Changing topics in healthcare 2017

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Primary care could tackle a greater range of low-acuity conditions, whereas hospitals or specialised health centres should provide care for conditions, such as births, that need advanced clinical expertise or have the risk of unexpected complications. Third, countries should transform the health workforce by adopting competency-based clinical education, introducing training in ethics and respectful care, and better supporting 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 high-quality 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. The past 20 years have been called a golden age for global health.

The newly ascendant health conditions, including chronic and complex conditions, require more than a single visit or standardised pill pack; they require highly skilled, longitudinal, and integrated care. Such care is also needed to address the substantial residual mortality from maternal and child conditions and infectious diseases.

In short, it is becoming clear that access to health care is not enough, and that good quality of care is needed to improve outcomes. India learned this with Janani Suraksha Yojana, a cash incentive programme for facility births, which massively increased facility delivery but did not measurably reduce maternal or newborn mortality.

High-quality care involves thorough assessment, detection of asymptomatic and co-existing conditions, accurate diagnosis, appropriate and timely treatment, referral when needed for hospital care and surgery, and the ability to follow the patient and adjust the treatment course as needed.

Health systems should also take into account the needs, experiences, and preferences of people and their right to be treated with respect. Finally, systems can be inefficient, wasting scarce resources on unnecessary care and on low-quality clinics that people bypass, while imposing high costs on users.

The SDG era demands new ways of thinking about health systems. Although they are only one contributor to good health—other major contributors being social determinants of health such as education, wealth, employment, and social protections, and cross-sectoral public health actions such as tobacco taxation and improved food, water, and road and occupational safety regulations 12 —access to high-quality health care is a human right and moral imperative for every country.

Addressing quality of care is particularly pertinent as countries begin to implement UHC. Newly transparent benefit packages can, in turn, create public expectations that governments will be under pressure to fulfil. Furthermore, new investments in health care will face scrutiny from finance ministers, who will demand efficient use of resources and better results measured in longer lifespans, restored physical and mental functions, user satisfaction, and economic productivity.

What should a high-quality health system look like in countries with resource constraints and competing health priorities that aspire to reach the SDGs? We review evidence of past approaches and look for strategies that can change the trajectory of health systems in LMICs.

Our work is informed by several principles. First, the principle that health systems are for people. Health systems need to work with people not only to improve health outcomes, but also to generate non-health-related value, such as trust and economic benefit for all people, including the poor and vulnerable.

Finally, the principle that fundamental change should be prioritised over piecemeal approaches. We recognise that health systems are complex adaptive systems that resist change and can be impervious to isolated interventions; indeed, multiple small-scale efforts can be deleterious. Quality of care is an emergent property that requires shared aims among all health system actors, favourable health system foundations, and is honed through iterative efforts to improve and learn from successes and failures.

These considerations guided our analysis. We are also aware of other major efforts on quality of care at the time of the writing of this Commission. WHO convened the Quality of Care Network to facilitate joint learning, accelerate scale-up of quality maternal, newborn, and child services, and strengthen the evidence for cost-effective approaches.

There is also new interest in stronger primary care that can promote health, prevent illness, identify the sick from the healthy, and efficiently manage the needs of those with chronic disease. Our work was substantially strengthened with input from nine National High-Quality Health Systems Commissions that were formed to explore quality of care in their local contexts alongside the global Commission. Our intended audiences for the report are people, national leaders, health and finance ministers, policy makers, managers, providers, global partners bilateral and multilateral institutions and foundations , advocates, civil society, and academics.

This report is arranged in the following manner: in section 1, we propose a new definition for high-quality health systems; in section 2, we describe the state of health system quality in LMICs, bringing together multiple national and cross-national data on quality of care for the first time; in section 3, we tackle the ethics of good quality of care and propose mechanisms for ensuring that the poor and vulnerable benefit from improvement; in section 4, we review the current status of quality measurements and propose how to measure better and more efficiently; in section 5, we reassess the available options for improvement and recommend new structural solutions; in section 6, we conclude with a summary of our key messages, our recommendations, and a research agenda.

We recognise that the level of ambition implied in our recommendations might be daunting to low-income countries that are struggling to put in place the basics of health care. In this Commission, we are describing a new aspiration for health systems that can guide policies and investments now. Regardless of starting point, every country has opportunities to get started on the path to high-quality health systems. The systematic examination of health-care quality began with the work of Avedis Donabedian, whose article 22 proposed a framework for quality of care assessment that described quality along the dimensions of structure, process, and outcomes of care.

At the turn of the 21st century, the Committee on Quality of Health Care in America of the Institute of Medicine IOM produced two influential quality reports 23 , 24 that galvanised the examination of quality in the US health system and prompted similar investigations in other industrialised countries.

Trying harder will not work. Changing systems of care will. International organisations, such as WHO, and many low-income and high-income countries have relied on the IOM definition of quality and its core dimensions. Building on this and other work, this section sets out our rationale for an updated definition of high-quality health systems and a conceptual framework ready for the health challenges, patient expectations, and rising ambitions of today.

