Health Equity Policy Statement

As a nation, the United States must meaningfully take action to achieve health equity by eliminating the health inequities and disparities experienced by significant segments of the population and creating a more equitable society. ASTHO believes that eliminating health inequities and disparities through the achievement of health equity is a fundamental American challenge that affects many and concerns all.

The U.S. Department of Health and Human Services (HHS) acknowledged the central importance of addressing health inequities and disparities to achieve overall improved health when it established “a renewed focus on identifying, measuring, tracking, and reducing health disparities through a determinants of health approach” as one of two overarching goals of Healthy People 2020, the national blueprint for public health.¹ The goals and mission of federal initiatives such as HHS’s National Stakeholder Strategy to Achieve Health Equity and HHS’s Action Plan to Reduce Racial and Ethnic Health Disparities stress the commitment to achieving health equity for the nation from the highest levels of the government. Health reform offers the opportunity and potential to address the needs of racial and ethnic minority populations by reducing the cost of health care, increasing the investment in prevention and wellness, supporting primary care improvements, and creating partnerships between the public health and health care field and social services. The National Stakeholder Strategy to Achieve Health Equity provides a flexible road map for public and private sector partnerships to collaborate on initiatives and programs to achieve health equity. In addition, ASTHO made “promoting health equity” a crosscutting goal of the organization, in alignment with the World Health Organization’s (WHO) position that: “The objective of good health is…twofold: the best attainable average level – goodness – and the smallest feasible differences among individuals and groups – fairness.”²

At present, significant inequities and disparities exist in key health indicators, such as infant mortality rates, life expectancy and rates of preventable disease; in key risk factors, such as smoking rates, access to care, nutrition and physical activity; and in the social determinants of compromised health, such as poverty, inadequate housing and unsafe working conditions. The health disparities that have their roots in social determinants of health are properly referred to as health inequities and are a reflection of the persistent inequities that exist in American society.

Recognizing the relationship between health disparities and health inequity, ASTHO advocates for interventions that achieve health equity by eliminating health disparities. As described by the WHO, the aim of a health equity approach “is not to eliminate all health differences so that everyone has the same level and quality of health, but rather to reduce or eliminate those which result from factors which are considered to be both avoidable and unfair.”³ As outlined by National Association of County and City Health Officials (NACCHO), this involves “acknowledge[ing] and address[ing] 1) the social determinants of health;…2) the ability of people to participate democratically to effect change in their living and working conditions; and 3) the underlying injustices based on race, class, gender, religion, immigration and sexual orientation that generate inequity in the distribution of disease.”⁴ Indeed, these underlying disparities have great costs to the American people as well. According to the Joint Center of Political and Economic Studies report, the indirect costs of health inequities in the US are $1.24 trillion between 2003 and 2006.⁵

1. DEFINITIONS

ASTHO relies on the following definitions for work related to health inequities, health disparities and health equity:

1. Health disparity: “a particular type of health difference that is closely linked with social or economic disadvantage. Health disparities adversely affect groups of people who have systematically experienced greater social and/or economic obstacles to health and/or a clean environment based on their racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation; geographical location; or other characteristics historically linked to discrimination or exclusion.”⁶
2. Health equity: “attainment of the highest level of health for all people. Achieving health equity requires valuing everyone equally with focused and ongoing societal efforts to address avoidable inequalities, historical and contemporary injustices, and the elimination of health and healthcare disparities.”⁷
3. Health inequity: “differences in health which are…unnecessary and avoidable…unfair and unjust.”⁸ Also, “…systematic disparities in health, or in the major social determinants of health, between groups with different levels of underlying social advantage/disadvantage (for example, by virtue of being poor, female, and/or members of a disenfranchised racial, ethnic, or religious group).”⁹
4. Social determinants of health: where we live, learn, work and play or “the economic and social conditions that influence the health of individuals, communities and jurisdictions as a whole.”¹⁰

2. DETERMINANTS OF HEALTH

ASTHO recognizes that:

1. Health inequities exist among groups based on sex, sexual orientation, race, ethnicity, education or income, disability and geographic location.
2. The following are major determinants of health status: access to and quality of health care, environmental and social exposures, education and economic opportunities, health behaviors and genomics.
3. Contributors to health inequities are interconnected and must be addressed through multifaceted and multisector approaches.
4. Being subject to racism is a root cause of health inequities that can affect health outcomes (i.e birth outcomes).
5. Exposure to risk factors for health inequities is intergenerational and can occur even prior to conception.¹¹

3. ROLE OF ASTHO

ASTHO acknowledges that the United States has made progress towards achieving fairness and goodness in health but realizes that there is more work to be done. In response, ASTHO proposes to accomplish the following to promote health equity:

1. Provide national and state leadership in achieving health equity.
2. Track state and territorial practices and policies and scientific research that promote health equity.
3. Educate decision-makers on health equity and its relationship to health disparities and otherwise ensure that health equity remains a priority issue in public health policies and programs.
4. Assist with the evaluation of state and territorial practices so as to develop an evidence-base for effective health equity promotion activities.
5. Develop and disseminate information and tools to state/territorial health agencies to support the replication of promising practices and policies.
6. Convene and otherwise facilitate collaboration among state, territorial, local, federal, tribal and private-sector decision-makers to both reduce health disparities and increase health equity.
7. Support state and territorial health agencies in advocating for policies that promote health equity.
8. Support state and territorial health agencies with integrating health equity into their state strategic plans and priorities.

