The Lancet Global Health Commission and respecting all workers to deliver the best care possible. Fourth, governments and civil society should ignite demand for quality in the population to empower people to hold systems accountable and actively seek high-quality care. Additional targeted actions in areas such as health financing, management, district-level learning, and others can complement these efforts. What works in one setting might not work elsewhere, and improvement efforts should be adapted for local context and monitored. Funders should align their support with system-wide strategies rather than contribute to the proliferation of micro-level efforts. In this Commission, we assert that providing health services without guaranteeing a minimum level of quality is ineffective, wasteful, and unethical. Moving to a highquality health system-one that improves health and generates confidence and economic benefits-is primarily a political, not technical, decision. National governments need to invest in high-quality health systems for their own people and make such systems accountable to people through legislation, education about rights, regulation, transparency, and greater public participation. Countries will know that they are on the way towards a high-quality, accountable health system when health workers and policymakers choose to receive health care in their own public institutions. Components Quality impacts Better health Level and distribution of patient-reported outcomes: function, symptoms, pain, wellbeing, quality of life, and avoiding serious health-related suffering Confidence in system Satisfaction, recommendation, trust, and care uptake and retention Economic benefit Ability to work or attend school, economic growth, reduction in health system waste, and financial risk protection Processes of care Competent care and systems Evidence-based, effective care: systematic assessment, correct diagnosis, appropriate treatment, counselling, and referral; capable systems: safety, prevention and detection, continuity and integration, timely action, and population health management Positive user experience Respect: dignity, privacy, non-discrimination, autonomy, confidentiality, and clear communication; user focus: choice of provider, short wait times, patient voice and values, affordability, and ease of use Foundations Population Individuals, families, and communities as citizens, producers of better health outcomes, and system users: health needs, knowledge, health literacy, preferences, and cultural norms Governance Leadership: political commitment, change management; policies: regulations, standards, norms, and policies for the public and private sector, institutions for accountability, supportive behavioural architecture, and public health functions; financing: funding, fund pooling, insurance and purchasing, provider contracting and payment; learning and improvement: institutions for evaluation, measurement, and improvement, learning communities, and trustworthy data; intersectoral: roads, transport, wa...

SummaryBackgroundUniversal health coverage has been proposed as a strategy to improve health in low-income and middle-income countries (LMICs). However, this is contingent on the provision of good-quality health care. We estimate the excess mortality for conditions targeted in the Sustainable Development Goals (SDG) that are amenable to health care and the portion of this excess mortality due to poor-quality care in 137 LMICs, in which excess mortality refers to deaths that could have been averted in settings with strong health systems.MethodsUsing data from the 2016 Global Burden of Disease study, we calculated mortality amenable to personal health care for 61 SDG conditions by comparing case fatality between each LMIC with corresponding numbers from 23 high-income reference countries with strong health systems. We used data on health-care utilisation from population surveys to separately estimate the portion of amenable mortality attributable to non-utilisation of health care versus that attributable to receipt of poor-quality care.Findings15·6 million excess deaths from 61 conditions occurred in LMICs in 2016. After excluding deaths that could be prevented through public health measures, 8·6 million excess deaths were amenable to health care of which 5·0 million were estimated to be due to receipt of poor-quality care and 3·6 million were due to non-utilisation of health care. Poor quality of health care was a major driver of excess mortality across conditions, from cardiovascular disease and injuries to neonatal and communicable disorders.InterpretationUniversal health coverage for SDG conditions could avert 8·6 million deaths per year but only if expansion of service coverage is accompanied by investments into high-quality health systems.FundingBill & Melinda Gates Foundation.

