Health equity

• Health equity is the state in which everyone has a fair

and just opportunity to attain their highest level of health.
Achieving this requires ongoing societal efforts to:
• Address historical and contemporary injustices;
• Overcome economic, social, and other obstacles to health
and health care; and
• Eliminate preventable health disparities.
Explaination
• To achieve health equity, we must change the systems
and policies that have resulted in the generational
injustices that give rise to racial and ethnic health
disparities. Through its CORE strategy, CDC is leading
this effort, both in the work we do on behalf of the
nation’s health and the work we do internally as an
organization.
Preventable Health Disparities

• Health disparities are preventable differences in the burden of

disease, injury, violence, or opportunities to achieve optimal
health that are experienced by populations that have been
disadvantaged by their social or economic status, geographic
location, and environment.[1] Many populations experience
health disparities, including people from some racial and ethnic
minority groups, people with disabilities, women, people who
are LGBTQI+ (lesbian, gay, bisexual, transgender, queer,
intersex, or other), people with limited English proficiency, and
other groups.
• Across the country, people in some racial and ethnic minority
groups experience higher rates of poor health and disease for a
range of health conditions, including diabetes, hypertension,
obesity, asthma, heart disease, cancer, and preterm birth,
when compared to their White counterparts. For example,
the average life expectancy among Black or African American
people in the United States is four years lower than that of
White people.[3] These disparities sometimes persist even when
accounting for other demographic and socioeconomic factors,
such as age or income.
• Communities can prevent health disparities when
community- and faith-based organizations, employers,
healthcare systems and providers, public health
agencies, and policymakers work together to develop
policies, programs, and systems based on a health
equity framework and community needs.
Social and community context
• A person’s social and community context includes their interactions
with the places they live, work, learn, play, and worship and their
relationships with family, friends, co-workers, community members,
and institutions.[4] Interventions are critical to protecting the health
and well-being of people who do not get the level of support they
need to thrive from their social and community context. For example,
children of incarcerated or detained parents may gain from their
parents’ participation in reentry programs that assist with job
placement or offer parenting support,[5] and lesbian, gay or bi-sexual
high school students who are bullied would benefit from school-
based programs to reduce violence and prevent bullying.
• Social and community context also includes discrimination – or the
unfair treatment of people or groups based on characteristics such as
race, gender, age, or sexual orientation. Discrimination exists in many
systems in society including those meant to protect well-being or
health such as health care, housing, education, criminal justice, and
finance.[7] Discrimination often has a negative effect on the people
and groups who experience it and some people who belong to groups
that historically have experienced discrimination, such as people with
disabilities, people experiencing homelessness, and people who are
incarcerated or detained. As a result, people who have experienced
discrimination may be affected by layered health and social inequities.
• A growing body of research shows that racism has occurred
for centuries at many levels in society in the United States
and has had a negative impact on communities of color.
[8]
Racism is a system, supported and maintained through
institutional structures and policies, cultural norms and
values, and individual behaviors.[9] There are various forms of
racism that—for more than 400 years—have defined and
created most of the inequitable structures that exist in our
society and lead to health inequities today. The three types
of racism include:
• Structural, Institutional, or Systemic Racism: Differential
access to the goods, services, and opportunities of society
by race
• Personally-mediated or Interpersonal Racism: Prejudice
(differential assumptions) and discrimination (differential
actions) by individuals towards others
• Internalized Racism: Acceptance by members of the
stigmatized races of negative messages about their own
abilities and intrinsic worth[10]
• Racism determines opportunity based on the way people
look or the color of their skin. It also shapes social and
economic factors that put some people from racial and
ethnic minority groups at increased risk for negative mental
health outcomes and health-related behaviors, as well as
chronic and toxic stress or inflammation.[11],[12] Racism
prevents millions of people from attaining their highest level
of health, and consequently, affects the health of our nation.
Healthcare access and use
• People with disabilities and people from some racial
and ethnic minority groups, rural areas, and White
populations with lower incomes are more likely to face
multiple barriers to accessing health care.[13][14] For
example, structural barriers related to socioeconomic
status, such as lack of insurance,[15] transportation,
childcare, or ability to take time off work, can make it
hard to go to the doctor.
• Cultural differences between patients and providers as well as
language barriers affect patient-provider interactions and
health care quality.[16] Inequities in treatment[17] and historical
events, like the
Tuskegee Study of Untreated Syphilis in the African American
Male
and
sterilization of American Indian women without their permissi
on
, might also explain why some people from racial and ethnic
minority groups do not trust health care systems and the
government’s health-related guidance.
Neighborhood and physical environment
• People from racial and ethnic minority groups are disproportionately
affected by difficulties finding affordable and quality housing. The
practice of redlining or denying mortgages among people of color –
and as a result, access to public transportation, supermarkets, and
health care – has contributed to segregation of cities in the United
States. Although the U.S. Federal Government has enacted
legislation since the 1970’s to reduce the segregation of cities, [22] this
historical discriminatory practice has limited housing options among
racial and ethnic minority groups to neighborhoods and residences
that have school districts with inadequate funding, higher crime
rates, and poorly resourced infrastructure.
• These conditions may make illnesses, diseases, and
injuries more common and more severe among these
groups. In addition, access to nutritious, affordable
foods may be limited for these groups, and they may
experience more environmental pollution within their
neighborhoods.
Work place and condition
• Not all workers have the same risk of experiencing a work-related
health problem, even when they have the same job.
• Occupational health inequities are avoidable differences in work-
related disease incidence, mental illness, or morbidity and
mortality that are closely linked with social, economic, and/or
environmental disadvantage, such as temporary work
arrangements, socio-demographic characteristics (e.g., age, sex,
gender identity, race, or class), and organizational factors (e.g.,
lack of worker safety measures, limited or no health insurance
benefits).
Education
• People who have been historically marginalized, such
as people from racial and ethnic minority groups,
people with disabilities, and people with lower
incomes, are disproportionately affected by inequities
in access to high-quality education. Policies that link
public school funding to the tax base of a
neighborhood limit the resources available in schools
of lower income neighborhoods.
• This results in lower-quality education for residents of
lower income neighborhoods, which can lead to lower
literacy and numeracy levels, lower high school
completion rates, and barriers to college entrance. In
addition to educational barriers, limited access to
quality job training or programs tailored to the
language needs of some racial and ethnic minority
groups may limit future job options and lead to lower
paying or less stable jobs.
Income and wealth gaps
• People from some racial and ethnic minority groups
and other historically marginalized groups also face
greater challenges in getting higher paying jobs with
good benefits due to less access to high-quality
education,[25] geographic location, language
differences, discrimination, and transportation
barriers. People with limited job options often have
lower incomes, experience barriers to wealth
accumulation, and carry greater debt.
• The historical practice of redlining and denying
mortgages to people of color has also created a lack of
opportunity for home ownership, and thus wealth
accumulation, due to the inability to pass down
property and build wealth. Such financial challenges
may make it difficult to manage expenses, pay medical
bills, and access affordable quality housing, education,
nutritious food, and reliable childcare.
1 LEARNING OBJECTIVES

