Lancet Global Health Communication.pdf

www.thelancet.com/lancetgh Vol 6 November 2018 e1196

The Lancet Global Health Commission

Lancet Glob Health 2018;

6: e1196–252

Published Online September 5, 2018 http://dx.doi.org/10.1016/ S2214-109X(18)30386-3

This online publication has been corrected. The corrected version first appeared at thelancet.com/lancetgh on Sept 18, 2018 and further corrections were made on Oct 12, 2018

Harvard T H Chan School of Public Health, Boston, MA, USA (M E Kruk MD, A D Gage MSc, C Arsenault PhD, H H Leslie PhD, S Roder-DeWan MD); New York University College of Global Public Health, New York, NY, USA (K Jordan MSc); The World Bank, Washington, DC, USA (O Adeyi MD); Institute for Healthcare Improvement, Cambridge, MA, USA (P Barker MD); WHO, Geneva, Switzerland (B Daelmans MD, E Kelley MD); Mexican Institute of Social Security, Mexico City, Mexico (S V Doubova MD);

KEMRI—Wellcome Trust Research Programme, Nairobi, Kenya (M English MD); Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina (E G Elorrio MD);

Inter-American Development Bank, Washington, DC, USA (F Guanais PhD); WHO Collaborating Centre for Research and Training in Mental Health, Neuroscience, Drug and Alcohol Abuse, University of Ibadan, Ibadan, Nigeria (Prof O Gureje PhD);

Northwestern University Feinberg School of Medicine, Chicago, IL, USA (Prof L R Hirschhorn MD);

National Centre for Cardiovascular Disease, Beijing, China (L Jiang MD); Federal Ministry of Health of Ethiopia, Addis Ababa, Ethiopia (E T Lemango MD); Bill & Melinda Gates Foundation, Seattle, WA, USA (J Liljestrand MD); Malawi

High-quality health systems in the Sustainable Development Goals era: time for a revolution Margaret E Kruk, Anna D Gage, Catherine Arsenault, Keely Jordan, Hannah H Leslie, Sanam Roder-DeWan, Olusoji Adeyi, Pierre Barker, Bernadette Daelmans, Svetlana V Doubova, Mike English, Ezequiel García Elorrio, Frederico Guanais, Oye Gureje, Lisa R Hirschhorn, Lixin Jiang, Edward Kelley, Ephrem Tekle Lemango, Jerker Liljestrand, Address Malata, Tanya Marchant, Malebona Precious Matsoso, John G Meara, Manoj Mohanan, Youssoupha Ndiaye, Ole F Norheim, K Srinath Reddy, Alexander K Rowe, Joshua A Salomon, Gagan Thapa, Nana A Y Twum-Danso, Muhammad Pate

Executive summary Although health outcomes have improved in low-income and middle-income countries (LMICs) in the past several decades, a new reality is at hand. Changing health needs, growing public expectations, and ambitious new health goals are raising the bar for health systems to produce better health outcomes and greater social value. But staying on current trajectory will not suffice to meet these demands. What is needed are high-quality health systems that optimise health care in each given context by consistently delivering care that improves or maintains health, by being valued and trusted by all people, and by responding to changing population needs. Quality should not be the purview of the elite or an aspiration for some distant future; it should be the DNA of all health systems.

Furthermore, the human right to health is meaningless without good quality care because health systems cannot improve health without it.

We propose that health systems be judged primarily on their impacts, including better health and its equitable distribution; on the confidence of people in their health system; and on their economic benefit, and processes of care, consisting of competent care and positive user experience. The foundations of high-quality health sys-tems include the population and their health needs and expectations, governance of the health sector and partnerships across sectors, platforms for care delivery, workforce numbers and skills, and tools and resources, from medicines to data. In addition to strong foundations, health systems need to develop the capacity to measure and use data to learn. High-quality health systems should be informed by four values: they are for people, and they are equitable, resilient, and efficient.