Declines in health service use during the Coronavirus Disease 2019 (COVID-19) pandemic could have important effects on population health. In this study, we used an interrupted time series design to assess the immediate effect of the pandemic on 31 health services in two low-income (Ethiopia and Haiti), six middle-income (Ghana, Lao People’s Democratic Republic, Mexico, Nepal, South Africa and Thailand) and high-income (Chile and South Korea) countries. Despite efforts to maintain health services, disruptions of varying magnitude and duration were found in every country, with no clear patterns by country income group or pandemic intensity. Disruptions in health services often preceded COVID-19 waves. Cancer screenings, TB screening and detection and HIV testing were most affected (26–96% declines). Total outpatient visits declined by 9–40% at national levels and remained lower than predicted by the end of 2020. Maternal health services were disrupted in approximately half of the countries, with declines ranging from 5% to 33%. Child vaccinations were disrupted for shorter periods, but we estimate that catch-up campaigns might not have reached all children missed. By contrast, provision of antiretrovirals for HIV was not affected. By the end of 2020, substantial disruptions remained in half of the countries. Preliminary data for 2021 indicate that disruptions likely persisted. Although a portion of the declines observed might result from decreased needs during lockdowns (from fewer infectious illnesses or injuries), a larger share likely reflects a shortfall of health system resilience. Countries must plan to compensate for missed healthcare during the current pandemic and invest in strategies for better health system resilience for future emergencies.

In-service training courses and supportive supervision of health workers are among the most common interventions to improve the quality of health care in low- and middle-income countries. Despite extensive investment from donors, evaluations of the long-term effect of these two interventions are scarce. We used nationally representative surveys of health systems in seven countries in sub-Saharan Africa to examine the association of in-service training and supervision with provider quality in antenatal and sick child care. The results of our analysis showed that observed quality of care was poor, with fewer than half of evidence-based actions completed by health workers, on average. In-service training and supervision were associated with quality of sick child care; they were associated with quality of antenatal care only when provided jointly. All associations were modest-at most, improvements related to interventions were equivalent to 2 additional provider actions out of the 18-40 actions expected per visit. In-service training and supportive supervision as delivered were not sufficient to meaningfully improve the quality of care in these countries. Greater attention to the quality of health professional education and national health system performance will be required to provide the standard of health care that patients deserve.

ObjectiveTo develop a composite measure of primary care quality and apply it to Haiti’s primary care system.MethodsUsing the Primary Health Care Performance Initiative’s framework, we defined four domains of primary care service delivery: (i) accessible care; (ii) effective service delivery; (iii) management and organization; and (iv) primary care functions. We gave each primary care facility in Haiti a quality score for each domain and overall, with poor, fair and good quality indicated by scores of 0.00–0.49, 0.50–0.74 and 0.75–1.00, respectively. We quantified access and effective access to primary care as the proportions of the population within 5 km of any primary care facility and a good facility, respectively.FindingsOf the 786 primary care facilities in Haiti in 2013, only 332 (43%) facilities were classified as good for accessible care. Fewer facilities were classified as good in the domains of effective service delivery (30; 4%), management and organization (91; 12%) and primary care functions (43; 5%). Although about 91% of the population lived within 5 km of a primary care facility, only an estimated 23% of the entire population – including just 5% of the rural population – had access to primary care of good quality.ConclusionDespite an extensive network of health facilities, a minority of Haitians had access to a primary care facility of good quality. Such facilities were especially scarce in rural areas. Similar systematic analyses of the quality of primary care could inform national efforts to strengthen health systems.

