There are vast blind spots in areas such as user experience, system competence, confidence in the system, and the wellbeing of people, including patient-reported outcomes.
In many of these countries, we know little about quality of care for respiratory diseases, cancer, mental health, injuries, and surgery, as well as the care of adolescents and elderly people.
New research is crucial for the transformation of low-quality health systems to high-quality onesĭata on care quality in LMICs do not reflect the current disease burden. Global development partners can support the generation and testing of public goods for health system measurement (civil and vital registries, routine data systems, and routine health system surveys) and promote national and regional institutions and the training and mentoring of scientists. To generate and interpret data, countries need to invest in national institutions and professionals with strong quantitative and analytical skills. Countries need agile new surveys and real-time measures of health facilities and populations that reflect the health systems of today and not those of the past. Robust vital registries and trustworthy routine health information systems are prerequisites for good performance assessment. Countries should report health system performance to the public annually by use of a dashboard of key metrics (eg, health outcomes, people's confidence in the system, system competence, and user experience) along with measures of financial protection and equity. This Commission calls for fewer, but better, measures of health system quality to be generated and used at national and subnational levels. Health systems should measure and report what matters most to people, such as competent care, user experience, health outcomes, and confidence in the system As a result of this, only one-quarter of people in LMICs believe that their health systems work well. Waste of resources and catastrophic expenditures are economic side effects of poor-quality health systems. Poor-quality care can lead to other adverse outcomes, including unnecessary health-related suffering, persistent symptoms, loss of function, and a lack of trust and confidence in health systems. The high mortality rates in LMICs for treatable causes, such as injuries and surgical conditions, maternal and newborn complications, cardiovascular disease, and vaccine preventable diseases, illustrate the breadth and depth of the health-care quality challenge.
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Quality of care will become an even larger driver of population health as utilisation of health systems increases and as the burden of disease shifts to more complex conditions. High-quality health systems could prevent 2♵ million deaths from cardiovascular disease, 1 million newborn deaths, 900 000 deaths from tuberculosis, and half of all maternal deaths each year. 60% of deaths from conditions amenable to health care are due to poor-quality care, whereas the remaining deaths result from non-utilisation of the health system. Poor-quality care is now a bigger barrier to reducing mortality than insufficient access. In 2015 alone, these deaths resulted in US$6 trillion in economic losses. More than 8 million people per year in LMICs die from conditions that should be treatable by the health system. Quality of care is worst for vulnerable groups, including the poor, the less educated, adolescents, those with stigmatised conditions, and those at the edges of health systems, such as people in prisons.
One in three people across LMICs cited negative experiences with their health system in the areas of attention, respect, communication, and length of visit (visits of 5 min are common) on the extreme end of these experiences were disrespectful treatment and abuse. At the system level, we found major gaps in safety, prevention, integration, and continuity, reflected by poor patient retention and insufficient coordination across platforms of care. Care can be too slow for conditions that require timely action, reducing chances of survival. Diagnoses are frequently incorrect for serious conditions, such as pneumonia, myocardial infarction, and newborn asphyxia. In LMICs, mothers and children receive less than half of recommended clinical actions in a typical preventive or curative visit, less than half of suspected cases of tuberculosis are correctly managed, and fewer than one in ten people diagnosed with major depressive disorder receive minimally adequate treatment.