Elsevier

The Lancet

Volume 390, Issue 10090, 8–14 July 2017, Pages 169-177
The Lancet

Series
Evidence for underuse of effective medical services around the world

https://doi.org/10.1016/S0140-6736(16)30946-1Get rights and content

Summary

Underuse—the failure to use effective and affordable medical interventions—is common and responsible for substantial suffering, disability, and loss of life worldwide. Underuse occurs at every point along the treatment continuum, from populations lacking access to health care to inadequate supply of medical resources and labour, slow or partial uptake of innovations, and patients not accessing or declining them. The extent of underuse for different interventions varies by country, and is documented in countries of high, middle, and low-income, and across different types of health-care systems, payment models, and health services. Most research into underuse has focused on measuring solutions to the problem, with considerably less attention paid to its global prevalence or its consequences for patients and populations. Although focused effort and resources can overcome specific underuse problems, comparatively little is spent on work to better understand and overcome the barriers to improved uptake of effective interventions, and methods to make them affordable.

Introduction

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

  • Underuse is responsible for substantial suffering, disability, and loss of life worldwide, in both high-income and low-income countries

  • Underuse is prevalent across different types of health-care systems, payment models, and health services

  • 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

  • Underuse occurs alongside overuse, particularly in areas where there is competitive tension between profitable and low-cost interventions

  • 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.

Section snippets

Measuring underuse

Although underuse is known to occur in all countries and health systems in which it has been studied, remarkably little research has focused on determining the global prevalence of underuse, or even the degree to which most medical services are underused in appropriate patients. Most studies of underuse have focused not on prevalence or harm, but rather on methods of remedying the underuse of specific services.

Studies of variations in practice, between and within countries, provide an indirect

Worldwide prevalence of underuse

The following section of this paper provides some estimates of underuse at each of the four stages shown in figure 2.

Harms to patients and health systems

What is the extent of harm caused by underuse? The most obvious and concerning harms are poor patient outcomes—unrelieved symptoms, serious disability, and deaths, including preventable maternal and perinatal deaths. Such adverse outcomes have been documented in both LMICs and HICs (figure 5), but there are also significant harms related to non-clinical outcomes, such as financial burdens for patients and families, spending precious remaining time in a hospital instead of at home, loss of

Conclusion

Underuse occurs at all stages along the care continuum: from poor health-care access, to lack of availability, failure of providers to deliver service, and failure of patients to use it. Underuse also appears to occur across countries, regardless of payment model or health system, and in clinical settings ranging from rural clinics to tertiary hospitals. Despite the fact that underuse is frequently recognised as a problem around the world, obtaining good estimates of its extent is hampered by a

References (57)

  • ZA Bhutta et al.

    Alma-Ata: Rebirth and revision 6 interventions to address maternal, newborn, and child survival: what difference can integrated primary health care strategies make?

    Lancet

    (2008)
  • AD Oxman et al.

    Use of evidence in WHO recommendations

    Lancet

    (2007)
  • Immunisation coverage factsheet No 378. Updated 2016

  • GC Liggins et al.

    A controlled trial of antepartum glucocorticoid treatment for prevention of the respiratory distress syndrome in premature infants

    Pediatrics

    (1972)
  • P Crowley

    Corticosteroids in pregnancy: the benefits outweigh the costs

    J Obstet Gynaecol

    (1981)
  • Effects of antenatal dexamethasone administration in the infant: long-term follow-up

    J Pediatr

    (1984)
  • I Chalmers et al.

    A guide to effective care in pregnancy and childbirth

    (1989)
  • Effect of corticosteroids for fetal maturation on perinatal outcomes. NIH consensus development panel on the effect of corticosteroids for fetal maturation on perinatal outcomes

    JAMA

    (1995)
  • J Mwansa-Kambafwile et al.

    Antenatal steroids in preterm labour for the prevention of neonatal deaths due to complications of preterm birth

    Int J Epidemiol

    (2010)
  • H Litorp et al.

    Increasing caesarean section rates among low-risk groups: a panel study classifying deliveries according to Robson at a university hospital in Tanzania

    BMC Pregnancy Childbirth

    (2013)
  • Geographic variations in health care: what do we know and what can be done to improve health system performance?

    (2014)
  • A Hancioglu et al.

    Measuring coverage in MNCH: tracking progress in health for women and children using DHS and MICS household surveys

    PLoS Med

    (2013)
  • Vital signs: prevalence, treatment, and control of hypertension — United States, 1999–2002 and 2005–2008

  • Tracking universal health coverage: first global monitoring report

  • HI Hall et al.

    Differences in human immunodeficiency virus care and treatment among subpopulations in the United States

    JAMA Intern Med

    (2013)
  • F Ataklte et al.

    Burden of undiagnosed hypertension in sub-saharan Africa: a systematic review and meta-analysis

    Hypertension

    (2014)
  • Glasziou P, Haynes B. The paths from research to improved health outcomes. ACP J Club; 142:...
  • S Mickan et al.

    Patterns of ‘leakage’ in the utilisation of clinical guidelines: a systematic review

    Postgrad Med J

    (2011)
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