The improvement of health outcomes is the sine qua non of health systems; these outcomes include longer lives, better quality of life, and improved capacity to function. In addition to better health, people derive security and confidence from having a trusted source of care when illness renders them most vulnerable. In this way, health systems also function as key social institutions, both deriving from and shaping social norms and able to promote or corrode public trust. This Commission defines a high-quality health system as the following:.

A high-quality health system is one that optimises health care in a given context by consistently delivering care that improves or maintains health outcomes, by being valued and trusted by all people, and by responding to changing population needs. Context is paramount in this definition; health systems have been shaped by different histories and, as a result, function differently across LMICs.

High-quality health systems are underpinned by four values: high-quality health systems are for people and are equitable, resilient, and efficient. A focus on people begins with the self-evident observation that health systems must reach people—access is a prerequisite for benefiting from health care.

However, this focus also signifies that people are not just beneficiaries of health services, but have a right to health care and have agency over their health and health-care decisions.

Therefore, people become accountability agents, able to hold health system actors to account. The emphasis on people-centredness is especially crucial in health care because of the asymmetry of power and information between provider and patient.

The focus on people works not only as a moral imperative to protect against the adverse effects of this power imbalance, but also as a corrective action that reduces the imbalance through patient empowerment and better accountability.

Health systems must also treat well the people that work within them, who deserve a supportive work environment safe working conditions, efficient and supportive management, and appropriate role assignment and are themselves health-care users. Demotivated providers cannot contribute to a high-quality health system.

A focus on equity means that high-quality health care needs to be available and affordable for all people, regardless of underlying social disadvantages. Measures of quality need to be disaggregated by stratifiers of social power—such as wealth, gender, or ethnicity—and quality improvements should explicitly include poor and vulnerable people to redress existing inequities.

Health systems in LMICs have been slow to change from their legacy functions focused on infectious diseases and maternal and child health, but health needs and expectations are shifting, sometimes quickly. Health crises, such as the Ebola epidemic, acutely illustrate the need for resilient systems, defined as systems that can prepare for and effectively respond to crises while maintaining core functions and reorganising if needed.

Lastly, health systems must be efficient: although spending on health systems is tightly associated with income and therefore varies greatly across LMICs, all health systems should aim to avoid waste and achieve the maximum possible improvement in health outcomes with the investment received.

We propose a new conceptual framework for high-quality health systems with three key domains: foundations, processes of care, and quality impacts figure 1. Our high-quality health system framework focuses on health system function, user experience, and how people benefit from health care.

This Commission believes that the quality of health systems should be primarily measured by these processes and impacts rather than by inputs. Facilities staffed by health workers and equipped with running water, electricity, and medicines are essential for good quality care, but the presence of these inputs is not itself a measure of high-quality care.

Empirical work shows that the quantity of such inputs does not predict the care that people receive and whether their health will improve—poor care often happens in the presence of adequate tools. Table 1 summarises the components of the three framework domains quality impacts, processes of care, and foundations.

The quality impacts begin with better health, including reduced mortality and morbidity, and positive health markers such as quality of life, function and wellbeing, and absence of serious health-related suffering.

Another impact of high-quality health systems is confidence in the system, including trust in health workers and appropriate care uptake. Confidence goes beyond the more traditional measure of satisfaction with care; it is the extent to which people trust and are willing to use health care. Trust is essential for maximising outcomes because it can motivate active participation in care—ie, adherence to recommendations and uptake of services, including in emergencies.

Finally, although good quality of care might require additional investment in many health systems of LMICs, high-quality health systems have the potential to generate economic benefits.

Second, high-quality health systems can reduce waste from unnecessary, ineffective, and harmful care and prevent inappropriate hospital admissions and the bypassing of cost-effective options, such as primary care.

Additionally, high-quality health systems with appropriate financing mechanisms, particularly mandatory insurance, can reduce the incidence of catastrophic or impoverishing health expenditures. Therefore, financing that provides people with financial protection and promotes high-quality, efficient care is an integral foundation of a high-quality health system.

The processes of care include competent care and user experience, which we consider to be complementary elements of quality. These elements must be present in both the health system as a whole and in individual care visits.

Competent systems provide people and communities with health promotion and prevention when healthy and effective and timely care when sick. People should be able to count on their conditions being detected and managed in an integrated manner.

When people visit providers, they should expect to receive evidence-based care, including careful assessment, correct diagnosis, and appropriate treatment and counselling. And providers should treat all people with dignity, communicate clearly, and provide autonomy and confidentiality.

Disrespectful and discriminatory behaviours are crucial quality failures, as are work environments that demean or disempower providers. The foundations of high-quality health systems begin with the populations that they serve: individuals, families, and communities. People are necessary partners in providing health care and improving health outcomes; they are not only the core beneficiaries of the health system, but also the agents who can hold these systems to account. The health needs, knowledge, and preferences of people should shape the health system response.

