The Lancet Global Health Commission on High Quality Health Systems—where's the complexity? – Authors' reply
Authors: Margaret E Kruk, Tanya Marchant, Svetlana Doubova, Hannah H Leslie, Muhammad Pate
Journal: The Lancet Global Health (2017)

Stephanie Topp points to the limitations of quality measurement in The Lancet Global Health Commission on High Quality Health Systems (HQSS Commission; May, 2017)1Kruk ME Pate M Mullan Z Introducing The Lancet Global Health Commission in High-Quality Health Systems in the SDG Era.Lancet Glob Health. 2017; 5: e480-e481Summary Full Text Full Text PDF PubMed Scopus (74) Google Scholar that might not fit the real-world contexts of low-income and middle-income countries (LMICs). She also takes issue with a narrow set of generic indicators and targets for quality that might be meaningless or even provide "perverse incentives to game the system". We agree these are important concerns and aim to tackle them in the work of the Commission. The HQSS Commission's goal is to move quality from a specialised, niche enterprise to a core pursuit of health systems, hence the need for a single, shared definition among policymakers, users, and providers. Improvements to accountability of health systems to users requires robust and timely information about what is going right or wrong when people access care. This information is not systematically available in most LMICs today, nor is there agreement about which information is needed across health conditions and the different parts of a health system. But we agree that measurement can be onerous and indicators can be unconnected to meaningful outcomes. For example, we are finding that the hundreds of indicators of equipment and supplies routinely collected in facility surveys do not shed much light on the content of the care people receive—a much more important construct. We agree that all measures should have a clear purpose and audience. In its work on measurement, the Commission will emphasise the need for actionable measures at different levels that permit advocacy for high quality care, promote accountability of the health system, and guide quality improvement actions. We will place a premium on measuring what matters most to users and on summative measures that capture the functioning of the health system as a whole. We share Topp's skepticism of using simple targets in place of tackling root causes; indeed, we intend to focus on structural approaches to quality improvement, such as governance, management, care delivery models, professional education, and regulation, among others that have influence across the health-care delivery chain. These approaches will necessarily take different shape in different LMICs to respond to the diverse organisational structures and nature of quality challenges. To contextualise the Commission's work, several national Commissions, including in Ethiopia and South Africa, will test and refine the global guidance by application to their particular settings. Nearly half the Commissioners are policymakers, most of whom are from LMICs; they too will reality-test our recommendations as the work progresses. Ultimately, the Commission will endorse those measures that are useful in holding health systems to account for improving health and for providing value to their users. We declare no competing interests. Introducing The Lancet Global Health Commission on High-Quality Health Systems in the SDG EraThe Millennium Development Goals on health have expanded access to basic health interventions to millions of people in low-income and middle-income countries (LMICs). However, access alone will not be sufficient to meet the Sustainable Development Goals (SDGs) if health systems cannot provide high quality care—ie, care that improves health outcomes and provides value to people. Emerging data show that many LMIC health systems struggle to consistently provide good quality of care.1,2 Yet change is possible. Full-Text PDF Open AccessThe Lancet Global Health Commission on High Quality Health Systems—where's the complexity?The Lancet Global Health Commission on High Quality Health Systems in the Sustainable Development Goals (SDG) Era (HQSS Commission).1 The launch draws attention to the fact that high quality health care, rather than just access to health care, will be necessary to meet the health-related SDGs. The Commission aims to address the lack of an "agreed upon single definition" of high quality health systems and produce "science-led, multidisciplinary, actionable work with […] measurable indicators". But phrases like single definition and measurable indicators in the context of an exercise seeking to strengthen quality in highly variable health systems in low-income and middle-income countries (LMICs) should raise red flags. Full-Text PDF Open Access