The following is a guest post by Katherine Andrinopoulos, PhD, MEASURE Evaluation, Tulane University
This week, the United Nations observed Zero Discrimination Day, meant to promote equality before the law and in practice—including healthcare—throughout all member countries of the UN. In public health, we know that zero discrimination is essentially about fairness. It is fundamental that everyone, regardless of their sexual orientation and gender identity, should have access to good care and healthy lives.
In my work with MEASURE Evaluation (funded by the United States Agency for International Development) a colleague and I were working on a report regarding the quality of healthcare for marginalized people. Specifically, we were looking at care for transgender people and men who have sex with men — MSM.
There is a lot that isn’t known about quality, though, which is why we decided it was important to summarize how different researchers, policymakers, and people running programs talked about quality care. We settled on a literature review because we wanted to examine the “state of knowledge” and analyze how this has changed over time. We took a qualitative approach to analyzing texts because we wanted room for ideas to emerge and we wanted to trace themes across different areas of expertise.
Our experience was two-fold. First, we were all but overwhelmed by the number of publications that discuss quality. Then we were underwhelmed by the narrow focus of most of that work. Almost everything was about stigma, from a Western cultural perspective, and written in economically developed countries. And studies were more about MSM than about transgendered people.
Here’s what we didn’t find: There was little examination of healthcare outside the provider level. What about organizations and national health systems, we wondered? There is a lot of “finger pointing” in discussions of quality, with providers being either blamed or heralded for their delivery of quality healthcare—or the lack thereof.
Second, we also noticed little discussion of technical competency and cultural competency regarding MSM and transgender people. There were discussions of “how to” gain technical competency and “how to” use correct terminology rather than discussion of why such competencies were not up to par and explanations of how culture might affect quality of service.
Here’s a summary of the competencies for quality that we considered:
At the provider level: Services should be voluntary, confidential, and timely; delivered in a stigma-free environment with client confidentiality preserved; approach should be non-judgmental and use proper terminology; and life partners should be included in services and support.
At the organizational level: Needs include education and supportive supervision for staff; facilitation and tracking of referrals; nondiscrimination policies; mechanisms to prohibit harassment in public and private spaces; and educational materials that address MSM and transgender people.
At the health system level: We would want to see diverse service delivery models (either embedded in a suite of services or stand-alone HIV services); gender affirmation services combined with HIV services; the recruitment of MSM and transgender people as providers; and national guidelines for quality services.
Moving forward, we hope people will begin to frame their discussions of quality with more detail and move past assuming that quality healthcare is only about creating a stigma-free environment. One would never define healthcare quality for any other group of people as merely the lack of discrimination. We also hope future work looks past the provider level and encompasses the contexts in which providers work — in organizations and health systems.
Find more information about the study here.
For more information about MEASURE Evaluation here.