CDE Appendix 1 Literature Review - Central East Local Health ...

Appendix 1: 

Health Equity Literature 

Review: 

Frameworks, Policies, Standards, Accountability & Quality 

Assurance Mechanisms, Training & Education 

The Culture, Diversity and Equity Project

EXECUTIVE SUMMARY 

The literature review of the Culture, Diversity and Equity Project draws on academic and grey 1 literature from local, 

national and international contexts in the following areas: 

• Policies and frameworks regarding health equity and cultural competence; 

• Documents on accountability, compliance, quality assurance agreements and other auditing tools to help ensure 

effective implementation of policies; and 

• Frameworks and standards for cultural competence education and training. 

The review gave priority to literature from North America, Europe, Australia and New Zealand because of 

similarities and transferability of findings to the Canadian context. 

This review is organized into three main parts: 

• PART I: Health Equity Frameworks and Policies; 

• PART II: Accountability, Compliance and Quality Assurance; and 

• PART III: Cultural Competence Education and Training. 

Part 1: Health Equity Frameworks and Policies 

Towards a Definition of Health In/equity 

There are different yet overlapping definitions of health equity and health inequity. In the Canadian context, the 

terms health disparity and health in/equity are frequently used, whereas in the UK/European context, health 

inequality is the recurring term, tending to relate health inequity to socio-economic status (SES). In the US, health or 

health care disparity is frequently used, in a way that evokes social divisions along racial and ethnic lines. 

Health inequity is defined as “those inequalities in health that are deemed to be unfair or stemming from 

some form of injustice” (The Health Disparities Task Group, 2004). It is also often defined as “those health 

differences that are avoidable, unnecessary and unfair” (Whitehead, 1998). 

Unlike health inequality or health disparity, health in/equity implies an ethical judgment, one that calls for action in 

the form of public policy intervention. 

At the core of discussions of health in/equity is the clear acknowledgement that certain health disparities are 

justifiable or unavoidable: for example, those that are self-inflicted or which result from biological inheritance. This 

review of international health equity policies makes clear the importance of articulating the ethical criteria by which 

to distinguish between just and unjust health inequalities. 

It also emphasizes the importance of forming a common language and ethics of health equity in Ontario, one that 

will make it possible to agree upon policy goals, commitments, and agreed-upon standards for judging progress. 

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The term grey literature is used to describe non-academic literature that is not easily found through regular channels.

The Culture, Diversity and Equity Project: Literature Review 

Frameworks 

Three main types of health equity frameworks emerged in the literature. Each of these frameworks approaches the 

problems to be tackled in slightly different ways. Though they are not explicitly named this way in the literature, we 

can refer to these overarching frameworks as: 

• Health equity frameworks; 

• Health care equity frameworks; and 

• Health equity in health care frameworks. 

Health Equity Frameworks 

Health equity frameworks are concerned with reducing disparities in health status broadly conceived and measured 

in terms of mortality and morbidity statistics, etc. 

Such frameworks focus on all potential determinants of health status, including those that extend beyond the health 

care system. These frameworks are exemplified by the WHO’s 2008 Closing the Gap Framework, New Zealand’s 

2002 Framework for Reducing Inequalities in Health and the Canadian Institute of Health Research’s (CIHR) 2002 

Population Health Framework. 

Health equity frameworks generally point towards ‘whole-of-government’ approaches to addressing health status 

inequities, since many of the strongest determinants of health status are located ‘upstream’ from the health care 

sector in broad social, political, and economic policies (e.g., poverty reduction). Health equity frameworks can be 

further subdivided between those that are primarily theoretical, exploring the causes and determinants of health 

status, and those that are focused more directly on evidenced-based intervention strategies (‘strategic intervention 

frameworks’). 

What makes the health equity frameworks discussed in this review so effective is that they: 

• Adopt a holistic understanding/definition of ‘health’ which enables them to recommend a wider range of 

preventative and health-promoting interventions beyond traditional medical-model approaches (that concentrate 

solely on treating individual illness); and 

• Ground proposed policy interventions in scientific and theoretical evidence, permitting more productive 

dialogues between stakeholders. 