High-quality health systems require strong governance, and financing, to promote the desired outcomes and policies to regulate providers, organise care, and institutionalise accountability to citizens.

However, regulation will not be enough; health system leaders will need to inspire and sustain the values of professionalism and excellence that underpin high-quality health care. In most countries, health care is provided by three platforms: community health, primary care, and hospital care. An appropriate facility and provider mix, quality-centred service delivery models, and functioning connections between levels of care eg, referral, prehospital transport will be required to ensure that the whole system maximises outcomes and the efficient use of resources.

Providers, from health workers to managers, are fundamental for health systems, and require adequate numbers, preparation, professionalism, and motivation. Providers need high-quality, competency-focused clinical education, with training in ethics, and a supportive environment for achieving the desired performance.

Finally, health systems require not only physical tools, such as equipment, medicines, and supplies, but also new attitudes, skills, and behaviours, including quality mindsets, supervision and feedback, and the ability and willingness to learn from data. The foundations alone will not create good care, and the system will not be able to adapt to new challenges without built-in mechanisms for learning and improvement, including having timely information on performance, assessment of new ideas, and the means to retire ineffective approaches.

This framework can be used to measure health systems over time on elements that matter to people through processes and impacts and to guide opportunities for improvement through shoring up or rethinking foundations.

In this section, we describe the current state of healthcare quality in LMICs. We compiled data from multiple sources to present the most comprehensive and detailed picture of health system quality. We analysed data from health facility, household, telephone, and internet surveys collected in the past 10 years, and summarised findings from global estimates, systematic reviews, and individual studies data sources are listed in appendix 1 and a comparison of methods used to collect the data can be found in appendix 2.

Within the constraints of the available data, we describe quality across all health conditions addressed by the SDGs list of conditions in appendix 1 and across health system platforms community outreach, primary and hospital care, and the linkages between them: referral systems and emergency medical services.

Our focus is on describing the processes of care and their impacts. Foundations—the facilities, people, and tools required for care—are crucial to high-quality health systems, but their availability does not guarantee quality care.

Lastly, we explore why some population groups are more vulnerable to poor-quality care. Where multicountry medians are presented throughout the section, country-specific data are included in appendix 2. Key findings are shown in panel 1. Evidence-based care includes systematic patient assessments, accurate diagnoses, provision of appropriate treatments, and proper patient counselling.

In this section, we assess how these aspects are being followed, across selected SDG conditions. Data from direct observations of clinical consultations allowed us to measure the quality of reproductive, maternal, and child health services.

Using guidelines from WHO, we identified essential elements of reproductive, maternal, and child health care and built quality indices appendix 1.

On the basis of these indices, data from observations of consultations in 18 countries showed that adherence to evidence-based guidelines is low figure 2A. However, median figures can mask important variations within countries appendix 2.

These large variations in performance across providers suggest that better quality of care is possible in these countries. Identifying and replicating local best practices might be valuable to inform improvement strategies. Dots represent country-specific means, vertical bars indicate median performance across countries, and boxes delineate the IQR. Indicator definitions are shown in appendix 1, and country specific means are shown in appendix 2.

Other studies have also shown that providers often fail to adhere to clinical guidelines. A systematic patient assessment involves gathering clinically relevant information by asking appropriate medical history questions and doing recommended examinations and tests. Data from LMICs showed that systematic patient assessments are not always done. For example, after giving birth, women should be assessed for abnormal bleeding, perineal tears, signs of infections, and high blood pressure.

Similarly, during antenatal care, monitoring of blood pressure and urine and blood sample analyses are crucial to detect pre-eclampsia, nutritional deficiencies, infections, and other pregnancy risks. For example, pathology service coverage in sub-Saharan Africa is approximately one-tenth of that in high-income countries.

Incorrect diagnoses have deleterious consequences on health and contribute to treatment delays and antimicrobial resistance. For example, diagnostic uncertainty about undifferentiated fever often leads to overprescription of antimicrobial therapy. For tuberculosis, uptake of newer diagnostics has been slow and many countries continue to rely on often inaccurate smear microscopy. Poor-quality care also includes the underuse 56 of effective care and the overuse 11 of unnecessary care.

Our analyses of survey data revealed that individuals in LMICs often do not receive appropriate treatments during consultations, including preventive interventions during skilled antenatal care, oral rehydration therapy for children with diarrhoea, or antibiotics for those with symptoms of pneumonia figure 3 , appendix 2. Additionally, despite being diagnosed, many patients are untreated or undertreated for conditions such as HIV, tuberculosis, hypertension, diabetes, and depression.

Individuals in severe pain are also systematically undertreated in LMICs. Proportion of individuals receiving appropriate treatments among those who seek care in low-income and middle-income countries.

Indicators are defined in appendix 1; country specific means are shown in appendix 2. Overuse of unnecessary or ineffective care has also been documented in LMICs.