For this Commission, we examined the literature, analysed surveys, and did qualitative and quantitative research to evaluate the quality of care available to people in LMICs across a range of health needs included in the Sustainable Development Goals (SDGs). We explored the ethical dimensions of high-quality care in resource-constrained settings and reviewed available measures and improvement approaches. We reached five conclusions:

The care that people receive is often inadequate, and poor-quality care is common across conditions and countries, with the most vulnerable populations faring the worst Data from a range of countries and conditions show systematic deficits in quality of care. In LMICs, mothers and children receive less than half of recommended clinical actions in a typical preventive or curative visit, less than half of suspected cases of tuberculosis are correctly managed, and fewer than one in ten people diagnosed with major depressive disorder receive minimally adequate treatment. Diag-noses are frequently incorrect for serious conditions, such as pneumonia, myocardial infarction, and newborn asphyxia. Care can be too slow for conditions that require timely action, reducing chances of survival.

At the system level, we found major gaps in safety, prevention, integration, and continuity, reflected by poor patient retention and insufficient coordination across platforms of care. One in three people across LMICs cited negative experiences with their health system in the areas of attention, respect, communi-cation, and length of visit (visits of 5 min are common);

on the extreme end of these experiences were disrespectful treatment and abuse. Quality of care is worst for vulnerable groups, including the poor, the less educated, adolescents, those with stigmatised conditions, and those at the edges of health systems, such as people in prisons.

Universal health coverage (UHC) can be a starting point for improving the quality of health systems.

Improving quality should be a core component of UHC initiatives, alongside expanding coverage and financial protection. Governments should start by establishing a national quality guarantee for health services, specifying the level of competence and user experience that people can expect. To ensure that all people will benefit from improved services, expansion should prioritise the poor and their health needs from the start. Progress on UHC should be measured through effective (quality-corrected) coverage.

High-quality health systems could save over 8 million lives each year in LMICs More than 8 million people per year in LMICs die from conditions that should be treatable by the health system.

In 2015 alone, these deaths resulted in US$6 trillion in economic losses. Poor-quality care is now a bigger barrier to reducing mortality than insufficient access.

60% of deaths from conditions amenable to health care are due to poor-quality care, whereas the remaining deaths result from non-utilisation of the health system.

High-quality health systems could prevent 2·5 million http://crossmark.crossref.org/dialog/?doi=10.1016/S2214-109X(18)30386-3&domain=pdf e1197 www.thelancet.com/lancetgh Vol 6 November 2018

University of Science and Technology, Limbe, Malawi (Prof A Malata PhD); London

School of Hygiene & Tropical Medicine, London, UK

(T Marchant PhD); National Department of Health of the

Republic of South Africa, Pretoria, South Africa

(M P Matsoso LLM);

Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA (Prof J G Meara MD); Duke University Sanford School of

Public Policy, Durham, NC, USA (M Mohanan PhD); Ministry of

Health and Social Action of the Republic of Senegal, Dakar, Senegal (Y Ndiaye MD);

Department of Global Public

Health and Primary Care, University of Bergen, Bergen, Norway (Prof O F Norheim MD);

Public Health Foundation of

India, New Delhi, India (K S Reddy MD); Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, US Centers for Disease

Control and Prevention, Atlanta, GA, USA

(A K Rowe MD); Stanford Medical School, Stanford, CA, USA (Prof J A Salomon PhD);

Legislature Parliament of

Nepal, Kathmandu, Nepal (G Thapa MA); MAZA, Accra, Ghana (N A Y Twum-Danso MD);

and Big Win Philanthropy, London, UK (M Pate MD)

Correspondence to:

Dr Margaret E Kruk, Harvard T H

Chan School of Public Health, Department of Global Health and

Population, Boston, MA 02115, USA mkruk@hsph.harvard.edu deaths from cardio vascular disease, 1 million newborn deaths, 900 000 deaths from tubercu losis, and half of all maternal deaths each year. Quality of care will become an even larger driver of population health as utilisation of health systems increases and as the burden of disease shifts to more complex conditions. The high mortality rates in LMICs for treatable causes, such as injuries and surgical con ditions, maternal and newborn compli-cations, cardio vascular disease, and vaccine preventable diseases, illustrate the breadth and depth of the health-care quality challenge. Poor-quality care can lead to other adverse outcomes, including un necessary health-related suffering, persistent symptoms, loss of function, and a lack of trust and confidence in health systems. Waste of resources and catastrophic expenditures are economic side effects of poor-quality health systems. As a result of this, only one-quarter of people in LMICs believe that their health systems work well.

