On World Health Day, Putting Quality at the Center of Universal Health Coverage

Quality. An elusive, hard-to-measure concept and current buzzword in discussions on the provision of health services. This word is everywhere, and it is rare to hear or read anything about health services without “quality” entering the dialogue. That is definite progress, especially when it comes to universal health coverage (UHC). We have gone from a conversation about “health for all” to one of “quality health for all,” clearly recognizing that without this qualifier, UHC will not come close to addressing the inequities in access and service around the world.

According to the 2017 Global Monitoring Report on UHC, the provision of high-quality services means that people are correctly diagnosed and receive necessary and currently agreed-upon interventions. While the report goes on to acknowledge that health systems strengthening is key to achieving UHC, this definition of quality restricts it to solely the point of service delivery, ignoring the fact that the delivery of high-quality services at the clinic level is dependent on a country’s legal, policy and regulatory spheres. These domains affect both the rights of individuals receiving care and the quality of care delivered.

While the interdependence between quality and governance is a factor in the provision of any health service, it is perhaps nowhere more crucial than in the provision of sexual and reproductive health services. The sexual and reproductive health of women and girls—particularly their ability to access modern contraception—is a critical factor for improving their lives and overall well-being. However, high-quality contraceptive services, information and supplies remain out of reach for 214 million women and girls around the world who want to prevent pregnancy. This reality not only paralyzes progress for women; it reflects a fundamental disregard of their rights. And as long as women’s and girls’ right to high-quality sexual and reproductive health care remains unfulfilled, progress on UHC will be stalled.

To better understand the systemic drivers and barriers of quality reproductive health care and the fulfillment of women’s rights, PAI embarked on a multi-year initiative called QUEST (Quality Upheld, Every Service, Every Time). As part of this initiative, PAI worked with partners in five geographies to analyze the gaps, opportunities and challenges of providing high-quality, rights-based reproductive health care. A synthesis of these analyses is available in our new publication, A Global Structural Examination of Quality and Rights. Despite significant variation in the legal economic and socio-political contexts of QUEST geographies, several key themes emerged that were common in the Democratic Republic of Congo, Ethiopia, India, Myanmar and Pakistan:

• Delivery of quality health services is dependent on a functional and coordinated government at the national and subnational levels.
• The absence of an open, constructive relationship between government and civil society inhibits the ability of the health system to deliver quality services that meet community needs. It also impedes accountability from the government and health system for ensuring reproductive health and rights.
• The gap between written policies and implementation, as well as a lack of harmonization among legal and policy systems, hinders the provision of high-quality services. Existing policies and laws governing health services and rights are difficult to reverse or override with new frameworks.
• Commodity stockouts, inadequately trained health care staff and unethical practices negatively impact quality of care and women’s rights.
• The best efforts of legal, regulatory and policy frameworks to address quality and rights are easily overridden by values and social norms.
• Youth and unmarried women are disproportionately affected by social and cultural taboos around sex and reproductive health.

Each of these themes is instructive not just for the provision of quality reproductive health services, but also for the provision of these services within UHC. As duty-bearers, governments have a responsibility to protect and fulfill the reproductive health and rights of their citizens—including provision of high-quality services and care. Including reproductive health services within UHC is one way to fulfill this responsibility, but that means looking beyond service delivery to understand the influencing environment, health system management and strength, as well as values and community norms that ultimately impact both the client-provider interaction and health outcomes. Fulfilling the human right to health—including reproductive health—demands a multifaceted, coordinated approach at the national and subnational levels. Creating harmony in policy and in practice is a must if we are to achieve the UHC vision of quality health for all.