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Appendix 2
Subcommittee on Health Equity and Health Disparities
Draft Criteria and Definitions for Health Equity
Criteria for a definition of health equity. An adequate definition of health equity should meet all of the following criteria:
It should reflect concerns about population health and the full range of key determinants of health, i.e., it should include but not be restricted to a focus on medical care or disease. Health is defined as a complete state physical, mental, and social well-being, not merely the absence of disease.
It should reflect concerns about fairness and justice that are expressed in widely held ethical and human rights principles. According to such principles, all social groups (groups of people categorized based on their social characteristics) should have equal opportunities to be as healthy as possible.
Attaining the highest possible level of health is a basic right of all human beings that should not vary according to people’s social characteristics, such as their race or ethnic group, economic resources, gender, whether or not they are physically or mentally disabled, their sexual orientation, or other characteristics associated with stigma or discrimination. Some disparities in health are unavoidable; for example, men do not experience complications of childbirth, and women do not suffer from prostate problems as they age; these are not health equity concerns.
Health equity is concerned with avoidable disparities between social groups.
C. The definition should make it clear that health equity involves improvement for everyone, with greater improvement for those with the greatest social obstacles to health. It does not mean sacrificing the health of more advantaged groups; it means improving the health of everyone beyond the current level enjoyed by the most advantaged group.
The definition must permit measurement and monitoring of progress over time. The approach to measurement must be consistent with the definition. This requires comparisons on health status and on key factors influencing health between/among social groups who are socially advantaged or disadvantaged to varying degrees. All other groups should be compared to the most advantaged group because the health of the most socially advantaged group should reflect at least a minimal level of what should be possible at present for everyone.
A Definition of Health Equity
Health equity means fairness and justice in efforts to achieve the best possible health for everyone, especially for those groups who have systematically faced greater social obstacles to being healthy—for example, racial or ethnic minorities, poor/low-income people, and other groups who have persistently experienced social disadvantage, discrimination, or marginalization. Women, people with physical or mental/substance use disabilities, people with HIV/AIDS, and people with sexual orientations other than heterosexual also have experienced systematic discrimination or marginalization.
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Health equity derives from a basic human right of achieving the
highest possible level of health for all people, regardless of race or ethnic group, wealth, gender, disability, sexual orientation, or other characteristics that carry social stigma, discrimination, or marginalization.
Health equity is an ethical principle calling for equal opportunity for all social groups to attain the highest possible level of health. Health equity means overcoming discrimination, including that which is unintentional. Human rights principles require governments to fulfill an obligation to overcome obstacles to health facing everyone, particularly those who have suffered discrimination or marginalization. In addition to that which is overt and deliberate, discrimination can be unconscious and unintentional; it can be built into deep-rooted institutional practices and conditions that promote more disadvantage—both socially and with respect to health—across lifetimes and across generations, even in the absence of intent to discriminate. A useful rule of thumb in assessing which groups are socially disadvantaged is to determine which groups have persistently had the least economic resources and standing in society, as reflected by positions of social or economic influence.
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Health equity means striving to eliminate avoidable social disparities in health and in the pre-requisites needed to be healthy, including not only high-quality medical, dental, and mental health/substance use care, but also appropriate education, child care, nutrition, and healthy conditions in homes, communities, schools, and workplaces.
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Health equity involves pursuing improvement for everyone, with greater improvement for those with the greatest social obstacles to health. It also requires a commitment to advocate for more resources if current resources are inadequate to achieve the best possible health for everyone.
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Health equity is a cornerstone concept of public health, but not its only concern. Health equity does not encompass comparisons of social groups who are equally well off, or comparisons in which the socially disadvantaged groups is doing better (despite generally doing worse). Such comparisons are very important in public health, but are not health equity considerations.
For example, higher rates of breast cancer among European-American women, and lower life expectancy among men are both very important public health concerns deserving of attention. But they are not health equity concerns because in these particular cases, the socially disadvantaged groups (African Americans, women) do not have worse health.
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Health equity seeks to eliminate disparities in health that put groups of people who are disadvantaged socially at additional disadvantage with respect to their health.
Disparity, Inequity, Equity, and Equality. All four of these terms have their place and are useful.
Health Disparity. This term literally means a
difference; in practice, however, in the U.S. the term has been used to
refer to differences in health that are health equity concerns. In some
cases, we may not know the causes of a given disparity (e.g., the large,
mostly unexplained Black-White disparities in low birth weight or
premature birth), so it may not be appropriate to call it a "Health Inequity", in itself. But it is a health equity issue because it puts a socially disadvantaged group (African Americans) at further disadvantage with respect to health. Pursuing equity would require devoting considerable resources to research to understand the unexplained racial disparities in birth outcomes.
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Health Inequity. From a communications perspective, this term may sound too judgmental, particularly if used repeatedly and broadly; it may tend to close off rather than open up important dialogues about the causes of and solutions for health disparities. It therefore should be used sparingly.
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Health Equity, Health Equality, and Health Improvement for Everyone. Equity means fairness or justice, while
equality refers only to lack of difference. An equitable distribution of resources does not necessarily mean an equal distribution of resources. However, measuring health equity requires measuring selected inequalities or disparities.
Measuring and monitoring progress. A serious commitment to health equity requires monitoring progress over time. Measuring health equity requires describing levels of health (and its pre-requisites) among population groups that have systematically been socially disadvantaged, and comparing their more socially advantaged counterparts with the same indicators. The comparisons should be made not only between the most and least disadvantaged groups, i.e., the extremes; all groups should be compared with the most socially advantaged. The health of the most socially advantaged group indicates at least a minimal level of what is possible for everyone at the present time. Comparing groups to an average for the entire population is inappropriate because the average will be very low if a high proportion of people are very disadvantaged. Comparing to the healthiest decile (or other fraction) is inappropriate because it may consist largely of people who are healthiest because of genetic endowment or other unavoidable reason; differences according to social advantage or disadvantage suggest a likely health equity concern.
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