Explain the concepts of health

1 and well-being

Recognize the responsibility of states to

2 uphold the health of their population

Identify the socioeconomic, biological and

3 behavioural factors that influence health

Explain the social determinants

4 of health
1 DEFINITION OF HEALTH

Health is a state of complete physical, mental

and social well-being, and not merely the
absence of disease or infirmity (World Health
Organization, 1948).

Health is an individual right and a social

justice issue. It is also a public good.

Governments have a responsibility for the

health of their peoples which can be
fulfilled only by the provision of adequate
health and social measures.
 FACTORS DETERMINING
1 HEALTH

Clinical care is less important than many people think

whereas socioeconomic factors and the physical environment
are quite influential on health and well-being.

Genetic characteristics are also less significant

than many people think.

Whether people are healthy or not, is determined by their

circumstances and environment – the social, economic and
environmental conditions which affect the health of the population.
 WHY FRAME HEALTH IN TERMS
1 OF SOCIETAL CONDITIONS?

IMPACT: 30 - 50% OR MORE

Canadian
Mc Giniss
Institute of
et al (2002)
Advanced
Research (2012)
Health care
Health care
(up to 15%)
(up to 25%)
Social circumstances
Socioeconomic (50%)
& environmental
Environmental (10%)
exposure (45%)
Genetics (15%)
Health behaviour
patterns (40%)

Figure: Estimates of the contribution of the main drivers of health status.

Source: Donkin, A., P. Goldblatt, J. Allen, V. Nathanson and M. Marmot (2017).

"Global action on the social determinants of health." BMJ Global Health.
 WHAT ARE THE SOCIAL DETERMINANTS
1 OF HEALTH?

The social determinants of health are the conditions in which

people are born, grow, live, work and age. These circumstances
are shaped by the distribution of money, power and resources
at global, national and local levels.

