Where is quality in health systems policy? An analysis of global policy documents
Authors: Keely Jordan, Robert Marten, Oye Gureje, Bernadette Daelmans, Margaret E Kruk
Journal: The Lancet Global Health (2018)

Addressing the quality of care provided by health systems is necessary if countries hope to improve health outcomes following the adoption of universal health coverage (UHC) as a global priority.1WHOTracking universal health coverage: first global monitoring report. World Health Organization, Geneva2015Google Scholar The Millennium Development Goals (MDGs) spurred expansion of funding for health and an increase in coverage of services.2Kruk ME Larson E Twum-Danso NA Time for a quality revolution in global health.Lancet Glob Health. 2016; 4: e594-e596Summary Full Text Full Text PDF PubMed Scopus (70) Google Scholar However, the breadth of global health ambition within the Sustainable Development Goals (SDG) demands that policymakers move beyond coverage to understand what happens once people reach a health facility or come into contact with health services.3Leslie HH Malata A Ndiaye Y Kruk ME Effective coverage of primary care services in eight high-mortality countries.BMJ Glob Health. 2017; 2: e000424Crossref PubMed Scopus (47) Google Scholar The Lancet Global Health Commission on High Quality Health Systems in the SDG Era4Kruk M Gage A Arsenault C et al.High-quality health systems in the Sustainable Development Goals era—time for a revolution.Lancet Glob Health. 2018; 6: e1197-e1252Summary Full Text Full Text PDF Scopus (1007) Google Scholar defines high-quality health systems as those that "optimise health in a given context by consistently delivering care that improves or maintains health, being valued and trusted by all people, and responding to changing population needs". The Commission also proposes new ways to define, measure, and improve the performance of health systems. It states that the quality of health systems should be primarily measured in terms of the processes of care and health impacts rather than inputs such as staff and equipment. We aimed to explore how the concept of health system quality has been considered in key health systems frameworks and policies since 2000. We searched the WHO website for World Health Reports, frameworks, and reports that included "health system" in the title or had a key aim mentioning health systems. We restricted our focus to WHO as it is the UN's leading technical agency for health, it is focused on health systems, and it has a powerful role in shaping the normative paradigms in the health systems discourse. We also included documents from the Alliance for Health Policy and Systems Research—an international partnership hosted by WHO that promotes the use of health policy and systems research to strengthen health systems in low-income and middle-income countries (LMICs). For Alliance reports, we included the flagship reports, which according to their mission are aimed at "stimulating thinking and debate on emerging gaps and challenges in strengthening health systems". Given the close link between UHC and health-system quality, we also included the 2015 and 2017 UHC monitoring reports. We did not include condition-specific documents. We manually searched each document for its use and discussion of "quality". Where quality was not explicitly mentioned, we searched for other health system concepts, such as "service access" and "coverage". The content was then summarised and analysed for common themes. We also compared the content to the Commission's definition and framework. We retrieved 20 documents: 13 from WHO and seven from the Alliance (table). Five documents did not explicitly discuss quality as defined by the Commission (2006 World Health Report, 2007 Sound Choices Enhancing capacity for evidence-informed health policy, 2012 WHO Strategy on research for health, 2012 Changing mindsets WHO strategy on health policy and systems research, and the 2016 Open mindsets participatory leadership for health). Among those that did mention quality, three themes emerged. The first was that documents overall emphasised access to health services; more recent ones included the equity of access. The World Health Report 20005WHOWorld health report 2000. Health systems: improving performance. World Health Organization, Geneva2000Google Scholar presented a framework for understanding health systems and clearly placed LMIC health system performance on the political and research agendas. The report briefly discussed quality care for the vulnerable, who receive the "worst levels of responsiveness—they are treated with less respect for their dignity, given less choice of service providers and offered lower-quality amenities". Shortly thereafter, the Alliance biennial report Strengthening health systems: the role and promise of health policy and systems research (2004) highlighted inequalities in access to care.6Alliance for Health Policy and Systems Research; Global Forum for Health ResearchStrengthening health systems: the role and promise