In the previously mentioned study 64 in China, almost a third of patients received magnesium sulphate—a treatment that is ineffective—on admission and more than half of patients were given traditional Chinese medicine, despite little evidence of its efficacy and safety. Inappropriate antibiotic prescribing practices included prescriptions for unknown diagnoses, prescriptions without stop or review dates to avoid unnecessarily long antibiotic courses , and prolonged surgical prophylaxis.

Proper counselling and health education are essential elements of evidence-based care. We found that during antenatal care, many skilled providers do not advise women on the signs of pregnancy complications or how to prevent HIV infections, and, when prescribing contraceptives, many providers fail to discuss their potential side-effects appendix 2.

Similarly, providers often do not state their diagnosis during the consultation. Counselling is particularly important for chronic disease management. Tobacco use, excess weight, unhealthy diets, and physical inactivity are the leading risk factors for non-communicable diseases.

Beyond the content of the health-care visit, competent care requires the whole health system to function for the patient. Here, we describe current evidence on four elements of competent health systems: safety, prevention and detection, continuity and integration, and timely care.

The literature documents a range of safety problems in health care, including adverse drug events, adverse events and injuries due to medical devices, injuries due to surgical and anaesthesia errors including wrong-site surgery , health-care-associated infections, improper transfusion and injection practices, falls, burns, and pressure ulcers. LMICs are estimated to have rates of medication-related adverse events similar to those of high-income countries, but they result in twice as many years of healthy life lost because more younger patients are affected in LMICs.

However, although water and sanitation are necessary, handwashing does not necessarily associate with their presence: low adherence to hand hygiene was found even in facilities with available supplies. The prevention and early detection of diseases, including through recommended screenings, is an important function of high-quality health systems. Across six Latin American and Caribbean countries, less than half of adults reported having had their blood pressure checked in the past year and their cholesterol checked in the past 5 years.

Integration is the extent to which health services are delivered in a complementary and coherent manner. These two dimensions are important for the management of non-communicable diseases and other chronic conditions, such as HIV, that require continuous patient support after diagnosis and a comprehensive treatment approach.

Regarding integration, all tuberculosis patients should be tested for HIV, because of risk factors shared between the two infections. For people with life-threatening emergencies, such as labour complications, trauma, and stroke, treatment delays substantially increase mortality risk. Timeliness is also central for other conditions that can be cured if treated early—including many cancers—and conditions such as tuberculosis or diabetes, in which early treatment prevents transmission or disease progression.

Time intervals from admission to surgery for traumatic fractures of the femur were found to be substantially longer in LMIC hospitals than in high-income country hospitals. However, the third delay—in providing high-quality care once women reach health-care facilities—is emerging as an important contributor to maternal and newborn child mortality.

Additionally, the absence of immediate postpartum care can lead to serious obstetric complications being missed. For infectious diseases, such as tuberculosis, making a timely diagnosis is crucial for interrupting transmission and optimising treatment outcomes. Regarding cancer care, delays caused by both patient and health system contribute to advanced disease at presentation and high cancer mortality rates in LMICs. Studies 54 , 87 , 88 from Brazil, Ghana, Mexico, Peru, and Rwanda reported delays of up to 28 weeks between presentation to a doctor and definitive diagnoses of cervical or breast cancer.

These delays are concerning because waiting more than 5 weeks before starting definitive treatment can worsen survival for cervical cancer, and delays in diagnosis longer than 12 weeks are considered suboptimal for breast cancer. Competent care and competent health systems are necessary for achieving high-quality care, but a positive user experience is also important.

In addition to having an intrinsic value, positive user experience can improve retention in care, adherence to treatments, and, ultimately, confidence in health systems. To address insufficient cross-national data on user experience, this Commission did an internet survey on user experience in 12 countries in Africa, Latin America, Asia, and the Middle East.

Full results will be presented in forthcoming papers, but some of the key results of this survey are shown in figure 4 , along with indicators from four other surveys done in 49 LMICs and 11 high-income countries appendix 2.

This result on the short time spent with providers was echoed by a review 93 that found that primary care consultations lasted fewer than 5 min on average in LMICs. User experience in 49 low-income and middle-income countries LMICs and 11 high-income countries.

High-income countries do not contribute to the illustrated medians. Data are from the surveys indicated. Interviews with patients help to paint a more comprehensive picture of their experiences within the health system. Since then, several qualitative studies have further illuminated the ways in which people receive differential treatment while seeking care. We did a rapid review of these studies methods are described in appendix 1. The stories described in these studies highlight disparities in both competent care and user experience.

Patients across a wide range of low-income and middle-income countries have described the lack of competent care and health systems. She is the only one who knows. She decides when she sees you coming. The obstacles are like these ones of medicines even if there are no medicines what makes me feel bad is the game.

