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High-Quality Health Systems in the Sustainable Development Goal Era: A Special Collection

Margaret Kruk, Hannah Leslie, and Muhammad Ali Pate introduce the PLOS Collection on High-Quality Health Systems in the Sustainable Development Goal Era.

In September 2015, the United Nations General Assembly adopted the 17 Sustainable Development Goals (SDGs) to guide global progress in economic, social, and environmental domains through 2030. In contrast to the health-condition specific approach of the 2000 – 2015 Millennium Development Goals (MDGs), the SDGs cover nearly all major health topics, spanning newborn health to noncommunicable disease, infections to road traffic injuries (see Sustainable Development Goals and targets related to health systems). With the inclusion of universal health coverage as a target, the SDGs highlight the need for a system-wide approach to addressing population health needs.

Low- and middle-income countries (LMICs) have demonstrated considerable success in expanding health system coverage for specific conditions, with notable achievements in child vaccination and HIV treatment, among others. The challenge today is to ensure that the care people receive consistently improves health outcomes and provides value to people. Existing evidence suggests the care provided in low-resource settings falls far short of this standard. For example, averting maternal and newborn mortality requires rapid, effective action for complicated deliveries, yet over 40% of facility-based deliveries in five countries in Africa took place in primary care facilities with major deficiencies in the resources and experience required to avert mortality. Poor quality care can undermine health system impact: massive increases in facility-based delivery in India failed to reduce maternal or neonatal mortality. The need for high-quality care will only increase as health systems are expected to provide integrated and longitudinal care for new health challenges from diabetes to mental health care.

To date however, research has not responded to the urgent challenges facing LMICs. Measurement of quality is difficult in any setting, particularly so in countries with fledgling health information systems. The plethora of disease-specific measures masks a cohesive view of health system quality. Users of health care are rarely if ever asked about the value of health services in the local clinic. Minimal guidance is available on what interventions are most promising for improving quality at a national scale and how countries might organize health systems to achieve the SDGs.

To promote systematic and rigorous research in the area, PLOS Medicine and PLOS ONE will host a collection on High Quality Health Systems in the Sustainable Development Goal Era (HQSS Collection). The papers will feature research related to the Lancet Global Health Commission on High Quality Health Systems, a global effort to 1) define health system quality, 2) describe the quality of care for sentinel SDG conditions in low- and middle-income countries and its equity, 3) propose tractable measures of quality, and 4) identify structural approaches to improve quality. The focus of this collection will be on innovative tools and interventions for quality measurement and improvement at scale. Quality healthcare is emerging as a global concern, relevant to countries at all stages of development and burden of disease. Rigorous research is more important than ever to illuminate the way. We launch the collection with a paper by Leslie and colleagues that challenges a commonly used measure of quality: facility infrastructure and a linked Perspective from Lars Åke Persson. We hope that this and future papers in the collection prompt policymakers and researchers alike to think anew about the health system quality and how to improve it in countries shouldering the bulk of the world’s avertable deaths.


Dr. Margaret E. Kruk is Associate Professor of Global Health at the Harvard T.H. Chan School of Public Health and a member of the PLOS Medicine Editorial Board.

Dr. Hannah H. Leslie is a postdoctoral fellow at the Harvard T.H. Chan School of Public Health. 

Muhammad Ali Pate is an adjunct professor at Duke Global Health Institute, at Duke University in North Carolina.

Featured image credit: Naima Joseph, MD


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