Lowering hospital walls to achieve health equity

Reorienting systems to the local: evidence of health inequities

Reorienting health services to be more responsive to local community realities is not new. The promise of primary care has been to bring services closer to people and to alleviate the need for hospital services.2 However, health inequities persist in access to, and use of, primary care as well as hospital services, with inequity magnified as people move through the health system. Similarly, multiple determinants of health such as housing, education, and income as well as less visible causes such as social connectedness, community participation, government policy processes, and corporate actions compound inequity for the same groups disadvantaged through health systems.3 Not surprisingly, illness in individuals also compounds over time, often leading to multimorbidities.4

Local compounding describes how inequities are magnified for different social groups through complex social processes.5 The emergence of inequity is explained by non-linearity and the concept of “sensitivity to initial conditions,” whereby initial conditions are reinforced and interactions can have disproportionate effects. Complex systems thinking is increasingly seen as necessary to make sense of health systems.67 It becomes even more useful when the wider social systems within which health systems are embedded are also conceptualised as complex. Understanding the underlying behaviour of complex systemscan identify actions that are likely to shift community systems from their existing states and stop prevailing health outcomes being repeatedly reproduced.8

Measuring, uncovering, and acting on health inequities

Social action focused on a geographical community can potentially capture many local factors that influence health, especially those associated with poverty.9 However, for some social groups other systemic factors compound geographical and socioeconomic effects. Indigeneity; gender; age; ethnic, religious, or cultural affiliation; disability; or being a new migrant or refugee are characteristics of groups likely to experience health inequities.

In Australia, Aboriginal and Torres Strait Islander people have a life expectancy 10 to 17 years less than other Australians. For Māori in New Zealand the difference in life expectancy compared with non-Māori is about seven years. In both countries, an important contributor to these differences is unequal access to healthcare at all levels of service provision.1011121314 In Pakistan, discrimination against women, including insufficient access to maternal, child, and infant services are major reasons for high rates of infant mortality.1516 Rwanda, on the other hand, has substantially reduced its infant mortality and seen improvements in other health indicators, and has begun to make progress on gender inequality.1718

The performance of health systems is usually measured by hospital admissions, population mortality, and disease incidence. However unmet need, an important driver of health inequities, is poorly measured.19 For some countries, particularly low and middle income, getting good health data of any kind is a challenge, but even in high income countries it is difficult to get good data on all population groups and context specific causes of health outcomes.

The example of the People’s Primary Healthcare Initiative (box 1) shows how even a small amount of local knowledge can inform more effective social actions. This fact is well known within some disciplines20 and increasingly recognised in others.21 The non-linear relation between emergent phenomena (such as inequalities by social group) and initial conditions means that pathways to achieving change, and therefore the effects of intervention, will vary between communities. The challenge is how to systematically gather and feed back local and contextual knowledge to inform how services are designed and delivered, and to empower and adapt to the circumstances of patients and communities.

Fig 1

Number of deliveries at PPHI Sindh facilities

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Good quantitative data on social groups are clearly important, especially for monitoring and enabling accountability.22 Equally important are methods that can capture and respond to less obvious features of populations and their contexts. Working in partnership with patients and communities and using adaptive and participatory methods, such as codesign to incorporate local voices and experimentation and prototyping to explore local solutions, can uncover and address unmet need. Furthermore, strengthening the way that communities are organised and amplifying community voice can help dismantle systemic barriers. Illuminating and communicating how determinants are experienced locally and strengthening community agency can help avoid harms to health caused by the decisions and actions of other societal actors such as corporations, driven by their pursuit for profit, and public and policy organisations using ineffective methods and strategies.

