Health Inequities: the Call to Action
Despite great improvements in health outcomes and life expectancy in much of the world, health inequities within and between countries continue to be sources of illness and premature death that are avoidable and unjust. The World Health Organization Commission on Social Determinants of Health laid out clear recommendations to address avoidable health inequalities that emerge from varying levels of social advantage or disadvantage in the conditions in which people grow, live, work and age.
The Commission’s report outlined three overarching recommendations, urging us to improve daily living conditions by addressing various key social determinants of health. It went on to describe the need to tackle the inequitable distribution of money, resources and power in order to modify the underlying systemic factors that lead to a maldistribution of the conditions for healthy lives. Lastly, it identified the importance of using available and new knowledge to measure and understand the problem and assess the impact of action in order to guide this ongoing effort.
In 2011, 125 countries signed on to the Rio Declaration on Social Determinants of Health, which echoed the above recommendations, and further emphasized the importance of a Health in All Policies approach. This idea recognizes that all ministries and departments in government can have impacts on population health. Taking a whole-of-government approach is necessary in order to deal with the complex upstream factors that influence health outcomes, and there are numerous international examples of positive health impacts from the adoption of a Health in All Policies approach.
Beyond Health in All Policies: Emphasizing Equity
However, Health in All Policies can fall short of what is needed, usually in one of two key ways. This approach can fail to bring a health equity lens to decisions, looking merely at aggregate health and ignoring the differential impact of policy decisions along the social gradient. Policy decisions made in that frame of mind can a exacerbate inequities, as those most poised to benefit from these efforts are in least need of assistance.
Even when equity is considered, for example through Health Equity Impact Assessments, this could still be seen as a reactive approach. While new initiatives may be subject to health equity analysis, existing policies and programs that perpetuate inequities may continue undisturbed. Whether at a national, regional or local scale, a system level approach is needed to seek out opportunities for action to decrease health inequities.
Taking an Active Approach
In order to achieve meaningful results, a more active approach is required. Using a Health Equity Action Lens (HEAL) is a means of fulfilling the promise of Health in All Policies by enhancing the attention to equity and catalyzing policy change. HEAL is an approach designed to identify health inequities and the factors that influence them in order to inform meaningful action on the social determinants of health.
The key feature of the HEAL approach is a focus on addressing avoidable inequalities in health through intersectoral action informed by the best available evidence. Depending on the level or field of use, the specific questions posed in the use of the lens will vary. HEAL can and should be used by individual ministries or departments to evaluate and guide their own activities. However, it is ideally employed by intersectoral committees or at a cabinet level to bring a whole-of-government approach to achieving health equity. Essential to this effort is the availability of data on health inequities and evidence-informed guidance for analysis of the available interventions and their outcomes.
The HEAL approach includes four key elements:
1) System level health inequities audits identifying the current social gradient in health
2) Analysis of relevant social determinants and health outcomes
3) A toolkit for the identification of available policy levers to affect outcomes
4) Evaluation of the effectiveness of implemented changes on health outcomes.
Some of these elements are already in existence; others require further development. The key difference between HEAL and previous approaches is the increased emphasis on mobilizing systemic action to address health inequities.
Building Healthy Societies
There has been increasing international attention to addressing health equity in recent decades. However, despite well-intentioned efforts, progress in this area has been slow. The HEAL approach is a means of improving policy coherence across branches of government. More importantly, it reorients the efforts of government to achieve optimal health outcomes, a societal goal that is both meaningful and measurable. By addressing the social determinants of health we can improve people’s lives and overcome unjust inequalities. Use of a Health Equity Action Lens is an opportunity to address the root causes of ill health and build healthier societies. It offers us a practical means to achieve a fairer, healthier world.
Closing the Gap: Action for Health Equity | April 2016, Ottawa