High-quality health systems: time for a revolution in research and research funding
Authors: David Beran, François Chappuis, Albertino Damasceno, Nilambar Jha, Maria Amalia Pesantes, Suman Bahadur Singh, Claire Somerville, L Suzanne Suggs, J Jaime Miranda
Journal: The Lancet Global Health (2019)

The launch of two landmark publications1Kruk ME Gage AD Arsenault C et al.High-quality health systems in the Sustainable Development Goals era: time for a revolution.Lancet Glob Health. 2018; 6: e1196-e1252Summary Full Text Full Text PDF PubMed Scopus (1007) Google Scholar, 2National Academies of Sciences, Engineering, and MedicineCrossing the global quality chasm: improving health care worldwide. The National Academies Press, Washington, DC2018Google Scholar on the quality of care in the world's poorest populations, including The Lancet Global Health Commission on high-quality health systems in the Sustainable Development Goals era (September, 2018),1Kruk ME Gage AD Arsenault C et al.High-quality health systems in the Sustainable Development Goals era: time for a revolution.Lancet Glob Health. 2018; 6: e1196-e1252Summary Full Text Full Text PDF PubMed Scopus (1007) Google Scholar is a welcome addition to the ongoing discourse on improving the quality of care that these populations receive. The authors of these reports rightly highlight that the push for universal health coverage in low-income and middle-income countries, as well as the setting of disease-specific targets, will not achieve their desired impact on health outcomes without a focus on improving quality. As such, improving quality of care is essential to meet the health-related targets of the Sustainable Development Goals.1Kruk ME Gage AD Arsenault C et al.High-quality health systems in the Sustainable Development Goals era: time for a revolution.Lancet Glob Health. 2018; 6: e1196-e1252Summary Full Text Full Text PDF PubMed Scopus (1007) Google Scholar With a focus on populational needs, Margaret Kruk and colleagues1Kruk ME Gage AD Arsenault C et al.High-quality health systems in the Sustainable Development Goals era: time for a revolution.Lancet Glob Health. 2018; 6: e1196-e1252Summary Full Text Full Text PDF PubMed Scopus (1007) Google Scholar align themselves with WHO's responsiveness framework, which includes aspects such as dignity, autonomy, confidentiality, clear communication, prompt attention, and quality of amenities.3de Silva A A framework for measuring responsiveness.https://www.who.int/responsiveness/papers/paper32.pdfDate accessed: October 5, 2018Google Scholar These factors are intimately linked to quality and trust, go beyond the immediate health-care needs people might have (eg, medicines and access to diagnostics), and focus on underlying issues related to provision of a high-quality service. This refocusing is in line with the view of strengthening instead of merely supporting the development of health systems in low-income and middle-income countries.4Chee G Pielemeier N Lion A Connor C Why differentiating between health system support and health system strengthening is needed.Int J Health Plann Manage. 2013; 28: 85-94Crossref PubMed Scopus (76) Google Scholar Although the authors of the Commission1Kruk ME Gage AD Arsenault C et al.High-quality health systems in the Sustainable Development Goals era: time for a revolution.Lancet Glob Health. 2018; 6: e1196-e1252Summary Full Text Full Text PDF PubMed Scopus (1007) Google Scholar do mention the roles of funders and researchers in creating a high-quality health system, we believe that this discussion should go further because a “revolution” in approaches, methods, and funding is needed. To improve the quality of health systems, it is necessary to thoroughly understand the needs of the community, as well as the existing conditions in which care is delivered and received. Accomplishing this task will require formative research with financial support from funders. As stated in the Crossing the global quality chasm report,2National Academies of Sciences, Engineering, and MedicineCrossing the global quality chasm: improving health care worldwide. The National Academies Press, Washington, DC2018Google Scholar “co-design” by communities and providers is needed for the responses from these formative studies to be adapted locally. Researchers will therefore have to work with communities through participatory processes to develop appropriate responses and interventions tailored to the communities' actual needs.5Beran D Lazo-Porras M Cardenas MK et al.Moving from formative research to co-creation of interventions: insights from a community health system project in Mozambique, Nepal, and Peru.BMJ Global Health. 2018; 3: e001183Crossref PubMed Scopus (24) Google Scholar They will need skills in communication and engagement to carry out this work successfully, as well as being able to deal with the uncertainty of not knowing what interventions they will implement in particular settings at the start of a grant or research project because the most appropriate interventions will only become apparent at the end of the formative research stage. Researchers and the academic establishment will have to adapt because not all studies will be randomised trials and the usual academic reward—publications in high-profile journals—will not necessarily be the currency of these research endeavours. Importantly, researchers will be challenged on their established approaches and ideas if they truly want to engage meaningfully in the co-creation of health systems. Similarly, funders also need to deal with these uncertainties by allowing room for innovation and development of interventions grounded in the needs of the communities they wish to impact. The complexity of research will need to be managed by both researchers and funders, and multicomponent rather than one-off interventions will be required to this end. Such interventions will add to the challenge of evaluating current health systems by necessitating the implementation of process evaluations, in conjunction with the measurement of traditional outcomes. The Crossing the global quality chasm report2National Academies of Sciences, Engineering, and MedicineCrossing the global quality chasm: improving health care worldwide. The National Academies Press, Washington, DC2018Google Scholar states that to improve quality of health care “this shift will require new skills, attitudes, and culture among health-care providers and new, more active roles for patients and families in shaping, evaluating, and delivering the care they need”. Given the chronicity of current challenges in health care, these factors should align with the principle of “careful and kind care”,6Montori V. Why we revolt: a patient revolution for careful and kind care. Rochester, MN: Patient Revolution, 2017.Google Scholar which aims to minimise the potential negative impacts of treatment on the individual, while ensuring high quality of care. We fully back such supportive care from the perspectives of health-care providers and the community but also believe that researchers will need new skills and attitudes and that a change in the culture of funding is essential. These changes require both researchers and their funders to take a more active role in focusing on the actual needs of populations. Moreover, researchers need to be given the space and time necessary to create the needed interventions and evaluate them appropriately. This shift in thinking, funding, and support for research should result in programmes and interventions that have a true impact on the quality of care provided to the world's poorest populations. The COHESION (COmmunity HEalth System InnovatiON) Project is funded by the Swiss National Science Foundation and the Swiss Development Cooperation under the Swiss Program for Research on Global Issues for Development. 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 Access