The Lancet Global Health Commission on High Quality Health Systems 1 year on: progress on a global imperative
Authors: Margaret E Kruk, Muhammad Pate
Journal: The Lancet Global Health (2019)

In September, 2018, The Lancet Global Health Commission on High Quality Health Systems (HQSS Commission) detailed the state of health system quality in low-income and middle-income countries.1Kruk ME Gage AD Arsenault C et al.High quality health systems—time for a revolution.Lancet Glob Health. 2018; 6: e1196-e1252Google Scholar The Commission found that nearly 9 million lives are lost each year from treatable conditions for lack of good quality care and that a startling 60% of the deaths were among people who actually obtained access to care. This “access” outcome has thus far topped every government's health agenda and the global community's efforts, as demonstrated by the sheer number of coverage indicators in the Millennium Development Goals and now Sustainable Development Goals. But for these people—for the baby born in a clinic who became infected with streptococcus before discharge, for the woman with myocardial infarction misdiagnosed with heartburn, and for the grandfather told that his glucose is high but who is then promptly forgotten by the health system—having access to health care is plainly not enough. Unsurprisingly, we found that Julian Tudor Hart's law of inverse care was alive and well: good quality care was most available to the rich.2Hart JT The inverse care law.Lancet. 1971; 1: 405-412Google Scholar The Commission argued that the sheer breadth of quality deficits means that incremental solutions will be insufficient and that what is needed is a reboot of health systems. We proposed a definition of high quality health systems that places people at the centre of its work and as its locus of accountability. With the user in mind, the Commission's core metrics of health system performance are competent and respectful care, better health, and health system trust. All other health system functions, be it financing, organisation, supply chain, or management, are at the service of high quality, equitable, efficient care for people. So where is the world a year later? We reflected on our experience as Commission co-chairs and conducted an informal poll of Commissioners and our Secretariat. Here are a few takeaways from an eventful year. Perhaps most significantly, the Commission's report prompted high-level discussions in a number of countries. The governments of Ethiopia, India, Kenya, Nepal, South Africa, and Argentina hosted national consultations on high quality health systems. National findings on quality were discussed by leaders from health ministries and regions, with participation from development partners and civil society. Quality of care is a sensitive subject, but despite sharing often dismaying data on the quality of the country's health system in these public fora, we were never asked to water down the Commission's findings. Researchers and policymakers from many countries actively participated in the work of the Commission and recognised that quality problems were a shared challenge. In the national consultations, we heard that many and overlapping quality improvement activities were being implemented but that these were difficult to manage, evaluate, and impossible to scale. We learned that most Ministries of Health had established quality units but that these were often tasked with hospital audit or accreditation, which may assist in establishing the minimum standards for care but cannot generate the leap to high quality care. Meanwhile disease-specific units made consequential decisions about resource allocation, service delivery models, and accountability mechanisms with major implications for quality but were uncoordinated and resulted in a jumble of regulations and interventions. Policymakers agreed that it was time to look beyond marginal improvements or system tweaks and consider major reforms.3Thapa G Jhalani M García-Saisó S Malata A Roder-DeWan S Leslie HH High quality health systems in the SDG era: country-specific priorities for improving quality of care.PLoS Med. 2019; 16e1002946Google Scholar They saw universal health coverage (UHC) as an opportunity. While the UHC discussion to date has been primarily about financing, UHC can serve as an entry point to reimagine health systems that are fit for a new millennium. After all, efficient financing of poor quality care is no one's vision of success. High quality health systems require strong financing but also new models of governance, provider training, service delivery, and community involvement. We heard that health ministries, particularly in countries with decentralised systems, felt mounting pressure from citizens to provide better care. “People won't tolerate even one maternal death in my county” said one senior health manager, “these days they are WhatsApping me any complaints straight from the clinic.” They noted that it was difficult to distinguish these complaints from overall sentiments—to know where people actually stood on health systems. Means to measure people's assessment of the health system were missing. Several of the Commission's “universal actions”—structural changes for large-scale health system improvement—resonated with national stakeholders. Kenya's Ministry of Health and the Council of Governors wanted to explore feasibility of service delivery redesign—a shift of all delivery and newborn care to advanced facilities (typically hospitals) that can respond immediately to emergencies, while moving care for chronic but lower-acuity conditions such as hypertension or uncomplicated diabetes to primary care. Redesign models would be developed with communities and include improvements in facilities, staffing, roads, and communication. We saw clearly that political commitment is a prerequisite for bold action: the First Lady of Kenya and HQSS Commissioner, Margaret Kenyatta, is champion of care excellence for mothers and children. Nepal's Ministry of Health and parliament under the leadership of former Minister of Health and Commissioner Gagan Thapa launched the Social Movement for Quality Health to ignite public demand for quality as a means to improve the system and increase accountability. Ethiopia's Ministry of Health declared that it was ready to move beyond coverage and facility “readiness” in tracking health system performance in its next health sector strategy, instead deciding to emphasise health outcomes, competence, and user experience and confidence. And South Africa's president announced that quality would be at the core of the country's universal health coverage reforms. Globally, there is a shortage of public goods to support countries like Kenya, Nepal, and Ethiopia in transforming their health systems. Evidence is needed on redesign models, strategies to modernise clinical education, and accountability mechanisms that work in similar contexts. Globally comparable but locally validated metrics that capture critical dimensions of quality are also in short supply. It has been encouraging to see serious discussions of health system quality, including ambitious health system reforms, taking place among development partners, including bilateral organisations, foundations, the World Bank, WHO, and the Interamerican Development Bank. One Commissioner noted that the report “has influenced a mind-shift among governments and partners, including WHO, towards prioritising quality of care as a major health system function that requires development and investment”. For example, the World Bank's large portfolio of health investments in the poorest countries is increasingly focused on quality of care metrics for rewarding performance of health facilities and providers. The Global Financing Facility (GFF) is refining its approach for measuring results by increasing focus on the quality of care provided in health systems. For example, health facilities in the Democratic Republic of Congo that receive performance-based payments through a programme jointly funded by the International Development Association and GFF have been assessed on process and outcome measures of quality. However, the measurement of user experience and confidence is still lagging. Preparations are well underway at the World Bank, in collaboration with the Bill & Melinda Gates Foundation, for a programme to reimagine primary health care, which would include systems redesign for improving quality in health systems. The Commissioners have reported that concepts proposed in the Commission have influenced research, policy, and practice. For example, the use of “mortality amenable to high quality care” as a health system measure has prompted new research at the Organisation for Economic Co-operation and Development; the broader concept of health system endorsement and user experience has led to a revision in health surveys in Mexico; and a new research collaborative has been formed to explore a health-systems-based approach to improving quality of surgery and anaesthesia. The Commission has raised more questions than it could answer with existing data. Some of the most pressing are how to comparably measure patient experience and outcomes across primary and secondary care platforms and over time, how to govern and manage systems that prize and reward excellence, and what it will cost to improve and sustain a high quality health system. Many of the questions will require a new wave of research and development. We look forward to the next chapter of the high quality health systems story—one that will be led by ambitious countries and hopefully supported by a like-minded global community. We declare no competing interests.