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Achieving Health Equity for All

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Posted January 7, 2019

At the recent American Public Health Association (APHA) conference in San Diego, California, more than 12,000 public health professionals gathered to present their research, discuss policy, and prepare to eliminate health disparities in their communities. APHA President Dr. Joseph Telfair shared his perspective on the conference theme, Health Equity Now, and what the gaps are in research both in the United States and globally. Dr. Telfair will be joining the PLOS ONE Editorial Board in January 2019.

To understand the conference theme, one first needs to understand the difference between equity and equality.

Equity. CC0 Public Domain

Equity. Image credit: Max Pixel, CC0 Public Domain

Equity is different than equality. Equality, essentially, everybody gets the same thing. Equity is equality plus. For example, if we want equality, then everybody gets a bike because everybody deserves a bike. That should happen, right? However, inequity says, you don’t give everybody the same type of bike because not everybody is the same. For example, you have people who have no use of their legs, so you can’t give them a bike with pedals. You have people of different heights and sizes and so forth. What you do then is you give everybody a bike, but you specialize the bike to fit their unique needs. That’s what equity is. Equity is the adjustments that you make in equality that allows all people to benefit from the outcome.”

Dr. Telfair explained that although we have a good definition of equity, intervention research is needed to identify solutions that reduce inequality.

“Essentially what we have done well is the conceptual research. We’re clear about defining equality and inequality, but we need more empirical research. We have not implemented the intervention research well. In other words, we need to look at interventions, look at program design, program development, test out research questions and hypotheses. We know what the variables are, but not too much of what happens if you change a variable. In other words, if we have a project that is designed to reduce poverty within a certain sector, does that reduction of poverty also lead then to changes in terms of inequality?”

Difference between equality and equity. Image credit: Interaction Institute for Social Change | Artist: Angus Maguire.

Difference between equality and equity. Image credit: used with permission from Interaction Institute for Social Change | Artist: Angus Maguire

In the United States, for example, research is needed to understand the effect of the Affordable Care Act (ACA), the healthcare reform law enacted in 2010. Part of the law extended health insurance coverage to people with pre-existing conditions.  The cost of their care was buffered by mandating that healthy individuals buy insurance as well. This mandate was later rescinded. Dr. Telfair proposed that research is needed to understand what impact changes in the law have had on providing equitable care.

“Equality assures that you have services and programs in place so that everybody gets equal access and equal care, however you also need to make adjustments such that you are addressing their unique needs. Take for example people with preexisting conditions. You can have a top-quality healthcare system but if you don’t allow people with preexisting conditions then you have an inequitable healthcare system. We’re just now beginning to see people begin to look at that question. What does it take intervention-wise to adjust systems such that you have this level of equity? We could do it by legislation and the implementation of outcome-based programs.

The Affordable Care Act (ACA) was trying to level the playing field. However, when the mandate was taken away, it took away a buffer for that. So that means that now the costs for folks with pre-existing conditions have gone up because there is no buffer. We don’t really know in the short and long run what that really means yet. What happens when you introduce an intervention and you take an intervention away? We just don’t know that yet and we need to know that.”

Dr. Telfair went on to explain the need for more complex research globally.

“That’s in the United States. But what about globally? Most countries that we work with do not have insurance plans. And for many of them, healthcare is a hit and miss proposition. Anybody can get healthcare if they show up to the place where healthcare is being delivered. However, we also know that there is unequalness in terms of quality. I’ve read several papers that people have submitted from countries where there’s civil war, and they’ve totally ignored the civil war influence. And it really frustrates me. Once I sent a paper back and I said, ‘you can’t look at this acontextually’. When we look at equity, we’re looking at it in all of those contexts, we know it’s a multi-layered, multi-contextual, multifactorial type of thing. We know it’s complex. There’s no such thing as a simple study, independent variable/dependent variable/outcomes when you look at equity. That’s what we need to be good at. That’s what we need to look at. Conceptually, we’re very clear.

We have all kinds of examples at this conference. People are beginning to tackle and struggle with, how we look at the intervention side of equity. How do we actually do things that are going to make the difference where we can achieve what we’re shooting for, because that’s aspirational at this point. We’re getting there in the sense that people are beginning to think really, really well and are beginning to use different types of models. In the health services arena, they use health services models, traditional models to look at the effect of adjustments that people are making, cost adjustments, personnel adjustments.”

In summary, equity has been defined, but research is needed to determine whether interventions are effective in increasing health equity for all. Researchers should study how changes in variables effect inequity. Health equity research must take the complexity of the local context into consideration, and models need to be translated into measurable outcomes.

Source: PLOS EveryONE

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