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Sentinels of inequity: examining policy requirements for equity-oriented primary healthcare Lavoie, Josée G; Varcoe, Colleen; Wathen, C. Nadine; Ford-Gilboe, Marilyn; Browne, Annette J Sep 10, 2018

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RESEARCH ARTICLE Open AccessSentinels of inequity: examining policyrequirements for equity-oriented primaryhealthcareJosée G. Lavoie1* , Colleen Varcoe2, C. Nadine Wathen3, Marilyn Ford-Gilboe4, and Annette J. Browne2 On behalfof the EQUIP Research TeamAbstractBackground: Non-government, not-for-profit community health centres (CHCs) play a crucial role within healthcaresystems in fostering equity, acting both as direct providers of services and as sentinels of health and social inequity.In a study of an intervention to promote equity-oriented health care, we enlisted four diverse primary healthcareclinics with mandates to serve highly marginalized populations. All of these CHCs operate as not-for-profit,non-government organizations (NGOs), and have a marginal relationship financially and socially to other partsof the system. The purpose of this paper is to provide an analysis of the factors that shape how CHCs areable to carry out an equity mandate and, from this, to identify what is required at the level of policy toenhance capacity to provide equity-oriented health care.Methods: We systematically examined the clinics’ policy and funding contexts, and identified influences onthe clinics’ capacities to promote equity-oriented health care.Results: We identified three key mechanisms of influence, each playing out against the backdrop of a contested andmarginal position of CHCs within the health care system: a) accountability and performance frameworks; b) patterns offunding and allocation of resources, and c) pathways for emergent priorities. We examine these mechanisms, consideringhow each influenced the pursuit of equity, and propose policy directions to optimize the primary health care sectors’capacity to support equity-oriented health care.Conclusions: Although this analysis is based on a study within a high-income country, we argue that becausethe dynamics between community health centres and broader healthcare systems are similar across nationalboundaries, the implications have applicability to low and middle-income countries.Keywords: Aboriginal, Indigenous, Marginalized populations, Underserved populationsBackgroundHealthcare systems are composed of multiple organiza-tions (Health Departments, Regional Health Authorities,hospitals, independent for-profit services providers, cor-porations and non-government not-for-profit organiza-tions), each with its own governance structure, priorities,accountabilities, mandates and budgetary constraints. Le-gislation, policies and contractual obligations link theseorganizations together to create a system where discon-tinuities of care can become visible and hopefully remed-ied. Where these links are lacking, relationships thatdepend on the will of individuals can act as short-livedpatches across gaps in the system.In both higher, and lower and middle income coun-tries (referred to as HIC and LMIC respectively), twoproblems persist: i) inverse care (that is, those who aremost Marginalized1 and have the greatest health prob-lems have the least access to care), and ii) fragmentationand under-resourcing of care for marginalized popula-tions [2]. In most healthcare systems, non-governmentnot-for-profit organizations (NGOs) such as community* Correspondence: Josee.Lavoie@umanitoba.ca1Department of Community Health Sciences, Faculty of Medicine, Universityof Manitoba, Ongomiizwin Research, 715 John Buhler Research Centre, 727McDermot Ave, Winnipeg, MB R3E 3P5, CanadaFull list of author information is available at the end of the article© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Lavoie et al. BMC Health Services Research  (2018) 18:705 https://doi.org/10.1186/s12913-018-3501-3health centres (CHCs) fill service gaps left by other pro-viders. The Canadian Association of Community HealthCenters (2016) defines CHCs as “multi-sector health andhealthcare organizations that deliver integrated, people-centred services and programs that reflect the needs andpriorities of the diverse communities they serve. A Com-munity Health Centre is any not-for-profit corporation,co-operative, or government agency which adheres to allfive of the following domains:1. Provides interprofessional primary care.2. Integrates services/programs in primary care, healthpromotion, and community wellbeing.3. Is community-centred.4. Actively addresses the social determinants of health.5. Demonstrates commitment to health equity andsocial justice.While we agree that CHCs could possibly be govern-ment agencies, the CHCs with which we workedemerged as a result of government services’ failure tomeet the needs of vulnerable populations [3–5]. A keycomponent of the success of CHCs in meeting needs hasbeen attributed to their community-grounded govern-ance structure, which ensures pathways for communityfeedback on the performance of the CHCs and their pro-grams to meet community needs [6–8]. Other studieshave shown that CHCs that become government agen-cies eventually lose some of their connection to commu-nity needs [9–11].In LMIC, CHCs are remarkably diverse: they span thefor-profit to non-profit continuum, can be religious orsecular, may offer a narrow or broad scope of services,may be larger or quite small, may employ professionals ordepend on volunteer, may exist to fulfil short or long termobjectives, and may be single or multisector focused [12].Funding for their existence may be from internationalsecular or faith-based organizations, from philanthropicfoundations, from membership, and/or a combinations ofthese. In their scoping review of non-governmental orga-nization’s contribution to global health, Anbazhagan andSurekha highlighted the following strengths: great varietyof programs to meet local needs; flexible and agile to en-sure a quick response to emerging needs; generally havelow operating costs; depend on staff and/or volunteerswith a high level of commitment; community-embedded;often less tainted by association with the local or nationalgovernment; and less likely to fall to corruption [12]. Theirdistancing from local and national government also meansthat their accountability to the national health authoritiesvary [13–15]: this can be a strength or a concern, depend-ing on context.In HIC, CHCs emerge out of two separate processes.In some cases, national and/or regional healthcareauthorities promote the creation of CHCs to take onpredefined tasks: services for a selected population suchas Indigenous populations in Canada, Australia andNew Zealand [16, 17] or selected services such as HIVcounselling [18]. The push for smaller government andinterest in harnessing competition among providers tostimulate innovation can act as an added incentive forgovernments to transfer healthcare responsibilities ontothe NGO sector [19]. In other cases, however, CHCssurface