Quality Care Is Key to Driving Health Gains from Universal Coverage

Deaths due to poor-quality health care represent a substantial challenge for universal coverage in low- and middle-income countries.

In 2016, 5 million deaths in low- and middle-income countries (LMICs) were estimated to be due to poor-quality health care, according to a study published by The Lancet.

Globally, universal health care (UHC) has been targeted as a potential solution to improve health and reduce the financial burden of care. Implementation of UHC is part of the Sustainable Development Goals (SDGs), which are new targets signed by 193 United Nations member states to improve health and development by 2030.

Although proponents suggest that UHC produces gains in population health and reduces financial hardship, successful implementation is contingent on the accompanying investment of high-quality care, according to the study authors.

“In low-income countries, evidence is emerging that expanding health care coverage does not necessarily result in better outcomes, even for conditions highly amenable to medical care,” the authors wrote.

For the study, the authors used data from the 2016 Global Burden of Disease study to calculate mortality amenable to personal health care for 61 conditions targeted by SDG. Additionally, they used health care utilization data from population surveys to estimate the portion of amenable mortality attributable to non-utilization of health care versus mortality that is attributable to poor-quality care.

Overall, data revealed that 15.6 million excess deaths from the targeted conditions occurred in LMICs in 2016. Of these deaths, 8.6 million were amenable to health care, of which 5 million were estimated to be a result of poor-quality care and 3.6 million were due to non-utilization of health care.

Lack of quality care was an important driver of amenable mortality across conditions, including 84% of cardiovascular mortality, 81% of vaccine preventable diseases, and 61% of neonatal conditions, as well as half of deaths from maternal causes, road injury, tuberculosis, HIV, and other infectious diseases.

Even in areas where progress has been made on UHC, deaths due to poor-quality services represent a substantial challenge. Coupling the expansion of UHC for SDG conditions with investments in high-quality health systems could improve health gains, potentially preventing 8.8 million deaths per year, according to the study.

“Countries pursuing UHC must put better quality on par with expanded coverage if they are to substantially improve health,” the authors concluded.


Kruk ME, Gage AD, Joseph NT, et al. Mortality due to low-quality health systems in the universal health coverage era: a systematic analysis of amenable deaths in 137 countries. The Lancet. 2018. https://doi.org/10.1016/S0140-6736(18)31668-4