by Margaret E Kruk, Shalom Sabwa, Todd P Lewis, Ifeyinwa Aniebo, Catherine Arsenault, Susanne Carai, Patricia J Garcia, Ezequiel Garcia-Elorrio, Günther Fink, Munir Kassa, Sailesh Mohan, Mosa Moshabela, Juhwan Oh, Muhammad Ali Pate & Jacinta Nzinga
We obtained responses from population-representative samples of adults (age ≥ 18 years) in these 16 countries: Argentina (Mendoza province only), Colombia, Ethiopia, Greece, India, Italy, Kenya, Lao People’s Democratic Republic, Mexico, Nigeria, Peru, Republic of Korea, South Africa, United Kingdom of Great Britain and Northern Ireland, United States of America, and Uruguay
Abstract
Objective — To demonstrate how the new internationally comparable instrument, the People’s Voice Survey, can be used to contribute the perspective of the population in assessing health system performance in countries of all levels of income.
Methods — We surveyed representative samples of populations in 16 low-, middle- and high-income countries on health-care utilization, experience and confidence during 2022–2023. We summarized and visualized data corresponding to the key domains of the World Health Organization universal health coverage framework for health system performance assessment. We examined correlation with per capita health spending by calculating Pearson coefficients, and within-country income-based inequities using the slope index of inequality.
Findings — In the domain of care effectiveness, we found major gaps in health screenings and endorsement of public primary care. Only one in three respondents reported very good user experience during health visits, with lower proportions in low-income countries. Access to health care was rated highest of all domains; however, only half of the populations felt secure that they could access and afford high-quality care if they became ill. Populations rated the quality of private health systems higher than that of public health systems in most countries. Only half of respondents felt involved in decision-making (less in high-income countries). Within countries, we found statistically significant pro-rich inequalities across many indicators.
Conclusion — Populations can provide vital information about the real-world function of health systems, complementing other system performance metrics. Population-wide surveys such as the People’s Voice Survey should become part of regular health system performance assessments.
Introduction
Introduction The notion that health systems should be people-centred seems unexceptional. Health systems are occupied with serving people, are funded by people and aim to improve people’s health as their primary objective. However, concerns have grown in the past two decades that health systems have not matched the steadily rising expectations of patients, and are not delivering optimal outcomes or user experience. The global drive towards universal health coverage (UHC) also relies on a social compact that presumes the population finds health services to be of high value. The integrated people-centred health services framework developed by the World Health Organization (WHO) calls for engaging communities and reorienting models of care to put people at the centre of health systems by expanding voice, co-production and choice. However, rhetoric on people-centredness has exceeded reality. The recently developed UHC framework for health system performance assessment (Fig. 1) highlights the need to evaluate health systems based on how they function for people and the outcomes they generate. Building on a body of literature that is arguing for a shift from measuring inputs to assessing health system function and health improvement, this emphasis on performance is especially relevant today with many health systems struggling in the aftermath of the coronavirus disease 2019 (COVID-19) pandemic. Incorporating people’s perspective in evaluating and steering health systems will require a robust and comparable set of measures obtained from the population. In this paper we describe the evaluation of health system performance by 16 different populations using the People’s Voice Survey (data publicly available in mid-2024), a new internationally comparable instrument. We hypothesize that the survey captures many of the domains in the WHO framework for health system performance assessment, and that it can provide unique insights into performance to complement other data sources. We report and discuss data from 16 countries on performance domains, and examine income-related inequality by analysing differences between income groups within each country.
Box 1. WHO health system performance assessment framework domains and corresponding People’s Voice Survey indicators
Intermediate objectives
- Care effectiveness: (i) public health effectiveness: percentage of respondents aged ≥40 years who had both a blood pressure and blood sugar test in the past year; (ii) quality of own care: percentage of respondents rating quality of care of most recent visit in past 12 months as very good or excellent; and (iii) quality of primary care services: average percentage of respondents rating three core primary care services (child, maternal, chronic disease) as very good or excellent.
- User experience: (i) respect: percentage of respondents rating respect that provider showed them and courtesy of office staff in most recent visit as very good or excellent, and who experienced no discrimination in health care; (ii) voice: percentage of respondents rating their desired level of involvement in their health care and their health-care provider’s explanation as very good or excellent; and (iii)customer service: percentage of respondents rating wait time and time spent with provider (as well as time waiting for appointment in six countries with appointment systems) as very good or excellent.
- Access: (i) connection to health system: percentage of respondents with usual source of care; (ii) use of needed health care: percentage of respondents with chronic disease who used care at least once in past year; and (iii) no unmet need: percentage of respondents with no unmet health care needs in past year.
Final goals
- People-centredness: (i) quality of public health system: percentage of respondents rating quality of the country’s public health system as very good or excellent; (ii) quality of private health system: percentage of respondents rating quality of the country’s private health system as very good or excellent; (iii) endorsement: percentage of respondents reporting that the health system works well as it is/needs only minor change; and (iv) involvement in decision-making: percentage of respondents rating that government considers public opinion as very good or excellent.
- Health improvement: (i) self-rated health: percentage of respondents reporting their overall health as very good or excellent; (ii) self-rated mental health: percentage of respondents reporting their mental health as very good or excellent; and (iii) absence of disease: percentage of respondents who do not have a chronic/longstanding condition.
- Financial protection: (i) insurance: percentage of respondents with any health insurance (public, private, other); and (ii) health security (affordability): percentage of respondents who are somewhat or very confident they can get and afford good care if they are sick.
Note: The findings and the discussion in this paper are particularly interesting and well worth reading, but were too long to include here.
SOURCE: Bulletin of the World Health Organization 30 April 2024;102: 486–497A.