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...

This article reports on the quality of care delivered by private and public providers of primary health care services in rural and urban India. To measure quality, the study used standardized patients recruited from the local community and trained to present consistent cases of illness to providers. We found low overall levels of medical training among health care providers; in rural Madhya Pradesh, for example, 67 percent of health care providers who were sampled reported no medical qualifications at all. What’s more, we found only small differences between trained and untrained doctors in such areas as adherence to clinical checklists. Correct diagnoses were rare, incorrect treatments were widely prescribed, and adherence to clinical checklists was higher in private than in public clinics. Our results suggest an urgent need to measure the quality of health care services systematically and to improve the quality of medical education and continuing education programs, among other policy changes.

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IMPORTANCE In rural India, as in many developing countries, childhood mortality remains high and the quality of health care available is low. Improving care in such settings, where most health care practitioners do not have formal training, requires an assessment of the practitioners’ knowledge of appropriate care and the actual care delivered (the know-do gap). OBJECTIVE To assess the knowledge of local health care practitioners and the quality of care provided by them for childhood diarrhea and pneumonia in rural Bihar, India. DESIGN, SETTING, AND PARTICIPANTS We conducted an observational, cross-sectional study of the knowledge and practice of 340 health care practitioners concerning the diagnosis and treatment of childhood diarrhea and pneumonia in Bihar, India, from June 29 through September 8, 2012. We used data from vignette interviews and unannounced standardized patients (SPs). MAIN OUTCOMES AND MEASURES For SPs and vignettes, practitioner performance was measured using the numbers of key diagnostic questions asked and examinations conducted. The know-do gap was calculated by comparing fractions of practitioners asking key diagnostic questions on each method. Multivariable regressions examined the relation among diagnostic performance, prescription of potentially harmful treatments, and the practitioners’ characteristics. We also examined correct treatment recommended by practitioners with both methods. RESULTS Practitioners asked a mean of 2.9 diagnostic questions and suggested a mean of 0.3 examinations in the diarrhea vignette; mean numbers were 1.4 and 0.8, respectively, for the pneumonia vignette. Although oral rehydration salts, the correct treatment for diarrhea, are commonly available, only 3.5% of practitioners offered them in the diarrhea vignette. With SPs, no practitioner offered the correct treatment for diarrhea, and 13.0% of practitioners offered the correct treatment for pneumonia. Diarrhea treatment has a large know-do gap; practitioners asked diagnostic questions more frequently in vignettes than for SPs. Although only 20.9% of practitioners prescribed treatments that were potentially harmful in the diarrhea vignettes, 71.9% offered them to SPs (P < .001). Unqualified practitioners were more likely to prescribe potentially harmful treatments for diarrhea (adjusted odds ratio, 5.11 [95% CI, 1.24–21.13]). Higher knowledge scores were associated with better performance for treating diarrhea but not pneumonia. CONCLUSIONS AND RELEVANCE Practitioners performed poorly with vignettes and SPs, with large know-do gaps, especially for childhood diarrhea. Efforts to improve health care for major causes of childhood mortality should emphasize strategies that encourage pediatric health care practitioners to diagnose and manage these conditions correctly through better monitoring and incentives in addition to practitioner training initiatives.

Endogeneity between health and wealth presents a challenge for estimating causal effects of health shocks. Using a quasi-experimental design, comprising exogenous shocks sustained as bus accident injuries in India, with controls drawn from travelers on the same bus routes one year later, I present new evidence of causal effects on consumption and debt. Using primary household survey data, I find that households faced with shock-related expenditures are able to smooth consumption on food, housing, and festivals, with small reductions in educational spending. Debt was the principal mitigating mechanism households used, leading to significantly larger levels of indebtedness.

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Low-and middle-income countries contain the majority of confirmed cases of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). India has the second highest number of reported cases, but most seroprevalence estimates come from cities. Cities, with denser population, are more vulnerable to SARS-CoV-2. However, millions of city workers fled to rural India where lockdown was less stringent.We assessed SARS-CoV-2 prevalence among volunteers from population-representative households in urban and rural areas of the state of Karnataka (population, 67.5 million).Methods | This study was approved by the Indian government and institutional review boards at participating institutions. Written informed consent was obtained from all participants (orally if respondents were unable to read or write). The sample was drawn from a population-representative panel survey, the Consumer Pyramids Household Survey 1 (CPHS) (details in the eAppendix in the Supplement). The primary sampling units were towns (urban) or villages (rural); the ultimate sampling units were households. From the CPHS's 9717 Karnataka households, we randomly selected 2912 to represent urban and rural areas of 5 state regions. We surveyed consenting household members aged 12 years or older between June 15 and August 29, 2020 (during partial lockdown). We requested 5 mL of blood and a nasopharyngeal swab from 1 volunteer per household. We compared the sex and age distribution of volunteers with the CPHS and the 2021 projection from the 2011 census.

India's health care sector provides a wide range of quality of care, from globally acclaimed hospitals to facilities that deliver care of unacceptably low quality. Efforts to improve the quality of care are particularly challenged by the lack of reliable data on quality and by technical difficulties in measuring quality. Ongoing efforts in the public and private sectors aim to improve the quality of data, develop better measures and understanding of the quality of care, and develop innovative solutions to long-standing challenges. We summarize priorities and the challenges faced by efforts to improve the quality of care. We also highlight lessons learned from recent efforts to measure and improve that quality, based on the articles on quality of care in India that are published in this issue of Health Affairs The rapidly changing profile of diseases in India and rising chronic disease burden make it urgent for state and central governments to collaborate with researchers and agencies that implement programs to improve health care to further the quality agenda.