primarily in urban areas where surplus capacity(underemployed community-engaged professionals) ex-ists and where unmet needs persist [5], to complementservices provided by for-profit providers (providers inprivate practice) and governmental not-for-profit pro-viders. Although histories vary, in either case, theseCHCs generally emerge as a result of social activism, tomeet the unique, and unmet or poorly met, healthcareneeds of marginalized populations.We argue that CHCs in HIC and LMIC implicitly orexplicitly operate with an equity mandate, leading themto prioritize the development of services and programsthat can best improve the health and social care needs ofthe population(s) they serve. However, as we discuss inthis paper, the capacity to provide health care that isequity-oriented can be undermined by policy and fund-ing contexts. In resource-stretched healthcare systems,these factors are important to understand and address.The CHCs we engaged with for this study were fundedprimarily through public money and occupy a potentiallyambiguous place in the healthcare systems, as they oper-ate semi-autonomously. We have observed the same situ-ation in other CHCs across Canada, Colombia, Australiaand New Zealand [5, 20–24]. Whereas government em-ployees can be directly controlled through firing and othermechanisms in government-owned and operated services,governmentfunders hold CHCs accountable for their useof public finances through accountability frameworks fo-cused on contractually defined outputs and outcomes [8,25]. However these may lead to tension between theCHCs and their funders: CHCs’ accountability to their ser-vice communities often leads them to advocate for thosecommunities to government agencies, which may them-selves be the CHCs’ funders [5, 8] or the policy-makerswho create or prune the space CHCs can occupy. Funderswho can also be service providers, have a dual role in thisdynamic: they can be both the source of unmet needs(since the services they provide are failing to meet theseneeds) and the solution (through their funding of CHCs,albeit at modest levels compared to government deliveredservices). Little is known about how to create a policy-entrenched environment that would support CHCs in cre-ating and operationalizing effective and equity-informedhealth services, when the policy-makers are also thosewho may be falling short of meeting needs. A detailedLavoie et al. BMC Health Services Research  (2018) 18:705 Page 2 of 12understanding of the factors enabling and constrainingthe capacity of CHCs to enact an equity mandate wouldoptimize the effectiveness of their advocacy roles and aidfunders and policy makers in designing better approaches.This paper discusses policy implications stemmingfrom a program of research examining an innovative pri-mary healthcare (PHC) intervention – EQUIP PrimaryHealthcare – designed to enhance capacity for equity-oriented health care (EOHC) at PHC clinics servingmarginalized populations [1, 26–29]. One aspect of thisresearch focuses on the policy environment required tosupport EOHC, defined as care that aims to mitigate thenegative health effects of structural inequities and struc-tural violence [1]. Our work has contributed to inter-national conversations focused on the provision oftrauma- and violence- informed, culturally safe andequitable PHC services to populations affected by healthinequities and marginalizing social conditions [30]. Inthis paper, we identify the policy level requirements toexpand the capacity for equity within healthcare systems,including enhancing the role of CHCs as “sentinels ofinequity”. We highlight key mechanisms that facilitate orimpede the ability of CHCs to realise their equitymandate, and illustrate how these mechanisms operatein the context of four Canadian CHCs that provide PHCfor populations living in marginalizing conditions, whoare generally underserved by other sectors of the health-care system. These findings have implications for im-proving equity across Canada’s healthcare systems andhave relevance more widely.Theoretical foundationsThe CHCs discussed in this study are not-for-profitNGOs. A large body of literature, primarily from the fieldof economics, focuses on the role the NGO sector plays inthe provision of public goods. Of relevance, the theoreticalliterature offers explanations as to why NGOs emerge toprovide public goods in parallel to public institutions, andhow these organizations are positioned in relation to pub-lic institutions. Salamon and Anheier [31] noted six broadtheories that aim to explain this phenomenon, briefly de-scribed as follows. Weisbrod’s government failure or het-erogeneity theory [10, 11] suggests that governmentprovision of public goods becomes homogenous over timein response to the needs of the majority. The NGO sectoremerges to meet unmet needs: it is a response to demandfor both enhanced quantity and range of public goods.Thus, this theory implies that NGOs are created to pro-vide goods for populations whose needs and preferencesare not met by government and other providers (e.g.through family physicians in private practice). Heterogen-eity of needs and preferences is thus key. Somewhatinterrelated is Hansmann’s trust theory [32] that positsthat information asymmetries between providers andconsumers create distrust about the quality of the productbeing procured. NGOs, being by definition not-for-profit,may be (or at least may be assumed to be) more trust-worthy. Thus, distrust in government providers or mar-kets is key to the emergence of NGOs.James’ supply-side theory [33] suggests demand aloneis not sufficient, and that social entrepreneurs must existin order for NGOs to emerge. James argues that this isparticularly true in areas where religious competition ex-ists, resulting in religious-based NGOs organizing forthe delivery of public goods as a mechanism to attractadherents. The surplus delivery capacity that exists inmany urban centres can also explain the proliferation ofNGOs providing social goods to underserved popula-tions. In their discussion of welfare state theory, Salamonand Anheier [34] suggest that the literature treats theNGO sector as a residue from imperfectly developedwelfare states. Thus, it is assumed that greater involve-ment of the state in social welfare services leads to asmaller NGO sector. Finally, Valentinov [35] developed arurality theory, arguing that NGOs emerge in rural set-tings to bridge inequities in services experienced inthose areas.The theories discussed above tend to position the stateas in conflict with the NGO sector. In contrast, theinterdependence theory suggests that conflict coexistswith interdependence and partnership [34]. For example,the NGO sector can be mobilized more readily thangovernment, and can secure political support to ensurethat government engagement occurs in areas of publicinterest. Salamon and Anheier further argue that, alongwith government and market failure, “NGO failure” alsoexists in that NGOs depend, to a greater or lesser de-gree, on government funding for their existence. Finally,they