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On Health Equity 

On Health Equity
Chapter:
On Health Equity
Author(s):

Viviana Martinez-Bianchi

DOI:
10.1093/med/9780190936013.003.0002
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date: 12 November 2019

Health equity is defined as the “attainment of the highest level of health for all people.”1 That “high level” of health is often determined by a mixture of personal responsibility, biology, and the options and possibilities for good health available to each individual (Figure 2.1). In equitable cultures, all persons can have similar choices. Health equity matters from many perspectives. At the highest level, health equity is rooted in the ethical principle of justice and requires providing everyone the opportunity to achieve good health. Pursuit of health equity requires addressing social factors that powerfully affect health, such as poverty, education, affordable housing, employment, wages, safe environments, discrimination, and racism, as well as access to health care. Importantly, access to health care alone is never sufficient to achieve health equity.

Figure 2.1 Conceptual representation of multi-sector partnerships by Fer Miguez.

Figure 2.1
Conceptual representation of multi-sector partnerships by Fer Miguez.

The economic survival of the entire community is affected by health equity; poor health is linked to absenteeism from school and work; chronic absenteeism from school contributes to school dropout and poor educational outcomes,2 which in turn negatively affects health.3,4 Healthy workers make healthy and productive workplaces and contribute to economically healthy communities, whereas absenteeism costs US employers more than $225 billion yearly in productivity losses.5

Pursuing Health Equity

Achieving health equity is not easy, and, in spite of long-standing multisector efforts to address avoidable health inequalities, we find ourselves in a world plagued by “differences in health status and in the distribution of health determinants between different population groups” (the definition of inequality in the WHO Glossary of Terms; http://www.who.int/hia/about/glos/en/index1.html) and in differences in resource allocation between neighborhoods and communities. Improving health equity requires identifying the underlying factors that cause health disparities and working in multisector partnerships to improve health outcomes for those groups suffering the worst disparities. This work should be a manifestation of the social accountability of physicians and health systems.

The World Health Organization describes social accountability as “the obligation [of physicians and medical institutions] to direct their education, research and service activities toward addressing the priority health concerns of the community, region, and/or nation they have a mandate to serve.”6 For health care to be socially accountable, it must be equitably accessible to everyone and responsive to patient, community, and population health needs.7 Social accountability in health care intentionally targets health care education, research, and services and addresses social determinants of health toward the priority health concerns of the people and communities served with the goal of achieving health equity.

Assuring conditions for optimal health requires academic health centers, health systems, industry, government, public health departments, nongovernmental organizations (NGOs), businesses, and large employers to demonstrate social accountability through engagement and investment in the local community. This upstream work requires multisector partnerships to improve health in organized approaches that do not leave vulnerable populations behind, value every member of a community, enhance services for those in most need, and engage all socioeconomic groups in the understanding that equity improves the lives of everyone in a community.

Multisector partnerships are highlighted in social obligation scales. Boelen8 proposes social accountability as one of the most important criteria for excellence in medical education. Boelen suggests that to become socially accountable, academic medical centers must anticipatively adapt medical education to the local community’s needs, define institutional objectives together with society, contextualize educational programs to improve local health outcomes, focus evaluations on impact, utilize partners as program assessors, and graduate true change agents. He proposes a social obligation scale (Table 2.1) that takes academic medical centers from “Responsible” through “Responsive” to “Accountable.” He argues that most health care institutions are generally socially responsible; that is, these institutions identify social needs in an implicit fashion, and they are aware of their duty to respond to society’s needs, but institutional objectives are defined by faculty, community-oriented programs and evaluations are focused on processes, and only internal assessors are used. These institutions graduate “good practitioners.” Some academic institutions can be described as socially responsive. In these academic medical centers, the social needs of the community are identified in an explicit way, with institutional objectives inspired from data, educational programs that are community-based and have interventions to address these needs, evaluations that focus on outcomes, assessors that are external but not true partners, and graduates who meet criteria of professionalism. However, few are wholly accountable, thus recommending that, to make an impact on health, institutions need to have a positive impact with interventions that address political, economic, cultural, environmental, social, and health care inequities. Only solid multisector partnerships can achieve the goal of true accountability.

