International evidence shows that enhancement of primary health care (PHC) services for disadvantaged populations is essential to reducing health and health care inequities. However, little is known about how to enhance equity at the organizational level within the PHC sector.
Through the analysis identified
· Ten strategies to guide organizations to enhance their capacity for equity-oriented services,
· Outcomes related to these dimensions and strategies (see Figure 1).
Conceptually, the four key dimensions provide a framework for understanding the essential elements of equity-oriented PHC services when working with marginalized populations. The dimensions are interrelated and overlapping, and include:
a. Inequity-Responsive Care: explicitly addressing the social determinants of health as legitimate and routine aspects of health care, often as the main priority.
b. Trauma- and Violence-Informed Care: recognizing that most people affected by systemic inequities and structural violence have experienced, and often continue to experience, varying forms of violence with traumatic impact. Such care consists of respectful, empowerment practices informed by understanding the pervasiveness and effects of trauma and violence, rather than 'trauma treatment' such as psychotherapy.
c. Contextually-Tailored Care: expanding the concept of patient-centred care to include services that are explicitly tailored to the populations served and local contexts. This may include organizational tailoring to address the local population demographics and social trends (e.g., programs or services addressing HIV, seniors, women's or men's issues, support for new immigrants, etc.).
d. Culturally-Competent Care: taking into account not only the cultural meaning of health and illness, but equally importantly, people's experiences of racism, discrimination and marginalization and the ways those experiences shape health, life opportunities, access to health care, and quality of life.
Ten strategies to guide organizations in enhancing capacity for equity-oriented services
1. Explicitly articulate the commitment to equity in the mission, vision and other organizational policy statements
2. Develop and advocate for structures, policies, and processes to support the enactment of equity
3. Revision use of time to meet the needs of client populations
4. Engage in decision-making on the basis of critical analyses of power differentials, flattened hierarchies within interdisciplinary teams, and shared leadership approaches
5. Tailor care, programs and services to the context of people's lives (e.g., cultural, social, gender, and demographic contexts)
6. Actively counter the impact of intersecting oppressions on health, access to care, and quality of life
7. Create opportunities to promote and fosterengagement with community and other sectors, including participatory engagement by patients
8. Tailor care, programs and services to the populations' individual and group histories, with an emphasis on trauma- and violence-informed care
9. Enhance access to resources that address the social determinants of health with an emphasis on advocacy and inter-sectoral collaborations
10. Optimize use of place/space to meet the needs of client populations
A commitment to equity and social justice in PHC requires recognition of the particular health and social needs of people subject to systematic discrimination and relatively little power. If the PHC sector is to become optimally relevant as a site for population health interventions, PHC organizations will need to prioritize locally-relevant strategies that are explicitly oriented to working with these groups, where it is expected that the greatest gains can be achieved. If equity-oriented PHC organizations are to flourish, they will require support by inter-sectoral government policies and flexible funding models that recognize the essential role of community-based organizations in fostering health equity. The four key dimensions and 10 strategies for enhancing capacity for equity-oriented PHC services are important to hold out as ideals, given the persistence and increasing levels of health and health care inequities across population groups in Canada and other nations.
References.
(Browne et al., 2012)Browne, A. J., Varcoe, C. M., Wong, S. T., Smye, V. L., Lavoie, J., Littlejohn, D., … Lennox, S. (2012). Closing the health equity gap: evidence-based strategies for primary health care organizations. International Journal for Equity in Health, 11( 1), 59. doi : 10.1186/1475-9276-11-59
Bambang Hermanto KMPK 2014
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