articulate a social origins theory that recognizes thatNGOs do not “float freely in social space” ([34], p. 18.)but are rather products of, and embedded in, social andeconomic structures.These theoretical perspectives suggest that NGOs havea unique and valuable role to play in the pursuit oftransforming health systems towards increased equity.Although helpful lens, they focus on the mergence ofNGOs but fail to adequately position NGOs within thehealthcare system in which they operate. It is our obser-vation that government-funders have an ambiguous rela-tionship with NGOs, including CHCs. Government-funders promote CHCs as a viable extension of health-care systems, recognizing their unique role in theprovision of needed services. At the same time, CHCsare not simply extensions of government-funded ser-vices, since they often fall outside traditional account-ability relationships. This autonomy can be framed asbeing at odds with the push to increase accountabilityacross healthcare systems. New systems of accountabilityLavoie et al. BMC Health Services Research  (2018) 18:705 Page 3 of 12have shifted from being based on trust, to those thatemphasize oversight and control [16, 36], which canundermine the sustainability and equity contributions ofthe NGO sector [6, 8], for example by setting onerousreporting requirements, setting targets for specificscreening tests or requiring measurement against certainindicators in ways that shape practice toward such activ-ities rather than the most pressing patient needs.Our program of research is informed by an equitylens, based on an understanding that all policy is valueladen and all policy work, since it involves decisions thataffect populations who have little involvement in policydecision-making [37], is ethical work. In developing thislens, we drew upon intersectional theory to guide ourexamination of how different forms of structural oppres-sion are constructed, affecting individuals, organizations,and broader social systems in complex and interdepend-ent ways. Because intersectional scholarship, driven bythe pursuit of social justice [38], is oriented beyonddescriptive analyses toward eradicating inequities, itprovides an ideal foundation for work aimed at movingpolicy towards equity. An equity lens directs attention tothe role of policy in shaping the relationship betweensocial conditions and health inequities, and relatedhealth system responsibilities, in four key areas: 1) thecontexts and conditions that shape access to healthcareand health outcomes; 2) structural determinants ofhealth; 3) a wide range of evidence related to social,historical and cultural roots of disadvantage; and 4)distribution of power in both the production of inequi-ties and policy processes (Pauly B, Varcoe C, McPhersonG, Laliberté S, Reimer J, Ponic P, Hancock T, Kenny N:Conceptualizing an equity lens for public health: Thecontribution of health policy ethics, in review). In thispaper, we apply an equity lens to examine the policy andfunding contexts of four diverse CHCs. We draw oninterdependence theory to frame the role of the CHCsas being that of sentinels of inequity,2 leading the devel-opment of responses to current and emerging unmetneeds, advocating to other service providers and healthdepartments, and educating the healthcare system.There are significant gaps in knowledge concerninghow to: make services as responsive as possible formarginalized populations; address the health effects ofstructural inequities and structural violence; make PHCservice delivery reforms more socially relevant; andcreate policy and funding environments to support theseaims [39]. Our analysis considers the latter: how mightpolicy decisions better promote EOHC throughouthealthcare systems through supporting CHCs? Wesought to understand how contemporary and emergingpolitical climates shape equity agendas and to identifyopportunities to enhance equity both locally and acrosssites.MethodsThis analysis was conducted as part of a larger study,entitled EQUIP Primary Healthcare, aimed at developingnew knowledge regarding how PHC services can serveas a key pathway to health equity at a population level.The study received ethical approval from the BehavioralResearch Ethics Boards of the University of BritishColumbia (H12–02994) and The University of WesternOntario (103357). All participants completed an in-formed consent process.Using a mixed methods, multiple case study designwithin a participatory framework, we developed and im-plemented an equity-oriented intervention in four PHCclinics and examined changes in key outcomes for pa-tients, staff and the organizations. Drawing on multiplesources of data, case study method is suited to studyingthe structures and processes of bounded systems incontext. In multiple case study, the emphasis is placedon generating both a detailed understanding of each caseand a broader understanding of commonalities that existacross cases [1]. In our study, the PHC clinics served asthe cases. We interpreted the impacts of the interven-tion within a broad understanding of the process ofimplementation at each site, including how the policycontext shaped their ability to implement and/or im-prove their equity-oriented models of care.For the analysis presented in this paper, three types ofdata were used. First, we developed a socio-historicalnarrative regarding each clinic, detailing its history, thehistory of the communities each clinic served, and itscontemporary profile, including its position within thewider healthcare system. To construct these profiles,we drew on the clinic’s own historical and currentrecords, and historical accounts of the communities.These narratives were used in multiple ways, includingas a tool to build consensus among different stake-holders (e.g., between staff and community organiza-tions, staff and board members) as to the history of,and challenges facing, the clinics. Second, following amethod developed by Lavoie [3], we reviewed and ana-lyzed the minutes of Board meetings along with fundingcontracts for each clinic for a 5-year period (2011–2016) to construct a profile of each clinic’s contractualenvironment. Minutes were reviewed to identify in-ternal pressures (e.g. lack of resources, relationshipwith staff, tensions) and external pressures (e.g. newpolicies, relationship with funders and the community,emerging unmet needs). Contracts were analyzed toassess funding stability over time, budgetary line flexi-bility, alignment between contractual obligations andthe clinics’ day-to-day operation, as well as reportingburden. Third, we conducted in-depth interviews withleaders (administrative and clinical leads, Board mem-bers) at each of the clinics (n = 7) specifically focusedLavoie et al. BMC Health Services Research  (2018) 18:705 Page 4 of 12on the policy/funding context and its impact on theclinic. These interviews were audio recorded and tran-scribed verbatim.To analyze this data, the team assigned one researchlead per CHC to collate the information available andconduct a preliminary analysis of Board minutes and