Health systems and quality of healthcare: bringing back missing discussions about gender and sexuality.

Gender and sexuality are recognised as social determinants of health. While gender and sexuality are becoming important frameworks guiding many disciplines and studies, discussions about quality of healthcare (QHC) lack a sufficient focus on these. When QHC studies have considered gender and sexuality the primary focus tends to be on the practice of individual professionals, patients' differential health seeking behaviours or outcomes. This commentary eapplies a gender and sexuality lens to Donabedian's framework to further understand the influence of gender and sexuality in shaping QHC. The framework illustrates how the very foundations of QHC (institutional structures, processes and outcomes), can increase or reduce inequalities in QHC linked to gender, sexuality (as well as other factors). The commentary suggests practices that would reduce these inequalities. In the context of present debates over inequality in medicine, science and global health , this commentary is a reminder that health systems have a critical role to play in ensuring that QHC does not perpetuate them. .