Health systems should measure and report what matters most to people, such as competent care, user experience, health outcomes, and confidence in the system Measurement is key to accountability and improve-ment, but available measures do not capture many of the processes and outcomes that matter most to people.

At the same time, data systems generate many metrics that produce inadequate insight at a substantial cost in funds and health workers’ time. For example, although inputs such as medicines and equipment are commonly counted in surveys, these are weakly related to the quality of care that people receive. Indicators such as proportion of births with skilled attendants do not reflect quality of childbirth care and might lead to false complacency about progress in maternal and newborn health.

This Commission calls for fewer, but better, measures of health system quality to be generated and used at national and subnational levels. Countries should report health system performance to the public annually by use of a dashboard of key metrics (eg, health outcomes, people’s confidence in the system, system competence, and user experience) along with measures of financial protection and equity.

Robust vital registries and trust worthy routine health information systems are prerequi sites for good performance assessment. Countries need agile new surveys and real-time measures of health facilities and populations that reflect the health systems of today and not those of the past. To generate and interpret data, countries need to invest in national institutions and professionals with strong quantitative and analytical skills. Global develop ment partners can support the generation and testing of public goods for health system measurement (civil and vital registries, routine data systems, and routine health system surveys) and promote national and regional institutions and the training and mentoring of scientists.

New research is crucial for the transformation of low-quality health systems to high-quality ones Data on care quality in LMICs do not reflect the current disease burden. In many of these countries, we know little about quality of care for respiratory diseases, cancer, mental health, injuries, and surgery, as well as the care of adolescents and elderly people. There are vast blind spots in areas such as user experience, system competence, confidence in the system, and the wellbeing of people, including patient-reported outcomes. Measuring the quality of the health system as a whole and across the care continuum is essential, but not done. Filling in these gaps will require not only better routine health information systems for monitoring, but also new research, as proposed in the research agenda of this Commission. For example, research will be needed to rigorously evaluate the effects and costs of recommended improvement approaches on health, patient experience, and financial protection. Implementation science studies can help discern the contextual factors that promote or hinder reform. New data collection and research should be explicitly designed to build national and regional research capacity.

Improving quality of care will require system-wide action To address the scale and range of quality deficits we documented in this Commission, reforming the foun-dations of the health system is required. Because health systems are complex adaptive systems that function at multiple interconnected levels, fixes at the micro-level (ie, health-care provider or clinic) alone are unlikely to alter the underlying performance of the whole system. However, we found that interventions aimed at changing provider behaviour dominate the improvement field, even though many of these interventions have a modest effect on provider performance and are difficult to scale and sustain over time. Achieving high-quality health systems requires expanding the space for improvement to structural reforms that act on the foundations of the system.

This Commission endorses four universal actions to raise quality across the health system. First, health system leaders need to govern for quality by adopting a shared vision of quality care, a clear quality strategy, strong regulation, and continuous learning. Ministries of health cannot accomplish this alone and need to partner with the private sector, civil society, and sectors outside of health care, such as education, infrastructure, communication, and transport. Second, countries should redesign service delivery to maximise health outcomes rather than geographical access to services alone. Primary care could tackle a greater range of low-acuity conditions, whereas hospitals or specialised health centres should provide care for conditions, such as births, that need advanced clinical expertise or have the risk of unexpected complications.

Third, countries should transform the health workforce by adopting competency-based clinical education, introducing training in ethics and respectful care, and better supporting www.thelancet.com/lancetgh Vol 6 November 2018 e1198 and respecting all workers to deliver the best care possible.

