Shift 3: From inequities to fairness and accountability

Some inequalities in health are unavoidable, since they stem from genetic differences or other factors beyond control. Health inequities, in contrast, are defined by WHO as “avoidable, unfair, or remediable differences among groups of people, whether those groups are defined socially, economically, demographically, or geographically or by other means of stratification” (WHO 2021). The goal of health equity implies that “everyone should have a fair opportunity to attain their full health potential and that no one should be disadvantaged from achieving this potential” (WHO 2021). Most observed health and health care inequities—between individuals and between populations—could be reduced or even eliminated by addressing the structural determinants of health along with disparities in health care resource allocation (box 3.5).

What is meant by fairness and accountability in PHC?

Fairness in health and health care refers to the absence of structural and systemic inequities that could be addressed through health promotion, disease prevention, and medical care. Fairness also encompasses the just distribution of the burden of health care costs according to people’s ability to pay—precluding any out-of-pocket payments, no matter how minimal, at the point of service. Finally, fairness entails a respectful and appropriate response to the nonmedical needs, rights, and expectations of those seeking and obtaining health care, delivered through a dignified interaction with providers (World Bank 2013). Fairness is thus closely linked to people-centeredness.

Accountability, in its simplest form, is the obligation to ensure that health and health care services are timely, effective, safe, appropriate, cost-conscious, and people-centered. As such, it requires a level playing field in the nexus of interactions among communities and care seekers, health care providers, and payers, often mediated through governance, that is, institutions, laws, and regulations.

PHC can address inequities in health and health care in multiple ways. One means—limited but important—is through primary care as the preferred first point of patients’ contact with clinical services to address illness, sickness, or disease (World Bank 2013). PHC networks can also deploy, contribute to, or promote a comprehensive set of community-based interventions to

59