Building healthy public policy to address health inequality

Ardene Robinson Vollman

Post date: March 1, 2021

The Government of Canada defines health inequalities as “differences in health status experienced by various individuals or groups in society. These can be the result of genetic and biological factors, choices made or by chance, but often they are because of unequal access to key factors that influence health like income, education, employment and social supports” (Government of Canada, 2008, p. 5).

When inequalities in health are understood to be unfair, particularly those that are caused from social and political circumstances that are potentially avoidable, they are frequently referred to as “inequity”. Governments and public health agencies are called to action to address inequalities in population health. There has been a great deal of research about the relationships between the determinants of health and population health. Despite this body of work, and despite repeated calls to action, there has been little in the way of success to reduce inequalities/inequity across the social gradient. Canadians in the lowest income levels still experience worse health status than those at the upper income levels.

The National Collaborating Centre for the Determinants of Health (NCCDH) focuses on advancing the social determinants of health and health equity through public health practice and policy. On its website (nccdh.ca) you can find a plethora of resources to build knowledge in this field, guide practice, and support research. The primary roles that inform the work of the NCCDH are: assess and report; participate in policy development and advocacy; partner with other sectors; modify and orient interventions; leadership and capacity; and communicate.

Other National Collaborating Centres – Environmental Health (NCCEH) and Indigenous Health (NCCIH) – also have resources to support health equity. I recommend checking out NCCEH resources if you are interested in the effects on people related to exposure to unhealthy environments (e.g., weather events, housing) and vulnerability to health hazards (e.g., air and water quality). The NCCIH focuses on the health, wellness, and cultural safety of First Nations, Inuit, and Métis peoples of Canada. For instance, a recent virtual series highlighted how Indigenous peoples’ experiences with health inequity, mental health, physical safety, and mobility have been exacerbated by the COVID-19 pandemic. Ideas for community-led solutions, policies, and services to enhance health and well-being were suggested. As well, the 2020 Report of the Chief Public Health Officer for Canada From risk to resilience: An equity approach to COVID-19 addresses the effects of the pandemic on Canadians.

In this blog I will focus on a common thread: health policy to address inequality.

Using the CCAP model to assess a community, population, or aggregate by using the means at your disposal (census tracts, reports, interviews, work experience) you will no doubt identify some segments of the population that experience differences in health status that other parts of the population do not. How you address these differences (inequalities) depends on how you understand them, what you believe about the causation of inequality (e.g., political, religious, ideological perspectives; historical and personal experiences), and the types of interventions with which you are familiar. Lessons from literature can open your mind to approaches of which you may not be aware, and research can be helpful in assessing which approach would best fit the issue at hand, the population of interest, and the resources that are available.

The National Collaborating Centre for Healthy Public Policy (NCCHPP, 2016, 2020) has created two documents that you and your team will find helpful as you analyze what you have learned. The first is an overview of approaches to addressing health inequalities/inequity and the second is an application of the approaches to the issue of food insecurity.

1. Policies and approaches to reducing health inequalities

A NCCHPP briefing note was written in 2016 to support the work of public health professionals by:

• • • Supporting their understanding of health inequalities and the factors that contribute to them;

    • Illustrating the differences between the social determinants of health and the social determinants of health inequalities;

    • Showing how different approaches to reducing health inequalities are founded on specific understandings of inequality and that this affects the type of interventions that are possible as well as their likely effects; and

    • Helping to draw out what kinds of impact they might hope to achieve through the different approaches to reducing health inequalities.

Eight approaches were discussed in this document:

• • • Political economy;

    • Macro social policies;

    • Intersectionality;

    • Life course approach;

    • Settings approach;

    • Approaches that aim at living conditions;

    • Approaches that target communities; and

    • Approaches aimed at individuals.

This document clarifies the theoretical foundations of the eight different approaches to action and the different potential impacts each approach has on inequalities. It presents three ways of describing inequalities: targeting disadvantaged/vulnerable groups; closing gaps; and addressing the social gradient. Which types of determinants may be targeted by various approaches and the potential impacts or consequences of each approach for health, inequality, risk, and social stratification are discussed, synthesized, and summarized in a table that includes pros and cons of each approach along with policy examples.

The summary comparative table of policy approaches is located at: http://www.ncchpp.ca/docs/2020-inequalities-policy-approaches-comparative-table.pdf

2. Policy approaches to reducing health inequalities: A practical exercise using the example of food insecurity

This 2020 NCCHPP briefing note builds on the 2016 document and includes an exercise to apply the lessons learned from the earlier document. Once you and your team have worked together through this example, you can apply this process to other health challenges.

Whatever intervention you choose to use, it is important to understand there may be unfavourable results to consider, and interventions “must not obscure the need to address the structured social inequalities that create health inequities in the first place” (Solar & Irwin, 2010). For example, your target population may be (or feel) stigmatized by being singled out (Government of Canada, 2019). Further, population data hides those that might be equally disadvantaged but not part of the target population, causing further disadvantage or vulnerability.

References

Government of Canada. (2008). The Chief Public Health Officer’s Report on the State of Public Health in Canada 2008: Addressing health inequalities. https://www.canada.ca/en/public-health/corporate/publications/chief-public-health-officer-reports-state-public-health-canada/report-on-state-public-health-canada-2008.html

Government of Canada. (2019). Addressing stigma: Towards a more inclusive health system.Chief Public Health Officer of Canada's Report on the State of Public Health in Canada 2019. https://www.canada.ca/en/public-health/corporate/publications/chief-public-health-officer-reports-state-public-health-canada/addressing-stigma-toward-more-inclusive-health-system.html

Government of Canada. (2020). From risk to resilience: An equity approach to COVID-19. The Chief Public Health Officer of Canada's Report on the State of Public Health in Canada 2020. https://www.canada.ca/en/public-health/corporate/publications/chief-public-health-officer-reports-state-public-health-canada/from-risk-resilience-equity-approach-covid-19.html

NCCEH. (n.d.). Health equity and environmental public health practice. https://ncceh.ca/environmental-health-in-canada/health-agency-projects/health-equity-and-environmental-public-health

NCCHPP. (2016). Policy approaches to reducing health inequalities. http://www.ncchpp.ca/141/Publications.ccnpps?id_article=1548

NCCHPP. (2020). Policy approaches to reducing health inequalities: A practical exercise using the example of food insecurity. http://www.ncchpp.ca/141/Publications.ccnpps?id_article=2054&utm_source=Cyberimpact&utm_medium=email&utm_campaign=E--Bulletin-February-2021

NCCIH. (2021). Virtual conference: Socioeconomic impacts of COVID19 on the health and wellbeing of First Nations, Inuit, and Métis populations. https://www.nccih.ca/495/Socio-economic_impacts_of_COVID-19_on_the_health_and_well-being_of_First_Nations,_Inuit,_and_Métis_populations.nccih?id=325

Solar, O. & Irwin, A. (2010). A Conceptual Framework for Action on the Social Determinants of Health. Social Determinants of Health Discussion Paper 2 (Policy and Practice). Geneva: World Health Organization. https://www.who.int/social_determinants/publications/9789241500852/en/