Quality and equity: a shared agenda for universal health coverage

Introduction

‘Health equity’ or ‘equity in health’ implies that everyone should have a fair opportunity to attain their full health potential. The COVID-19 pandemic has reinforced how far we are from attaining health equity with subpopulations experiencing: differing COVID-19 exposure risks, vulnerability and access to prevention and treatment services; differing health outcomes; and differing socioeconomic impacts of both (a) pandemic control measures and (b) illness and convalescence. For health equity to exist there should be an absence of unjust, avoidable and remediable differences in health across populations.1 Endeavouring towards health equity, Target 3.8 of the Sustainable Development Goals (SDGs) focuses on achieving universal health coverage (UHC)—meaning everyone can access necessary health services of sufficient quality to be effective without experiencing financial hardship.2 The 2030 Agenda for Sustainable Development and its SDGs has as a cross-cutting principle the concept of ‘leaving no one behind’.3 This commitment is reaffirmed in: the United Nations UHC political declaration; the World Health Assembly Resolution 69.11, which calls for ‘health system strengthening for UHC, with a special emphasis on the poor, vulnerable and marginalized segments of the population’; and the zero draft of the WHO CA+, an international instrument on pandemic, preparedness and response that has equity as a guiding principle.4–6 Global commitments have brought a welcome focus on equitable service access and effective coverage, based on a primary healthcare (PHC) approach but for this to be achieved attention must also be given to equity in the quality of services being used, particularly by the most disadvantaged subpopulations. Quality of care is ‘the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with evidence-based professional knowledge’.7 Equity has been consistently highlighted as a key quality dimension alongside safety, effectiveness, people-centredness, efficiency, timeliness and integration.7 Attention to equity as a key dimension of quality is critical for successful resilience and recovery, as well as for ongoing preparedness and response to health threats. In this commentary, we examine the interplay between equity and quality and explore actions that can be taken to address and strengthen their shared contribution to the goal of health for all.

The interplay between equity and quality

Equitable health services should provide care that does not vary in quality on account of age, sex, gender, race as a social construct, ethnicity or indigeneity, geographical location, religion, socioeconomic status, migrant status, disability, language, sexual orientation, political affiliation or other factors. They should respond to the varying health needs, both expressed and unexpressed, of all subpopulations, as well as their differing social circumstances. Thus, equity as a quality dimension goes beyond access and financing. Equal access to healthcare does not equate to equal treatment outcomes if the quality of care received is inequitable, failing to take account of the diverse needs across populations. Delivery of equitable care necessitates an understanding of the complex interplay of factors influencing a person’s health and experience of healthcare services. This in turn requires appreciation of health inequities generated by health system deficiencies and supply-side bottlenecks, as well as those which arise from the wider determinants of health—the conditions in which people are born, grow, live, work and age and which are controlled by other sectoral domains.1 The impact of structural discrimination must not be overlooked. Structural discrimination is in itself a social determinant of health; discrimination modulates other determinants by activating exclusionary dynamics across political, economic, cultural and social domains.8 Social determinants influence risks for ill health, health-seeking behaviours, access to healthcare and positive treatment outcomes, as well as trust in and acceptance of healthcare systems, providers and treatments. The differing needs of subpopulations must be considered when designing and delivering health services as the quality of healthcare experienced is determined by how well an individual’s needs are met. A perspective that takes intersectionality into account is necessary as the compounded discriminatory and oppressive impact of overlapping pathways generating inequities must be recognised if it is to be addressed. Illustrative equity orientated actions that encompass quality of care domains and impact health outcomes are given in table 1. While far from an exhaustive list, the case examples demonstrate how a focus on the nexus between health service quality and equity can achieve improvements in population health.

