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Lancet. 2017 Jul 8;390(10090):178-190. doi: 10.1016/S0140-6736(16)30947-3. Epub 2017 Jan 9.

Drivers of poor medical care.

Author information

Lown Institute, Brookline, MA, USA. Electronic address:
Aragon Agency for Research and Development, Zaragoza, Spain; Aragon Health Sciences Institute, Aragon, Spain.
Ostbayerische Technische Hochschule Regensburg, Fakultät Angewandte Sozial-und Gesundheitswissenschaften, Regensburg, Germany.
Health Division, Organisation for Economic Co-operation and Development, Paris, France.
Lown Institute, Brookline, MA, USA; Menzies Centre for Health Policy, School of Public Health, Sydney Medical School, University of Sydney, NSW, Australia.
Lown Institute, Brookline, MA, USA; Department of Health Policy, Havard T.H. Chan School of Public Health, Cambridge, MA, USA.
Stanford Prevention Research Center, Department of Medicine, Stanford University, Stanford, CA, USA; Department of Health Research and Policy, Stanford University School of Medicine, Stanford University, Stanford, CA, USA; Department of Statistics, Stanford University School of Humanities and Sciences and Meta-Research Innovation Center at Stanford, Stanford University, Stanford, CA, USA.
The Dartmouth Institute for Health Policy and Clinical Practice, Stanford University, Stanford, CA, USA; Geisel School of Medicine at Dartmouth, Hanover, NH, USA.


The global ubiquity of overuse and underuse of health-care resources and the gravity of resulting harms necessitate an investigation of drivers to inform potential solutions. We describe the network of influences that contribute to poor care and suggest that it is driven by factors that fall into three domains: money and finance; knowledge, bias, and uncertainty; and power and human relationships. In each domain the drivers operate at the global, national, regional, and individual level, and are modulated by the specific contexts within which they act. We discuss in detail drivers of poor care in each domain.

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