Because they are impatient, they did not examine me. After I gave birth, I rested there for 5 h but no one came and asked me whether I was bleeding… After 3 days, my face got swollen… I almost died. Studies also highlight poor user experience, including verbal abuse and neglect from health-care workers.

They only care for those big people who have money to give them. Some differences across surveys are worth noting. Differing expectations of quality can also influence the perception of user experience. No benchmarks exist for what constitutes good user experience. Disrespect and abuse of women during childbirth has been widely reported in LMICs, 9 including documented instances of physical abuse, non-consented clinical care, no confidentiality and dignity, discrimination, abandonment, and detention in facilities.

Beyond being an indicator of poor-quality care, disrespect and abuse should be unacceptable in any health system. Nonetheless, these numbers can only tell part of the story. The quality of the processes of care, particularly of the user experience, is also reflected in the patient voices in panel 2.

In this section, we present available evidence on morbidity and mortality linked to poor quality care. Although the causes of death are often multifactorial, and are not solely influenced by health care, deaths from some conditions are highly dependent on quality of care and are regarded as sensitive indicators of how well a health system is functioning. For this Commission, we did an analysis of the mortality burden of poor-quality care across health conditions relevant to SDGs.

Poor-quality care resulted in 82 deaths per people in LMICs—an annual mortality rate equivalent to that from cerebrovascular disease globally. Across several other health priorities for which coverage is still low, including chronic respiratory disease, cancer, mental health, and diabetes, non-utilisation of health systems plays a larger role than poor-quality care, but this will change as access increases. Our results highlight that health systems could be more effective in saving lives across a spectrum of conditions by improving quality of care along with expanding coverage.

Deaths from Sustainable Development Goal conditions due to poor-quality care and non-utilisation in low-income and middle-income countries. External factor deaths are those due to poisonings and adverse medical events. Other infectious diseases deaths are those due to diarrhoeal diseases, intestinal infections, malaria, and upper and lower respiratory infections.

Maternal and newborn deaths are a particularly sensitive measure of health system quality, because many deaths stemming from labour complications can be averted with appropriate treatment. Countries were grouped by income to reduce the influence of social and economic determinants. Across countries with similar coverage, large disparities in maternal and neonatal mortality are apparent.

Mortality estimates are from WHO, using modelled estimates. Skilled birth attendance is from the World Bank World Development Indicators, using the most recent data available in the past 10 years. Horizontal lines indicate Sustainable Development Goal targets. Few deaths in these countries are recorded in complete vital registration systems; global estimates must account for missing and unreliable data.

Mortality estimates should be interpreted with caution because of uncertainty from measurement error. References can be found in appendix 1.

The frequency of stillbirths can also be reduced with high-quality care. Because quality was measured by use of inputs to care rather than by processes of care, these figures might underestimate actual mortality.

An older analysis that used different methods found similar effects on stillbirths, but more maternal and newborn lives saved. Population-based cancer survival is also an indicator of overall health system effectiveness.

For example, most countries reported an increasing trend in 5-year net survival from breast cancer since , but survival did not always increase in countries such as India, Thailand, and several eastern European countries.

More broadly, hospital mortality can be useful for gauging the quality of care in facilities, when adjusted for disease severity and underlying risk, and can provide useful insight on the quality of secondary care in a region or country, when aggregated. Delivering high-quality hospital care requires well functioning facility systems that include appropriate triage in emergency departments, rapid decision making for very sick patients, close inpatient monitoring, and rigorous infection prevention practices, among other elements.

Studies in LMICs have revealed high institutional maternal, perioperative, and emergency department mortality rates and high in-hospital mortality rates in patients admitted for acute myocardial infarctions. For example, the WHO multicountry survey on maternal and newborn health found intrahospital maternal mortality ratios that were 2—3 times higher than expected on the basis of case severity.

High rates of perioperative and anaesthetic-related mortality were also found in LMIC hospitals, reflecting gaps in surgical and hospital care quality. Most of the deaths occurred post surgery, suggesting that many lives could be saved by effective surveillance for physiological deterioration in patients who have developed complications.

Similarly, although the quality of emergency and trauma care in LMICs is understudied, one study found that mortality recorded in emergency departments in LMICs is many times higher than that generally reported in high-income countries, pointing to gaps in the quality and appropriateness of services being provided in these emergency departments. Mortality alone does not capture the full burden of poor-quality care. People accessing poor-quality care can develop morbidities, including physical sequelae, persistent symptoms, reduced function, pain, and poor quality of life.

For example, for many people in LMICs, access to health care does not result in control of manageable conditions such as hypertension, diabetes, HIV, tuberculosis, chronic lung diseases, and depression.

Poor quality of care during childbirth can also result in morbidities with lifelong consequences. Complications of diabetes such as blindness, kidney failure, and lower limb amputation can be largely averted through high-quality primary care.

However, in , the Mexican Social Security Institute reported major lower limb amputations in patients with diabetes, for an incidence of per patients. This continues a previously documented trend of increasing incidence of diabetic amputations and is higher than the comparable incidence in most, but not all, OECD countries.

