Hannah H. Leslie, Lisa R. Hirschhorn, Bernadette Daelmans, Keely Jordan, Alexander K. Rowe, Muhammad Pate, Catherine Arsenault, Anna D. Gage, Gagan Thapa, Address Malata, Joshua A. Salomon, Ezequiel García Elorrio, Svetlana V. Doubova, Olusoji Adeyi, Youssoupha Ndiaye, Lixin Jiang, John G. Meara, Nana A Y Twum-Danso, Sanam Roder-DeWan, K. Srinath Reddy, Margaret E Kruk, Ephrem T. Lemango, Mike English, Tanya Marchant, Manoj Mohanan, Oye Gureje, Malebona Precious Matsoso, Ole Frithjof Norheim, Frederico C. Guanais, Pierre M. Barker, Edward Kelley, and Jerker Liljestrand
The past 20 years have been called a golden age for global health.1 Fuelled by a major increase in domestic health spending and donor funding, LMICs have vastly expanded access to health determinants (eg, clean water and sanitation) and health services alike (eg, vaccination, antenatal care, and HIV treatment).2–4 These expansions have saved the lives of millions of children, men, and women, largely by averting deaths from infectious diseases.5 However, these past decades were not as favourable for preventing deaths from non-communicable diseases and acute conditions, such as ischaemic heart disease, stroke, diabetes, neonatal mortality, and injuries, for which mortality stagnated or increased.6 The lowest-income countries and the poorest people within countries generally had the worst outcomes, despite considerable efforts to increase use of health care.7 The strategy that brought big wins for child health and infectious diseases will not suffice to reach the health-related SDGs. The newly ascendant health conditions, including chronic and complex conditions, require more than a single visit or standardised pill pack; they require highly skilled, longitudinal, and integrated care. Such care is also needed to address the substantial residual mortality from maternal and child conditions and infectious diseases. In short, it is becoming clear that access to health care is not enough, and that good quality of care is needed to improve outcomes. India learned this with Janani Suraksha Yojana, a cash incentive programme for facility births, which massively increased facility delivery but did not measurably reduce maternal or newborn mortality.8 High-quality care involves thorough assessment, detection of asymptomatic and co-existing conditions, accurate diagnosis, appropriate and timely treatment, referral when needed for hospital care and surgery, and the ability to follow the patient and adjust the treatment course as needed. Health systems should also take into account the needs, experiences, and preferences of people and their right to be treated with respect.9 Although many consumer services make user experience a central mission, health systems—like other public sector systems—are often difficult to use, indifferent to the time and preferences of people, and reluctant to share decision-making processes.10 Indeed, some providers are rude and even abusive—a fundamental abrogation of human rights and health system obligations.9 At the same time, health workers might not receive the support and respect required to have a fulfilling professional life. Finally, systems can be inefficient, wasting scarce resources on unnecessary care and on low-quality clinics that people bypass, while imposing high costs on users.11 The SDG era demands new ways of thinking about health systems. Although they are only one contributor to good health—other major contributors being social determinants of health such as education, wealth, employment, and social protections, and cross-sectoral public health actions such as tobacco taxation and improved food, water, and road and occupational safety regulations12—access to high-quality health care is a human right and moral imperative for every country.13 Moreover, health systems are a powerful engine for improving survival and wellbeing and they are the focus of our report.14,15 We endorse WHO’s definition of a health system as consisting of “all organisations, people, and actions whose primary intent is to promote, restore, or maintain health”, and we focus this Commission on the organised health sector, public and private, including community health workers.16 Although informal providers (those with little or no formal clinical training) also provide care in some countries, there are—with a few notable exceptions—insufficient data on the quality of care offered by these providers, and we do not cover them in this Commission. Addressing quality of care is particularly pertinent as countries begin to implement UHC.17 UHC represents a substantial new investment of national resources—one that embodies new concrete commitments about the type of care that people have a right to expect. Newly transparent benefit packages can, in turn, create public expectations that governments will be under pressure to fulfil. Furthermore, new investments in health care will face scrutiny from finance ministers, who will demand efficient use of resources and better results measured in longer lifespans, restored physical and mental functions, user satisfaction, and economic productivity. What should a high-quality health system look like in countries with resource constraints and competing health priorities that aspire to reach the SDGs? The Lancet Global Health Commission on High-Quality Health Systems in the SDG Era, comprised of 30 academics, policy makers, and health system experts from 18 countries, seeks to answer this question.18 In this Commission, we propose new ways to define, measure, and improve the performance of health systems. We review evidence of past approaches and look for strategies that can change the trajectory of health systems in LMICs. Our work is informed by several principles. First, the principle that health systems are for people. Health systems need to work with people not only to improve health outcomes, but also to generate non-health-related value, such as trust and economic benefit for all people, including the poor and vulnerable. Second, the principle that people should be able to receive good quality, respectful care for any health concern that can be tackled within their country’s resource capacity. Third, the principle that high-quality care should be the raison d’etre of the health system, rather than a peripheral activity in ministries of health. Finally, the principle that fundamental change should be prioritised over piecemeal approaches. We recognise that health systems are complex adaptive systems that resist change and can be impervious to isolated interventions; indeed, multiple small-scale efforts can be deleterious. Quality of care is an emergent property that requires shared aims among all health system actors, favourable health system foundations, and is honed through iterative efforts to improve and learn from successes and failures. These considerations guided our analysis. We are also aware of other major efforts on quality of care at the time of the writing of this Commission. WHO convened the Quality of Care Network to facilitate joint learning, accelerate scale-up of quality maternal, newborn, and child services, and strengthen the evidence for cost-effective approaches. WHO, the World Bank, and the Organisation for Economic Co-operation and Development (OECD) published a global report on quality of health care earlier in 2018.19 The US National Academy of Medicine has begun a study on improving the quality of health care across the globe. There is also new interest in stronger primary care that can promote health, prevent illness, identify the sick from the healthy, and efficiently manage the needs of those with chronic disease.20 The Primary Health Care Performance Initiative, a multistakeholder effort, is focusing on measuring and comparing the functioning of primary health-care systems and identifying pathways for improvement.21 Primary care has been a main platform for provision of health care in low-income countries, but there—as elsewhere—the changing disease burden, urbanisation, and rising demand for advanced services and excellent user experience are challenging this current model of care. Our work was substantially strengthened with input from nine National High-Quality Health Systems Commissions that were formed to explore quality of care in their local contexts alongside the global Commission. To ensure that our work reflects the needs of people and communities, we have sought input from a people’s voice advisory board and we obtained advice and policy perspectives from an external advisory council. Our intended audiences for the report are people, national leaders, health and finance ministers, policy makers, managers, providers, global partners (bilateral and multilateral institutions and foundations), advocates, civil society, and academics. This report is arranged in the following manner: in section 1, we propose a new definition for high-quality health systems; in section 2, we describe the state of health system quality in LMICs, bringing together multiple national and cross-national data on quality of care for the first time; in section 3, we tackle the ethics of good quality of care and propose mechanisms for ensuring that the poor and vulnerable benefit from improvement; in section 4, we review the current status of quality measurements and propose how to measure better and more efficiently; in section 5, we reassess the available options for improvement and recommend new structural solutions; in section 6, we conclude with a summary of our key messages, our recommendations, and a research agenda. We recognise that the level of ambition implied in our recommendations might be daunting to low-income countries that are struggling to put in place the basics of health care. In this Commission, we are describing a new aspiration for health systems that can guide policies and investments now. Regardless of starting point, every country has opportunities to get started on the path to high-quality health systems.