fi-nancial records and contracts. Missing documents andgaps in knowledge were systematically identified, andshared with the team (the four leads) in regular meet-ings. Once major gaps were filled, focused interviewswere conducted to address any remaining gaps in know-ledge. A cross-case analysis was then undertaken toidentify commonalties and differences.ResultsThe CHCs we studied emerged in areas with unmet PHCneeds. Importantly, these needs were unmet because thepeople being underserved faced complex challenges interms of both their health status, socioeconomic condi-tions, and their ability to access quality and responsivehealthcare. The particular unmet needs to which theyresponded initially set the course for each clinic’s develop-ment. Each of the four CHCs in our study arose throughtheir own unique sets of circumstances, needs and oppor-tunities, and as shown in Table 1, have been described inmore detail in a prior publication [40]. The patient popu-lations served by these clinics ranged in size from 1300 to3700 individuals.Our findings show that CHCs which have a close rela-tionship with their funder, and whose mandate in theoverall healthcare system is clearer (for example, ClinicY), benefit from a more flexible funding environmentand adapted accountability frameworks. Where distanceand ambiguity exist, CHCs’ contributions to equity isundermined.[W]hen there’s a request to do something that all theother primary care organizations do, the request isn’talways filtered through an understanding of ‘wouldthis need to be different for the [CHC]?’ Until wecome back and go ‘wait a minute guys this doesn’tmake any sense’… so just, you know, as an example, weall report on the same indicators every year. (ClinicB-C03)In my opinion [the funders] still do not have anunderstanding of the value of the CHCs on thesystem. They know we do some things, they knowwe work with [the] vulnerable, but it’s not, it’s noton the same respect or level of the other [fee-for-service] bigger model which is maybe to be expectedbecause you’ve got ten thousand [fee-for-service]doctors and you’ve got two hundred [CHC-based]doctors. (Clinic D-C01)We identified three key mechanisms shaping theprovision of equity-oriented care that can potentiallyundermine CHCs’ equity mandate: the use of account-ability metrics/indicators that are not matched to anequity mandate, patterns of funding and allocation of re-sources that are poorly tailored to needs, and the lack ofsupport for continuous change management. Thesemechanisms persist because of a lack of clarity regardingthe role that CHCs ought, and can, play, in an equity-oriented healthcare system.Accountability and performance frameworks are notmatched to an equity mandateIn an equity-oriented healthcare system, where differentpopulations are served by a variety of service providers(e.g. fee-for-service family physicians, salaried nursepractitioners, CHCs), indicators of performance moni-toring must reflect the populations served, and beTable 1 Descriptions of Each ClinicOrganizational FeaturesClinic Wa • Founded in 2011.• Located in a city which is a regional hub for many ruralcommunities.• Serves people who face barriers to health and social care andthose ‘in transition,’ with a primary focus on women and familiesliving in marginalizing conditions, including recent immigrants,many of whom have experienced violence and trauma.• Primary health care services include identification, ongoingassessment and management of acute and chronic healthproblems, counseling, education and health promotion, andsupport in navigating complex systems.Clinic X • Founded in 1994.• Located in a rural region serving rural farming communitiesand First Nations communities.• Provides primary care at multiple sites to populations across thelifespan, from seniors to families with young children, throughdirect primary care and a wide range of responsive healthpromotion programs.Clinic Y • Founded in 1991.• Located in a northern regional city where high proportions ofIndigenous people reside.• Serves Indigenous and non-Indigenous people experiencingmajor socioeconomic challenges including people living onvery low incomes, in unstable or temporary housing, and thosewho are unable to work due to disability. 75% of the patientpopulation self-identifies as Indigenous.• Provides a wide range of primary health care services includingmedical and nursing care, counselling, social work, physiotherapy,and outreach services.Clinic Z • Founded 1970.• Located in an inner-city metropolis and serves low incomepopulations, including many experiencing inadequate housingor homelessness, major mental health and substance use issues,and significant barriers to accessing basic health services.• Provides a wide range of primary health care services, including apharmacy, dental clinic, and physical and mental health services.aTo protect anonymity, the clinics are designated “W, X, Y, Z”, and theinterviewees are designated as being from Clinic A, B, C, D withoutcorrespondence between the two designations (thus obscuring which cliniceach interviewee was from).Lavoie et al. BMC Health Services Research  (2018) 18:705 Page 5 of 12benchmarked appropriately to reflect patient complex-ities. The CHCs we studied, however, reported that theperformance indicators they report on fail to appropriatelyor completely reflect their population’s needs and servicesprovided.[S]o we’ve been operating this, this service for Xamount of years and then all of a sudden the contractthis year stipulates these different [performanceindicators], you know, in terms of measurements…it’s just all of a sudden they’re going to start measuringthese indicators so I mean we’ll see how that goes.(Clinic C-C01)Even in cases where there were efforts to index fund-ing to complexity, the alignment was not ideal.Yeah so [some CHCs] have a complexity score that’sused to adjust their panel size [number of patients theclinic is expected to serve], you know, they would sayit isn’t perfect, in fact it has a lot of weaknesses in itbut it’s better than not having anything. So there alsohas been some discussion about using that type of ascoring mechanism with [our clinic] to adjust our…panel size or an expectation based on complexitywhich for [our clinic] would be a helpful thing becausewe’re a bit of an odd duck. (Clinic B-C03)Importantly, when used, these efforts were typicallyonly used to estimate numbers of patients to be served,not what targets are set or indicators used. For example,a clinic serving primarily women with children who haveexperienced high levels of violence, poverty and home-lessness, and a clinic primarily serving a high-incomearea both must achieve 70% Pap smear targets.CHCs’ ability to meet their benchmarks is contingenton funding, staffing and infrastructure adequatelyaligned to the needs of the population served. Short-term funding contracts, and an inability to offer com-petitive salary and benefits, can result in staff attritionand undermine the CHCs’ ability to meet their contrac-tual obligations.So they don’t ever take that into consideration that,you know, the physicians - we need to be fully staffedand if you don’t have the right recruitment or salaries,that hard. And if you don’t have that then you can’treach panel size. If you don’t have infrastructure …like you’re supposed to have three examining roomsfor each provider, we have one. You’re supposed tohave so many nurses for a thing, we only have oneright, you know, so you don’t have the supports or theinfrastructure [and] that will reduce your ability tomeet panel size, right? (Clinic D-C01)Unique features of equity-oriented CHCs, such asculturally-safe care, and trauma- and violence-informedcare, are not captured by conventional indicators.