Obstetric fistula is a highly debilitating condition with severe social and health consequences. Women with fistula have leakage of urine or stool through the vagina and are ostracised because of this in some regions. Although cultural factors, such as child marriage, increase the risk of obstructed labour, the existence of fistulas on a wide scale, as documented in studies, is an indicator of poor quality obstetric care and a broader health system failure.

By contrast, obstetric fistulas have been almost eliminated in high-income countries. Another goal of treatment is remission or reduction of symptoms. The quality of care that people receive also has important consequences for their confidence and trust in their government and health system, which can affect their decisions of when and where to seek care. Figure 7 shows varying degrees of confidence and trust in health systems across 45 LMICs.

For example, increased confidence in the ability to receive the care needed present in the internet survey led by this Commission might be explained partly by a higher socioeconomic status of internet users. Nonetheless, patient satisfaction should be interpreted with caution as a measure of quality panel 3. Confidence and trust in health systems in 45 low-income and middle-income countries LMICs and 11 high-income countries.

Perhaps paradoxically, because of the prevalence of poor-quality health care, patients in low-income and middle-income countries tend to report high satisfaction with the care received. High satisfaction with health care is common across low-income and middle-income country surveys, but patient satisfaction as a measure of quality should be carefully interpreted.

Although satisfaction is influenced by the quality of care, it is also influenced by care accessibility, costs, health status, expectations, immediate outcomes of care, and gratitude.

A9 Additionally, satisfaction measures can be subject to substantial survey bias. Respondents were asked to rate the quality of care on the basis of short vignettes. Low expectations of what constitutes good quality might be a consequence of the prevailing poor-quality care, low agency, and inadequate functioning mechanisms to hold systems accountable.

Other studies have also shown that patient satisfaction surveys are influenced by acquiescence bias. Surveys framing statements in a positive way and inviting patients to agree or disagree will lead to positive responses much more frequently than surveys with more neutral statements. A10 More discussion on the utility of patient satisfaction as a measure of health system quality can be found in Section 4. Other research has found that increased technical quality of health services, combined with responsive service delivery, fair treatment, better health outcomes, and financial risk protection, was associated with an increase in the probability of having trust in government.

Similarly, a study in Haiti found that higher quality primary care facilities were associated with higher utilisation. Perceived poor quality of care can also lead people to bypass certain facilities. Households might choose to travel further distances or pay more out of pocket to seek better quality care. Some people might also choose to bypass primary care facilities and seek care at hospitals or higher-level facilities for conditions that could be treated in primary care.

Primary care is the cornerstone of a high-quality health system, serving as the main entry point for most concerns and playing a crucial role in coordinating care and ensuring continuity across health system platforms. Nonetheless, primary care facilities often fail to fulfil their role.

A crucial area for future research will be to estimate the demand response to higher quality of care, focusing on the role of information and perception of quality in influencing utilisation patterns. Proportion of households that report quality concerns as reason for bypassing public facilities in districts in India. A quality concern was defined as mentioning any of the following as a reason for bypassing government facilities: inadequate infrastructure, doctor not available, absent health workers, poor quality, drugs not available, inconvenient hours, long wait time, or distrust.

In darker coloured districts, a higher proportion of households cited quality concerns. Improving health system quality can be justified on ethical, epidemiological, and economic grounds. Little evidence exists on the link between levels of quality of care and economic outcomes. Here, we describe three types of economic consequences that could be averted by high-quality health systems: macroeconomic effects of premature mortality, health system waste, and catastrophic or impoverishing health expenditures faced by households.

A analysis 95 estimated the macroeconomic effect of mortality that could be prevented with access to high-quality care in LMICs. The analysis was done by use of two distinct approaches to quantify economic losses from preventable mortality. The first approach projected gross domestic product GDP losses over 15 years due to the consequences of mortality on labour force and physical capital accumulation. This analysis shows that poor-quality care can result in a great macroeconomic burden that is inequitably distributed across countries.

Beyond the economic losses from premature mortality, poor-quality care can also lead to important waste and inefficiency. There have been few measurements of health-care waste attributable to poor-quality care in LMICs. However, evidence from high-income settings suggests that averting these costs could help LMICs make better use of scarce resources. High-quality primary care can prevent the need for hospital admissions for several health conditions called ambulatory care-sensitive.

Finally, people living in countries with poorly functioning health systems, without appropriate financing mechanisms and insurance, risk suffering from catastrophic or impoverishing expenditures when seeking care. Out-of-pocket payments ie, health spending made by patients themselves at the point of care as a share of household consumption have been increasing worldwide. Nearly million people are pushed into extreme poverty each year because of out-of-pocket expenses.

To help reduce impoverishing and catastrophic expenditures, prepaid health expenditures should replace out-of-pocket payments. A study published in , found that the proportion of the population covered by health insurance schemes or by national or subnational health services was not associated with financial protection.

