Underuse—the failure to deliver a health service that is highly likely to improve the quality or quantity of life, which is affordable, and that the patient would have wanted—is responsible for considerable avoidable morbidity and mortality. For example, WHO estimated1 that in 2015, 1·5 million children died of vaccine-preventable illnesses. The Born too Soon Preterm Action Group estimates that an 84% reduction in the more than 1 million annual deaths in preterm babies could be achieved through universal health coverage and use of selected interventions, such as antenatal corticosteroids (panel 1) and kangaroo mother care, which involves maintaining prolonged skin-to-skin contact between the baby and mother; however, the uptake of such interventions has been painfully slow.
Underuse varies substantially between and within countries. For example, high-income countries (HICs), which already have relatively low cervical cancer rates and well established screening programmes, have documented a 68% reduction in high-risk human papilloma virus (HPV) infection rates as a result of HPV immunisation programmes.9 By contrast, in India, where more women die from cervical cancer than childbirth, access to HPV vaccination and even to low-technology screening, such as visual inspection of the cervix with acetic acid, is limited.10
Key messages
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Underuse is responsible for substantial suffering, disability, and loss of life worldwide, in both high-income and low-income countries
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Underuse is prevalent across different types of health-care systems, payment models, and health services
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The causes of underuse are multi-layered: from inadequate access, health system failures, clinicians being unaware or unskilled to provide required interventions, and patients not accessing or declining them
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Underuse occurs alongside overuse, particularly in areas where there is competitive tension between profitable and low-cost interventions
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Policy makers, funders, clinicians, and civil society urgently need to recognise, invest, and resolve the slow uptake of effective, affordable, but non-promoted interventions
Underuse and overuse can occur simultaneously. A common tragedy in both wealthy and poorer countries is the use of expensive, and sometimes ineffective, technology while low-cost effective interventions are neglected. For example, a 2013 study in Tanzania found a concurrent increase in maternal mortality and caesarean section in low-risk births;11 at the same time, whether due to distance or financial barriers, only 50% of all deliveries were done by a skilled provider.12
In this paper we review what is known about the scope and consequences of underuse around the world. We undertook a literature search for primary resources and systematic reviews on underuse, supplemented with an iterative citation search of relevant articles. From this literature we offer a description of what is known about the prevalence of underuse and the harm it causes patients, populations, and health systems worldwide.