Strengthening systems for PHC equity

High-quality PHC is, by definition, equitable and fair (as described in Chapter 1). Fairness underpins the concept of social justice, whereby everybody in society has equal rights, including the right to good health. The United Nations has characterised equity-related determinants of health, which enable or hinder people in achieving their health potential, as social, economic and environmental.1 Cultural determinants of health are interrelated with equity-related determinants for many Indigenous peoples and other groups for whom cultural identity is centred on rights and linked to good health and wellbeing.2 

In Part I (Chapter 3), we highlighted the link between quality of care and equity, describing health equity and CQI as a “natural fit”. An equity focus is essential in CQI, as poor-quality care accounts for more deaths globally than lack of access to care, with the most disadvantaged populations having the worst outcomes.3 Part II described some of the CQI tools and processes for improving PHC. In Part III, we wrote about CQI achievements and challenges, drawing on experiences in Aboriginal and Torres Strait Islander PHC in Australia and on international literature to identify key findings and messages for improving PHC quality. Some are messages for PHC practices, teams and communities. Others are targeted at promoting action at higher levels of the health system (for example, policymakers, regional health authorities) and in other systems that influence the social, cultural, structural and environmental determinants of health. At the heart of these messages is the recognition that globally, and within countries, there is much work to be done to improve PHC quality and to achieve equitable health care and fairer health outcomes.

Improving health equity involves simultaneously dealing with the institutional or structural bias in systems that perpetuate injustice and poor health outcomes (for example, based on ethnicity, race, wealth, gender, disability), and issues such as poverty and unfair wages, lack of access to land and resources intrinsic to survival, and poor access to high-quality education, housing and health care.4 Organisations and individuals involved in PHC can contribute actions that advance these necessary reforms. Health services are ideally positioned to implement strategies to address both the indirect and direct determinants of health (for example, policies and training to address institutionalised racism and other forms of discrimination), and link with other agencies and sectors to integrate service delivery and promote wellbeing.5 Services can also partner with consumer groups, community organisations and researchers to identify and bridge gaps in knowledge and services involving equity-related issues, including ways to deal with systemic racism, and avoidable and unfair differences in the quality of care provided to different groups. PHC teams using CQI can strengthen care systems and sustain the gains made through service initiatives. Everyone involved in CQI, including PHC clients and communities, researchers and service providers as well as program managers and funding bodies, should be an advocate for more equitable policies and practices. In Part IV, we explore how these actions can come together in a comprehensive PHC approach for greater healthcare equity, concluding with considerations for future directions in CQI.

References