Conversely, increased shares of prepayment in total health expenditure, typically achieved through taxes and mandatory contributions, were important for protecting people against catastrophic spending. The economic consequences we have described could be attenuated or averted in high-quality health systems. However, improving health system quality will require additional investments in many countries. Analyses have suggested that these will be substantial but affordable in most settings, excepting the poorest countries.

Further research is needed to measure the costs of specific quality improvement strategies, including those advanced by this Commission.

A health systems view must also be used to understand quality. This section addressed health care that is delivered at different levels of the health system, including through community outreach, primary care, and hospital care, and the linkages between them—referral systems and emergency medical services.

Figure 9 summarises evidence on quality across these key health system platforms. We have thus far reviewed the available evidence on quality of care at a national or multinational level.

However, these estimates mask important variations within countries. Equitable distribution of high-quality health care is essential to make the gains in health set out by the SDGs and ultimately contribute towards the realisation of the right to health.

We now explore why some groups are more vulnerable to poor-quality care than others and who receives worse quality care. This definition emphasises equitable health outcomes. The health-care system is one major determinant of health, and equitable access to the system is, therefore, important. But equitable access will not result in more equitable health outcomes unless all people—not just the privileged—are able to access high-quality services.

Equity in the quality of health care can be defined as the absence of disparities in the quality of health services between individuals and groups with different levels of underlying social disadvantage.

For instance, tuberculosis has a strong socioeconomic gradient between countries, within countries, and within communities. Similarly, a systematic review focused on diabetes showed that low individual socioeconomic status and deprivation in the residential area are associated with worse process indicators and intermediate outcomes, resulting in higher risks of microvascular and macrovascular complications. The agenda for sustainable development is built on principles of universality and aims to ensure that no one is systematically left behind.

Therefore, an effective implementation demands the defining and targeting of those most vulnerable. These factors are often fluid and have intersecting points, presenting serious obstacles to individuals in accessing high-quality health services.

As a result, the experiences and needs of these populations are not integrated into national health strategies, further entrenching the discrimination and disadvantage that they face. In this Commission, we highlight three dimensions that might make people especially vulnerable to poor-quality care: settings of care, conditions, and demographic factors figure Within settings of care, vulnerability is greater for individuals on the margins of mainstream services or displaced from home, such as those who are in a humanitarian crisis or in refugee camps, internally displaced, living in informal settlements, prisoners, and migrant populations.

People with stigmatised conditions can face worse treatment in the health system than others; these conditions can include HIV and AIDS, mental health and substance abuse disorders, and some reproductive health services such as abortion. Finally, previously recognised social and demographic factors that indicate asymmetric power, such as gender, age, sexual orientation, ethnic group, disability, and insurance coverage, can predispose people to experiencing poor-quality care.

Reasons for poor-quality care in these three dimensions include the collapse of health services, insufficient financial and human resources, low patient empowerment, barriers to continuity of care, insufficient legislative controls, and breakdown in trust between patient and system. These dimensions of vulnerability, along with an understanding of why these groups could receive poor-quality care and suffer worse health outcomes than others, can inform policies and programmes that target specific vulnerability factors.

Women with perinatal depression can experience stigma associated with mental illness in some low-income and middle-income countries. People with mental disorders are often victims of discrimination and denial of basic rights. A37 They can also internalise shame, anticipate rejection and discrimination, and accept diminished expectations from others. These two forms of stigma, enacted and felt, have the effect of exposing individuals with mental disorders to poor and inequitable quality of care.

Therefore, in the context of perinatal depression, stigma would increase the likelihood that those suffering are denied access to the basic and often rudimentary services available. A formative study done as part of the project Scaling up Care for Perinatal Depression for Improving Maternal and Infant Health in Nigeria, assessed the factors that might promote or hinder the delivery of quality services to women with perinatal depression appendix 1.

All 23 facilities sampled had the lowest level of institutional support for continuous care for depression. Of the patients who screened positive for perinatal depression by use of a validated tool, only three were identified by primary health-care workers. The treatment offered to these three patients was non-existent or grossly inadequate. None were provided with structured psychosocial interventions or offered specific follow-up to address their depression.

The low capacity of all the sampled facilities to provide quality care for depression, and the extremely low detection rates of depression by primary health-care workers recorded in the study showed important gaps in both the organisational structures and the manpower capacity of the front-line facilities to respond to common perinatal mental health conditions in a fully functional integrated chronic care model.

Despite the objectively rated poor quality of service being provided, the women using these facilities still rated them high regarding quality of care and personal satisfaction with the level of service provided. This paradox is an important indicator of the existing inequity in the system: people who have never experienced high-quality services set their expectations low and do not know how to demand higher-quality health care.

