## Takeaways - Quality of healthcare should not be defined only from clinical indicators, but also the perception of patients that drive service utilization and are essential to increasing demand - The paper six specific challenges related to the conceptualization and measurement of the quality of care: perceived quality as a driver of service utilization; quality as a concept shaped over time through experience; responsiveness as a key attribute of quality; the role of management and other so-called upstream factors; quality as a social construct co-produced by families, individuals, networks and providers; and the implications of our observations for measurement. - Quality of care cannot be understood outside social norms, relationships, trust and values - We need to improve not only technical quality but also acceptability, responsiveness, and levels of patient-provider trust. Thus, measurement approaches need to be reconsidered. - An improved understanding of all the attributes of quality in health systems and their interrelationships could support the expansion of access to essential health interventions. - If uptake of health services is to be increased, we require not only better technical quality but also better acceptability and patient-centredness – across the continuum of care. Perceptions of quality are shaped by interconnected community, health-system and individual factors. Moreover, quality of care cannot be understood fully without some appreciation of the social norms, relationships and values and trust within the communities and societies where care is provided. --- ## Principles for measuring the quality of health care - Measure aspects of care that go beyond technical quality, e.g. responsiveness, acceptability and trust. - Measure perceived quality and compare with clinical quality. - Measure quality at different points in the patient pathway through the health system. - Measure the immediate and upstream drivers of quality of care. - Measure collective and individually assessed quality and its relationship to power, social norms, trust and values.