Policy and Position Statements


Achieving Optimal Health for All Guiding Principles

Health disparities and health inequities are among the reasons why the United States is falling behind other economically advanced countries in traditional public health indicators.1 To reverse this trend, the United States should act at the national, state, and local levels to eliminate disparities and inequities experienced by significant segments of the population and create opportunities for optimal health for all individuals. Every public health professional and agency is encouraged to undertake eliminating health disparities and advancing health equity as a critical part of their activities.

According to the Joint Center for Political and Economic Studies, between 2003 and 2006 the combined direct and indirect costs of health inequities in the United States totaled $1.24 trillion.2 Racism—structural and at the individual level—and other forms of discrimination and historical trauma contribute to health inequities.3 Multigenerational exposure to these issues is unavoidable since they are embedded in our nation’s cultural fabric, policies, and institutions.Public health agencies, as well as private and social institutions, continue to grapple with how to proactively respond to these social justice challenges. However, it is imperative to honestly confront these issues to neutralize their eminent threat to our nation’s well-being and overall national security.

The U.S. Department of Health and Human Services acknowledged the importance of addressing health inequities and disparities to achieve overall improved health when the agency developed Healthy People 2020 and established “a renewed focus on identifying, measuring, tracking, and reducing health disparities through a determinants of health approach.”5


Recognizing the relationship between health inequity and health disparities, ASTHO supports policies and strategies that advance health equity and eliminate health disparities and socially-determined barriers to positive health outcomes. The social and economic factors that impact health have been intractable problems resistant to systematic change. ASTHO encourages agencies across all relevant sectors of the federal, state, and local government, private sector, and others to provide leadership, financial, and administrative support for the research, education, policy development, and system changes needed to effectively address health inequities and health disparities. With a focus on both health and healthcare, ASTHO realizes there is more work to be done to mobilize leadership to promote health equity. In response, ASTHO proposes the following actions to promote health equity and optimal health for all:


  1. Provide national and state leadership to achieve optimal health for all. Foster a broader understanding about what determines health and the will to implement the policy, system, and programmatic changes necessary to advance health equity.
  2. Monitor state and territorial practices, policies, and scientific research which function to advance health equity.
  3. Share timely information and strategies with decision makers on health equity and its relationship to health disparities and ensure that health equity remains a priority issue in public health policies and programs.
  4. Convene and facilitate collaboration among state, territorial, local, federal, tribal, and private sector decision makers to recommend and implement systems, environmental, and policy change initiatives to advance health equity. Leverage and broadly engage both public and private partners in health equity solutions.
  5. Support state and territorial health agencies in implementing policies that integrate health equity into their state strategic plans, priorities, and policies.
  6. Identify and promote viable strategic plans and frameworks for action that guide the creation of health equity at the national, state, and local levels.

Capacity Building

  1. Leverage existing and new funding for all activities that advances health equity.
  2. Develop and promote a set of foundational practices for health equity for state and territorial health departments.
  3. Assist with the evaluation of state and territorial practices to develop an evidence-base for effective health promotion activities.
  4. Develop and disseminate information and tools to state and territorial health agencies to replicate promising practices and policies.
  5. Provide guidance on organizational structure and governance which strengthens and sustains enterprise-wide capacity to advance health equity.
  6. Develop the capacity and promote the use of health equity impact assessments with a broad range of social, economic, environmental, and health policies.
  7. Develop and promote community engagement strategies that help build the capacity of communities to advance health equity.
  8. Support states in expanding primary care and community prevention efforts related to specific racial and ethnic populations that have been historically socially excluded and marginalized, and those with low socioeconomic status.


State and territorial health agencies play a critical role in promoting health equity and developing strategies to achieve that goal. However, promoting health equity and reducing disparities is not solely the responsibility of the state or territorial health agency. Partnerships among communities, states, and national organizations should incorporate a Health in All Policies approach that includes non-health agencies and organizations in sectors that impact the physical, social, and economic factors that influence health, such as education, housing, labor, justice, transportation, agriculture, economic development, and environmental protection.

Public health agencies must work closely with state and local healthcare systems and develop shared goals to reduce disparities. Collectively, healthcare and public health can assure better access to care, improve healthcare quality, and develop approaches to best meet the needs identified across all populations, regardless of race, ethnicity, gender, socioeconomic status, or religion. ASTHO encourages its member agencies to:


  1. Provide leadership at the executive level to ensure that health equity and related health
    disparities are integrated at the strategic, policy, and programmatic levels.
  2. Use the prominent authority of the state and territorial health official to broaden the understanding of what determines health and raise public awareness of health inequities and increase the focus on solutions.
  3. Provide specific recommendations to governors, legislators, the public, governmental partners, and business communities on legislative solutions to overcome the economic and human impacts of health inequity.
  4. Advocate for cross-cutting Health in All Policies approaches across all programmatic areas.
  5. Advocate for the use of health equity impact assessments on a broad range of social, economic, environmental, and health policies.
  6. Support programs that ensure the health workforce in the states and territories reflects the ethnic and racial mix of the populations served.
  7. Partner with education and research institutions on workforce development and training on research and applied health equity policy analysis.
  8. Engage with local health departments and communities in a way that builds community capacity to advance health equity.


