The Quintuple Aim: measuring equity.

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The recent focus on health equity as a new fifth Aim for high-performing patient care is gaining traction among funders and commissioning bodies in Australia.

The Quadruple Aim has been serving as a well-regarded framework for optimising health system performance worldwide since 2014. It focuses on improving:

  • people’s experience of care
  • the health of populations
  • the cost-efficiency of the health system
  • the work life of health care providers.

The inclusion of an equity lens to create the Quintuple Aim comes at a crucial time, with increasing challenges in terms of health care access, rising vulnerabilities for some community segments and disparities in their health outcomes, as well as commitment to new and innovative but untried health care delivery and funding models.

In Australia, as elsewhere in the world, under-resourced communities and marginalised populations continue to experience various barriers in accessing health care. The increasing cost pressures on the general practice sector, compounded by the continuing impacts of COVID-19 and increasing living expenses, have amplified the risks of inequity in access to health care. One of the biggest current issues — out of pocket costs for basic primary health care – are leading to reports of more people going without medicines, appointments and diagnostics[1].

  • Around 7 million people – or 28% of the Australian population – who live in rural and remote areas are vulnerable to higher rates of hospitalisations, injury, death, and overall poorer health outcomes than their counterparts in metropolitan areas.
  • These individuals utilise Medicare, including general practitioner visits, up to 50% less than those living in major cities and inner regional areas[2], while also being less likely to receive dental care, medical specialist attention[3], and participate in cancer screening programs.

So how should we be thinking about equity in the context of the Australian primary health care system?

How can we strengthen our approach to addressing equity in a systematic way?

How can we embed equity into our design thinking (to design for outcomes) and our evaluation thinking (to measure what matters)?

We need to consider some steps to implement the fifth aim into health care delivery and clinical practice at local and catchment level:

  1. Identify disparities at the local and catchment level
  2. Design and implement evidence-based interventions to reduce disparities
  3. Invest in equity measurement
  4. Incentivise the achievement of equity (What might a financial model to incentivise equity look like?)

Measuring equity in primary health care services is critical for ensuring that all individuals have access to high-quality care, regardless of their background, socioeconomic status or location, but measuring equity can be challenging. At Larter, we have recently been brainstorming different approaches to measurement.

  • How do we define equity? What do we mean by equitable access to care? Equitable outcomes? Equitable patient experience?
  • Is health equity measurable?
  • What metrics can be used to measure progress towards equity in primary health care services?
  • Should we set equity benchmarks?
Image by on Freepik

When we think about our work in the commissioning environment, with Primary Health Networks (PHNs) and state/territory health catchment areas – in the context of service design, evaluation or commissioning strategy development – we see a number of opportunities to measure equity in the context of the Quintuple Aim.

Health disparities analysis (including service utilisation)

  • Commissioning bodies can undertake health disparities analyses by catchment as part of regular gap analyses and needs assessments, which would include deep dives into patterns of health service utilisation by demographic cohort, amongst other insights

Patient satisfaction surveys

  • Commissioning bodies can undertake patient satisfaction surveys to assess patient experience with health care services, designed to capture feedback from diverse patient populations, with a focus on those from underserviced communities and/or backgrounds.

Workforce wellbeing

  • Commissioners can assess workforce wellbeing through surveys that measure burnout, job satisfaction, and work-life balance. Assessments can identify any differences in wellbeing among different groups, such as clinicians serving in rural or remote areas, or those working with underserved populations.

Workforce diversity

  • A diverse health workforce can contribute to culturally competent care, which can positively impact health outcomes for diverse populations. Commissioners can assess the diversity of the local health workforce, including clinicians, staff, and leadership positions by collecting data in indicators of Aboriginal and Torres Strait Islander status, ethnicity, gender, age, and other relevant characteristics.

Data-informed improvements

  • Commissioning bodies can establish regular reporting and monitoring mechanisms to track progress on equity-related metrics over time. This can involve setting evidence-based targets and benchmarks for key equity indicators. Regular monitoring can help identify trends, patterns, and areas for improvement, and ensure that equity remains a priority in the strategic planning and commissioning.

Equity is an important concept to consider when it comes to commissioning the health care market more broadly. The distribution of funding for primary care services via competitive procurement activity, providing equitable access to funding across the region, and supporting a more diverse marketplace for commissioning bodies to award funds will result in better health outcomes for our communities. Supporting market-readiness and diversity (i.e. Who is applying for funding, and who is being awarded funding?) need to be ongoing endeavours.

How Larter can help

Measuring equity in primary health care is complex and multi-dimensional, requiring a combination of quantitative and qualitative data sources, as well as a comprehensive understanding of the local context and social determinants. For example,

  • We find tools such as ‘I statements’, ‘we statements’, personas, and patient journey mapping provide meaningful insights on service access, experience and person-centred care. These are particularly useful when funders and commissioning bodies in Australia need to tailor their approach to measuring equity based on local context (i.e. specific populations, communities, health care market).
  • Applying principles of design thinking to work with community members from underserved populations and those at risk of poorer health outcomes provides very valuable, real-world, understanding of issues which impact greatly on equity outcomes.

If you are considering options to strengthen equity for your local primary health care sector and community, contact us for a conversation on 1800 527 837 or reach out at


[1] Australian Institute of Health and Welfare. Rural and remote health [web article]. 2022 Jul 07.

[2] Australian Bureau of Statistics. Patient experiences in Australia: summary of finding. 2022 Nov 18. health/health-services/patient-experiences/latest-release