of policy and systems research. Alliance for Health Policy and Systems Research, Geneva2014Google Scholar In 2008 The World Health Report addressed the role that primary health care could play in getting health development "back on track".7WHOWorld health report 2008. Primary health care: now more than ever. World Health Organization, Geneva2008Google Scholar The report found a wide-range of inequities in health outcomes, access to care, and payment for services and warned that "left to their own devices, health systems do not move towards greater equity."TableHealth system policy documents retrieved and analysedSourceTitleSignificance2000WHOWorld Health Report 2000—Health systems: improving performanceOne of the first conceptual frameworks for health systems2004AllianceStrengthening health systems: the role and promise of health policy and systems researchFirst of a series of Alliance biennial reports2005WHOWorld Health Report 2005—Make every mother and child countAddresses the need to provide families universal access to a continuum of care2006WHOWorld Health Report 2006—Working together for healthAssessment of workforce crisis in global health2007WHOStrengthening health systems to improve health outcomesDiscussion of building blocks that make up health systems and how to strengthen them2007AllianceSound choices: enhancing capacity for evidence-informed health policyLooks at the capacity to generate and apply research evidence2008WHOWorld Health Report 2008—Primary health care: now more than everThe role of primary health care in health systems responding to changing challenges2008WHOScaling up research and learning for health systemsWHO High-level Consultation and Task Force Report on acceleration of the development of research tools and common frameworks for health systems strengthening2009AllianceSystems thinking for health systems strengtheningConnected HPSR to complex adaptive systems2010WHOWorld Health Report 2010—Health Systems Financing: The path to universal coverageThe role of universal health coverage in addressing current health challenges2012WHOWHO Strategy on Research for HealthPrioritised research that met health needs and underscored investments in capacity development and knowledge translation2012AllianceChanging mindsets: WHO strategy on health policy and systems researchFirst WHO Strategy focused on HPSR2013WHOWorld Health Report 2013—Research for universal health coverageCalls for greater investment in HPSR in LMICs2014AllianceMedicines in health systems: advancing access, affordability and appropriate useAddresses the challenges to achieve equitable access to essential medicines2015WHOTracking universal health coverage: first global monitoring reportWHO and World Bank joint monitoring report on global assessment of the current state of universal health coverage2016WHOWHO framework on integrated, people-centred health servicesConsiders patient rights across all levels of the health system2016AllianceOpen mindsets: participatory leadership for healthAssesses the different aspects of leadership within the health system2016WHOGlobal strategy on human resources for health: workforce 2030Examines the role of health workers within health system strengthening on the path to universal health coverage2017AllianceWorld report on health policy and systems researchFirst world report aimed at monitoring and measuring developments in HPSR2017WHOTracking universal health coverage: 2017 global monitoring reportWHO and World Bank follow-up monitoring report on goals and aims of universal health coverageHPSR=health policy and systems research. LMIC=low-income and middle-income country. Open table in a new tab HPSR=health policy and systems research. LMIC=low-income and middle-income country. The World Health Report 2013: research for universal health coverage8WHOWorld health report 2013. Research for universal health coverage. World Health Organization, Geneva2013Google Scholar expanded the definition of equity and noted that achieving universal health coverage means "reaching remote and conflict-affected populations where the challenges of dilapidated infrastructure and the shortage of qualified, skilled human resources are enormous". Even though the report recognised that it is not just the quantity of services that is important but also their quality, the majority of quality improvement suggestions it proposed focused on system inputs rather than process of care or health impacts. The 2015 and 2017 Tracking universal health coverage reports1WHOTracking universal health coverage: first global monitoring report. World Health Organization, Geneva2015Google Scholar, 9WHOTracking universal health coverage. World Health Organization, Geneva2017Google Scholar recognised that "ensuring access to quality health services is a central tenet of UHC". Both reports highlighted the role that quality plays in effective coverage (health services obtained in a timely manner and at a level of quality necessary to obtain the desired effect and potential health gains) but noted the