At ISQua, we are committed to advancing quality and equity in health systems worldwide. In this thought-provoking piece, ISQua Board Member Camilla Covello reflects on one of the most pressing — yet often overlooked — barriers to achieving truly integrated and equitable care: governance. Drawing on her experience across health systems, she explores why strengthening management structures is essential to delivering meaningful, sustainable improvements in care.
What Stands Between Health Systems and Equity?
The answer lies in governance. Without structure, care integration remains out of reach.
While progress in access is evident, the main challenge facing health systems does not lie in care delivery itself, but in how these systems are governed. Without structured governance, meaningful integration is not possible — and this is precisely where one of the greatest barriers to truly integrated and equitable care lies.
Discussions around primary care, integrated care, and health equity are still often framed as primarily clinical challenges. In practice, however, the fragmentation we see on a daily basis is far more a result of gaps in strategic management than of clinical limitations. There is no shortage of qualified professionals or well-designed theoretical models. What is missing is alignment between strategy, management, and frontline care.
From Fragmentation to Alignment
There is a fundamental difference between integrating services and integrating management. Care networks may be well designed on paper, with defined pathways and organized levels of care. Yet without alignment between leadership, operations, and the frontline, integration does not materialize. The system begins to operate in silos, undermining continuity of care.
This challenge is compounded by misaligned incentives. In many contexts, health systems still operate under a volume-driven logic rather than a value-based one. What gets measured is activity — the number of consultations, tests, and procedures — rather than clinical outcomes and patient experience. This model is not only inefficient, but it also deepens inequalities by prioritizing what generates more activity, rather than what creates the greatest impact for those who need it most.
Another direct consequence of weak governance is the absence of integrated indicators. When each area measures what it considers relevant, the ability to see the patient journey as a whole is lost. Without this systemic perspective, it becomes difficult to identify inequalities, address gaps, or drive consistent improvement. Equity ultimately depends on integrated data and evidence-informed decision-making.
Strengthening Systems Through Governance
In this context, accreditation emerges as a strategic lever. By establishing clear and measurable standards, it helps translate good intentions into consistent practice, reducing variability and increasing predictability in outcomes.
Throughout my experience, I have seen firsthand how management decisions directly influence care outcomes. From the definition of care protocols to how teams are trained and led, every decision shapes the quality of care delivered. Management decisions , such as defining indicators or redesigning care pathways, have a direct impact on waiting times, risk reduction, and clinical outcomes.
If we are to move forward in advancing integration and equity in health, the focus of the discussion must shift. It is not only about redesigning care models, but about strengthening the governance structures that sustain them. It is management that ultimately determines whether we can deliver care that is integrated, efficient, and fair.
Transforming local health systems into global references is possible, but it requires maturity in how they are led and organized. Integrating care necessarily begins with integrating management. Without this, any attempt at progress will, at best, be partial. And in healthcare, partial is rarely enough.
Camilla Covello
Board Member, ISQua & Board Member, ISQua EEA