Fourth, governments and civil society should ignite demand for quality in the population to empower people to hold systems accountable and actively seek high-quality care. Additional targeted actions in areas such as health financing, management, district-level learning, and others can complement these efforts. What works in one setting might not work elsewhere, and improvement efforts should be adapted for local context and monitored.

Funders should align their support with system-wide strategies rather than contribute to the proliferation of micro-level efforts.

In this Commission, we assert that providing health services without guaranteeing a minimum level of quality is ineffective, wasteful, and unethical. Moving to a high-quality health system—one that improves health and generates confidence and economic benefits—is primarily a political, not technical, decision. National governments need to invest in high-quality health systems for their own people and make such systems accountable to people through legislation, education about rights, regulation, transparency, and greater public participation. Countries will know that they are on the way towards a high-quality, accountable health system when health workers and policymakers choose to receive health care in their own public institutions.

Introduction 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.

e1199 www.thelancet.com/lancetgh Vol 6 November 2018

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’être 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.

Section 1: Redefining high-quality health systems The systematic examination of health-care quality began with the work of Avedis Donabedian, whose 1966 article22 proposed a framework for quality of care assessment that described quality along the dimensions of structure, process, and outcomes of care. At the turn of the 21st century, the Committee on Quality of Health Care in America of the Institute of Medicine (IOM) produced two influential quality reports23,24 that galvanised the examination of quality in the US health system and prompted similar investigations in other industrialised countries. The IOM Committee defined quality of care as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge”.23 The committee noted that 21st century health systems should seek to improve performance on six dimensions of quality of care: safety, effectiveness, patient-centredness, timeliness, efficiency, and equity.

The committee also observed that “the current care www.thelancet.com/lancetgh Vol 6 November 2018 e1200 systems cannot do the job. Trying harder will not work.

Changing systems of care will.”23 In 2010, Michael Porter proposed25 that health systems be fundamentally account-able for producing value, which should be defined around the user. International organisations, such as WHO, and many low-income and high-income countries have relied on the IOM definition of quality and its core dimensions. WHO has also separately defined integrated people-centred health systems as systems where “all people have equal access to quality health services that are coproduced in a way that meets their life course needs”.26

Building on this and other work, this section sets out our rationale for an updated definition of high-quality health systems and a conceptual framework ready for the health challenges, patient expectations, and rising ambitions of today.27,28

The improvement of health outcomes is the sine qua non of health systems; these outcomes include longer lives, better quality of life, and improved capacity to function. In addition to better health, people derive security and confidence from having a trusted source of care when illness renders them most vulnerable. In this way, health systems also function as key social institutions, both deriving from and shaping social norms and able to promote or corrode public trust.29,30 Finally, health systems cannot be static and must adapt to changing societal needs. This Commission defines a high-quality health system as the following:

A high-quality health system is one that optimises health care in a given context by consistently delivering care that improves or maintains health outcomes, by being valued and trusted by all people, and by responding to changing population needs.

Context is paramount in this definition; health systems have been shaped by different histories and, as a result, function differently across LMICs.

High-quality health systems are underpinned by four values: high-quality health systems are for people and are equitable, resilient, and efficient. A focus on people begins with the self-evident observation that health systems must reach people—access is a prerequisite for benefiting from health care. However, this focus also signifies that people are not just beneficiaries of health services, but have a right to health care and have agency over their health and health-care decisions. Therefore, people become accountability agents, able to hold health system actors to account. The emphasis on people-centredness is especially crucial in health care because of the asymmetry of power and information between provider and patient. The focus on people works not only as a moral imperative to protect against the adverse effects of this power imbalance, but also as a corrective action that reduces the imbalance through patient empowerment and better accountability. Health systems must also treat well the people that work within them, who deserve a supportive work environment (safe working conditions, efficient and supportive manage-ment, and appropriate role assignment) and are them-selves health-care users. Demotivated providers cannot contribute to a high-quality health system.

