Defining Health Equity for Action and Research

Understanding Health Equity: A Call for Shared Understanding and Action

The concept of “health equity” has become increasingly prevalent in public health practice and research over the past two decades. Despite its frequent use, the term often lacks a consistent definition, leading to misunderstandings that can hinder effective action by policymakers, organizations, and communities. Varying interpretations of health equity can reflect deep divides in values and beliefs, potentially justifying and promoting divergent policies and practices, and ultimately risking the failure of efforts to achieve health equity.

To address this challenge, Braveman et al. (2018) aim to stimulate discussion and promote greater consensus on the meaning of health equity and its implications for both action and research. Their goal is not to enforce identical definitions but to identify crucial elements that can guide efforts in both public and private sectors.

Defining Health Equity

The authors propose a comprehensive, two-part definition for health equity:

• For a broad, nontechnical audience: “Health equity means that everyone has a fair and just opportunity to be as healthy as possible.” Achieving this necessitates “removing obstacles to health—such as poverty and discrimination and their consequences, which include powerlessness and lack of access to good jobs with fair pay; quality education, housing, and health care; and safe environments”.
• For the purposes of measurement: “Health equity means reducing and ultimately eliminating disparities in health and in the determinants of health that adversely affect excluded or marginalized groups”.

Key Concepts and Distinctions

• Health vs. Health Care: Throughout the discussion, “health” refers to health status or outcomes, distinct from “health care,” which is only one of many significant influences on health.
• “Being as healthy as possible” refers to the highest level of health an individual could achieve if society made adequate efforts to provide opportunities, even accounting for unavoidable genetic variations. It emphasizes that lack of political will does not justify considering a health disparity unavoidable.
• Social Determinants of Health: Opportunities to be healthy are profoundly influenced by living and working conditions and other resources that vary across social groups. These non-medical factors include income, wealth, education, neighborhood characteristics, and social inclusion. The concept acknowledges individual responsibility while recognizing that many people lack access to necessary opportunities and resources.
• Health Disparities and Health Inequity: These terms are intimately related. Health equity is the ethical and human rights principle that motivates the elimination of health disparities. Health disparities, often synonymous with health inequalities (especially outside the U.S.), are “presumably avoidable differences in health or in its key determinants that adversely affect marginalized or excluded groups”. A health inequity is a specific type of health disparity that is a “cause for concern in that it is potentially a reflection of injustice”. It is important to address health disparities even if their causes are unknown or contested, especially if they affect socially disadvantaged groups.
• Discrimination and Systemic Oppression: Discrimination is adverse treatment based on prejudicial assumptions about a social group. This can manifest at an interpersonal level (e.g., hate crimes, denial of jobs) or systemically, built into institutional structures, policies, and practices (e.g., policing, bank lending, school underfunding, housing segregation). Systemic discrimination can have inequitable effects regardless of individual intent to discriminate. It takes a heavy toll on victims’ health, partly due to chronic stress.
• Powerlessness: Often a consequence of poverty and discrimination, powerlessness is the objective and subjective inability to control one’s life and access resources. Persistent experiences can lead to hopelessness and an inability to assert rights.
• Excluded or Marginalized Groups: These are individuals who have experienced discrimination or been pushed to society’s margins, often lacking access to health-promoting resources and key opportunities. Examples include people of color, those living in poverty, religious minorities, people with disabilities, LGBTQ persons, and women.

Implications for Action and Accountability

Achieving health equity requires societal actions to remove obstacles to health and increase opportunities for everyone to be healthier, with a particular focus on those who have worse health, face more social obstacles, and have fewer resources. This involves engaging excluded or marginalized groups in planning and implementation. It’s crucial to understand that equity is not the same as equality; those with the greatest needs require more, not equal, effort and resources. While focusing on the needs of marginalized groups, advocates can garner broader support by highlighting how health equity benefits all of society, leading to a more productive workforce and reduced healthcare spending. Furthermore, advancing health equity requires addressing a more generally equitable society, as overall health tends to be better in more equal societies.

Effective health equity efforts must aim to improve the fundamental and structural causes of ill health, such as poverty and discrimination, rather than just addressing consequences. Measurement is vital for accountability, documenting disparities, and informing efforts to eliminate them. This includes constant monitoring of overall health levels and routine comparisons between more and less advantaged groups. Crucially, disparities should be closed by improving the health of excluded or marginalized groups, not by worsening the health of those who are better off. Disadvantaged groups should be compared with the most advantaged, not the general population average, to accurately assess the gap.

In essence, health equity involves reducing health disparities by improving the health of socially disadvantaged groups and addressing the social determinants of health disparities, particularly poverty and discrimination. Clarity on this concept is paramount, as efforts to achieve health equity will inevitably face significant challenges.

References

Braveman, P., Arkin, E., Orleans, T., Proctor, D., Acker, J., & Plough, A. (2021). What is health equity? Behavioral Science & Policy, 4(1), 1–14.