Introduction to The Lancet Global Health's Series on the People's Voice Survey on Health System Performance
Authors: Margaret E Kruk, Todd P Lewis
Journal: The Lancet Global Health (2023)

The Lancet Global Health Commission on high quality health systems in the SDG era defined a high-quality health system as being fundamentally for people, adding to the growing international calls for putting people at the centre of health systems.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 (1362) Google Scholar The Commission found that many systems in low-income and middle-income countries underperform in terms of health outcomes, provider and system competence, and user experience. As a result, approximately 5 million people die each year from treatable conditions, despite seeking health care.2Kruk ME Gage AD Joseph NT Danaei G García-Saisó S Salomon JA Mortality due to low-quality health systems in the universal health coverage era: a systematic analysis of amenable deaths in 137 countries.Lancet. 2018; 392: 2203-2212Summary Full Text Full Text PDF PubMed Scopus (417) Google Scholar Understanding how health systems perform is key to improving health service delivery and health outcomes. Like any other service sector, health systems need to learn from the populations who use and fund them. Currently, there are few rapid and comparable approaches that incorporate population views when tracking health system performance. For example, in low-income and middle-income countries, many existing performance measures focus on the administrative aspects of the health system (eg, provider numbers and availability of drugs and other supplies), which are necessary but not sufficient for good care.3Leslie HH Sun Z Kruk ME Association between infrastructure and observed quality of care in 4 healthcare services: a cross-sectional study of 4,300 facilities in 8 countries.PLoS Med. 2017; 14e1002464Crossref PubMed Scopus (101) Google Scholar In high-income countries, the focus has been on health outcomes (eg, the Organization for Economic Cooperation and Development Health Statistics). Although these aspects are crucial, what is missing in both settings is information on how health systems work for people on the ground. Measures reflecting how the health system functions, such as patterns of use, reasons for non-use, respectful care, customer service, and trust in the health system, are important to people and can provide valuable insights to policy makers. However, these data are not regularly collected. The People's Voice Survey was designed to address these gaps. The People's Voice Survey is a new survey designed by the Quality Evidence for Health System Transformation (QuEST) Network—an initiative focused on the measurement and improvement of health system quality through a multicountry research consortium. The People's Voice Survey is a rapid, low-cost, population-representative telephone survey. With proper adaptation, it is applicable to any country, regardless of national income, health expenditure, or health system structure. The People's Voice Survey aims to promote health system accountability to the population, track the impact of reforms and policies over time, promote benchmarking across countries and subnational regions, and inform action towards more effective and person-centred health systems. The instrument was developed with a large global group of collaborators in 18 countries and in consultation with policy makers and regional stakeholders.4Lewis TP Kapoor NR Aryal A et al.Measuring people's views on health system performance: design and development of the People's Voice Survey.PLoS Med. 2023; 20e1004294Crossref Scopus (0) Google Scholar As the world begins to recover from the turmoil of the COVID-19 pandemic, the time is opportune to gauge how populations regard their health systems. This assessment could form a basis for evaluation and course corrections. This Series aims to examine quality and confidence in health systems as well as people's experience with several prominent health system initiatives, such as universal health coverage, primary care, and vaccination drives. Given the manifest inequities in health quality and effective coverage, apparent long before COVID-19, we sought to examine wealth, location, and gender equity in key aspects of health system performance. The six papers in the Series highlight the innovative measures featured in the People's Voice Survey, including confidence in public primary care, system competence in preventive care, and user activation. The papers compare various aspects of health system performance globally, both within regions (eg, equity of care in Latin America) and across regions (eg, experience of universal health coverage in south Asia and sub-Saharan Africa). They tackle several key themes in health system performance assessment. The first paper in this Series addresses population confidence in the health system, which is critical for the appropriate use of services and the public's commitment to fund systems. We update the definition of population confidence and provide data on its two key components—health security and health system endorsement—across 15 low-income, middle-income, and high-income countries. The paper explores sociodemographic differences in confidence and potential drivers of confidence. The second paper addresses user-reported quality of health care. Data on user quality are typically collected on exit and are subject to courtesy bias. This comparative analysis investigates people's ratings of provider and system competence and user experience during their last care visit in the past 12 months, including important measures of medical mistakes and discrimination. We explore the relative contribution of multiple aspects of quality in user ratings of care. The third paper concerns universal health coverage in Africa and Asia. Africa and Asia are pursuing expanded insurance coverage for their populations with the goal of achieving universal health coverage. Using data from Ethiopia, Kenya, South Africa, India, and Laos, we analyse whether and to what degree public and private insurance are associated with health-care use, unmet need for care, and uptake of preventive services. The fourth paper is on primary care performance across low-income and high-income countries. Primary care continues to be a focus area for WHO and many individual countries, but the reality of primary care on the ground often departs from ambitious policy documents. This paper explores the prevalence of having a usual source of care and examines where in the health system that care is sought, including the type (public or private) and level (primary or secondary). It measures how having a usual provider correlates with quality ratings and health system confidence. The fifth paper is about inequities in health system coverage and quality in Latin America. Despite a proclaimed right to health and affiliation to a health system, significant barriers to health service quality exist in