A focus on equity means that high-quality health care needs to be available and affordable for all people, regardless of underlying social disadvantages. Measures of quality need to be disaggregated by stratifiers of social power—such as wealth, gender, or ethnicity—and quality improvements should explicitly include poor and vulnerable people to redress existing inequities.

Health systems in LMICs have been slow to change from their legacy functions focused on infectious diseases and maternal and child health, but health needs and expectations are shifting, sometimes quickly. Health crises, such as the Ebola epidemic, acutely illustrate the need for resilient systems, defined as systems that can prepare for and effectively respond to crises while maintaining core functions and reorganising if needed.31 High-quality health systems also need everyday resilience to respond to routine challenges, and this requires accountable leaders who respect and motivate their front-line staff.32

Lastly, health systems must be efficient: although spending on health systems is tightly associated with income and therefore varies greatly across LMICs, all health systems should aim to avoid waste and achieve the maximum possible improvement in health outcomes with the investment received.

We propose a new conceptual framework for high-quality health systems with three key domains: found-ations, processes of care, and quality impacts (figure 1).

This framework stems from our definition of high-quality health systems and is informed by past frameworks in the fields of health systems and quality improvement, including Donabedian’s framework,22 WHO’s building blocks16 and maternal quality of care27 frameworks, Judith Bruce’s family planning quality framework,28 Getting Health Reform Right,33 the Juran trilogy, and the Deming quality cycle.34

Figure 1: High-quality health system framework

For people

Equitable Resilient Efficient

Processes of care

Population health needs and expectations

Governance policy, insurance, and non-health sectors

Platforms accessibility and organisation of care

Workforce numbers, skill, and support

Tools equipment, medicines, and data

Competent care and systems

Quality impacts Better health

Confidence in system

Economic benefitPositive user experience

Learning and improvement

Foundations e1201 www.thelancet.com/lancetgh Vol 6 November 2018

Our high-quality health system framework focuses on health system function, user experience, and how people benefit from health care. This Commission believes that the quality of health systems should be primarily measured by these processes and impacts rather than by inputs. Facilities staffed by health workers and equipped with running water, electricity, and medicines are essential for good quality care, but the presence of these inputs is not itself a measure of high-quality care.

Empirical work shows that the quantity of such inputs does not predict the care that people receive and whether their health will improve—poor care often happens in the presence of adequate tools.35

Table 1 summarises the components of the three framework domains (quality impacts, processes of care, and foundations). The quality impacts begin with better health, including reduced mortality and morbidity, and positive health markers such as quality of life, function and well being, and absence of serious health-related suffering.36 These health outcomes should also encompass patient-reported measures. Another impact of high-quality health systems is confidence in the system, including trust in health workers and appropriate care uptake. Confidence goes beyond the more traditional measure of satisfaction with care; it is the extent to which people trust and are willing to use health care. Trust is essential for maximising outcomes because it can motivate active participation in care—ie, adherence to recommendations and uptake of services, including in emergencies.37 Trust is also essential for the success of UHC, because financing for UHC will be primarily domestic and people are unlikely to agree to contribute taxes or pay premiums for health services that they do not value. Finally, although good quality of care might require additional investment in many health systems of LMICs, high-quality health systems have the potential to generate economic benefits. First, by reducing premature mortality and improving people’s health, ability to work, and ability to attend school, high-quality health systems can foster economic productivity. Second, high-quality health systems can reduce waste from unnecessary, ineffective, and harmful care and prevent inappropriate hospital admissions and the bypassing of cost-effective options, such as primary care. Additionally, high-quality health systems with appropriate financing mechanisms, particularly manda tory insurance, can reduce the incidence of catastrophic or impoverishing health expenditures.

Therefore, financing that provides people with financial protection and promotes high-quality, efficient care is an integral foundation of a high-quality health system.

