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Bellagio Declaration on high-quality health systems: from a quality moment to a quality movement

In the past two decades, the world has markedly improved health and economic opportunities for millions of people. Low-income and middle-income countries have enhanced access to safe water, sanitation, education, and nutrition and have expanded health services for women and children. These efforts have reduced mortality from vaccine-preventable diseases, maternal and child health conditions, tuberculosis, malaria, and HIV. Although access to health services has grown, quality of care is often weak and varies greatly, with excellent and inadequate care coexisting in the same country. Good quality care is least available to the poor and vulnerable, including migrants and people affected by conflict. Not infrequently, diagnoses are missed, treatment is incorrect, unsafe, or too slow, and people are not treated with the respect they deserve. This leads to poor health, preventable deaths, antimicrobial resistance, economic hardship, and loss of trust and confidence in the health system. High-quality health systems are a crucial determinant of both health and economic growth. More than 8 million lives could be saved each year if health systems consistently provided high-quality care, and saving these lives could avert US$6 trillion per year in economic welfare losses. These quality gaps cannot be closed through incremental fixes. This is the moment for a health system quality revolution. The Sustainable Development Goals (SDGs), national commitments to universal health coverage, and the 40th anniversary of Alma Ata present a unique opportunity for action. High-quality health systems are central to the success of all these efforts, but good quality cannot be assumed; it needs to be made explicit, and investments in large-scale improvement must be included in all health programmes. In June 2018, the Bellagio Forum for High-Quality Health Systems brought together policymakers, global stakeholders, and academics to preview findings of The Lancet Global Health Commission on High-Quality Health Systems in the SDG Era and to discuss how to turn these results into action. The WHO Director General Dr Tedros Adhanom Ghebreyesus and the Deputy UN Secretary General Amina J Mohammed expressed their support for this agenda, as has a growing group of quality champions (panel). As Forum participants, we declare the following statements. We endorse the new definition of high-quality health systems, as systems that consistently deliver services that improve or maintain health, are trusted by people, and can adapt to changing needs and health shocks. Health systems are first and foremost for people, and they should embrace people-centredness, equity, efficiency, and resilience as core values. Although high-quality systems require strong foundations—including skilled and motivated health workers, infrastructure, equipment, and other tools of care—these are pre conditions for, but are not in themselves measures of good care. We believe that health systems cannot be static. Many health systems were originally built to minimise distance to care rather than maximise health outcomes. Providing competent services to people requires the redesign of service delivery. Although this redesign will look different in different countries, the notion of right-place care means that services should be provided at the level that is best able to deliver them effectively; for example, complex services might need to move from clinic to hospital, and care requiring frequent contact with people might move from hospital to clinic. All countries need to reimagine Published Online September 5, 2018 http://dx.doi.org/10.1016/ S2214-109X(18)30372-3


Bellagio Declaration on high-quality health systems: from a quality moment to a quality movement
In the past two decades, the world has markedly improved health and economic opportunities for millions of people. Low-income and middle-income countries have enhanced access to safe water, sanitation, education, and nutrition and have expanded health services for women and children. These efforts have reduced mortality from vaccine-preventable diseases, maternal and child health conditions, tuberculosis, malaria, and HIV.
Although access to health services has grown, quality of care is often weak and varies greatly, with excellent and inadequate care coexisting in the same country. Good quality care is least available to the poor and vulnerable, including migrants and people affected by conflict. Not infrequently, diagnoses are missed, treatment is incorrect, unsafe, or too slow, and people are not treated with the respect they deserve. This leads to poor health, preventable deaths, antimicrobial resistance, economic hardship, and loss of trust and confidence in the health system. High-quality health systems are a crucial determinant of both health and economic growth. More than 8 million lives could be saved each year if health systems consistently provided high-quality care, and saving these lives could avert US$6 trillion per year in economic welfare losses. 1 These quality gaps cannot be closed through incremental fixes. This is the moment for a health system quality revolution. The Sustainable Development Goals (SDGs), national commitments to universal health coverage, and the 40th anniversary of Alma Ata present a unique opportunity for action. High-quality health systems are central to the success of all these efforts, but good quality cannot be assumed; it needs to be made explicit, and investments in large-scale improvement must be included in all health programmes.
In June 2018, the Bellagio Forum for High-Quality Health Systems brought together policymakers, global stakeholders, and academics to preview findings of The Lancet Global Health Commission on High-Quality Health Systems in the SDG Era 1 and to discuss how to turn these results into action. The WHO Director General Dr Tedros Adhanom Ghebreyesus and the Deputy UN Secretary General Amina J Mohammed expressed their support for this agenda, as has a growing group of quality champions (panel). As Forum participants, we declare the following statements.
We endorse the new definition of high-quality health systems, as systems that consistently deliver services that improve or maintain health, are trusted by people, and can adapt to changing needs and health shocks. Health systems are first and foremost for people, and they should embrace people-centredness, equity, efficiency, and resilience as core values. Although high-quality systems require strong foundations-including skilled and motivated health workers, infrastructure, equipment, and other tools of care-these are pre conditions for, but are not in themselves measures of good care.
We believe that health systems cannot be static. Many health systems were originally built to minimise distance to care rather than maximise health outcomes. Providing competent services to people requires the redesign of service delivery. Although this redesign will look different in different countries, the notion of right-place care means that services should be provided at the level that is best able to deliver them effectively; for example, complex services might need to move from clinic to hospital, and care requiring frequent contact with people might move from hospital to clinic. All countries need to reimagine models of hospital and primary care, which are likely to differ in rural and urban settings, and incorporate advances in community and home-based care. These reforms will not succeed without involving the private health sector and other sectors, including transportation infrastructure, water, energy, and communication. Such reforms will also require a transformation of the health workforce. Countries should modernise provider training to emphasise skills and competencies and to promote a culture of excellent care, ethical conduct, and respect.
We affirm that communities and providers are key partners in this movement, which is why informing communities about their rights, responsibilities, and entitlements is key. Conveying to people what they should expect in a quality visit, providing redress mechanisms if care falls short, and empowering communities to codesign health systems will accelerate the journey to better quality care.
To know whether health policies and investments are effectively transforming health systems for the better, we must rethink how quality is measured. Measures should reflect what matters most to people: the competence and courtesy of their provider, better health outcomes, and confidence in the health system-in the whole population and in vulnerable groups. This requires better use of existing data, innovative metrics, and updated measurement approaches and technologies. Stronger measurement promotes accountability and will help countries build health systems that learn, adapt, and improve, traits that are key tenets of a high-quality health system.
To get started on the high-quality health systems agenda, we call for the following: (1) for countries to invest in high-quality health systems, providing stewardship of quality in both public and private sectors, working on providing universal health coverage services that are of sufficient quality to improve health, engaging local authorities to agree on a coherent vision of quality, educating people on their rights and enhancing their understanding of what constitutes effective and safe care, and making progress on trustworthy and transparent measurement.
(2) For global partners and countries to embed quality centrally in the SDG and universal health coverage agendas and meaningfully track progress; this, in practice, will require updating metrics of health system quality, emphasising collection of timely and useful data, and developing new measures to reflect the valued outcomes of people. (3) For researchers to work closely with implementers and policymakers to ask and answer priority questions; rigorous evaluation is essential to document and spread change.
High-quality health systems are at the heart of global equity. Quality care should not be a privilege for a lucky few, in a few facilities, and in a few countries. Health systems must effectively protect, treat, and respect all people, especially the vulnerable. As countries work to achieve universal health coverage, let us use this moment to ignite a movement for high-quality health systems.