[The] reporting, you know, this has been an area oftension particularly in the health center is the thingsthat we think are important in terms of health metricsare very different than the things that our contractagencies think are [important] in terms of metrics. Imean obviously we think access, you know, they’revery focused on how again the number, how manypeople are receiving these types of things… I meansome of the health outcomes which are very easy toidentify in terms of Hep C or HIV, viral suppressionin clients and things like that but some of the otherthings that we think are important aren’t really thatimportant to them. So there is that tension there interms of we’re trying to deliver a certain set of valuesand services and the funders … sometimes [theirpriorities are] different. (Clinic C-C01)Throughout the study, the clinics sought to identify,integrate and monitor indicators that were reflective oftheir equity mandate, including those for acceptability,accessibility and safety for people marginalized by pov-erty and multiple forms of discrimination, how well theywere able to facilitate access to health services and socialdeterminants, and overall fit of care to needs. These arehowever not the indicators embedded in the account-ability frameworks used by funders. Thus, the essentialwork performed by the clinics remain largely invisible,and undervalued.The patterns of funding and allocation of resources arenot optimally tailored to needsCHCs perform best when able to tailor services to thosethey serve. In an equity-oriented healthcare system, theyrequire resources to support their ability to respond toever-changing needs.The CHCs we studied access funding through stream-lined and sustainable sources (Clinic Y), or fragmentedand siloed but generally renewable funding (Clinic Z,Clinic X), or a constellation of yearly contracts withspecific performance expectations (Clinic W). With theexception of Clinic Y, all reported considerable misalign-ment between their funding, the size and needs of thepopulation they serve, and serious gaps in funding in keyareas, limiting their ability to respond to existing andemerging needs.[T]he original funding formula for [our CHC] has notchanged in twenty years, it’s been a little bit modifiedwith the new [Ministry mandate], a few differentpositions. But the original core, particularly theLavoie et al. BMC Health Services Research  (2018) 18:705 Page 6 of 12primary care nurse practitioner and physicianformula that you get from the ministry, you know,I have the same number of doctors here as [when]I started twenty-one years ago. (Clinic D-C01)[I]t looks to me like that’s the budget we’ve alwayshad, that’s the same budget we’ve had by the wayfrom the time we were established, there’s been noincreases… [T]he salaries we have to pay to the staffare set by the Ministry, we have a little bit of a rangeand we’ve tried to set criteria to be fair to peoplewho’ve got more experience or less. We couldn’t dealwith that so what we’ve chosen to do in a policy wayis to give some people more vacation time or somethingto at least reward them. It’s not a nice system but thesystem itself we had to work within what the Board hadthe availability to do. (Clinic B-C02)Flexibility has been eroded where it once existed. Insome clinics, flexibility is based on long term, trust-based relationships between funders and clinic adminis-trators. These relationships can however be eroded as aresult of attrition (either with the clinic, the funder orboth).And I think we’ve always had a really good workingrelationship with the person assigned to manage ourcontract. And actually a week ago, the first time, theearliest ever we had a meeting with our fundingperson and so it was, they really wanted to get out infront of the budget process of [our main funder] tomake sure that if anything happened within thesestrained times that there might be something they canfloat our way in terms of assisting our growth. (ClinicA-C01)[W]e had to get rezoning for two of the clinics fromthe city. So we ended up, we had a conversation withour Ministry person at the time who said don’t worryabout it just go ahead and do it. And, of course, thatperson changed… you see where I’m going with this?So it’s been an ongoing discussion with the Ministryabout how do we settle up and finally last year …after three plus years [we] finally got sorted out howmuch money was actually due back to the Ministry…And so last year finally that big cheque was themoney that had been sitting in our bank account thatwe knew had to be returned, some of it, we didn’t knowthe amount, finally got sorted out. (Clinic B-C03)Opportunities to innovate to ensure continued respon-siveness to the community’s needs are at times thwartedby siloed thinking on the part of funders, and the lack ofvalue attached to CHCs. For example, one CHC wasapproached by a family physician who wanted to retireand who wanted the CHC to take over his caseload, asignificant number of whom had complex health issuesand challenges accessing health care. Initial meetingswith the CHC’s primary government funder, who also,through the provincial health insurance plan, fundsfamily physicians being paid on a fee-for-service basis,seemed promising. However, after over a year of discus-sions, including the CHC developing a business plan, thefunder decided to transfer the funding to another fee-for-service based provider group:So why is the [CHC] not an option, why are we justthrown away again and the [family health team] willget the money because that’s what they always do?(Clinic B-C01)But we, we become I don’t know jaded orwhatever you want to call it over the years when,you know, the community money that’s to come tothe [primary funder] goes to the [hospitals] eachyear, right? Like they get about five million and itsalways a priority, [the hospital] is always in deficitbut … are there’s probably ten, twenty of us [CHCs]that will be in deficit this year, the older centers.(Clinic B-C01)All the CHCs we studied received the vast majority oftheir funding from government agencies (over 90%).While unallocated funding under primary contractsmust generally be returned to the funder at year-end,CHCs are responsible for any deficits. Opportunitiesexist to seek alternative funding sources such as compet-ing for project dollars or fundraising, but all recognizedthis as problematic.