The processes of care include competent care and user experience, which we consider to be complementary elements of quality. These elements must be present in both the health system as a whole and in individual care visits. Competent systems provide people and communities with health promotion and prevention when healthy and effective and timely care when sick. People should be able to count on their conditions being detected and managed in an integrated manner. Systems should also be user-focused: easy to navigate, with short wait times and attention to people’s values and preferences—this is the definition of people-centredness. When people visit providers, they should expect to receive evidence-based care, including careful assessment, correct diagnosis, and appropriate treatment and counselling. And providers

Components

Quality impacts

Better health Level and distribution of patient-reported outcomes: function, symptoms, pain, wellbeing, quality of life, and avoiding serious health-related suffering

Confidence in system Satisfaction, recommendation, trust, and care uptake and retention

Economic benefit Ability to work or attend school, economic growth, reduction in health system waste, and financial risk protection

Processes of care

Competent care and systems

Evidence-based, effective care: systematic assessment, correct diagnosis, appropriate treatment, counselling, and referral; capable systems: safety, prevention and detection, continuity and integration, timely action, and population health management

Positive user experience Respect: dignity, privacy, non-discrimination, autonomy, confidentiality, and clear communication; user focus: choice of provider, short wait times, patient voice and values, affordability, and ease of use

Foundations

Population Individuals, families, and communities as citizens, producers of better health outcomes, and system users: health needs, knowledge, health literacy, preferences, and cultural norms

Governance Leadership: political commitment, change management; policies: regulations, standards, norms, and policies for the public and private sector, institutions for accountability, supportive behavioural architecture, and public health functions; financing: funding, fund pooling, insurance and purchasing, provider contracting and payment; learning and improvement: institutions for evaluation, measurement, and improvement, learning communities, and trustworthy data; intersectoral:

roads, transport, water and sanitation, electric grid, and higher education

Platforms Assets: number and distribution of facilities, public and private mix, service mix, and geographic access to facilities; care organisation: roles and organisation of community care, primary care, secondary and tertiary care, and engagement of private providers; connective systems: emergency medical services, referral systems, and facility community outreach

Workforce Health workers, laboratory workers, planners, managers: number and distribution, skills and skill mix, training in ethics and people-centred care, supportive environment, education, team work, and retention

Tools Hardware: equipment, supplies, medicines, and information systems; software: culture of quality, use of data, supervision, and feedback

Table 1: High-quality health system framework components www.thelancet.com/lancetgh Vol 6 November 2018 e1202 should treat all people with dignity, communicate clearly, and provide autonomy and confidentiality. Disrespectful and discriminatory behaviours are crucial quality failures, as are work environments that demean or disempower providers.

The foundations of high-quality health systems begin with the populations that they serve: individuals, families, and communities. People are necessary partners in providing health care and improving health outcomes;

they are not only the core beneficiaries of the health system, but also the agents who can hold these systems to account. The health needs, knowledge, and preferences of people should shape the health system response. High-quality health systems require strong governance, and financing, to promote the desired outcomes and policies to regulate providers, organise care, and instit ution alise accountability to citizens. However, regulation will not be enough; health system leaders will need to inspire and sustain the values of professionalism and excellence that underpin high-quality health care. In most countries, health care is provided by three platforms: community health, primary care, and hospital care. An appropriate facility and provider mix, quality-centred service delivery models, and functioning connect ions between levels of care (eg, referral, prehospital transport) will be required to ensure that the whole system maximises outcomes and the efficient use of resources. Providers, from health workers to managers, are fundamental for health systems, and require adequate numbers, preparation, profession-alism, and motivation. Providers need high-quality, competency-focused clinical education, with training in ethics, and a supportive environment for achieving the desired performance. Finally, health systems require not only physical tools, such as equipment, medicines, and supplies, but also new attitudes, skills, and behaviours, including quality mindsets, supervision and feedback, and the ability and willingness to learn from data. The foundations alone will not create good care, and the system will not be able to adapt to new challenges without built-in mechanisms for learning and improve ment, including having timely information on performance, assessment of new ideas, and the means to retire ineffective approaches.

This framework can be used to measure health systems over time on elements that matter to people (through processes and impacts) and to guide opportunities for improvement (through shoring up or rethinking foundations).

