Adding quality to primary care
Authors: None The Lancet Global Health
Journal: The Lancet Global Health (2018)

There 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. The world has changed drastically since 1978, and with it the health needs of the global population. Ambitious global health goals requiring quantitative leaps in access to health care have met their deadline with varying degrees of success. Powerful demographic processes such as urbanisation have transformed the way people access care. The health profiles of populations have shifted towards chronic conditions with longer-term health care needs. What has endured is the clearest legacy of Alma Ata—the necessity of strong, resilient primary care services. This legacy has become particularly crucial in the context of the current quest for universal health coverage. And attached to it almost systematically now, and even mentioned twice in the wording of Sustainable Development Goal 3.8, is the term “quality.” In this issue, Margaret Kruk and her colleagues of The Lancet Global Health Commission on High-Quality Health Systems in the SDG Era demonstrate that it is high time to let the word truly sink into the collective mind and the concept permeate the discourse around health systems. The Commission has a clear message: improving quality is imperative and it will require health system-wide interventions. The framework it puts forth links five foundational pillars of health systems (population, governance, platforms, workforce, and tools) to processes of care which, as they impact quality positively, feed back into the foundations in a virtuous cycle. Primary care is a fundamental service delivery platform in many health systems that is highly sensitive to quality. Poor-quality primary care leads to poor health outcomes because of inadequate diagnosis and treatment of health conditions. It derails the health system by introducing inefficiencies and encouraging waste of resources through underuse of effective care or overuse of unnecessary care. It discourages patients to seek care and increases inequalities. And yet, the truth is that not much is known about the quality of primary care outside of high income countries. Also in this issue, Erlyn Macarayan and colleagues use the Commission's framework to analyse the most comprehensive Service Provision Assessment surveys from ten low-income and middle-income countries, in an attempt to measure the quality of their primary care. What they show is a blatant lack of data on important aspects of primary care quality, such as user experience, health outcomes, or confidence, and low scores (an average of 0·41 out of 1 in overall quality of primary care in the ten countries considered) for those indicators with data. It is clear that improving the quality of primary care will require better indicators, rigorous measurements, and new research to illuminate the way forward. Encouragingly, the concept of quality is slowly taking hold in the global health sector and as it relates to primary care. As Keely Jordan shows in a Comment retracing the place given to quality in global policy documents over the last 20 years or so, while equity and access used to take precedence over quality, the need for people-centred care is slowly surfacing, a notion in line with patient empowerment, a requirement for quality of care identified by the Commission. And finally as Adolfo Rubinstein highlights in another Comment, the Commission's framework is the opportunity for countries, such as Argentina, that have been able to reach universal health coverage via a functioning primary care strategy, to work out how to elevate the model with quality as the goal. Ultimately, “quality” and “primary care” should be indissociable words. Together, they may even carry enough weight to start a revolution. This online publication has been corrected. The corrected version first appeared at thelancet.com/lancetgh on October 17, 2018 This online publication has been corrected. The corrected version first appeared at thelancet.com/lancetgh on October 17, 2018 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 AccessAssessment of quality of primary care with facility surveys: a descriptive analysis in ten low-income and middle-income countriesFacility surveys do not capture key elements of primary care quality. The available measures suggest major gaps in primary care quality. If not addressed, these gaps will limit the contribution of primary care to reaching the ambitious Sustainable Development Goals. Full-Text PDF Open AccessWhere is quality in health systems policy? An analysis of global policy documentsAddressing 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.1 The Millennium Development Goals (MDGs) spurred expansion of funding for health and an increase in coverage of services.2 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. Full-Text PDF Open AccessQuality first for effective universal health coverage in low-income and middle-income countriesThe UN has set universal health coverage (UHC) as a target for Sustainable Development Goal (SDG) 3.8, to be achieved by 2030.1 The dimensions of UHC run along three axes: the population that is covered by pooled funds, the proportion of direct health costs covered by pooled funds, and the health services included. However, as use of health services increases and, at the same time, the burden of disease in low-income and middle-income countries (LMICs) shifts greatly to more complex conditions such as non-communicable diseases (NCDs), quality of health services rather than access alone appears as a key determinant for improving population health and reducing disease burden. Full-Text PDF Open AccessCorrection to Lancet Glob Health 2018; 6: e1139The Lancet Global Health. Adding quality to primary care. Lancet Glob Health 2018; 6: e1139—In the third paragraph of this Editorial, the name Arlyn Macarayan should have been Erlyn Macarayan. This correction has been made as of Oct 17, 2018. Full-Text PDF Open Access