Table 2.1 The Social Obligation Scale

Responsibility On Health Equity

Responsiveness On Health Equity

Accountability

Social needs identified

Implicity

Explicity

Anticipatively

Institutional objectives

Defined by faculty

Inspired from data

Defined with society

Educational programs

Community-oriented

Community-based

Contextualized

Quality of graduates

“Good” practitioners

Meeting criteria of professionalism

Health system change agents

Focus of evaluation

Process

Outcome

Impact

Assessors

Internal

External

Health partners

From Boelen C. Why should social accountability be a benchmark for excellence in medical education? Educación Médica. July–September 2016;17(3):101–105.

Access to health care is necessary but not sufficient to achieve health equity. Good health requires access to preventive and therapeutic health care services, from immunizations and prenatal care to treatments for chronic diseases. This in turn requires access to providers and health insurance coverage. Policies to make high-quality health care available to patients of all backgrounds are essential to health equity. However, even the best medical care cannot abolish health inequities; only 20% of health outcomes are determined by health care access and quality. Patients will continue to experience health inequities, even in health systems where all patients—regardless of race, ethnicity, or insurance status—have similar access to providers and services.

Multisector partnerships are valuable in advocacy and as allies against structural inequalities that marginalize people through power structures embedded in organizations. Effective allyship is a process of lifelong relationship building, where persons or organizations with positions of privilege and power work in solidarity with marginalized communities and groups of people. This relationship is based in comprehension, continuity, trust, education, consistency, and accountability. Allyship requires the ability to listen, humility, mutual understanding, community organizing, advocacy, collaboration, and the development of grassroots leadership to work toward economic, racial, ethnic, and gender justice (Figure 2.1).9,10,11,12

Improving health equity requires advocacy and advocacy planning and the use of an equity and empowerment lens, such as the one published by Multnomah County’s Office of Diversity and Health Equity, when planning, allocating resources, and making policy decisions.13

Pursuing health equity requires the following:

  • Addressing inequities

  • Understanding the care of the individual patient in the context of his or her community

  • Understanding, researching, and training to recognize the roles of bias and discrimination in systems and making needed changes to decrease their negative impact

  • Looking at gaps in access or inadequate care for disadvantaged groups

  • Addressing health determinants (negative and positive ones) using community health assessments that look at problems as well as social capital

  • Paying attention to root causes of disease and wellness because it is through that knowledge that we will learn from our community how to make a positive difference

  • Adopting practice models that include respect for the values and culture of the community, as well as those who work in health-related organizations

  • Partnering with community organizations and respecting their history and leadership

  • Engaging in cross-sector dialogue

  • Ceasing to tolerate inequity

Teaching Health Equity

The importance of health equity, awareness of bias and patterns of discrimination, and strategies for improving the health of groups that have been historically marginalized are issues that can be taught and role-modeled in all health-related educational programs and institutions. It has been the topic of multiple national and local programs.12,13 One exemplar is the Institute for Health Care Improvement (IHI),14 which states that health care professionals should play a major role in improving health outcomes for disadvantaged populations and that efforts should go beyond clinical work to leveraging the economic, social, and political power of the health care industry and of each organization within it. The IHI guide to achieving health equity has five key components:

  1. 1. Make health equity a strategic priority that is leader driven and articulated by senior management. Advancing equity is not a charitable afterthought but a critical component of the organization’s mission.

  2. 2. Develop structure and processes to support health equity work. To advance equity, health systems must dedicate financial and information resources accordingly.

  3. 3. Deploy specific strategies to address the multiple determinants of health on which health care organizations can have a direct impact, such as health care services, socioeconomic status, physical environment, and healthy behaviors. Make sure research is done to identify the disparities existing in each community.

  4. 4. Confront institutional racism within the organization, addressing in particular any structures, policies, and norms that perpetuate race-based advantages.

