A New Definition Of Health Equity To Guide Future Efforts And Measure Progress

Editor's note: Paula Braveman was one of the theme advisors for the June 2017 Health Affairs equity theme issue.

Until recently, talking about "equity" as a health researcher in the United States seemed almost radical.

Today, the term "health equity" is mainstream. The number of scientific papers with "health equity" in the title or text has skyrocketed. Some of this work examines the health effects of racism and other forms of discrimination, some addresses biases in science, and some explicitly mentions social justice. It's gratifying to see a broad research agenda developing around health equity.

In particular, it is thrilling to realize that explicit discussions about health equity are occurring across the country, among health policy researchers and their funders — and in boardrooms, hearing rooms, community meetings, in print, and online.

Yet it is clear that health equity means different things to different people. And while it's not imperative that everyone define it exactly the same way, a common understanding of the core elements of health equity is essential — for researchers, advocates, decision makers, and policy makers. The words we use can matter. Definitions can matter. While some differences in definitions may reflect only stylistic preferences, others convey values and beliefs that can be used explicitly or implicitly to justify and promote particular views, policies, and practices.

Clarity is particularly important because pursuing equity often involves engaging diverse audiences and stakeholders, each with their own constituents, beliefs, and agendas.

And in an era of data, a sound definition is crucial to shape the benchmarks against which progress can be measured.

Health Equity in a Culture of Health

The Robert Wood Johnson Foundation's "Culture of Health" initiative aims for a society in which "every person has an equal opportunity to live the healthiest life they can." "Every person" includes those who have been most marginalized — people of color, those living in poverty or with disability, Lesbian, Gay, Bisexual Transgender, and Queer or questioning persons, and others who have historically been excluded from mainstream society. Embarking on this initiative led RWJF to explore how people were talking and thinking about health equity.

My colleagues and I at the University of California, San Francisco, joined RWJF staff in that exploration a year or so ago. That joint work culminated in a report "What Is Health Equity? And What Difference Does a Definition Make?," released in May.

There is no lack of definitions of health equity—the American Public Health Association, Centers for Disease Control and Prevention, Health Resources and Services Administration, National Association of County and City Health Officials, World Health Organization, and countless other public health organizations have their own—each with its own strengths and weaknesses. In crafting a definition, this was both encouraging and a bit daunting. We identified a set of criteria, trying to capture the essential elements. We sought a definition of health equity that would:

• Reflect a commitment to fair and just practices across all sectors of society. This means that education, housing, transportation, community development, commerce, finance, and other sectors must be involved in efforts for health equity, and that our definition should acknowledge explicitly that health equity requires efforts beyond the health care sector.
• Be sufficiently unambiguous and concrete that it can guide policy priorities. We felt that many existing definitions were inspiring to those who already were committed to this work, but some were abstract and general enough that they left too much room for interpretation.
• Be actionable.
• Be conceptually and technically sound, and consistent with current scientific knowledge.
• Be possible to operationalize for the purpose of measurement, because without measurement there is no accountability.
• Be respectful of the groups of particular concern, not only defining the challenges they face but also affirming their strengths.
• Resonate with widely held values in order to garner and sustain broad support.
• Be clear, simple, intuitive, and compelling without sacrificing the other criteria, in order to create and sustain political will.

In other words, we set our sights high.

Where We Landed

After months of research, reflection, and consultation with some of the nation's leaders in health disparities and health equity research and policy, we landed on the following definition:

Health equity means that everyone has a fair and just opportunity to be as healthy as possible. This requires removing obstacles to health such as poverty, discrimination, and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe environments, and health care.

And because we wanted to ensure accountability, we added the following:

For the purposes of measurement, health equity means reducing and ultimately eliminating disparities in health and its determinants that adversely affect excluded or marginalized groups.

Is this definition perfect? No. Does everyone need to use these exact words? Absolutely not.

But we believe that it provides concrete guidance on what it means to pursue health equity. Notably, this definition implies that if an effort does not address poverty, discrimination, or their health-damaging consequences for groups of people who have historically been excluded or marginalized — it's probably not a health equity effort.

This definition allows us to assess whether we are reducing inequitable gaps rather than other kinds of gaps in health. That's an important distinction. Even without malicious intent, health equity efforts can be hijacked, with resources diverted to issues that may be legitimate public health or medical concerns, but are not explicitly about health equity.

A more detailed explanation of the rationale behind this definition is provided in the RWJF report, which also outlines key steps toward achieving health equity, presents principles to guide efforts and definitions of terms that often arise in discussions of health equity, and offers examples of programs and policies that are advancing health equity.

In addition to the examples highlighted in this report, there are others in the recent National Academy of Medicine report, Communities in Action: Pathways to Health Equity. It's one of the most downloaded reports on the Academy's website, a significant achievement just a few months after its release. The report warns that persistent health disparities pose "severe consequences" for America and calls for action to make health equity a top priority for the nation. It highlights nine communities across the United States that are taking steps to address health inequities and calls on leaders from sectors such as education, transportation, housing, planning, public health, and business to join this effort.

Why Now? Where Next?

For me, the growing interest in health equity—and in getting clearer about a definition—signals readiness for a paradigm shift in the focus of health equity research and action in this country, and a growing resolve to identify the underlying inequities in opportunities to be healthy and to acknowledge the need for systematic strategies to address them. It also signals a willingness to say: This is about core values—namely, fairness and justice—as well as important pragmatic considerations (such as reducing health care costs and linking economic productivity to a healthy workforce).

It's encouraging to be at a point in time when there is greater willingness to have tough conversations about policies and programs that have led to inequitable gaps in health. Unfortunately, the current national political context is more hostile to health equity—and to justice in general—than any other during my lifetime. And that makes it all the more crucial for us to be crystal clear and strategic in our words as well as our deeds.

Author's Note

The Robert Wood Johnson Foundation is hosting a webinar on June 29: Building Health Equity: From Resources to Community Action. The definition of health equity presented above will be discussed as a resource for advancing solutions and measuring progress, and other participants will share examples of how their communities are working to ensure that everyone can be as healthy as possible. Register here.

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