Health inequities related to the social determinants of health are long-standing and pervasive in healthcare. New approaches are needed to help improve health and wellbeing in underserved and at-risk communities. This article explores a population health management approach that empowers local communities to take on responsibility for keeping their own populations healthy.

The COVID-19 pandemic greatly magnified the already existing correlation between the social determinants of health, medical utilization, healthcare spending, and health outcomes. This existing link between social determinants of health and health outcomes is even more evident and even growing in groups of ethnic minorities and indigenous communities, as well as in lower income groups, people living in remote areas, with disabilities and the elderly. This is one of the findings that has been underscored through research commissioned by the Partnership for Health System Sustainability and Resilience (PHSSR). A global collaboration between academic, non-governmental, life sciences, healthcare and business organizations. 

This research program in – until now – 13 healthcare systems around the world, found that health inequities are pervasive and, have deepened during COVID-19.1 Notwithstanding this growing gap in health equity, it is clear that the social determinants of health remain an under-emphasized agenda item in national policies. It is however not only the role of all stakeholders in health systems to do more to meet the needs of under-served groups. Addressing the structural causes of health inequalities requires attention to a wide range of social determinants of health and action that goes beyond health systems.

As the Global Head of Healthcare for KPMG International, I have the privilege of sitting on the PHSSR’s Steering Committee. One of the goals of this group is to build knowledge through independent evidence-informed insights and help to activate and accelerate action on the issue of health equity. One of the recommendations formulated by the PHSSR is that healthcare systems need to improve and deepen their understanding of the communities they serve. This can be achieved by focusing on identifying vulnerable groups and their needs and targeting them with culturally appropriate interventions. One of the most important pillars in supporting this is the availability of complete and real time data, disaggregated in a way that reveals gaps along the lines of gender, ethnicity, geographical location and socio-economic status. Data collection and public reporting can be used for monitoring and the development of early and targeted interventions and help in developing social and health policies that can reduce inequalities in access to care and health outcomes.

While governments are most often seen as solely responsible for creating more equitable societies and protecting the most vulnerable, there is increased acknowledgement that these complex problems can be addressed through collaboration. Government institutions, healthcare organizations and community organizations all have a role to play. Together with the very communities and individuals that are concerned, through hyper local community healthcare models, communities have the democratic mandate, the cultural insight, and the social capital necessary to make long-term and lasting changes. Health outcomes for entire communities can be improved by addressing health inequities, and embedding monitoring, targeted prevention and early intervention.

Hyper local healthcare models in action

Australia has a good example of community-led, operated and controlled health organizations. Aboriginal Community Controlled Health Organisations (ACCHOs) deliver holistic, comprehensive and culturally appropriate healthcare services to almost 410,000 Aboriginal and Torres Strait Islander peoples.2 ACCHOs are initiated and operated by local Aboriginal communities and are controlled through locally elected Boards of Management.3 Between 2006 and 2019 there was a significant 15 percent decline in avoidable mortality rates for Indigenous Australians4 partly due to advances in health care delivery and improved inter-sectoral services.5 Aboriginal Community Controlled Health Services have also been found to have a preventative effect upon hospitalizations.6

In the United States, the Equity-First Vaccine Initiative is an example of how community-based organizations can be leveraged to address a targeted public health priority (increasing COVID-19 vaccination) and build upon existing trusted community partners that are already addressing root causes of inequity, such as housing and transportation.7

These examples from Australia and the US, illustrate how hyper local community healthcare models are responding to the needs of communities by delivering care that is culturally safe, provided in an appropriate manner and based on targeted approaches to the social determinants of health.

When it comes to care delivery, hyper-local models are typically best suited for primary and community care, prevention, and well-being. One such example is Community Cavell Centers in the UK —that aim to integrate primary care, diagnostics, community health services and social care for populations of up to 150,000.8 These centers not only play a critical role as brokers to draw on partnerships for certain services such as tertiary care, but they also leverage on funding and accountability agreements to ensure that the health and cultural needs of community members are met outside of the walls of their communities. 

Implementing hyper local healthcare models

To implement hyper local healthcare models the following three factors are key

  • Service and organizational redesign: Health services and organizations will likely need to be redesigned to better reflect the needs of patients and local communities. This may involve: 
    • Vertical integration of hospitals, primary and community care 
    • Scaling up of primary care, creating multidisciplinary settings that are based on more professionalized organizations and back offices   
    • Governance reforms to create stronger voices for local community groups in decision-making
  • Data capabilities: Success in delivering on population-specific needs also depends on health system’s ability to triangulate data from multiple sources to gain real time and detailed population level insights. For example, in the United States, the CDC’s Places program provides health data for small areas, which helps local health departments “to better understand the burden and geographic distribution of health measures in their areas” and assists with public health intervention planning.9 In order to create preventative and population-based health services, health system EMRs would also need to be integrated and interoperable, and feed into health data centers that act as a centralized data repository and monitoring and command center for local service delivery. Health data centers can transform linked data into actionable insights that can be used to establish proactive population health management approaches.  
  • Partnerships: Greater collaboration between all stakeholder groups and industries from the public and private sector is needed to solve the issues of socially driven differences in health equity and accessibility. This calls for increased collaborations and private public partnerships that can help improve health and wellness.  

In closing, I feel that hyper local healthcare models and the caring communities empowered to take on responsibility for keeping their own populations healthy can be one of the biggest drivers of improved health and care in the future.  

Key takeaways

  • Addressing the structural causes of health inequalities requires attention to the social determinants of health and action beyond health systems. 
  • Communities can play a key role in addressing health equity issues through hyper local healthcare delivery models that tailor interventions to address specific local needs and culturally sensitive contexts. 
  • Success in delivering on population-specific needs depends on health system’s ability to triangulate data from multiple sources, respond to needs with innovative and timely interventions in collaboration between communities and partners. 


Author: Dr. Anna van Poucke, Global Head of Healthcare at KPMG International

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1Partnership for Healthcare System Sustainability and Resilience. (2022). Press release: Governments urged to invest in healthcare
systems despite global economic uncertainty.
2National Aboriginal Community Controlled Health Organisation. (2022) About NACCHO.
3National Aboriginal Community Controlled Health Organisation. (2022) Aboriginal Community Controlled Health Organisations (ACCHOs).
4Australian Institute of Health and Welfare. (2023 January 16). Aboriginal and Torres Strait Islander
Health Performance Framework - Summary report 2023, Tier 1 - Health status and outcomes, 1.24 Avoidable and preventable deaths.
7Faherty L.J. et al. (2022). The U.S. Equity-First Vaccination Initiative: Impacts and Lessons Learned. Rand Corporation.
8National Health Service (2022). Shrewsbury Health and Wellbeing Hub: Case for change. Shropshire, Telford & Wrekin Integrated Care System
9Center for Disease Control. (2022 December). PLACES: Local Data for Better Health.