challenge in coming to an agreed definition of quality and in monitoring it effectively. The second theme to emerge was that what the Commission calls "foundations" (particularly workforce and tools) have been the focus of discussions on quality in the reviewed documents. This dimension of care includes the factors affecting the context in which care is delivered. It does not, however, address the process or impacts of care. Prior to 2007, the reports reviewed mentioned quality improvement with regard to better infrastructure and a prepared workforce.5WHOWorld health report 2000. Health systems: improving performance. World Health Organization, Geneva2000Google Scholar, 10WHOWorld health report 2006. Working together for health. World Health Organization, Geneva2006Google Scholar In 2007, WHO published Framework for action: strengthening health systems to improve health outcomes,11WHOStrengthening health systems to improve health outcomes: WHO's framework for action. World Health Organization, Geneva2007Google Scholar which elaborated the building blocks of a well functioning health system and which became the basis of measuring health system performance. The building blocks are: health services; health workforce; health information; medical products, vaccines, and technologies; health financing; and leadership and governance.23 Quality and access were featured as the outputs of such a system. The report suggested that the building blocks should be used to monitor trends in health systems and performance. It does not specify, however, how the building blocks could come together to produce quality and eventually better health, with the assumption being that good service quality flows naturally from having the building blocks in place. Other health documents applied the building blocks for understanding and analysing health systems. For example, the Alliance report Sound choices: enhancing capacity for evidence-informed health policy,12Green A Bennett S Alliance for Health Policy and Systems ResearchWorld Health OrganizationSound choices: enhancing capacity for evidence-informed health policy. World Health Organization, Geneva2007Google Scholar the WHO High-level Consultation and Task Force Report Scaling up research and learning for health systems,13WHOScaling up research and learning for health systems: now is the time: report of a high level task force. World Health Organization, Geneva2009Google Scholar and the 2009 Alliance report Systems thinking for health systems strengthening14De Savigny D Adam T Alliance for Health Policy and Systems ResearchSystems thinking for health systems strengthening. World Health Organization, Geneva2009Google Scholar focused their quality measures on the building blocks. Sound choices12Green A Bennett S Alliance for Health Policy and Systems ResearchWorld Health OrganizationSound choices: enhancing capacity for evidence-informed health policy. World Health Organization, Geneva2007Google Scholar noted that health policy and systems research should aim to produce "reliable and rigorous evidence" on any or all of the six building blocks. The World Health Report 201015WHOWorld health report 2010. Health systems financing: the path to universal coverage. World Health Organization, Geneva2010Google Scholar emphasised the need to analyse one of the building blocks—financing mechanisms—to "enhance the quality and quantity of service delivery, and ensure appropriate medicines and technologies are available". The third theme was the people-centred care is emerging as a focus. The World Health Report 20005WHOWorld health report 2000. Health systems: improving performance. World Health Organization, Geneva2000Google Scholar included responsiveness—and, within that, respect for persons—as a key component of health system performance, and the World Health Report 20087WHOWorld health report 2008. Primary health care: now more than ever. World Health Organization, Geneva2008Google Scholar noted that "people-centredness" becomes the "clinical method of participatory democracy", measurably improving the quality of care, the success of treatment, and the quality of life of those benefiting from such care". The World Health Report 20138WHOWorld health report 2013. Research for universal health coverage. World Health Organization, Geneva2013Google Scholar echoed this call for "integrated, high-quality, patient-centred services at all levels of primary to tertiary care". The inclusion of patient-centred services in these reports helped solidify patient-centred care in the quality discussion. In 2016, the WHO Framework on integrated, people-centred health services16WHOWHO global strategy on people-centred and integrated health services: interim report. World Health Organization, Geneva2015Google Scholar addressed people's needs and preferences across all levels of the health system. The report points out that "where it is accessible, care is too often fragmented or of poor quality, and consequently the responsiveness of the health system and satisfaction with health