  1. Build infrastructure within organizations regarding funding and dedicated personnel to implement and sustain health equity activities by adapting programs to meet the needs of specified populations.
  2. Implement a set of foundational practices for health equity which align with the Public Health Accreditation Board standards for health equity.
  3. Standardize data collection at the state and local levels.
  4. Collect data and develop reports for decision makers and local communities that measure progress towards eliminating health inequities and achieving health equity.
  5. Invest and implement integrated data systems that collect data from various health and human service agencies. Data should include program activities, as well as resource and funding allocation.
  6. Evaluate the feasibility of harmonizing state data collection with HHS data collection on race, ethnicity, gender, primary language, and disability status as required by Chapter 6A, Section 300kk of U.S.C. Title 42.6
  7. Train and provide resources to healthcare and public health professionals to ensure cultural and linguistic competency and quality healthcare through the National Culturally and Linguistically Appropriate Services Standards in Health and Health Care.7


  1. Conduct a health equity analysis of all policies and modify them when necessary to assure that they advance health equity and don’t structurally disadvantage any group or community.
  2. Routinely engage diverse communities and organizations (e.g., rural health agencies, community- and faith-based organizations, local health departments, tribal governments, community health centers) in planning and decision making activities to develop and implement strategies to achieve health equity.
  3. Modify existing financial and funding processes which include health equity as a component, especially as it relates to grantmaking, funding, and procurement by state health agencies.


  1. Coordinate programs to ensure equitable distribution of health resources throughout the state and territory.
  2. Consult and collaborate with state offices of minority health, centers of excellence in health disparities, and other entities whose mission is health equity.
  3. Encourage and provide resources for cross-agency collaboration on the social determinants of health, such as transportation, housing, education, environment, and labor.


The social determinants of health play a major role in health outcomes and public health must focus on increasing access to the conditions necessary for people to be healthy where they live, work, learn, and play.8 State and territorial health agencies are uniquely positioned to advance health equity by providing executive leadership to ensure that health equity is integrated into programs and policies, building infrastructure within organizations to support and sustain health equity, informing policies intended to support the health of all people, and guiding strategies to coordinate programs to ensure equitable distribution of health resources.


Health disparities are measurable differences in health status and outcomes between different groups. When health disparities result from the systemic and unjust distribution of social determinants of health they are referred to as health inequities.i Disparities and inequities contribute to the widespread and persistent barriers to optimal health in American society. Significant disparities and inequities exist in key health indicators, such as infant and maternal mortality rates, life expectancy, rates of disease, and in key risk factors such as smoking rates, access to care, nutrition, and physical activity. Notable inequities also exist in the social and economic factors that influence health, such as poverty, inadequate housing, educational achievement, and unsafe working conditions. The causes of health disparities (socioeconomic factors) are interconnected and must be addressed through multifaceted and multisector approaches. Health equity occurs when everyone in our society has the same opportunity to achieve the best health possible, regardless of race, ethnicity, gender, sexual orientation, economic status, or geographic location.

i  From the World Health Organization: The social determinants of health are the conditions in which people are born, grow, live, work and age. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels.



Approval History:

Access Policy Committee Review and Approval: April 2017
Board of Directors Review and Approval: August 2017
Ratified by the ASTHO Assembly of Members: September 2017
Policy expires: September 2020

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




  1. The Commonwealth Fund. US Health Care from a Global Perspective. Available at: http://www.commonwealthfund.org/publications/issue-briefs/2015/oct/us-health-care-from-a-globalperspective. Accessed 6-12-2017.
  2. Joint Center of Political and Economic Studies. “The Economic Burden of Health Inequalities in the United States.” Available at: http://hsrc.himmelfarb.gwu.edu/cgi/viewcontent.cgi?article=1224&context=sphhs_policy_facpubs. Accessed 6-14-2017.
  3. National Academies of Sciences, Engineering, and Medicine. 2017. Communities in Action: Pathways to Health Equity. Washington, DC: The National Academies Press. Available at: https://doi.org/10.17226/24624. Accessed 7-25-17.
  4. Gee, Gilbert C., and Chandra L. Ford. “Structural Racism and Health Inequities: Old Issues, New Directions.” DuBois Review: Social Science Research On Race 8.1 (2011): 115–132. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4306458/. Accessed 7-24-17.
  5. ODPHP. “Healthy People 2020—Disparities.” Available at: http://www.healthypeople.gov/2020/about/DisparitiesAbout.aspx. Accessed 6-14-2017.
  6. U.S. Code, Title 42, Chapter 6A, Section 300k: Data collection, analysis, and quality. 2010. Available at: https://www.gpo.gov/fdsys/pkg/USCODE-2010-title42/pdf/USCODE-2010-title42-chap6A.pdf. Accessed 7-24-17.
  7. HHS. “National CLAS Standards.” Available at https://www.thinkculturalhealth.hhs.gov/clas. Accessed 6-14-2017.
  8. Braveman, Paula, and Laura Gottlieb. “The Social Determinants of Health: It’s Time to Consider the Causes of the Causes.” Public Health Reports 129.Suppl 2 (2014): 19–31. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3863696/. Accessed 7-24-17.