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...

JS and AA declare no competing interests. The authors alone are responsible for the views expressed in this Comment and they do not necessarily represent the views, decisions, or policies of the institutions with which they are affiliated.

Hannah Leslie and co-authors discuss priorities in individual countries for health system reform.

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