Health Policy

Journal of General Internal Medicine

, Volume 23, Issue 5, pp 672-677

First online:

Reducing Disparities Downstream: Prospects and Challenges

  • Peter FranksAffiliated withCenter for Healthcare Policy and Research, Department of Family and Community Medicine, University of California at Davis Email author 
  • , Kevin FiscellaAffiliated withDepartment of Family Medicine, University of Rochester School of Medicine and DentistryDepartment of Community and Preventive Medicine, University of Rochester School of Medicine and Dentistry

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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