Section 2: What quality of care are people receiving in LMICs today?

In this section, we describe the current state of health-care quality in LMICs. We compiled data from multiple sources to present the most comprehensive and detailed picture of health system quality. We analysed data from health facility, household, telephone, and internet surveys collected in the past 10 years, and summarised findings from global estimates, systematic reviews, and individual studies (data sources are listed in appendix 1 and a comparison of methods used to collect the data can be found in appendix 2). Within the constraints of the available data, we describe quality across all health conditions addressed by the SDGs (list of conditions in appendix 1) and across health system platforms (community outreach, primary and hospital care, and the linkages between them: referral systems and emergency medical services).

Following the Commission’s framework, we describe the current situation with regard to provision of evidence-based care, competent health systems, and user experience and we present available evidence on the links between quality and health, confidence, and economic benefits.

Our focus is on describing the processes of care and their impacts. Foundations—the facilities, people, and tools

See Online for appendix 1

See Online for appendix 2

Panel 1: Section 2 key findings

1 Poor-quality health systems result in more than 8 million deaths per year in LMICs, leading to economic welfare losses of $6 trillion.

2 Health providers in low-income and middle-income countries (LMICs) often do less than half of recommended evidence-based care actions. For example, only two in five women who delivered in a facility were examined within 1 h after birth.

3 Approximately one third of patients experience disrespectful care, short consultations, poor communication, or long wait times.

4 Inadequate integration across platforms and weak referral systems undermine the ability of health systems to care for complex and emerging conditions.

5 Less than one quarter of people in LMICs believe that their health system works well, compared with half of people in high-income countries.

6 Clinics and providers with good performance can be found in every country and studying them can inform country-wide efforts for improvement.

7 High-quality health care is inequitably distributed in many countries, with poor and vulnerable groups having worse quality care—both in terms of competent care and user experience.

8 People can be especially vulnerable to poor-quality care on the basis of particular settings of care, health conditions, and demographic factors.

e1203 www.thelancet.com/lancetgh Vol 6 November 2018 required for care—are crucial to high-quality health systems, but their availability does not guarantee quality care. Lastly, we explore why some population groups are more vulnerable to poor-quality care. Where multicountry medians are presented throughout the section, country-specific data are included in appendix 2. Key findings are shown in panel 1.

Processes of care Evidence-based care Evidence-based care includes systematic patient assess-ments, accu rate diagnoses, provision of appropriate treatments, and proper patient counselling. In this section, we assess how these aspects are being followed, across selected SDG conditions.

Data from direct observations of clinical consultations allowed us to measure the quality of reproductive, maternal, and child health services. Using guidelines from WHO, we identified essential elements of reproductive, maternal, and child health care and built quality indices (appendix 1).

On the basis of these indices, data from observations of 81 856 consultations in 18 countries showed that adherence to evidence-based guidelines is low (figure 2A). On average, providers fulfilled only 47% of recommended care—with median performance ranging from 44% for family planning consultations to 64% for labour and delivery care (appendix 2). However, median figures can mask important variations within countries (appendix 2). These large variations in performance across providers suggest that better quality of care is possible in these countries.

Identifying and replicating local best practices might be valuable to inform improvement strategies.38

Other studies have also shown that providers often fail to adhere to clinical guidelines. In Uttar Pradesh, India, facility-based birth attendants did only 40% of items on the WHO safe childbirth checklist in a typical birth.39 Across 12 countries, only 50% of diarrhoea cases were correctly managed in health-care facilities according to WHO and UNICEF recommendations.40 In standardised patient studies in China41 and Kenya,42 only 13–45% of suspected tuberculosis cases were correctly managed by primary care providers according to the International Standards for Tuberculosis Care guidelines.

