Lancet Global Health
May 2017 Volume 5 Number 5 e467-e555
Introducing The Lancet Global Health Commission on High-Quality Health Systems in the SDG Era
Margaret E Kruk, Muhammad Pate, Zoë Mullan
The Millennium Development Goals on health have expanded access to basic health interventions to millions of people in low-income and middle-income countries (LMICs). However, access alone will not be sufficient to meet the Sustainable Development Goals (SDGs) if health systems cannot provide high quality care—ie, care that improves health outcomes and provides value to people. Emerging data show that many LMIC health systems struggle to consistently provide good quality of care.1, 2 Yet change is possible. Primary health-care facilities, which tend to reach the poorest segment of populations, are an important plank in the drive towards achieving the SDGs. In Nigeria, supporting primary health-care centres in rural areas with quality assessment, an action plan, and technical assistance in management resulted in significant improvements in adoption of quality practices.3
Health system quality in lower-income countries has been under-defined and under-researched. There is no agreed upon single definition of a high-quality health system or its aims and there is no consensus on metrics. Instead, many countries face a proliferation of definitions and measures across disease areas. The emphasis in quality measurement has been on inputs: equipment, medicines, staff. Yet, this does not paint the full picture of quality—a well-equipped facility may still provide poor care. And patients’ experience of care and patient-reported outcomes, which influence people’s decisions to use or avoid services and provide valuable insights on performance, are rarely measured. There is little information on national and regional levels of quality and its distribution, weak evidence on the factors that drive quality variations, and low effectiveness of current quality improvement approaches. Finally, there is an urgent need to expand the solution space for quality improvement: to move beyond in-service training and other clinic-focused approaches to consider structural solutions, such as service regionalisation, updating medical and nursing education, technological innovation, and strengthening professional and community oversight of care.
To galvanise research and action on quality of care in LMIC health systems, The Lancet Global Health has commissioned a major report: The Lancet Global Health Commission on High-Quality Health Systems in the SDG Era (HQSS Commission). This will be a piece of science-led, multidisciplinary, actionable work with wide-reaching goals and measurable indicators, and will embody the journal’s commitment to “the best science for better lives”. The HQSS Commission will be chaired by Margaret Kruk and Muhammad Pate and brings together 30 academics, policymakers, and health system experts from 18 countries. Guided by the values of originality, rigour, relevance, and respect for local context and actors, the Commission will review current
and improving quality in pursuit of the SDGs. It will produce a single conceptual framework of high-quality health systems to increase the salience of the concept to policymakers, providers, and people. It will build on and inform the work of other ongoing efforts including Countdown to 2030; the Health Data Collaborative; the Quality, Equity, and Dignity Network; and the Primary Health Care Performance Initiative.
The Commission’s specific aims are to (1) define health system quality, (2) describe quality of care and its distribution across tracer SDG conditions, (3) propose practical measures of quality, and (4) identify structural approaches to improve quality. The work will be underpinned by an exploration of the ethical dimensions of quality, including the right to quality health-care and equity. The analysis will be done by four Commission working groups, shown in the panel. The HQSS Commission will hold its first meeting on March 13–15, 2017, in Boston, USA, convening the commissioners and an Advisory Council of experts and global partners.