SummaryBackgroundPrimary care has the potential to address a large proportion of people's health needs, promote equity, and contain costs, but only if it provides high-quality health services that people want to use. 40 years after the Declaration of Alma-Ata, little is known about the quality of primary care in low-income and middle-income countries. We assessed whether existing facility surveys capture relevant aspects of primary care performance and summarised the quality of primary care in ten low-income and middle-income countries.MethodsWe used Service Provision Assessment surveys, the most comprehensive nationally representative surveys of health systems, to select indicators corresponding to three of the process quality domains (competent systems, evidence-based care, and user experience) identified by the Lancet Global Health Commission on High Quality Health Systems in the Sustainable Development Goals Era. We calculated composite and domain quality scores for first-level primary care facilities across and within ten countries with available facility assessment data (Ethiopia, Haiti, Kenya, Malawi, Namibia, Nepal, Rwanda, Senegal, Tanzania, and Uganda).FindingsData were available for 7049 facilities and 63 869 care visits. There were gaps in measurement of important outcomes such as user experience, health outcomes, and confidence, and processes such as timely action, choice of provider, affordability, ease of use, dignity, privacy, non-discrimination, autonomy, and confidentiality. No information about care competence was available outside maternal and child health. Overall, scores for primary care quality were low (mean 0·41 on a scale of 0 to 1). At a domain level, scores were lowest for user experience, followed by evidence-based care, and then competent systems. At the subdomain level, scores for patient focus, prevention and detection, technical quality of sick-child care, and population-health management were lower than those for other subdomains.InterpretationFacility 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.FundingBill & Melinda Gates Foundation.

Background High satisfaction with healthcare is common in low- and middle-income countries (LMICs), despite widespread quality deficits. This may be due to low expectations because people lack knowledge about what constitutes good quality or are resigned about the quality of available services. Methods and findings We fielded an internet survey in Argentina, China, Ghana, India, Indonesia, Kenya, Lebanon, Mexico, Morocco, Nigeria, Senegal, and South Africa in 2017 ( N = 17,996). It included vignettes describing poor-quality services—inadequate technical or interpersonal care—for 2 conditions. After applying population weights, most of our respondents lived in urban areas (59%), had finished primary school (55%), and were under the age of 50 (75%). Just over half were men (51%), and the vast majority reported that they were in good health (73%). Over half (53%) of our study population rated the quality of vignettes describing poor-quality services as good or better. We used multilevel logistic regression and found that good ratings were associated with less education (no formal schooling versus university education; adjusted odds ratio [AOR] 2.22, 95% CI 1.90–2.59, P < 0.001), better self-reported health (excellent versus poor health; AOR 5.19, 95% CI 4.33–6.21, P < 0.001), history of discrimination in healthcare (AOR 1.47, 95% CI 1.36–1.57, P < 0.001), and male gender (AOR 1.32, 95% CI 1.23–1.41, P < 0.001). The survey did not reach nonusers of the internet thus only representing the internet-using population. Conclusions Majorities of the internet-using public in 12 LMICs have low expectations of healthcare quality as evidenced by high ratings given to poor-quality care. Low expectations of health services likely dampen demand for quality, reduce pressure on systems to deliver quality care, and inflate satisfaction ratings. Policies and interventions to raise people’s expectations of the quality of healthcare they receive should be considered in health system quality reforms.

BackgroundExpanding coverage of primary healthcare services such as antenatal care and vaccinations is a global health priority; however, many Haitians do not utilize these services. One reason may be that the population avoids low quality health facilities. We examined how facility infrastructure and the quality of primary health care service delivery were associated with community utilization of primary health care services in Haiti.MethodsWe constructed two composite measures of quality for all Haitian facilities using the 2013 Service Provision Assessment survey. We geographically linked population clusters from the Demographic and Health Surveys to nearby facilities offering primary health care services. We assessed the cross-sectional association between quality and utilization of four primary care services: antenatal care, postnatal care, vaccinations and sick child care, as well as one more complex service: facility delivery.ResultsFacilities performed poorly on both measures of quality, scoring 0.55 and 0.58 out of 1 on infrastructure and service delivery quality respectively. In rural areas, utilization of several primary cares services (antenatal care, postnatal care, and vaccination) was associated with both infrastructure and quality of service delivery, with stronger associations for service delivery. Facility delivery was associated with infrastructure quality, and there was no association for sick child care. In urban areas, care utilization was not associated with either quality measure.ConclusionsPoor quality of care may deter utilization of beneficial primary health care services in rural areas of Haiti. Improving health service quality may offer an opportunity not only to improve health outcomes for patients, but also to expand coverage of key primary health care services.Electronic supplementary materialThe online version of this article (10.1186/s12992-018-0379-0) contains supplementary material, which is available to authorized users.