Improving health and social systems for all children in LMICs: structural innovations to deliver high-quality services

Abstract

Despite health gains over the past 30 years, children and adolescents are not reaching their health potential in many low-income and middle-income countries (LMICs). In addition to health systems, social systems, such as schools, communities, families, and digital platforms, can be used to promote health. We did a targeted literature review of how well health and social systems are meeting the needs of children in LMICs using the framework of The Lancet Global Health Commission on high-quality health systems and we reviewed evidence for structural reforms in health and social sectors. We found that quality of services for children is substandard across both health and social systems. Health systems have deficits in care competence (eg, diagnosis and management), system competence (eg, timeliness, continuity, and referral), user experience (eg, respect and usability), service provision for common and serious conditions (eg, cancer, trauma, and mental health), and service offerings for adolescents. Education and social services for child health are limited by low funding and poor coordination with other sectors. Structural reforms are more likely to improve service quality substantially and at scale than are micro-level efforts. Promising approaches include governing for quality (eg, leadership, expert management, and learning systems), redesigning service delivery to maximise outcomes, and empowering families to better care for children and to demand quality care from health and social systems. Additional research is needed on health needs across the life course, health system performance for children and families, and large-scale evaluation of promising health and social programmes.

Figure 1

Coverage versus quality of care in the neonatal and early childhood periods by region Data on coverage and quality of care provided for institutional delivery and postnatal care (A), care for children with diarrhoea (B), and care for children with suspected pneumonia. Data taken from the latest Demographic and Health Survey and Multiple Indicator Cluster Survey conducted in 95 countries between 2010 and 2018., Country-level estimates are weighted using individual survey weights and regional averages are weighted according to each country's weighted sample size. Countries, survey years, and regional classification are available in the appendix (pp 4–10). *Proportion of all live births in the past 3 or 5 years (Demographic and Health Survey) or last live birth in the past 2 years (Multiple Indicator Cluster Survey) born in a health facility (n=97 countries). †Proportion of last live birth in the past 2 years who received postnatal care within 2 days of birth (n=82 countries). ‡Proportion of all children aged 0–59 months with diarrhoea in the past 2 weeks who sought care from an appropriate facility or provider (excluding traditional attendant, pharmacy, or shop; n=77 countries). §Proportion of all children aged 0–59 months with diarrhoea in the past 2 weeks who received oral rehydration solution (n=94 countries). ¶Proportion of all children aged 0–59 months with suspected pneumonia (ie, cough, short and rapid breaths, and problem in the chest) in the past 2 weeks for whom advice or treatment was sought from an appropriate facility or provider (excluding traditional attendant, pharmacy, or shop; n=90 countries). ||Proportion of all children aged 0–59 months with suspected pneumonia (ie, cough, short and rapid breaths, and problem in the chest) in the past 2 weeks who took antibiotics (n=84 countries).

Figure 2

Quality of reproductive health services for adolescent girls (aged 13–19 years) by region Data taken from the latest Demographic and Health Survey conducted in 58 countries between 2010 and 2018. Country-level estimates are weighted using individual survey weights and regional averages are weighted according to each country's weighted sample size. Countries, survey years, and regional classification are available in the appendix (pp 4–10). *Proportion of adolescent girls who were informed about potential side-effects when first prescribed the modern contraceptive method they were using. In each country in eastern Europe and central Asia, the surveys included fewer than 25 adolescent girls who obtained a modern contraceptive method; therefore, that region was not included. †Proportion of adolescent girls who had their blood pressure checked, and urine and blood taken at any point during pregnancy. ‡Proportion of adolescent girls who gave birth in a hospital according to the facility categories used in the Demographic and Health Survey. §Proportion of adolescent girls who had any health checkup by a health provider (ie, by asking questions or examining them) after giving birth in any facility before discharge.

Figure 3

Proportion of adolescents and older individuals across middle-income countries in Latin America and the Caribbean, and HICs who report having a regular doctor or usual place for medical care Data in six middle-income Latin American and Caribbean countries taken from the Inter-American Development Bank survey conducted in 2013 on primary care access, use, and quality. Data for HICs taken from the International Health Policy Survey conducted by the Commonwealth Fund across 11 HICs in 2013. Country-level estimates are weighted using individual survey weights. Countries, survey years, income groups, and regional classification are available in the appendix (p 11). HICs=high-income countries.

Figure 4

Endorsement and confidence in health systems among adolescents (aged 18–19 years) in 17 LMICs and 11 HICs Proportion of adolescents who agreed that their health system worked pretty well and that only minor changes were needed (A) and who were confident that they could get the care they needed if they got sick the following day (B). Data for LMICs taken from a nationally representative survey conducted by the Inter-American Development Bank on primary care access, use, and quality across five middle-income Latin American and Caribbean countries in 2013, and an internet survey conducted by The Lancet Global Health Commission on high-quality health systems in the Sustainable Development Goals era across 12 LMICs in 2017. Data for HICs taken from the International Health Policy Survey conducted by the Commonwealth Fund across 11 HICs in 2013. Country-level estimates are weighted using individual survey weights. Countries, survey years, income groups, and regional classification are available in the appendix (p 11). HICs=high-income countries. LMICs=low-income and middle-income countries.