Introducing The Lancet Global Health Commission on High-Quality Health Systems in the SDG Era
Authors: Margaret E Kruk, Muhammad Pate, Zoë Mullan
Journal: The Lancet Global Health (2017)

The 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.1Kruk 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, 2Das J Hammer J Leonard K. The quality of medical advice in low-income countries.J Econ Perspect. 2008; 22: 93-114Crossref PubMed Scopus (205) Google Scholar Yet change is possible. Primary health-care facilities, which tend to reach the poorest segment of populations, are an important plank in the drive towards achieving the SDGs. In Nigeria, supporting primary health-care centres in rural areas with quality assessment, an action plan, and technical assistance in management resulted in significant improvements in adoption of quality practices.3World BankEvidence and prospects for a healthy Nigeria: lessons from five impact evaluations in health. World Bank, Washington, DC2016Google Scholar Health system quality in lower-income countries has been under-defined and under-researched. There is no agreed upon single definition of a high-quality health system or its aims and there is no consensus on metrics. Instead, many countries face a proliferation of definitions and measures across disease areas. The emphasis in quality measurement has been on inputs: equipment, medicines, staff. Yet, this does not paint the full picture of quality—a well-equipped facility may still provide poor care. And patients' experience of care and patient-reported outcomes, which influence people's decisions to use or avoid services and provide valuable insights on performance, are rarely measured. There is little information on national and regional levels of quality and its distribution, weak evidence on the factors that drive quality variations, and low effectiveness of current quality improvement approaches. Finally, there is an urgent need to expand the solution space for quality improvement: to move beyond in-service training and other clinic-focused approaches to consider structural solutions, such as service regionalisation, updating medical and nursing education, technological innovation, and strengthening professional and community oversight of care. To galvanise research and action on quality of care in LMIC health systems, The Lancet Global Health has commissioned a major report: The Lancet Global Health Commission on High-Quality Health Systems in the SDG Era (HQSS Commission). This will be a piece of science-led, multidisciplinary, actionable work with wide-reaching goals and measurable indicators, and will embody the journal's commitment to "the best science for better lives". The HQSS Commission will be chaired by Margaret Kruk and Muhammad Pate and brings together 30 academics, policymakers, and health system experts from 18 countries. Guided by the values of originality, rigour, relevance, and respect for local context and actors, the Commission will review current knowledge, undertake new empirical work, and propose policy recommendations for measuring and improving quality in pursuit of the SDGs. It will produce a single conceptual framework of high-quality health systems to increase the salience of the concept to policymakers, providers, and people. It will build on and inform the work of other ongoing efforts including Countdown to 2030; the Health Data Collaborative; the Quality, Equity, and Dignity Network; and the Primary Health Care Performance Initiative. The Commission's specific aims are to (1) define health system quality, (2) describe quality of care and its distribution across tracer SDG conditions, (3) propose practical measures of quality, and (4) identify structural approaches to improve quality. The work will be underpinned by an exploration of the ethical dimensions of quality, including the right to quality health-care and equity. The analysis will be done by four Commission working groups, shown in the panel. The HQSS Commission will hold its first meeting on March 13–15, 2017, in Boston, USA, convening the commissioners and an Advisory Council of experts and global partners.PanelHQSS Commission working group tasksDefinition and description working group•Propose a definition and conceptual framework of health system quality•Describe current quality of care for sentinel SDG conditions across countries•Analyse drivers of variation in quality•Estimate the global burden of low quality on health, financial protection, utilisation, and other outcomesMeasurement working group•Assess utility of current quality measures•Propose new measures for undermeasured constructs—eg, technical quality, patient experience, and patient-reported outcomes•Explore innovative and efficient tools for measuring health system quality•Identify quality measurement research agendaImprovement working group•Review evidence and evidence gaps for current quality improvement approaches•Identify structural (macro-level) approaches for improving quality•Identify typology of local contexts for improvement approaches•Model scenarios for quality improvement and their impact on health, utilisation, and equityEthics and equity working group•Explore the ethics of the right to quality health care in the context of limited resources•Review minimum standards for quality of care in countries•Measure the equity distribution of high-quality and low-quality care Definition and description working group •Propose a definition and conceptual framework of health system quality•Describe current quality of care for sentinel SDG conditions across countries•Analyse drivers of variation in quality•Estimate the global burden of low quality on health, financial protection, utilisation, and other outcomes Measurement working group •Assess utility of current quality measures•Propose new measures for undermeasured constructs—eg, technical quality, patient experience, and patient-reported outcomes•Explore innovative and efficient tools for measuring health system quality•Identify quality measurement research agenda Improvement working group •Review evidence and evidence gaps for current quality improvement approaches•Identify structural (macro-level) approaches for improving quality•Identify typology of local contexts for improvement approaches•Model scenarios for quality improvement and their impact on health, utilisation, and equity Ethics and equity working group •Explore the ethics of the right to quality health care in the context of limited resources•Review minimum standards for quality of care in countries•Measure the equity distribution of high-quality and low-quality care To extend and enrich the work of the Commission and to reality test Commission innovations, National Commissions will be formed in several countries. National Commissions will clarify definition and measurement of quality for the local context and assess opportunities for broad health-system quality improvement. National Commissions will be led by Ministries of Health and will bring together policymakers with development partners, academia, patient advocates, and other stakeholders. They will buttress analytical capacity for quality measurement and analysis within countries. The HQSS Commission will publish its report in The Lancet Global Health in late 2018. The report will be complemented by related papers in leading global health journals. The public can engage with the work of the Commission by visiting its website, which will feature summaries of meetings, progress updates, and research highlights, and by following the Commission on Twitter (@HQSSCommission). As countries embark on achieving diverse and ambitious health goals, it is time to think anew about the means at our disposal to improve people's health. High-quality health systems are indispensable to this agenda. We thank the Bill and Melinda Gates Foundation for providing funding for the HQSS Commission. The content is the sole responsibility of the authors and does not represent the official views of the Foundation. We declare no competing interests. Unreliable estimation of prevalence of fetal alcohol syndromeSvetlana Popova and colleagues (March, 2017)1 sought to estimate the global, regional, and national prevalence of alcohol use during pregnancy and fetal alcohol syndrome (FAS). The authors reviewed international literature from 1984 for country-specific quantitative studies and for countries with one or no studies they predicted gestational alcohol use prevalence by fractional response regression modelling and prevalence of FAS by an estimated quotient for the average number of women consuming alcohol during pregnancy per one case of FAS. Full-Text PDF Open AccessUnreliable estimation of prevalence of fetal alcohol syndrome – Authors' replyWe thank Katrine Strandberg-Larsen and colleagues from Denmark and Simona Pichini and colleagues from Italy for their comments on our paper.1 Both comments underline the immense interest in the related public health problems of alcohol use during pregnancy and fetal alcohol syndrome (FAS). 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 AccessThe Lancet Global Health Commission on High Quality Health Systems—where's the complexity? – Authors' replyStephanie Topp points to the limitations of quality measurement in The Lancet Global Health Commission on High Quality Health Systems (HQSS Commission; May, 2017)1 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. Full-Text PDF Open AccessUnreliable estimation of prevalence of fetal alcohol syndromeSvetlana Popova and colleagues (March, 2017)1 estimated that about one quarter of pregnant women in Europe drink alcohol. The authors state that this estimate is 2·6 times higher than the global prevalence and estimate that Europe has the world's highest fetal alcohol syndrome (FAS) prevalence of 37·4 per 10 000 people. If true, these numbers are alarming and require urgent action; however, we are not convinced that they are valid for contemporary Europe. Full-Text PDF Open Access