Listening to people in evaluating health systems across the world

By Elizabethe Holland Durando

GENEVA — Health systems typically are evaluated with a range of metrics from the system perspective: clinical outcomes, health worker numbers, utilization of services, among others. These metrics are important, but they fail to capture an essential dimension: How do health systems work for people? Populations are the intended beneficiaries, the clients, but systems, especially in lower-income countries, rarely ask for feedback.

The multicountry People’s Voice Survey — which includes measures of health system utilization patterns, ratings of care quality, and confidence and trust in health systems, offering insight on national performance across geographies and income levels — is intended to fill this gap and to provide a more representative view of the public’s assessment of health systems. 

Washington University School of Public Health, in partnership with the Quality Evidence for Health System Transformation (QuEST) Network and the Alliance for Health Policy and Systems Research of the World Health Organization, hosted a talk and panel discussion May 22, in Geneva, to highlight new trend data from the People’s Voice Survey (PVS), revealing perspectives on health system performance, across several countries, after the COVID-19 pandemic. The talk and panel discussion were a side event during the 78^th World Health Assembly.

“This event is part of series of events we are doing at Washington University, domestically and globally, to catalyze conversations about topics that we think are important at the moment, and particularly a turbulent moment like this one,” Sandro Galea, MD, DrPH, the Margaret C. Ryan Dean of the School of Public Health at WashU, said in kicking off the event and discussion. “This survey does the fairly radical thing of actually asking people what they think … which is something that has not been done enough.” Galea is also the Eugene S. and Constance Kahn Distinguished Professor in Public Health and vice provost for interdisciplinary initiatives at WashU.

Margaret E. Kruk, MD, MPH, the Distinguished Professor of Health Systems and Medicine in WashU Medicine’s Department of Medicine and director of the QuEST Center at WashU, spoke about the survey and moderated the panel discussion.

“Here in the U.S., we have more surveys, but these are directed to patients with recent visits,” Kruk explained. “Worldwide, when health systems do hear from people, it’s usually complaints. The People’s Voice Survey is intended to fill this gap and to provide a more representative view of the public’s assessment of the health system. This includes people who don’t regularly use services, since they, too, have a perspective. This matters since people are the ultimate payers for health care in all countries, and systems cannot continue to function without public confidence and support. Public input is essential for systems to improve.” 

The survey — used in 21 countries — uses a flexible, mixed-mode design that includes telephone, online, and in-person data collection to achieve a nationally representative sample of adults and place people at the center of health system performance assessment.

“The PVS is the product of our global partnership in the QuEST Network,” Kruk said. “We collected the data collaboratively to ensure state-of-the-art research methods were used everywhere and to promote comparison across countries. But the PVS data are just numbers until they are interpreted in light of the local context. For this, we look to our colleagues, in participating countries, who are knowledgeable about the health systems where they live. Most of our primary investigators also have well-established links with local governments to promote reflection and hopefully action on the findings.” 

It is beneficial to share survey findings in concert with the World Health Assembly meetings, Kruk continued, because the WHA is a gathering of health ministers who may wonder how to incorporate public views into their health system planning. “We heard at the seminar from a ministry of health official from Ethiopia, for example, about the insights he got regarding what people value about private versus public care,” she said.

Todd Lewis, PhD, WashU assistant professor of medicine and QuEST’s research lead, also presented survey findings at the event. The panel included Sailesh Mohan, MD, MPH, PhD, and Dorairaj Prabhakaran, MD, both of the Public Health Foundation of India and QuEST; Emelda Okiro, PhD, of the Kenya Medical Research Institute-Wellcome Trust program; Rosanna Tarricone, MSc, PhD, of the Department of Social and Political Sciences at Bocconi University in Milan, Italy; and Muluken Argaw, MD, strategic affairs lead executive officer for the Ministry of Health in Ethiopia.

“At this time of major disruption and change in global health, we do need ideas, we need technical excellence, and we need thoughtful consideration and the ability to share across cultures,” said Kumanan Rasanathan, executive director of the WHO’s Alliance for Health Policy and Systems Research, in closing remarks at the event. “That is the beautiful idea of global health.”

Elizabethe Holland Durando is the director of communications and change management at Washington University School of Public Health in St. Louis.