Addressing inequity in receipt of quality health services

The authors advocate using the entry point of quality of care as a mechanism to help ground equity in everyday healthcare services planning and delivery. A nationally led multi-level whole system commitment is essential, requiring country level contributions by all actors, including government, public and private health service providers, communities, civil society, research institutes and multilateral partners. Development of a National Quality Policy and Strategy (NQPS) is a pragmatic framework for countries to start taking action on equitable health service provision (figure 1). The WHO has developed a NQPS Handbook and offers technical assistance to support strategic direction-setting for quality at country level.9 10

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Ultimately, health systems have the power to be at the forefront of efforts to address health inequities. PHC orientated health system strengthening can serve to enhance both service quality and address structural discrimination, as effective PHC tackles the root causes of poor health, embodies social justice, engages in intersectional and multisectoral approaches, and empowers communities.11 Indeed, PHC-oriented health systems are health systems organised and operated so as to make the right to the highest attainable level of health the main goal, while maximising equity and solidarity. The strategic and operational levers identified in the WHO-UNICEF Operational Framework for Primary Health Care offer concrete entry points for actions to address discrimination, promote intercultural care and enable delivery of equitable high-quality healthcare.12

In implementing UHC, the adoption of progressive universalism is required in the roll-out and expansion of services to ensure they benefit disadvantaged populations at least as much as they benefit better-off populations. Effective delivery of both PHC-oriented health systems strengthening and progressive universalism requires health system actors and policy makers to be aware of and understand the inequities in access to quality healthcare that exist. Collection of data disaggregated by socioeconomic, spatial and demographic factors known to differentially affect health outcomes and linkages across data sets is necessary. Equity-oriented health information systems can enable monitoring of health inequalities in terms of service coverage, morbidity and mortality, and detect inequities in inputs (eg, health personnel, medicines, devices, basic amenities) and responsiveness. In addition, barrier assessments can facilitate identification of factors that influence suboptimal quality to which subpopulations experiencing disadvantage may be disproportionately exposed and can inform the development of health interventions and policies that address health inequities.13 Mixed-method approaches can be employed to explore barriers in relation to the following, for example:

• Availability—for example, lack of availability of appropriately skilled health workforce, necessary equipment, health products; lack of same sex provider for certain services

• Accessibility—for example, financially inaccessible services, geographically inaccessible services, service information provided in formats inappropriate for the heterogeneity of the local population; inaccessible service opening times and systems to schedule appointments.

• Acceptability—for example, service design does not account for cultural beliefs about health and illness; limited connectivity/integration of health services with indigenous/traditional health systems; lack of age-appropriate and gender-transformative service delivery; discriminatory treatment by providers; lack of confidentiality.

• Effective coverage—for example, inadequate treatment adherence as a consequence of: unclear instructions, poor patient–provider relationship, mismatch between treatment prescribed and patient compliance ability; lack of service provider support to ensure patient follow through with timely referral.

To ensure equitable access to quality healthcare across all subpopulations healthcare services and their providers must be responsive to their needs, as outlined in table 1. Meaningful social participation of subpopulation groups in the development, implementation and evaluation of health services, including leadership in quality improvement activities can be a progressive step to achieving this ambition.14 Integration of compassion throughout the healthcare system and at all interfaces can also play a facilitative role. There is evidence that compassionate leadership enables a culture of improvement and innovation and ultimately improves quality of patient care.15 Introduction of indicators of compassion into performance-based finance schemes and supportive supervision checklists may also increase healthcare quality and address health inequities.

Conclusion

To successfully achieve ambitions to deliver quality or equitable healthcare, attention must be given to both. Table 1 demonstrates how equity orientated approaches help deliver on the dimensions of quality and highlights that actions are required at facility, community, regional and national levels. A collaborative effort from all stakeholders across the system (including decision makers, data analysts, healthcare providers, community groups and patients) with an intentional focus on addressing quality through an equity lens could trigger a transformational change in the way healthcare services are delivered, leading to better UHC, improvements in population health and a reduction in health inequities. Tools and approaches exist for integrating equity into national strategic direction on quality of care (figure 1) and this also provides a key entry point for national and subnational dialogue on provision of equitable services based on a PHC approach. By aspiring to quality and equity, stakeholders across the healthcare system can overcome key barriers to the global ambition of UHC.