[W]e had made some decisions several years ago thatwe weren’t going to be forced to be in competitionwith our, with our colleagues and with our sisterorganizations. (Clinic A-C01)CHCs might collaborate with other NGOs to decidewhich agency is best positioned to apply for funding andeliminate opportunities for funders to use competition.While competition is not necessarily problematic, it doespit NGOs against NGOs and can undermine relation-ships among those who also must collaborate to ensurethat community members can access a broad range ofservices that fit their needs. A competition-basedprocess also leads NGOs, and in this case CHCs, tospend considerable time on writing proposals that maynot be funded. Finally, many calls for proposals relevantto NGOs and CHCs are for relatively small pots offunding.Lavoie et al. BMC Health Services Research  (2018) 18:705 Page 7 of 12[W]e’re very deliberately not looking for a lot ofproposals or one time funding due to our [in]ability tomanage that. So every little additional funding comeswith reporting, we’ve kind of reached our maximumon our ability to do all those reports. Nor do we likehiring people for a year and then terminating theiremployment… (Clinic B-C01).I mean a lot of the other [CHCs] fundraise, a lot ofthe other [CHCs] have foundations, we’ve lookeddown that avenue a bit but we find, you know, in alittle town you’re competing with the other peoplethat need the money so that really defeats some of thecommunity good will right? [W]e looked into thefoundation this past year but we didn’t decide to go inthat direction … [Also] we don’t have proposalwriters or people looking at opportunities formoney, if you will. So I mean… something [we]might have to focus on is trying to find somesustainable [funding], but [this] is not that easy tofind, right? So I try to go more for base funding soI’ve written four or five business cases to [ourfunder] … just lately for an integrated chronicdisease team to help with a little bit more moneythere. I’ve written, you know, for salaries, I’vewritten for the roof, I wrote for a memory team, Ican see the trend of dementia increasing and noresources for that. (Clinic B-C01)A key need expressed by the CHCs was to accesscapital funding to secure and maintain facilities.Contracts that frame the funded services as essentialmay support the retrofitting of facilities, and provideupkeep funding. This was the case when the fundersclearly saw the CHC as an extension of the localhealthcare system. In contexts where this was not thecase (three out of four sites in our study), fundraisingwas key to survival. Where fundraising is not possible(given the community served), sustainability can becompromised.We have two people dedicated to fundraising andcommunications because they’re so inter-related.Right now a big focus of our fundraising efforts,though, is on our capital campaign for buildinghousing and that’s where my time gets spent.(Clinic C-C01)Yeah no capital reserves. I had to create four examrooms on my own budget; like I’ve got no money forthat, right? So I created more exam rooms to try to bemore efficient; you just try and it’s not the best way tooperate without any kind of reserve for, formaintenance... (Clinic B-C01)Funding mechanisms are not structured to be responsiveto emergent prioritiesAlthough each clinic was founded in response to agiven set of unmet needs, the breadth and complexityof those needs has continued to expand and shift. Forexample, one clinic began to explicitly serve Indigen-ous people, but insisted on an inclusive mandate,serving all people living in poverty in the community.CHC mandates inherently mean that people who arenot well served by the broader system are increasinglyfunneled to them.When we actually tracked the health and social issuesthat these people were presenting with, on averagethere were between three and sixteen… [S]o oneproblem at a time is not going to do it for thispopulation and you cannot separate social issuesfrom health issues because they intertwine... Andwhat we did actually that really caught the politicians, iswe reduced ER visits by 50 % in the initial project… Imean it was, it was so easy because they had nowhereelse to go. And they had no physicians who would takethem on, you know, because they’re too complicated…And in addition to that they, they went to walk-inclinics and, of course, they have complex issues sothere’s no continuity of care. And they go to ERsand they’d get almost thrown out. (Clinic B- C02,emphasis added)The CHCs understand that operationalizing theirmandate and equity orientation requires them to identifyexisting and emergent health and social conditions thatcreate inequities in order to advocate and provide caretailored to the needs of local populations. Consequently,the populations they serve also expand and shift. Inaddition, they become the clinic serving more complexand challenging populations. This is not necessarilyproblematic, if matched with appropriate resourcing.One leader explained how funding flexibility allowedthem to adapt to needs.[W]e welcome persons with disabilities and we, ourfunding model does allow for that collaboration ofteam members to, to work on case conferencing andwork on the best for the client. So I think we’re luckythat way… (Clinic D-C01)Paradoxically, trust in CHCs’ ability to meet the com-plex needs of marginalized populations allows otherservice providers (fee-for-service physicians, publiclyfunded PHC access clinics) to redirect complex patientsto CHCs, and divest themselves of the responsibility toprovide care to these people. This redirection may befinancially advantageous to service providers, andLavoie et al. BMC Health Services Research  (2018) 18:705 Page 8 of 12problematic for the CHC, unless associated with ad-equate resourcing. Redirection is at times also activelyand explicitly pursued by government-funders, requiringCHCs to redesign programs and processes to adapt tonew locales or populations (Clinic Z-001). Rarely is theredirecting bi-directional, in part because there is no in-centive for family physicians and other providers to takeon complex patients, and in part because the role of theCHCs in sharing how the models of care they developcan be adopted by other providers is not recognized,funded nor systematized. For example, one of our part-ners discussed how the introduction of a new service inan urban area near the original, rurally-based, CHC wasinitially intended to be a sharing of approaches thatwould be implemented by other providers, and how thisfocus shifted over time, leaving then inappropriatelyfunded to operate multiple communities:So we’re very small staff as you know... But it was awhole new community, it was an urban community,you know, we were from the country… so it meant awhole new relationship building with a whole bunchof new partners [and], you know, we hadn’t been partof that group before. And it came with no additionaladministrative support so that was another… so thatwas okay because we didn’t think we were going to bethere to run it, we were just getting it going. But thenwhen it ended up that it was put under our umbrellathat was significant so we had to relook at how weoperated everything, right? And the next year then[another community] came so it was back-to-backyears of capital and new communities so that wassignificant. (Clinic D-C01, emphasis added)In some cases, CHCs are able to refer patients to otherCHCs set up to support specific populations. A key con-dition for this to occur is the co-existence of multipleCHCs, each serving distinct populations.