  5. 5. Develop partnerships with community organizations to improve health and equity.

Similarly, the Robert Wood Johnson Foundation, in its Roadmap to Reduce Racial and Ethnic Disparities in Health Care, provides a six-step framework for health care organizations to reduce disparities and foster health equity. This comprehensive approach encompasses the following components:

  1. 1. Link quality and equity

  2. 2. Create a culture of equity

  3. 3. Diagnose the disparity

  4. 4. Design the intervention

  5. 5. Secure buy-in of partners

  6. 6. Implement and sustain change

Health Equity as a Personal Value

The principle of health equity attracted many of us to health fields. At the heart of our work is the desire to be of help to others, to care for people of all ages and in all life circumstances, to be accountable to our communities, to improve community and population health, to be engaged leaders, and to provide continuous, integrated, and whole person-oriented care. For many of us, our professions became our vehicle for social justice and health equity. To move the needle in health equity, we need to learn to look for the root causes of illness and to help advance whole communities toward equity in health. In the words of Rishi Manchanda, we must be true “upstreamists” in the delivery of health care if we want to improve health.

Finding passion in improving health for all and making a difference beyond the confines of the hallways of the hospital and the walls of the office—being active participants in true wellness in the community—can become a vehicle for personal resilience and prevention of burnout for members of the health care team. In working to make our communities healthy, we can find that we are often restoring meaning and health to our own lives.

References

1. National Partnership for Action to End Health Disparities’ Federal Interagency Health Equity Team and Healthy People 2020, accessed 3.1.18 https://minorityhealth.hhs.gov/npa/files/Plans/NSS/NSS_05_Section1.pdf

2. State of Chronic Absenteeism and School Health A Preliminary Review for the Baltimore Community http://www.elev8baltimore.org/site/wp-content/uploads/2012/04/Absenteeism-and-School-Health-Report.pdf

3. The Causes And Costs Of Absenteeism In The Workplace https://www.forbes.com/sites/investopedia/2013/07/10/the-causes-and-costs-of-absenteeism-in-the-workplace/#3fc62e4e3eb6

4. Absenteeism Problems And Costs: Causes, Effects And Cures. Mehmet C. Kocakülâh, University of Southern Indiana, USA, Ann Galligan Kelley, Providence College, USA. Krystal M. Mitchell,Life Point Hospitals, Inc., USA Margaret P. Ruggieri, Providence College, USA International Business & Economics Research Journal—May 2009 Volume 8, Number 5 81 https://www.cluteinstitute.com/ojs/index.php/IBER/article/download/3138/3186

5. CDC Foundation, Business Pulse, Healthy Workers infographic https://www.cdcfoundation.org/businesspulse/healthy-workforce-infographic.

6. Boelen C, Charles, Heck, Jeffery E & World Health Organization. Division of Development of Human Resources for Health. 1995). Defining and measuring the social accountability of medical schools / Charles Boelen and Jeffery E. Heck. Geneva: World Health Organization. http://www.who.int/iris/handle/10665/59441

7. S Buchman, R Woollard, R Meili, R Goel: Practising social accountability: From theory to action Canadian Family Physician, 2016.Find this resource:

8. Boelen C. Why is social accountability a benchmark for excellence in medical education? Educ Médica. 2016;17:101–105 https://www.sciencedirect.com/science/article/pii/S1575181316300766#!Find this resource:

9. Guide to allyship http://www.guidetoallyship.com/

10. What is allyship? Why can’t I be an ally? http://www.peernetbc.com/what-is-allyship

11. Ally Bill of Responsibilities, © Dr. Lynn Gehl http://www.lynngehl.com/uploads/5/0/0/4/5004954/ally_bill_of_responsibilities_poster.pdf

12. AAMC Health Equity Research and Policy https://www.aamc.org/initiatives/research/healthequity/

13. Multnomah county Equity and Empowerment Lens https://multco.us/diversity-equity/equity-and-empowerment-lens

14. https://catalyst.nejm.org/health-equity-must-be-strategic-priority/