Journal of General Internal Medicine

, Volume 23, Issue 5, pp 672–677

Reducing Disparities Downstream: Prospects and Challenges

Health Policy

DOI: 10.1007/s11606-008-0509-0

Cite this article as:
Franks, P. & Fiscella, K. J GEN INTERN MED (2008) 23: 672. doi:10.1007/s11606-008-0509-0


Addressing upstream or fundamental causes (such as poverty, limited education, and compromised healthcare access) is essential to reduce healthcare disparities. But such approaches are not sufficient, and downstream interventions, addressing the consequences of those fundamental causes within the context of any existing health system, are also necessary. We present a definition of healthcare disparities and two key principles (that healthcare is a social good and disparities in outcomes are a quality problem) that together provide a framework for addressing disparities downstream. Adapting the chronic care model, we examine a hierarchy of three domains for interventions (health system, provider–patient interactions, and clinical decision making) to reduce disparities downstream and discuss challenges to implementing the necessary changes.


healthcare disparity poverty downstream upstream education 

Copyright information

© Society of General Internal Medicine 2008

Authors and Affiliations

  1. 1.Center for Healthcare Policy and Research, Department of Family and Community MedicineUniversity of California at DavisSacramentoUSA
  2. 2.Department of Family MedicineUniversity of Rochester School of Medicine and DentistryRochesterUSA
  3. 3.Department of Community and Preventive MedicineUniversity of Rochester School of Medicine and DentistryRochesterUSA

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