many Latin American countries. This paper examines inequities in coverage, user experience, system competence, and confidence among users and non-users of health care in Colombia, Peru, Uruguay, and Mexico. We assess the contribution of public, private, and social security sectors to identified inequities. The sixth and final paper in the Series addresses health system quality and COVID-19 vaccination. Although much has been written about the personal, social, and political reasons for vaccine uptake, less is known about how vaccinated people use and rate their health systems. This paper assesses links between the uptake of COVID-19 vaccines and measures of health-care use and health system quality in 14 countries. Although these analyses shed light on several questions about health system performance, they pose even more. The People's Voice Survey should be a starting point and platform for further academic inquiry into performance assessment, including examining undermeasured areas of the health system (eg, mental health) and priority topics (eg, care for non-communicable diseases). Moreover, it could enable important comparative work at regional or national levels that would not be possible with ad hoc national or subnational surveys. As a global good, People's Voice Survey data will be publicly available for further use by multilateral organisations, governments, researchers, and students. The People's Voice Survey was designed to be used in tandem with other health system performance data (eg, health system amenable health outcomes, cost and efficiency data, and human resources) to inform health system improvement. The People's Voice Survey could help governments to implement and monitor health system changes, such as large-scale reform of service delivery platforms or initiatives targeted to priority areas (eg, integration of telehealth) or populations (eg, care for older adults). The People's Voice Survey will be of the most use for health system review if repeated over time to track changes and provide feedback for regular health system reviews. At its core, the People's Voice Survey aims to bring a social voice to health system measurement. As such, these data should be shared with the population. To this end, the QuEST Network will be publishing country-specific findings as well as research papers. This data sharing could help to engage communities as active participants in health system planning and enable governments and service providers to be more effectively held to account. Funders had no role in study design and conduct or writing of the report. We declare no competing interests. Population confidence in the health system in 15 countries: results from the first round of the People's Voice SurveyPopulation confidence is essential to a well functioning health system. Using data from the People's Voice Survey—a novel population survey conducted in 15 low-income, middle-income, and high-income countries—we report health system confidence among the general population and analyse its associated factors. Across the 15 countries, fewer than half of respondents were health secure and reported being somewhat or very confident that they could get and afford good-quality care if very sick. Only a quarter of respondents endorsed their current health system, deeming it to work well with no need for major reform. Full-Text PDF Open AccessUser-reported quality of care: findings from the first round of the People's Voice Survey in 14 countriesHigh-quality care is essential for improving health outcomes, although many health systems struggle to maintain good quality. We use data from the People's Voice Survey—a nationally representative survey conducted in 14 high-income, middle-income, and low-income countries—to describe user-reported quality of most recent health care in the past 12 months. We described ratings for 14 measures of care competence, system competence, and user experience and assessed the relationship between visit quality factors and user recommendation of the facility. Full-Text PDF Open AccessThe path to universal health coverage in five African and Asian countries: examining the association between insurance status and health-care useDespite major efforts to achieve universal health coverage (UHC), progress has lagged in many African and Asian countries. A key strategy pursued by many countries is the use of health insurance to increase access and affordability. However, evidence on insurance coverage and on the association between insurance and UHC is mixed. We analysed nationally representative cross-sectional data collected between 2022 and 2023 in Ethiopia, Kenya, South Africa, India, and Laos. We described public and private insurance coverage by sociodemographic factors and used logistic regression to examine the associations between insurance status and seven health-care use outcomes. Full-Text PDF Open AccessPrimary health care in practice: usual source of care and health system performance across 14 countriesPrimary health care (PHC) is central to attainment of the Sustainable Development Goals, yet comparable cross-country data on key aspects of primary care have not been widely available. This study analysed data from the People's Voice Survey, which was conducted in 2022 and 2023 in 14 countries. We documented usual source of care across countries and examined associations of usual source of care with core PHC services, quality ratings, and health system confidence. We found that 75% of respondents had a usual source of care, and that 40% of respondents accessed usual care in the public sector at primary level. Full-Text PDF Open AccessInequalities in health system coverage and quality: a cross-sectional survey of four Latin American countriesThe premise of health as a human right in Latin America has been challenged by health system fragmentation, quality gaps, a growing burden of chronic disease, sociopolitical upheaval, and the COVID-19 pandemic. We characterised inequities in health system quality in Colombia, Mexico, Peru, and Uruguay. We did a cross-sectional telephone survey with up to 1250 adults in each country. We created binary outcomes in coverage, user experience, system competence, and confidence in the system and calculated the slope index of inequality by income and education. Full-Text PDF Open AccessHealth system quality and COVID-19 vaccination: a cross-sectional analysis in 14 countriesThe social and behavioural determinants of COVID-19 vaccination have been described previously. However, little is known about how vaccinated people use and rate their health system. We used surveys conducted in 14 countries to study the health system correlates of COVID-19 vaccination. Country-specific logistic regression models were adjusted for respondent age, education, income, chronic illness, history of COVID-19, urban residence, and minority ethnic, racial, or linguistic group. Estimates were summarised across countries using random effects meta-analysis. Full-Text PDF Open Access