Panel 4 and panel 5 illustrate how conditions eg, mental health and settings of care eg, humanitarian crisis or refugee camps can exacerbate poor-quality care and what might be done to address these inequalities. The monitoring and tracking of equity in health intervention coverage has been the focus of major international efforts. However, there has been less work done on equity in the quality of care. As described earlier in this section, quality of care varies between and within countries.

Quality of care can also vary between certain population groups and across conditions in the same area. For example, a study in Kenya showed that the quality of labour and delivery care was generally low, but care available to the poor was substantially worse than that for wealthier people. Similarly, it was found that in Madhya Pradesh, India, poor people living in poor communities received especially poor-quality care.

We disaggregated several indicators of quality in maternal and child health presented earlier in this section by wealth, urban and rural residence, maternal age, gender, and education appendix 1 ; we also assessed variation in quality between the public and private sector. A significant problem specific to health care is that almost two-thirds of all change projects fail for many reasons, such as poor planning, unmotivated staff, deficient communication, or excessively frequent changes [1].

All healthcare providers, at the bedside to the boardroom, have a role in ensuring effective change. Using best practices derived from change theories can help improve the odds of success and subsequent practice improvement. Suppose a health care provider works in a hospital department that has experienced a 3-month increase in unwitnessed patient falls during the hours surrounding shift change. Evidence-based changes in the current shift change process would likely decrease patient falls; however, departmental leadership has attempted unsuccessfully to fix this problem twice in the past 3 months.

Staff continues to revert to previous shift change protocols to save time, which leaves patients unmonitored for extended periods. The answer may lie within the work of several change leaders and theorists. Although theories may seem abstract and impractical for direct healthcare practice, they can be quite helpful for solving common healthcare problems. Lewin was an early change scholar who proposed a three-step process for ensuring successful change [2].

All change initiatives, no matter how big or small, unfold in three major stages: pre-change, change, and post-change.

Within those stages, healthcare providers working as change agents or change champions should select actions that match change theories. One of the most critical aspects of pre-change planning is involving key stakeholders in problem identification, goal setting, and action planning [5].

Involving stakeholders in change planning increases staff buy-in. These stakeholders should include staff from all shifts, including nights and weekends, to create peer change champions for all shifts [5]. During pre-change planning, change agents should assess their departmental staff to determine which staff belong to each category. Rogers described the different categories of staff as innovators, early adopters, early majority, late majority, and laggards [4].

He further qualified those change acceptance categories with the following descriptions:. Most departmental staff will likely belong to the early or late majority. Change agents should focus their initial education efforts on Innovator and Early Adopter staff. Early adopters are often the most pivotal change champions that persuade early and late majority staff to embrace change efforts [4]. A force field analysis involves a review of change facilitators and barriers at work in the department.

Change leaders should work to reduce change barriers through open communication and education while also aiming to strengthen change facilitators through staff recognition and various incentives. One of the biggest mistakes a change leader can make during the midst of change implementation is failing to validate that staff members are performing new processes as planned. Ongoing leader engagement throughout change execution will increase the chances of success [5].

Staff resistance remains common during this stage. Change leaders may find it helpful to conduct another Force Field Analysis during this changing phase to ensure no new barriers have emerged [3].

Further strengthening of change facilitators through staff engagement, recognition, and sharing of short-term wins will help maintain momentum. Staff may require additional on-the-spot training to overcome knowledge deficits as the change process continues. Finally, leaders must continue to monitor progress toward goals using information like patient satisfaction, staff satisfaction, fall rates, and chart audits [3].

Change agents can redefine their relationship with the staff to take on a less active role in the change maintenance process. However, once the change leader begins to release control over the change process, staff members may slowly revert to old, negative behaviors. Change managers should celebrate wins with staff while continuing to share evidence of success in staff meetings or with departmental communication boards [5].

Change is inevitable, yet slow to accomplish. While change theories can help provide best practices for change leadership and implementation, their use cannot guarantee success. The process of change is vulnerable to many internal and external influences.

Using change champions from all shifts, force field analyses, and regular supportive communication can help increase the chances of success [5]. Knowing how each departmental staff member will likely respond to change based on the diffusion of innovation phases can also indicate the types of conversations leaders should have with staff to shift departmental processes.

You are not required to obtain permission to distribute this article, provided that you credit the author and journal. Turn recording back on. Help Accessibility Careers. StatPearls [Internet]. Search term. Change Management Jennifer M.

Affiliations 1 McNeese State University. Confirmation staff recognize the value and benefits of the change and continue to use changed processes.

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Accenture alight	Moreover, our analysis found that readiness metrics are only weakly connected to the content of care delivered. Perceived poor quality of care can also lead people to bypass certain facilities. Proper counselling and health education are essential elements of evidence-based care. A69,A72—A74 Although governments often claim to want to reach healtbcare through open government initiatives, scant attention to how people understand and use information has led to an abundance of information but a minimal effect on care seeking and other outcomes. Some people might also choose to bypass primary care facilities and seek care at hospitals or higher-level facilities for conditions that could accenture stock treated in primary care.

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