HQ Team
July 24, 2026: Nearly one in six people surveyed across 18 countries rated a textbook case of poor primary care, including a missed diagnosis, no follow-up, rushed advice, as “fair” or better, according to a new cross-sectional study of 18,312 adults published in The Lancet Primary Care.
The People’s Voice Survey collected data from 18 countries between 2022-23. These countries were: Ethiopia, Nigeria, Kenya, South Africa, Colombia, Peru, Mexico, Argentina (Province of Mendoza), Uruguay, Laos, India, China, South Korea, Romania, Greece, Italy, the UK, and the USA. Adults aged 18 years and older with at least one health-care visit in the past 12 months were surveyed.
The finding matters because patient satisfaction scores, long used by health systems to judge themselves, may be measuring low expectations rather than good care.
How the study tested what people actually expect
Researchers led by Todd P Lewis and Margaret E Kruk used the People’s Voice Survey, showing respondents two fictional clinic visits — one deliberately poor, one adequate — and asking them to rate each. The gap between what people accepted and what was actually good revealed their true benchmark for quality, independent of any real visit. Overall, 16.1% showed “low expectations” (tolerating the bad visit), while a striking 64.4% showed “high expectations”, rating a genuinely adequate (competent, if unremarkable) visit as merely good, fair, or poor.
South Korea and the UK sit at opposite extremes
Tolerance for poor care ranged from just 6.3% of respondents in the UK to 41.1% in South Korea — a nearly seven-fold gap. India wasn’t far behind South Korea, at 31.2%. The authors suggest this isn’t simply about wealth: national health spending barely correlated with how much bad care people were willing to accept (r=–0.15). The stakes of misjudging quality are real, not academic.
A separate 2018 Lancet analysis by the same senior author, Margaret Kruk, found that poor-quality care already kills roughly five times as many people worldwide each year as HIV/AIDS does.
Why ‘patient activation’ beat income as a predictor
Older age, higher income, and more education each modestly reduced the odds of tolerating bad care. But one factor stood out: patients who felt confident raising concerns with their provider and saw themselves as responsible for their own health, described in the study as “activated”, were less likely to either under- or over-rate care. The authors note that such patients appear better equipped to tell poor-quality care apart from adequate care, regardless of their income or education level.
Italy’s paradox: too much distrust of good care
Even where care was rated adequate, 85% of Italian respondents still marked it down; the highest rate of any country, hinting at a communication gap between citizens and their health system rather than an actual quality failure.
Globally, primary care already handles more than 80% of people’s routine health needs, according to WHO-aligned estimates from the Primary Health Care Performance Initiative, making public misjudgment of it a policy-relevant blind spot, not a niche statistic.
The takeaway for health systems, including India’s
The researchers conclude that satisfaction surveys can mask real problems: populations with low expectations may under-report failing care, silently letting standards slide. Their recommendations are: Invest in health literacy and patient activation. This has direct relevance for India, where 31.2% of respondents showed low expectations, well above high-income peers like the UK. Raising awareness of what “adequate” care actually looks like, the study argues, may do as much for accountability as raising healthcare budgets.
Source: Lewis TP, Sabwa S, Breda J, et al. Population expectations of primary care quality in 18 countries: a cross-sectional analysis of data from the People’s Voice Survey. Lancet Prim Care 2026; 2: 100151.