4. ROLE OF THE STATE AND TERRITORIAL HEALTH AGENCY

State and territorial health agencies play a critical role in setting and moving forward a health equity agenda. However, promoting health equity and reducing disparities is not solely the responsibility of the state or territorial health agency. Partnerships between communities, states, and national organizations should incorporate an approach that includes agencies involved in not only health, but education, housing, labor, justice, transportation, agriculture and the environment.

ASTHO encourages its member agencies to perform the following in pursuit of health equity and a reduction in related health inequities:

1. Provide leadership at the executive level to ensure that health equity and related health disparities are considered at both policy and programmatic levels.
2. Use the prominent authority of the state and territorial health official to raise public awareness of health inequity and increase the focus on solutions.
3. Serve as a resource on health equity to the governor, legislators and other agencies in their states and territories.
4. Advocate for policies that promote health equity, such as a “health-in-all-policies” approach.
5. Gather data that allow informed decision-making on programs and policies for populations affected by inequities.
6. Evaluate the feasibility of harmonizing state data collection with HHS data collection on race, ethnicity, sex, primary language and disability status as required by Section 3101 of the Public Health Services Act.
7. Coordinate programs to ensure equitable distribution of health resources throughout the state/territory.
8. Sponsor and otherwise promote programs that ensure that the health workforce in the states/territories reflects the ethnic and racial mix of the populations served.
9. Train and provide resources to health care and public health professionals to ensure cultural competency and quality health care.
10. Engage communities (community- and faith-based organizations, local health departments, tribal governments, community health centers) to develop and implement strategies to achieve health equity.
11. All grants and funding require that health equity be addressed as a component of the work.
12. Evaluate innovative programs and strategies that promote health equity and reduce related health disparities.
13. Ensure health equity is fully integrated into state and territorial strategic priorities and plans.
14. Share promising and best practices with and between other states.
15. Encourage and provide resources for cross-agency collaboration on the social determinants of health, such as transportation, housing, education, environment, labor, etc.
16. Set goodness and fairness goals for state health agency initiatives.

5. ROLE OF GOVERNORS, FEDERAL OR NATIONAL STAKEHOLDERS

To support the state/territorial health agency in its efforts to achieve health equity, ASTHO encourages governors, executive offices and agencies of the federal government, research institutions and others to:

1. Provide leadership, financial and administrative support for information and analysis on underrepresented population groups.
2. Evaluate and promote successful state and territorial health equity promotion practices at the national level.
3. Lead all state/territorial government agencies in evaluating and optimizing the impact that agencies’ policies and programs have on population health status and ensure interagency collaboration to end health inequities.
4. Engage all sectors of state, territorial, tribal and federal executive government in health equity promotion efforts, including the application of solutions that directly address the social determinants of health.
5. Use the opportunities provided through health reform increase access to health care for racial/ethnic minorities, reduce discrimination based on medical history, increase cultural competency among providers and increase diversity in the workforce.

Approval History:

Access Policy Committee Review and Approval on November 8, 2011.
Board of Directors Review and Approval on December 12, 2011.
Ratified by the ASTHO Assembly of Members on December 14, 2011.
Policy expires December 31, 2014.

ASTHO policies are broad statements of enduring principles related to particular policy areas that are used to guide ASTHO’s actions and external communications. 

Related ASTHO Documents:

Policy Statements: 
Access Policy Statement

Notes

1. Healthy People 2020. http://www.healthypeople.gov/2020/about/DisparitiesAbout.aspx. Accessed on May 18, 2011.
2. World Health Organization. The World Health Report 2000. Health Systems Improving Performance. http://www.who.int/whr/2000/en/index.html. Accessed on Feb. 21, 2008.
3. M. Whitehead. The concepts and principles of equity and health; Copenhagen: World Health Organisation Regional Office for Europe, 1990 (EUR/ICP/RPD 414)
4. National Association of County and City Health Officials. Health Equity and Social Justice Strategic Direction Team.
5. TA. LaVeist, DJ. Gaskin, P. Richard. The Economic Burden of Health Inequities in the United States. Washington D.C.: Joint Center of Political and Economic Studies; September 2009.
6. Office of Minority Health. National Stakeholder Plan to Achieve Health Equity. http://minorityhealth.hhs.gov/npa/templates/browse.aspx?lvl=1&lvlid=34. Accessed on May 18, 2011.
7. Office of Minority Health.
8. M. Whitehead.
9. P. Braveman, S. Gruskin. Defining equity in health. Journal of Epidemiology and Community Health 2003; 57:254-258.
10. D. Raphael (ed.) Social Determinants of Health: Canadian Perspectives. Toronto: Canadian Scholars Press; 2004: 1
11. Centers for Disease Control and Prevention. Recommendations to improve preconception health and health care—United States. Morbidity and Mortality Weekly. April 21, 2006; 55 (RR-6).