Although recent times have brought about significant technological and social advancements, the quality of healthcare worldwide continues to be inadequate.

Estimates suggest that between 5.7 and 8.4 million people die yearly because of the poor quality of care in low- and middle-income countries; up to 15% of hospital costs in these countries are a result of patient harm caused by adverse events. A viewpoint article published in JAMA1 lays out some of the obstacles to improving healthcare across the globe, and the authors attempt to provide some possible solutions.

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Donald Berwick, MD, from the Institute for Healthcare Improvement in Boston, Massachusetts, and colleagues pointed to 3 main challenges present in current healthcare systems. One concern is the proliferation of informal health workers, who provide as much as 75% of all care in some nations. Because these workers are often not licensed or trained and operate outside of established healthcare systems, it is difficult to regulate the quality of care they provide. Another obstacle to improving the current healthcare climate is the inaccessibility of healthcare to those in fragile states; for instance, those living through a humanitarian crisis. Such settings make it very difficult to provide continuous, high-quality, basic care. In many parts of the world, corruption and collusion are huge barriers to providing quality healthcare, with an estimated $455 billion of the total $7.35 trillion spent annually on healthcare lost to fraud or abuse.

Further research, especially in low- and middle-income settings, is needed to address quality improvement in healthcare around the world. Some research does already exist on the topic. For example, a 2001 report by the Institute of Medicine2 pointed to 6 dimensions of quality: safety, effectiveness, patient-centeredness, timelines, efficiency, and equity. The National Academies of Sciences, Engineering, and Medicine also issued a report on the quality of global health care in low-resource settings that provides design principles for healthcare systems,3 including prioritizing needs of patients, healthcare staff, and community, using evidence-based decision making, and using continuous feedback and learning to improve. The report emphasizes leadership and cooperation in many of their principles and can be applied to system redesigns in many countries.

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Dr Berwick and colleagues concluded that improving the quality of healthcare around the world will require a commitment from both governments and members of the private sector. If these leaders can focus on redesigning their healthcare systems with the goal of providing care that truly helps patients, they can greatly improve the quality of healthcare across the globe.


  1. Berwick D, Snair M, Nishtar S. Crossing the global health care quality chasm: a key component of universal health coverage [published online August 31, 2018]. JAMA. doi: 10.1001/jama.2018.13696.
  2. Richardson WC, Berwick DM, Bisgard JC, et al. Crossing the quality chasm: A new health system for the 21st century. Washington, DC: Institute of Medicine. Published March 2001. Accessed September 19, 2018.
  3. National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies Press; 2018.