's responses. McConnell et al. 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.⁸ 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 beta-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 non-clinical processes in US cardiac units.

Table 1.

Management practice dimensions from the World Management Survey.⁷ (http://worldmanagementsurvey.org/)

Operations	Layout of patient pathway
	Rationale for improving patient management
	Standardization and protocols
	Continuous improvement
	Use of human resources
Performance	Performance tracking
	Performance review
	Performance dialogue
	Consequence management
Targets	Target balance
	Target interconnection
	Time horizon of targets
	Target stretch
	Clearly defined accountability for clinicians
	Clarity and comparability of targets
Talent	Rewarding high performers
	Removing poor performers
	Promoting high performers
	Instilling a talent mindset/managing talent
	Retaining talent
	Attracting talent

The World Management Survey has been adapted and validated in four industry sectors, including healthcare, across 35 countries, including low- and middle-income countries such as Brazil and India. Despite its utility 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 management

Studies 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 forward

Since 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 non-clinical 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 non-clinical 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 six 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.