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As nations move toward universal health coverage (UHC), the stakes on quality of care rise. The poorest people in the world can least aff ord poor quality health care. They do not have the resources to repair the damage when care goes wrong, their development requires a healthy workforce, and money wasted on ineff ective or harmful care is money denied to other essential services. Poor quality care damages wealthy nations, too. Few high-income countries have the political will to increase tax rates, and therefore government investments refl ect zero sum choices—what public health care gets, public schools and public housing lose. Private sector employers, the source of half the health-care spending in the USA, also must trade those costs off against worker incomes, capital investments, and profi t margins. Quality refers to the degree of match between health products and services, on the one hand, and the needs they are intended to meet, on the other. Health care that meets needs is high quality; health care that does not meet needs is low quality. Four papers in a Series in The Lancet focus on two important types of quality defect: overuse of ineff ective care and underuse of eff ective care. With comprehensive reviews of the available evidence, the Series authors leave little doubt that reducing both overuse and underuse must take centre stage in evolving health-care policies. The magnitude of overuse reported by Shannon Brownlee and colleagues may surprise many readers. For example, a study in China found that 57% of patients received inappropriate antibiotics; inappropriate hysterectomies in the USA range from 16% to 70%; inappropriate total knee replacement rates were 26% in Spain and 34% in the USA. WHO has estimated that 6·2 million excess caesarean sections are performed each year—50% of them are in Brazil and China. Underuse of eff ective practices, especially in low-income settings, is less surprising, although its magnitude is harder to estimate. The variation is large across clinical procedures, but, overall, in both low-income and high-income nations, ineff ective, scientifi cally unwarranted care seems to account for close to about one-quarter to one-third of total volume for many procedures, and for some specifi c conditions and procedures, probably quite a bit more. The problems of overuse and underuse highlighted in this Lancet Series call to mind an unexpected fi nding published nearly 30 years ago by the RAND Corporation: that there was no correlation between geographical variation in appropriateness of care and geographical variation in the volume of care. Within the USA, regions with low use of care had the same levels of inappropriate care as regions with high use of care. The same fi nding seems true today on a global scale. No one knows whether, in a perfect world, eliminating all underuse and overuse would produce net savings or increase total health-care costs. In richer nations, especially the USA, the result would almost certainly be reduced costs; in poorer ones, probably not. But, rich or poor, no country can avoid the conclusion that overuse drains opportunities from fi nite health resources—what Nobel Prize winning political economist Eleanor Ostrom called “common pool resources”. For nations with tight constraints on investments in health, reducing overuse could off er the biggest opportunity for releasing resources to address underuse. The social, economic, political, and psychological factors that drive overuse are many, as highlighted by Vikas Saini and colleagues. The authors classify these drivers into three clusters: (a) the fl ow of money and consequent eff ects on incentives and the integration of care; (b) gaps in knowledge, misleading psychological tendencies, and erroneous beliefs; and (c) asymmetries in power between patients and providers, impeding proper consideration of patients’ aims and preferences. These infl uences are highly interrelated. For example, the medical–industrial complex, aiming to increase revenues and profi t, feeds public expectations that more care is always better care (even though it is not), funds the incomes and education Published Online January 8, 2017 http://dx.doi.org/10.1016/ S0140-6736(16)32570-3