Illustrative actions to support equitable provision of quality health services
| Illustrative actions to support equitable provision of quality health services | Quality domains implicated | Case examples |
| Health services should address the disproportionate risk of physical and mental ill health experienced by marginalised subpopulations through responsive reconfiguring of service delivery models for successful prevention and management of disease | Effective People-centred Timely Integrated | Outreach screening for marginalised populations: Systematic household-based and mobile outreach tuberculosis (TB) screening can address the geographic and financial barriers to access, reduce stigma and increase patient awareness. Earlier diagnosis can improve health outcomes and lessen the socioeconomic impacts of TB, for example, decreased work absence and reduced earning loss.16 For example, one Nigerian state has integrated outreach TB screening with COVID-19 screening and vaccination; done in non-stigmatising ways, this has been successful in overcoming healthcare access barriers but also in building trust within communities for increased service uptake17 |
| Language and literacy needs should be accounted for to enable effective communication for accurate diagnosis and dissemination of treatment advice | Safe Effective People-centred Timely Efficient | Use of interpreters and translators: Evidence shows that use of medical translators improves patient safety, quality of care and health outcomes for people who do not speak the same language as their health and care worker and at limited additional cost.18 19 In the UK, the National Health Service (NHS) Act 2006 states that NHS England, ‘in the exercise of its functions, must have regard to the need to reduce inequalities between patients with respect to: their ability to access health services; and the outcomes achieved for them by the provision of health services’.20 Guidance is available to support local commissioners of primary care services when commissioning translation or interpreting services21 |
| Health workers should be aware of how physical and mental health problems may present, manifest and respond to treatment differently due to biological and social factors and be able to manage patients accordingly | Safe Effective People-centred Timely Integrated | Sex-specific clinical education, guidelines and research: Among females, myocardial infarction accounts for one-third of all deaths globally and has worse outcomes and higher mortality than in males.22 Reasons for this disparity include male-biased clinical research and insufficient awareness by health professionals of sex-specific symptoms and presentation of cardiovascular disease (CVD). The Lancet Commission to reduce global burden of cardiovascular disease in women by 2030 recommends the development of educational programmes on CVD in women for healthcare professionals.22 Sex-specific clinical recommendations for primary prevention of CVD in women have been produced by the American College of Cardiology.23 The European Union is committed to addressing sex and gender inequalities in research and innovation and provides methodological tools for sex, gender and intersectional analysis and case studies on how these can be applied in the field of health24 |
| Intercultural care and integration of public and private (including non-governmental organisations, voluntary, community and social enterprise organisations and traditional medicine) health sectors should be used to help people navigate the patient pathway to access quality care | Safe People-centred Timely Efficient Integrated | Integration of traditional medicine and intercultural care into national and local health systems: The WHO established a Global Centre for Traditional Medicine, responsible for creating an evidence base for policies and standards on traditional medicine practices and products and supporting countries to integrate it as appropriate into their health systems and regulate its quality and safety for optimal and sustainable impact.25 There are examples of intercultural care interventions to improve quality of maternity services and address health inequities including: The Australian Queensland government’s ‘Growing Deadly Families Aboriginal and Torres Strait Islander Maternity Services Strategy 2019–2025’ which prioritises creation of an ethnically representative maternity workforce with culture competence delivering services codesigned with communities; and the Pan-American Health Organisation’s culturally safe childbirth tool and manual to guarantee the safety of childbirth for indigenous women26 27 |
| The health system should account for and be responsive to life circumstances and adverse living and working which influence service use and pose barriers to accessing health and care services. Patients should receive the required social support to facilitate effective access to health services, across the full continuum of care | Effective People-centred Efficient Integrated | Integrated health and social care: People experiencing homelessness face a range of barriers to effective service access and also tend to have greater health needs, largely influenced by social determinants of health. In recognition of this, the Neunerhaus non-governmental organisation in Austria worked to address the needs of people experiencing homelessness through integrated social and healthcare.28 By providing health and dental care, housing and counselling in the neighbourhood of homeless shelters, Neunerhaus focused on addressing exclusion and achieving sustainable improvement in social conditions that influence health |
| Attention should be given to preventing the negative impact of corruption on equitable access to health services (eg, informal payments, stockouts of public sector medicines due to drugs being sold on the black market, etc) | Safe Effective Timely Efficient | Minimising corruption risks in COVID-19 vaccine roll-out: Corruption risks in some settings threaten to impede whole population access to safe and effective COVID-19 vaccines necessary for pandemic control. Corruption threats include substandard and falsified vaccines, vaccine theft, leakages in emergency funding designated for the development and distribution of vaccines, nepotism, favouritism and corrupted procurement systems.29 There is an evidenced nexus between corruption and governmental and health sector performance.30 The WHO supports countries to focus on anticorruption, transparency and accountability in national health policies, strategies and plans31 |
| At the point of delivery, healthcare must be devoid of discrimination and stigmatisation, including in relation to racism, classism and sexism, known to detrimentally affect provider behaviour and decision making | Safe Effective People-centred Timely | Decolonisation of medical education and diversification of the workforce: Decolonisation, diversity and inclusion, antiracist and human-rights based approaches offer potential entry points to addressing discrimination at the point of healthcare delivery.32 The Joint United Nations Statement on ending discrimination in healthcare settings highlights areas for targeted action.33 An example of action at health workforce level is decolonisation of medical education by the Northern Ontario School of Medicine. The school reserves places for indigenous applicants, delivers core modules on indigenous health, provides a 1-month residency programme whereby students live and work in indigenous communities, and promotes activities associated with advocacy and public health of indigenous communities11 |
| Social participation platforms should be in place for codesign, decisions on coimplementation, and comonitoring and evaluation of health services and action on social determinants with communities | Safe Effective People-centred Efficient Timely Integrated | Participatory processes for health decision making and service delivery: WHO has published a handbook and toolkit on social participation to support stakeholders to meaningfully engage with the population, communities and civil society.14 34 Thailand’s National Health Assembly’s ‘People Sector’ has reportedly motivated, enabled and empowered communities to engage with the health policy-making process.14 Health mediation programmes are one example of implementation of social participation tools. In Romania, The Roma Health Mediation Programme appointed Roma specialists to develop its training. The role of mediators included facilitating communication between patients and clinical staff; advising on bureaucratic processes with the Roma population to ensure their medical assistance; and conducting community work with Roma to encourage prevention in healthcare and to improve access to the healthcare system34 |