[N]ow there is a youth clinic here in the city that weencourage youth to [attend]… we certainly see, youknow, a few youth here but we certainly encouragethe youth to go to the youth clinic. (Clinic C-C01)However, this is unlikely to occur in rural and evennorthern urban centres where surplus provider capacityis scarce.These kinds of redirecting – to CHCs and betweenCHCs – or funnelling, is dynamic within constantlyshifting systems and contexts, and changes as new issuesbecome championed within the broader healthcare sys-tem (for example frail elders, dementia, diabetes, refu-gees) while others remain hidden or less attractive as abasis for social policy initiatives (for example, HIVtransmission among people who use IV drugs, the opioidcrisis).CHCs are somewhat more agile than their counter-parts that are directly embedded and financed within thehealthcare system, and thus CHCs are better able torecognize emerging needs and respond. This was thecase in the late 1980s in the context of the HIV crisis,and is now apparent as Canada opens its doors to asignificant number of refugees. Through their commu-nity relationships, the CHCs we studied significantly ex-panded the healthcare system’s capacity to effectivelyrespond to emerging needs, and were able to alert fun-ders and governments to emergent issues. As such theyplay an essential, sentinel, role in any equity-orientedhealthcare system.This function can, however, be undermined by fundingmodels that dis-incentivize taking on complex clients, orare coopted by funders who may be tempted to dependon CHCs for stopgap measures, while overlooking thatCHCs can serve a key role in providing models for andeducating other providers to increase the overall equitycapacity of the healthcare system. Thus pathways be-tween funding and emerging priorities tend to be react-ive to crises, rather than proactive.DiscussionThe ambiguous and underdeveloped role of CHCs withinhealthcare systemsOur findings show that CHCs have an essential role toplay in increasing equity in the broader healthcare sys-tem, pointing to four key roles: first, CHCs are sentinelsof inequity. Their commitment to meeting the needs ofthe community makes them more likely to becomeaware of inequities, or emerging vulnerable populations,and of healthcare crises. Second, CHCs are betterequipped to develop care responses that fit with theevolving needs and contexts of local populations. This ispartly due to their agility (i.e., ability to respond quickly)but also to their connection with the community, whichcan result in community-driven or at least community-informed innovations. Once new needs have been identi-fied, CHCs are (or at least should be) able to advocate tothe larger healthcare system to ensure that emergingneeds are recognized and met. Finally, CHCs are wellequipped to educate the healthcare system in the devel-opment of a system-wide response to new needs. Ourdata also show that this last role is rarely enacted, be-cause of lack of recognition, resources and time. Otherroles remain under-operationalized.The CHCs we studied saw their populations shiftand expand, at times through choices made by theclinics (such as a recognition of the need to includepeople with disabilities) but often out of necessity(such as in response to an influx of newcomers, andLavoie et al. BMC Health Services Research  (2018) 18:705 Page 9 of 12in the absence of other health care sector responses).While they were able to develop some responses tomeet emerging needs, they did so with limited re-sources, which strained their ability to deliver currentservices, and protect staff and leaders from burnout.Our analysis shows that the CHCs were not in a pos-ition to educate the broader system regarding thesystem-level responses to the needs of vulnerable andunderserved populations. If this happened, the CHCscould play an essential transformative role in thehealthcare system. This role was unrealized largelybecause CHCs are positioned in the healthcare sys-tem as “lesser than” formal care structures. As a re-sult, opportunities to exchange ideas simply did notexist.The CHCs we studied fit well within a number of the-ories discussed earlier in this paper, namely, heterogeneity theory: all 4 CHCs emerged to provideservices that complemented those that existed butserved specific populations poorly; trust theory: all 4 CHCs developed relationshipswith the communities they served and legitimatelyclaimed a closer, trust-based relationship with theirclients; supply-side theory: the urban-based CHCs were ableto draw on a skilled workforce to meet their humanresource needs; and welfare state and rural theories: all were fillingimportant service gaps left by government-sponsoredservices.While a good explanatory fit, these theoretical fram-ings provide little direction on how to operationalizeand promote CHCs’ equity role in healthcare systems.Salamon’s interdependency theory [41] offers somepromise. Three decades ago, Salamon framed the rela-tionship between the US welfare state and the NGOsector as a partnership, where governments are best po-sitioned to provide a steady stream of resources, set pri-orities, articulate high-level values for which systemsmust strive, and institute quality control standards. Incontrast, NGOs are better able to personalize services,operate on a smaller scale, and adjust care to needs ra-ther to the structure of government agencies ([41], p.42). These roles are inherently incomplete in themselves,hence complementary.More recently, Svidroňová and colleagues’ study of 60NGOs in Slovakia concluded that interdependency the-ory best explains the role the NGO sector plays in thedelivery of social goods [42], including the enhancementof equity. An empirical study by Lecy and van Slyke [43]which tested Weisbrod’s government failure or heterogen-eity theory against Salamon’s interdependency theoryfound that the NGO sector is stronger when NGOs havea robust interdependent relationship with government-funders. State-NGO interdependence requires a facilitat-ing relationship. An important body of literature hasemerged reporting on the nature of this relationship (seefor examples, [44–46]), but this literature remains largelydescriptive and has not yet addressed the followingquestion: given interdependence, how should the relation-ship be structured to ensure that the NGO sector canachieve its equity mandate? Brinkerhoff [47] has arguedthat State-NGO relationships require a high degree ofmutuality, manifested by coordination, joint decision-making and mutual accountability, and the maintenanceof organizational