Institutional racism: a systemic pathway to inequity

Institutional racism has been clearly evidenced for indigenous populations; colonisation has shaped the policies, structures, governance, and practices of public institutions, including hospitals, to respond poorly to the needs and rights of indigenous people.23242526 Institutional racism also contributes to systemic societal exclusion and compounds the already devastating effects of poverty. In Australia and New Zealand, institutional racism has been gaining visibility through better identification, measurement, and articulation (boxes 2 and 3). In Pakistan and Rwanda it still has low visibility and the United Nations has highlighted it as a human rights concern.31

Although partial successes have been shown in some areas, such as workforce discrimination,32^“whole system” attempts by hospitals to tackle institutional racism are rare.2433 In Australia, it is early days in creating greater awareness and acceptance. While in New Zealand, one long recognised approach to promote cultural responsiveness and produce system change within hospitals has not been widely implemented or used to redistribute power, as was its intent (box 3).

Investing effectively to achieve shared health goals

Creating culturally safe services, decentralising to empower local communities, or setting social justice goals can be undermined by less obvious relationships and processes. In Rwanda, where health gains are being made, political will for championing health equity has been instrumental (box 4). Achieving political will often requires many years of tumultuous social and political struggle, and even when this will is able to be sustained it remains prone to subversion by the actions of national and global organisations.36 Rwanda, for example, has historically been reliant on fragmented and uncertain donor funding for the health system, constraining cohesive, longer term planning to meet health goals.

Precarious funding and unresponsive investment strategies between different parts of the health system also affect communities. For example, uncertain funding and short term contracts have weakened community based Māori health providers who have facilitated access for Māori to hospital services for many years.37 This vulnerability is exacerbated by pressures from providing unfunded services in response to previously unrecognised need encountered in the community as well as a competitive funding environment that degrades trust and impedes collective community action on shared goals.

Hospitals must act as facilitators

The health system is one of the determinants of health. Moreover, there is considerable evidence that hospitals, and the health systems they are embedded within, contribute to health inequities. Whereas primary and community based health services are likely to have explicit goals of addressing health inequity and prioritising local community needs, hospitals have been slower to adapt and respond effectively to the circumstances of indigenous people and other marginalised population groups such as poor people. Overcoming the institutional inertia of hospitals is important because their power and status makes them uniquely positioned to influence the rest of the health system, including how money is distributed between prevention and primary and acute care.

Some actions are clear for hospitals, and those who make decisions about hospitals, to contribute to improving health equity. Firstly, health equity needs to be a fundamental and shared goal of the health system. Hospitals can unashamedly exploit their pivotal role to champion and facilitate shared actions with health and other sectors. They can also reflect on how their own organisational decisions affect the circumstances of local populations, especially through employment and procurement practices.

Secondly, they can improve their knowledge of local populations with more appropriate data and information, including ways to ensure accountability on equity. This means collecting comprehensive information on all population groups that hospitals serve. It also means uncovering key factors that are harder to identify and measure, such as unmet need and institutional racism.

Thirdly, hospitals can better respond and adapt to local populations, recognising their agency in producing health outcomes and their effect on people’s lives. They can do this by empowering and incentivising the workforce to identify detrimental living conditions or lifestyle factors among inpatients. In coordination with primary care and other relevant sectors, they can support and follow up patients back in the community. Hospitals can normalise community participation that promotes real power sharing and the inclusion of community voice through codesigning services, representation in leadership, and cross-sector advocacy. Moreover, the education and training of the entire workforce, especially leaders and decision makers, needs a rethink to ensure systemic barriers are consciously considered.

Finally, hospitals can be mindful of the unintended, but predictable, consequences of their actions on health equity. For example, the potentially counterproductive behaviours that targets might incentivise, and how other policy actions might create perverse incentives, such as rewarding volume in hospital admissions inadvertently growing hospitals’ share of health budgets. Furthermore, they should look at the way that funding is delivered and managed to ensure community trust is maintained and that resources can be aligned to achieve shared goals.

None of this is new. The Ottawa charter recognised the need to reorient health services more than 30 years ago. However, implementation has often been piecemeal and lacked the close, responsive, and often challenging local relationships required for the meaningful sharing of information (including evidence), power, and resources. A shift in collective thinking towards whole systems is necessary to enable effective action on both emerging and longstanding health inequities. Bold leadership is needed to recognise complex causes and to implement strategies to transform health and community systems to achieve better health for all.