title: Improving health system quality in low- and middle-income countries that are expanding health coverage: a framework for insurance.
abstract: OBJECTIVE
  Low- and middle-income countries are increasingly pursuing health financing reforms aimed at achieving universal health coverage. As these countries rapidly expand access to care, overburdened health systems may fail to deliver high-quality care, resulting in poor health outcomes. Public insurers responsible for financing coverage expansions have the financial leverage to influence the quality of care and can benefit from guidance to execute a cohesive health-care quality strategy.
  
  
  METHODS
  and selection Following a literature review, we used a cascading expert consultation and validation process to develop a conceptual framework for insurance-driven quality improvements in health care.
  
  
  RESULTS
  The framework presents the strategies available to insurers to influence the quality of care within three domains: ensuring a basic standard of quality, motivating providers and professionals to improve, and activating patient and public demand for quality. By being sensitive to the local context, building will among key stakeholders and selecting context-appropriate ideas for improvement, insurers can influence the quality through four possible mechanisms: selective contracting; provider payment systems; benefit package design and investments in systems, patients and providers.
  
  
  CONCLUSIONS
  This framework is a resource for public insurers that are responsible for rapidly expanding access to care, as it places the mechanisms that insurers directly control within the context of broader strategies of improving health-care quality. The framework bridges the existing gap in the literature between broad frameworks for strategy design for system improvement and narrower discussions of the technical methods by which payers directly influence the quality.
authors: Department of Medicine, Weill Cornell Medical College, 525 E. 68th Street, New York, NY 10065, USA. kmate@ihi.org.
authors: Kedar S
authors: KS
authors: Mate
authors: Zoe K
authors: ZK
authors: Sifrim
authors: Kalipso
authors: K
authors: Chalkidou
authors: Francoise
authors: F
authors: Cluzeau
authors: Derek
authors: D
authors: Cutler
authors: Meredith
authors: M
authors: Kimball
authors: Tricia
authors: T
authors: Morente
authors: Helen
authors: H
authors: Smits
authors: Pierre
authors: P
authors: Barker
mesh_terms: D003906:Developing Countries; D018166:Health Care Reform; D006301:Health Services Needs and Demand / Q000458:organization & administration / Q000592:standards; D006801:Humans; D019458:Insurance Coverage / Q000458:organization & administration* / Q000592:standards; D007348:Insurance, Health / Q000458:organization & administration / Q000592:standards; D017146:Models, Organizational; D058996:Quality Improvement / Q000458:organization & administration*; D011787:Quality of Health Care / Q000458:organization & administration / Q000592:standards
keywords: access to health care; developing countries; health systems strengthening; insurance; quality assurance; quality improvement; universal coverage