Translating the Lancet Global Health Quality Commission report into action: can we implement a UHC4Survival agenda?

Translating the Lancet Global Health Quality Commission report into action: can we implement a UHC4Survival agenda? Kojo Nimako, MD, DrPH, MPH1, Jeffrey Michael Smith, MD, MPH2, and Patricia Akweongo, PhD3 1Maternal, Newborn and Child Health Team (Consultant), Bill and Melinda Gates Foundation, Accra, Ghana 2Maternal, Newborn and Child Health Team, Bill and Melinda Gates Foundation, Seattle, Washington, USA 3Department of Health Policy, Planning and Management, School of Public Health, University of Ghana, Accra, Ghana Corresponding author: Kojo Nimako, P. O. Box AN 11671, Accra-North, Accra, Ghana. E-mail: kojotwumnimako@gmail.com

It has been nearly three years since the seminal report of the Lancet Global Health Commission on High-Quality Health Systems in the Sustainable Development Goals Era (HQSS) was published [1]. The HQSS proposed four macro-level actions to accelerate progress towards the Sustainable Development Goals (SDGs): governing for quality, transforming the health workforce, implementing service delivery redesign to ensure right-place care, and igniting population demand for quality.
One year after the launch of the report, there were encouraging indications that reform was on the horizon; Kenya was considering piloting health system redesign, Nepal had launched a movement to hold the health system accountable to citizens, and Ethiopia was shifting to process-and outcome-focused health metrics. Similarly, development partners like the Global Financing Facility (GFF) had agreed to apply a health systems quality lens to their investments [2].
Unfortunately, few additional countries have taken up the recommendations of the HQSS since then.
With many low-and middle-income countries (LMICs) significantly off-track to achieving key SDG health targets [3], there could not be greater urgency for countries to join the charge for large-scale transformative change than now. The global push for Universal Health Coverage (UHC) presents a veritable opportunity to do this.
As most LMICs today work towards achieving UHC by 2030, the conversation has mostly centred on extending healthcare services and removing financial barriers to care [4]. Additional value can be brought to the UHC cause if it is focused not simply on access but also survival-a 'UHC4Survival agenda'. To make this happen, governments would need to be deliberate about quality and effective care. We provide here three key areas where countries can intervene to jump-start health system revisions that are survivalfocused. We draw on examples from the priority area of maternal and child health to illustrate.
The first opportunity is through strengthening of health governance and management. Governance is the function that drives all other health system functions, and in implementing UHC, countries have an opportunity to build strong institutions that transcend personalities and time. This could be achieved through setting up multi-level performance standards, establishing health management programmes, and implementing ongoing improvement mechanisms for managers. Data generation and use-for example, tracking the targets of the Every Newborn Action Plan and the Ending Preventable Maternal Mortality strategy-are also central to stronger governance.
In addition to local and national governance, greater regional and global cooperation is necessary. The importance of such cooperation between national governments for strengthening supply chains, improving infection control, and maintaining essential service delivery has been clearly demonstrated during the COVID-19 pandemic, through, e.g., the COVAX facility and the establishment of the AlignMNH initiative [5,6].
The second opportunity concerns primary health care (PHC), which is the backbone of the UHC agenda [7]. Without intentional selection of intervention packages aligned to staffing and infrastructure, PHC risks becoming decentralized without recourse to quality, leading to the perception that primary care is 'watered-down hospital care'. Primary care quality and effectiveness lie in the capacity to deliver effective coverage of listed services, not simply in the geographic proximity of the PHC building to the community. The health system is thus best served when the distribution of PHC facilities maximizes quality, efficiency, and survival, not just access. Also, systems benefit when the content of primary care is clearly defined and aligned with PHC competence. For example, while calcium supplementation to prevent preeclampsia can be distributed at a PHC centre, the PHC service to manage pre-eclampsia might best occur at a district hospital with the capacity to manage obstetric complications. Mothers and newborns would also be best served if the health system is designed to ensure access to definitive care for severe complications, which may mean providing birth care for all mothers in or close to hospitals in some settings [8]. Such a reorganization would require intersectoral investments, including in the transportation sector, to ensure that all can reach and receive care.
The third opportunity lies in elevating and visibly incentivizing quality and outcomes in the discharge of the UHC agenda. Health systems benefit when there is public recognition of high-performing health system managers and health facility teams that improve not only care processes but also population outcomes. The standards they achieve can be used as benchmarks to which peers can be supported to meet [9]. Strategic purchasing in which healthcare facility/provider reimbursement is aligned with expected outputs/outcomes [10], when effectively applied, is a UHC financing mechanism that could be used to continuously reward good performance. The routine reporting of effective coverage measures can also catalyze quality. Effective-in contrast to crude-coverage metrics unveil the value and impact of the services that are being provided to people [11].
To move this ambitious UHC4Survival agenda forward, and to reach targets set by the high-quality health systems movement, the health sector needs to be adequately funded; many African countries would need to double health sector funding to reach agreed targets for domestic health expenditure [12]. Beyond that, equitable allocation of resources is also necessary to ensure that no one is left behind. Additionally, as exemplified by institutions like the GFF [13], development partners need to look beyond 'safe investments' like procuring equipment or supplying drugs and support countries in their efforts to improve system-wide quality, e.g. supporting pre-service education reforms and assisting health sector financial re-engineering to encourage performance-based reimbursements.
Finally, a rigorous implementation research agenda, driven by national government needs and priorities, is required to document lessons learned and guide institutionalization of health system improvements. It is thus significant that one key follow-on from the HQSS is the establishment of the Quality Evidence for Health System Transformation Network, which investigates health system function and innovations, in partnership with governments and collaborating institutions. This platform is further intended to help improve understanding of the process and causal pathways to highquality health systems and further elevate the health system quality-for-impact discourse.
We encourage further dialogue and evidence generation that will provide countries with the information they need to consider the recommendations of the HQSS report and support the evolution of their health system strategies towards a greater impact. It is only through such deliberate action that, as the World Health Organization Director General puts it, 'the term "quality care" will fall into disuse-because there is no other kind' [14]. The HQSS provides a framework to reach this goal, and LMICs have a great opportunity to leverage this framework in their push towards UHC4Survival. Countries must take bold actions to accelerate the path to high-performing health systems that produce the outcomes that people value.

Data availability
No data were analyzed for this paper.

Conflict of interest
We declare no competing interests. The views expressed in this paper are those of the authors only and do not represent the views of the institutions to which they are affiliated.