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...
SummaryBackgroundUniversal health coverage has been proposed as a strategy to improve health in low-income and middle-income countries (LMICs). However, this is contingent on the provision of good-quality health care. We estimate the excess mortality for conditions targeted in the Sustainable Development Goals (SDG) that are amenable to health care and the portion of this excess mortality due to poor-quality care in 137 LMICs, in which excess mortality refers to deaths that could have been averted in settings with strong health systems.MethodsUsing data from the 2016 Global Burden of Disease study, we calculated mortality amenable to personal health care for 61 SDG conditions by comparing case fatality between each LMIC with corresponding numbers from 23 high-income reference countries with strong health systems. We used data on health-care utilisation from population surveys to separately estimate the portion of amenable mortality attributable to non-utilisation of health care versus that attributable to receipt of poor-quality care.Findings15·6 million excess deaths from 61 conditions occurred in LMICs in 2016. After excluding deaths that could be prevented through public health measures, 8·6 million excess deaths were amenable to health care of which 5·0 million were estimated to be due to receipt of poor-quality care and 3·6 million were due to non-utilisation of health care. Poor quality of health care was a major driver of excess mortality across conditions, from cardiovascular disease and injuries to neonatal and communicable disorders.InterpretationUniversal health coverage for SDG conditions could avert 8·6 million deaths per year but only if expansion of service coverage is accompanied by investments into high-quality health systems.FundingBill & Melinda Gates Foundation.
People in all but about 20 countries have a higher risk of dying prematurely from a noncommunicable disease (NCD) than from infectious and parasitic diseases, maternal and perinatal conditions, and nutritional deficiencies combined. The risk of dying from an NCD is highest in low-and middle-income countries, especially in sub-Saharan Africa for both sexes and in central Asia and eastern Europe for men. Progress towards Sustainable Development Goal (SDG) target 3.4 is markedly different across countries. At current rates of decline in NCD mortality, SDG target 3.4 is expected to be met for women in 35 countries (19% of all countries) and men in 30 countries (16%). Most of these are high-income countries with already-low NCD mortality and countries in central and eastern Europe. A further 50 countries (for women) and 35 countries (for men) would achieve the target with a modest acceleration of decline. Mortality from the four NCDs included in SDG target 3.4 has stagnated or increased since 2010 among women and men in 15 and 24 countries, respectively. Another 86 countries (for women) and 97 (for men) are progressing too slowly, and need to implement policies that significantly increase the rates of decline, if they are to meet SDG target 3.4. NCD deaths beyond the age range and causes of death included in SDG target 3.4 cause a larger mortality burden in low-and middle-income countries than in high-income countries. Health policies should address NCDs beyond the causes and age groups covered in SDG target 3.4, so as to "leave no one behind". Substantial reduction of NCD mortality requires policies that significantly reduce tobacco and alcohol use and blood pressure levels, and provide access to efficacious and high-quality preventive and curative care for NCDs in the context of UHC. 86 countries (46%) for women and 97 (52%) for men need the implementation of policies that significantly increase the rates of decline. Mortality from the four NCDs included in SDG target 3.4 has stagnated or increased since 2010 among women and men in 15 (8%) and 24 (13%) countries, respectively. NCD causes and age groups other than those included in the SDG target 3.4 are responsible for a higher risk of death in low-and middle-income countries than in high-income countries. For countries to substantially reduce NCD mortality requires policies that significantly reduce tobacco and alcohol use and blood pressure levels, and provide efficacious and high-quality preventive and curative care for NCDs, including timely diagnosis and treatment of hypertension, diabetes, and treatment-amenable cancers, and treatment pathways that improve the survival of those with acute and chronic NCDs.
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