identity. This in our view requires apolicy enabling environment.It is our position that, in order for healthcare systemsto fully realize CHCs’ equity potential, five policy condi-tions must be met:1. System-wide recognition of the unique equity-enhancingrole that CHCs play, including understanding how theycomplement other state-sponsored services;2. Availability and use of performance indicators thatmap onto the needs and issues most salient to localpopulations to ensure accountability for the use ofpublic funds;3. Resourcing to support innovation and responsivenessto community needs, to capitalize on CHCs’ agility;4. Feedback pathways to ensure a system-wideunderstanding of emerging needs; and5. System uptake of appropriate models of care forspecific populations.We recognize some obvious limitations to our study.We studied 4 CHCs operating it the Canadian context.Although we are aware of the generalizability of ourfindings to other settings (elsewhere in Canada,Australia, New Zealand, Colombia, and to a lesser ex-tent, Niger), we cannot claim generalizability across thefull diversity of CHCs. We recognize that a key featurediscussed in this paper is the role of the government-funder which shapes accountabilities of the CHCs. Argu-ably, CHCs funded through philanthropic means, bytheir membership, faith-based organizations or othermeans will face different power relations with their fun-ders, and different forms of accountabilities. Still, we be-lieve that CHCs operating in LMIC, which are less likelyto be government-funded and therefore closely regu-lated, are likely be undermine by a lack of system-widerecognition, are vulnerable if unable to track their per-formance in the delivery of social goods, require ad-equate funding to deliver on their mandate, can play aninvaluable role in providing up to date information togovernment on emerging issues, and are fertile groundLavoie et al. BMC Health Services Research  (2018) 18:705 Page 10 of 12for the development of innovations that might benefitother providers. We however recognize that these prop-ositions are at this point speculative, and require testingin LMIC.ConclusionThe NGO sector, including the CHCs that we studied, hasbeen shown effective at addressing inequities throughinnovation [48]. CHCs are an integral part of health sys-tems design, and require a policy enabling environment toachieve their equity potential. To date, in the Canadiancontext, the federal and provincial governments have pro-moted the CHC model as key to addressing the healthcareand social care needs of vulnerable populations, and ofthose poorly served by other service providers, but havenot provided adequate mechanisms to support CHCs inachieving this mandate.The situation is not unique to Canada. We and othershave document have similar issues in other contexts(Australia, New Zealand, Colombia). We believe that al-though there may be some nuances, this is also the casein many other HICs and LMIC. We believe that CHCshave an invaluable goal in the pursuit of equity, and inthe pursuit of some if not all Millennium DevelopmentGoals [49].3 Their role must however be supported bypolicy. A supportive policy environment has yet toemerge. The recommendations we offer are a startingpoint governments and funders can use to develop amore supportive policy environment for CHCs, in thepursuit of health equity.More research is however needed to develop bettertypologies of CHCs across HICs and LMICs. Further,additional work is required to refine our recommenda-tions to ensure a good fit with this complex context.Endnotes1The terms ‘marginalization’ or ‘marginalized’ refer tothe marginalizing conditions (social, political andeconomic) that create and sustain structural, social andhealth inequities, versus a characteristic that can beattributable to any particular population or group [1].2In Canada (and likely elsewhere), it was the CHCsand other NGOs who first reported the HIV epidemicsin the 1980s, and who were positioned or created torespond to those affected. The same has been said of theopioid crisis.3which include (1) the eradication of extreme povertyand hunger; (2) the achievement universal primaryeducation; (3) the promotion of gender equality andempower women; (4) the reduction of child mortality;(5) the improvement of maternal health; (6) combattingHIV/AIDS, malaria and other diseases; (7) ensuringenvironmental sustainability; and (8) developing a globalpartnership for development.AbbreviationsCHC: Community health center; EOCH: Equity-oriented health care; HIC: Higherincome countries; LMIC: Lower and middle income countries; NGO: Not-for-profit organization; PHC: Primary health careAcknowledgementsOur research team thanks the four clinics for sharing their perspectives andfor enabling us to conduct this research. We would like to thank all themembers of the EQUIP Primary Health Care team, with special thanks toJoanne Parker, Janina S. Krabbe, and Phoebe Long for their outstandingcontributions as research managers on the EQUIP research program.FundingThe EQUIP Research Program is funded through a Canadian Institutes ofHealth Research Operating Grant: Programmatic Grants to Tackle Health andHealth Equity [#ROH-115210] (www.cihr.irsc.gc.ca). CIHR did not contribute tothe design of the study, data collection, analysis, interpretation of data nor inwriting the manuscript.Availability of data and materialsThe datasets used/or analyzed during the current study are available fromthe corresponding author on.reasonable request.Authors’ contributionsAJB is the nominated PI for the EQUIP research program, MFG, CNW, CV areco-PIs, and JL is a co-I. JL led the development and writing of this manuscript.CV, AJB, MFG, and CNW contributed to the ongoing development of the finalmanuscript. The additional EQUIP Research Team members provided input intothe overall conceptualization and operationalization of this research program.All authors read and approved the final manuscript.Ethics approval and consent to participateEthical approval was received from the Behavioral Research Ethics Boards ofUBC (H12–02994) and UWO (103357).All participants completed an informed consent process.Consent for publicationNot applicable.Competing interestsThe authors declare that they have no competing interests.Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.Author details1Department of Community Health Sciences, Faculty of Medicine, Universityof Manitoba, Ongomiizwin Research, 715 John Buhler Research Centre, 727McDermot Ave, Winnipeg, MB R3E 3P5, Canada. 2School of Nursing, TheUniversity of British Columbia, T201-2211 Wesbrook Mall, Vancouver, BC V6T2B5, Canada. 3Centre for Research and Education on Violence againstWomen and Children, Faculty of Information & Media Studies, WesternUniversity, FIMS & Nursing Building, Room 2050, London, ON N6A 5B9,Canada. 4Arthur Labatt Family School of Nursing, Western University, FIMS &Nursing Building, Room 3306, London, ON N6A 5B9, Canada.Received: 28 May 2018 Accepted: 28 August 2018References1. 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