services remain low in many countries". The report marks a progression in global health policy from the vertical to the horizontal and from the technocratic to the user-focused, noting that "hospital-based, disease-based and self-contained 'silo' curative care models further undermine the ability of health systems to provide universal, equitable, high-quality and financially sustainable care". On the path to UHC, the framework suggests a health system in which "all people have equal access to quality health services that are co-produced in a way that meets their life course needs, are coordinated across the continuum of care, and are comprehensive, safe, effective, timely, efficient and acceptable; and all careers are motivated, skilled and operate in a supportive environment". Empowering and engaging users and providers are core values of the framework and the WHO calls for their implementation to be country-led, equity-focused, participatory, systems strengthening, evidence based, results-oriented, ethics-based, and sustainable. The Alliance report Open mindsets: participatory leadership for health also recognised the importance of quality leadership to "raise the performance of the health system high above the welter of complexity".17WHOOpen mindsets: participatory leadership for health. World Health Organization, Geneva2016Google Scholar The same year, the WHO Global strategy on human resources for health: workforce 203018WHOGlobal strategy on human resources for health: workforce 2030. World Health Organization, Geneva2016Google Scholar recognised that it is not just the availability of health workers that is needed but a workforce that is "motivated to deliver quality care and build a positive relationship with the patients". These values were again seen in the 2017 World report on health policy and systems research19WHOWorld report on health policy and systems research. World Health Organization, Geneva2017Google Scholar and the Alliance's call for an interdisciplinary approach to improving user quality with a focus on user experience. The 2017 Tracking universal health coverage report9WHOTracking universal health coverage. World Health Organization, Geneva2017Google Scholar included responsiveness or people-centredness within its dimensions of quality and noted the importance but also difficulty in properly measuring these elements of quality. This Comment presents an overview of the role that quality has played in health system policy as elaborated by the WHO and the Alliance for Health Policy and Systems Research since 2000. Our findings pertain to this set of reports. We did not review the many disease-specific and other more narrowly focused documents that address quality of care—eg, tuberculosis, HIV, and maternal health reports or policies on patient safety or antimicrobial resistance. There are also many documents written by agencies other than WHO, such as the World Bank, UNICEF, and UNFPA. This would be an area of future inquiry for health system scholars. As countries continue to move towards UHC and implement the broader SDG3 agenda, WHO and other global actors will need to raise the profile of health system quality in their support to countries and in normative guidance. This will require reorienting health systems as primarily accountable to people, raising our expectation of what quality of services health systems provide to people, and focusing health systems measurement on processes and outcomes of care that are most valued by people. It will also require compiling an evidence base of what works to improve health system quality at scale to meet the increasingly complex and pressing needs of populations in LMICs. The authors alone are responsible for the views expressed in this article and they do not necessarily represent the views, decisions, or policies of the institutions with which they are affiliated. We declare no competing interests. High-quality health systems in the Sustainable Development Goals era: time for a revolutionAlthough 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. Full-Text PDF Open AccessAdding quality to primary careThere is a word missing from the 1978 Declaration of Alma Ata: a close examination reveals that "quality", the adjective, does not appear in it. True, the stated definition of primary health care includes the notions of practicality, scientific soundness, and social acceptability, all elements of quality when referring to the provision of health care. But the omission of the actual term could almost be taken as a foretelling sign of what happened in the four decades following the Alma Ata conference—the attainment of Health for All through community-led and participative primary health care did not come as a natural evolution for most health systems, and most importantly, health-care delivery suffered from such deficiencies that poor-quality care ultimately became a more formidable obstacle to reducing mortality in low-income and middle-income countries than insufficient access to care. Full-Text PDF Open Access