A systematic patient assessment involves gathering clinically relevant information by asking appropriate medical history questions and doing recommended examinations and tests. Data from LMICs showed that systematic patient assessments are not always done. For example, after giving birth, women should be assessed for abnormal bleeding, perineal tears, signs of infections, and high blood pressure.43 However, in many countries, few women reported receiving any postpartum check-up after giving birth in a health-care facility, including only 27% of women in Swaziland and 44% in Ethiopia, Burundi, and Rwanda (appendix 2). Similarly, during antenatal care, monitoring of blood pressure and urine and blood sample analyses are crucial to detect pre-eclampsia, nutritional deficiencies, infections, and other pregnancy risks.44 Across 91 countries, only 73% of women attending antenatal care with a skilled provider reported receiving these elements of care—ranging from an average of 54% in 30 low-income countries to 94% in 27 upper-middle-income countries (appendix 2).45 Poor availability of laboratory facilities and diagnostic equipment are also barriers to patient assessment and diagnosis, even when providers are aware of the necessary tests. For example, pathology service coverage in sub-Saharan Africa is approximately one-tenth of that in high-income countries.46 Even simple tests are often unavailable: studies showed that blood glucose meters and urine strips were available in only 18–61% of facilities across Mali, Mozambique, and Zambia.47 A study of ten countries found that only 2% of health-care facilities had the eight diagnostic tests defined as essential for basic service readiness by WHO.48

Incorrect diagnoses have deleterious consequences on health and contribute to treatment delays and anti-microbial resistance. For example, diagnostic uncertainty

Figure 2: Adherence to evidence-based guidelines and diagnostic accuracy Dots represent country-specific means, vertical bars indicate median performance across countries, and boxes delineate the IQR. Indicator definitions are shown in appendix 1, and country specific means are shown in appendix 2.

(A) Data are from Service Provision Assessment (SPA) surveys done in ten countries (Ethiopia 2014, Haiti 2013, Kenya 2010, Malawi 2013, Namibia 2009, Nepal 2015, Rwanda 2007, Senegal 2015–16, Tanzania 2015, and Uganda 2007) and baseline facility surveys of Results-based Financing impact evaluations (RBF) in eight countries (Burkina Faso 2013, Central African Republic 2012, Cameroon 2011, Republic of the Congo 2014, Democratic Republic of the Congo 2015, Kyrgyzstan 2012–13, Nigeria 2013, and Tajikistan 2014–15). (B) Data are from clinical vignettes from the Service Delivery Indicators surveys done by the World Bank, in cooperation with the African Economic Research Consortium and the African Development Bank in Kenya (2012), Nigeria (2013), Tanzania (2014), Togo (2013), and Uganda (2013) and from the Service Provision Assessment survey in Ethiopia (2014).

0 20 40 60 80 100 Proportion of items fulfilled (%)

Sick child care

Family planning

Delivery care

Antenatal care

Country income level Low income Lower-middle income Upper-middle income

0 20 40 60 80 100 Providers diagnosing correctly (%)

Diarrhoea

Malaria and anaemia

Pneumonia

Neonatal asphyxia

Diabetes

Tuberculosis

Postpartum haemorrhage

A

B

For the SPA surveys see https://dhsprogram.com/What-

We-Do/Survey-Types/SPA.cfm

For the RBF surveys see http://microdata.worldbank.org/

For the Service Delivery Indicators see https://data.

worldbank.org/data-catalog/ service-delivery-indicators https://dhsprogram.com/What-We-Do/Survey-Types/SPA.cfm http://microdata.worldbank.org/ https://data.worldbank.org/data-catalog/service-delivery-indicators https://dhsprogram.com/What-We-Do/Survey-Types/SPA.cfm https://dhsprogram.com/What-We-Do/Survey-Types/SPA.cfm http://microdata.worldbank.org/ https://data.worldbank.org/data-catalog/service-delivery-indicators https://data.worldbank.org/data-catalog/service-delivery-indicators https://data.worldbank.org/data-catalog/service-delivery-indicators www.thelancet.com/lancetgh Vol 6 November 2018 e1204 about undifferentiated fever often leads to over prescription of antimicrobial therapy.49 Our analyses of data from clinical vignettes done in LMICs revealed wide variations in diagnostic accuracy.