The social determinants of health are mostly responsible for health

inequities – the unfair and avoidable differences in health status seen
within and between countries.

The social determinants of health are multi-layered

and range from societal to individual factors.
 THE SOCIAL DETERMINANTS
1 OF HEALTH

Source: Dahlgren G and Whitehead M (1991)

Policies and strategies to promote social equity
in health. Stockholm, Institute of Future
Studies.
 SOCIAL DETERMINANTS OF HEALTH
1 CONCEPTUAL FRAMEWORKS

Global
PAHO Equity Dahlgren
Commission
Commission & Whitehead
on SDH
(2019) (1991)
(2008)
 GLOBAL COMMISSION ON SOCIAL
1 DETERMINANTS OF HEALTH CONCEPTUAL
FRAMEWORK (2008)

SOCIOECONOMI
C
POLITICAL

CONTEXT SOCIOECONOMIC
Material
POSITION Circumstances
Governance (Living and Working,
Conditions, Food IMPACT ON
Macroeconomic SOCIAL CLASS Availability, etc.) EQUITY IN
Policies GENDER HEALTH
ETHNICITY Behaviours and AND
Social Policies (RACISM) Biological Factors WELL-BEING
Labour market,
Housing, Land Psychosocial
EDUCATION Factors
Public Policies, Social cohesion & Social
Education, Health, capital
Social protection OCCUPATION

Culture and
Societal value INCOME HEALTH
SYSTEM

STRUCTURAL INTERMEDIARY
DETERMINANTS DETERMINANTS OF
OF HEALTH INEQUITIES HEALTH
 PAHO CONCEPTUAL FRAMEWORK ON
1 SOCIAL DETERMINANTS OF HEALTH
AND HEALTH EQUITY (2019)

INTERSECTIONALITY: SOCIAL AND ECONOMIC INEQUITIES,

GENDER, SEXUALITY, ETHNICITY, DISABILITY, MIGRATION

STRUCTURAL DRIVERS CONDITIONS OF DAILY

LIFE
Political, Social, Cultural and
Economic Structures Early Life and Education

Working Life
Natural Environment,
Land and Climate Change
Older People
History and Legacy, HEALTH EQUITY
Income and Social Protection
Ongoing Colonialism, AND DIGNIFIED
Structural Racism Violence LIFE
Environment and Housing

Health Systems

TAKING ACTION
Governance
Human Rights

Source: Pan American Health Organization. Just Societies: Health Equity and Dignified Lives. Report of the
Commission of the Pan American Health Organization on Equity and Health Inequalities in the Americas.
1 ACTION RECOMMENDATIONS

Global PAHO Equity

Commission on Commission
SDH (2008) – (2019) –
3 overarching 12
recommendation recommendations
s
 PRIORITY RECOMMENDATIONS:
1 THE GLOBAL COMMISSION

The World Health Organization’s Commission on Social Determinants

of Health final report (2008) contains three overarching recommendation

Improve daily living conditions:

1
the circumstances in which people are
born, grow, live, work, and age

2 Tackle the inequitable distribution of power, money and

resources:
the structural drivers of those conditions of daily life
– globally, nationally, and locally

3 Measure and understand the problem and assess the

impact of action: expand the knowledge base, develop a
workforce that
is trained in the social determinants of health, and raise public
awareness about the social determinants of health
 PRIORITY RECOMMENDATIONS:
1 PAHO COMMISSION

The 12 recommendations include priority objectives

and specific measures in the following general categories:

TRUCTURAL DRIVERS: INEQUITIES IN POWER, MONEY, AND RESOURCES

Achieving equity in political, social,

1
cultural, and economic structures

2 Protecting the natural environment, mitigating climate

change, and respecting relationships to land

3 Reversing the health equity impacts of ongoing

colonialism and structural racism
 PRIORITY RECOMMENDATIONS:
1 PAHO COMMISSION

CONDITIONS OF DAILY LIFE

4 Equity from the start: Early life and education

5 Decent work

6 Dignified life at older ages

7 Income and social protection

8 Reducing violence for health equity

9 Improving environment and housing conditions

10 Equitable health systems

 PRIORITY RECOMMENDATIONS:
1 PAHO COMMISSION

GOVERNANCE FOR HEALTH EQUITY

11 Governance arrangements for health equity

12 Fulfilling and protecting human rights

 End of
Module 1 Part 2

Please continue
to Module 2 Part
1