Operationalizing Health Equity in Public Emergency and Primary Care in Urban Brazil.

Abstract

Health systems globally continue to struggle to translate health equity commitments into consistent day-to-day practice at the point of care. Although equity strategies are often articulated at national or system levels, frontline health care services frequently lack the governance structures, partnerships, operational tools, and learning environments needed to prioritize populations experiencing inequities amid competing clinical and organizational demands. This challenge is particularly visible in high-volume, resource-constrained settings. Early findings suggest that equity work becomes more actionable and sustainable when embedded into routine operational structures rather than implemented as a parallel initiative. Unit-level equity committees, psychologically safe learning environments, codesign with communities, and continuous testing cycles have helped teams integrate equity into everyday decision-making, workflow redesign, and care delivery. An initiative to elevate equity care and incorporate it into routine practice began in 2022 at the Unidade de Pronto Atendimento (UPA) Campo Limpo, a high-volume public emergency care center, and was later adapted for three primary care units in Paraisópolis, one of São Paulo's largest socioeconomically marginalized urban communities. The work combined improvement science, codesign, and locally led governance structures to strengthen the ability of frontline teams to identify, prioritize, and respond to inequities affecting lesbian, gay, bisexual, transgender, queer or questioning, intersex, asexual, and other sexual and gender minority (LGBTQIA+) individuals, people with disabilities, and other populations experiencing marginalization. At the same time, the initiative revealed persistent implementation barriers common across health systems, including fragmented demographic data systems, competing operational priorities, workforce strain, and difficulty sustaining equity-focused work during periods of crisis. This case study offers practical lessons for health systems seeking to operationalize equity through frontline governance, codesign, workforce capability building, and continuous improvement structures.