Among the major limitations of such frameworks is the fact they bring into policy consideration various 

determinants of health that are beyond the immediate control of the health care sector such as poverty. Many such 

frameworks - at least from the more limited and immediate health care service/system vantage point - are better at 

identifying problems than offering solutions. 

In fact, the broad diagnoses and prognoses gained from these frameworks often require extensive intersectoral 

collaboration with stewardship at a national level, which itself poses many challenges, due to the structural 

organization of government along departmental lines (see WHO, 2008; Public Health Agency of Canada, 2007; 

PHAC & WHO, 2008). 

Health care Equity Frameworks 

Health care equity frameworks are concerned more narrowly with inequities in the accessibility and quality of health 

care services. They focus on disparities between advantaged and disadvantaged populations that can be traced back 

to the health care system: this includes, for example, access to primary care physicians and health practitioner 

stereotyping/racism, leading to inequitable diagnoses and treatment. 

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The primary example of health care equity frameworks are cultural competence frameworks. Particularly dominant 

in the US, such frameworks address issues of culture in health care services in order to reduce healthcare disparities 

(and as a consequence, health status disparities). 

Health care equity frameworks have the great advantage of ‘do-ability,’ due to their more narrow focus on the role 

of the health care sector in reducing health care inequities. Moreover, cultural competence frameworks pay close 

attention to the often neglected role of cross-cultural dynamics in negatively impacting the accessibility and quality 

of health care services received by cultural minorities or marginalized populations. 

However, the narrow focus on healthcare inequities invites many critics, who cite considerable research evidence. 

Health care inequity approaches are repeatedly subject to the following criticisms: 

• The most important determinants of health that lie ‘upstream’ from the healthcare sector are not engaged; 

• Health care inequities play a relatively minor role in explaining health status disparities more generally; 

• The scope of policy options and interventions is seriously limited by such a narrow focus, diminishing the 

ability to reduce health status inequalities. 

• Policymakers are forever in a reactive mode, playing catch up, since pursuing ‘downstream’ strategies is like 

patching a structurally compromised leaking bucket: just as old holes are filled, new holes quickly open up 

(further upstream); 

• Individuals must fall ill before health care inequity approaches can begin to make their impact, which 

reproduces illness-centred models of health. 

Cultural competence approaches, more specifically, have ongoing limitations, i.e., their: 

• Excessive focus on individual-level cultural competencies to the neglect of organizational and system-level 

forms of cultural competency. While competencies at the frontline individual service level are highly important, 

agency and structural-level competencies should also be considered, since they condition and constrain 

possibilities for cultural competence at the frontline provider level; 

• Tendency to restrict concerns with ‘culture’ to ethnic and racial dimensions of cultural difference; 

• Use of definitions of ‘culture’ that assume cultural consensus and homogeneity, thus failing to appreciate the 

complex, intersectional nature of individual social and cultural experience and identity (intersectionalities). 

Health Equity in Health care Frameworks 

The third type of framework identified in this literature review bridges the two other approaches; it is called the 

Health Equity in Health care Frameworks. These are fundamentally concerned with reducing inequities in health 

status (conceived broadly), except that they focus on policy interventions that can be achieved from within the 

confines of the health care system (as per health care equity frameworks). 

Whereas health equity frameworks tend to be entirely concerned with reducing inequities in health status (often 

promoting whole-of-government approaches), and health care equity with reducing inequities in health care (e.g. 

quality and access), health equity in health care frameworks are concerned with disparities in health status and 

they propose solutions more squarely (though not exclusively) within the parameters of the health care system. 

By focusing on the broader determinants of health status, yet from the standpoint of the health care system, such 

approaches: 

• Widen the range of potential policy options pursued by the health care system (for instance, enabling a focus on 

community-based, health promotion initiatives etc.); and 

• Remain grounded within the more immediate spheres of strategic possibility of the health care system. 

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The two examples of health equity in health care frameworks discussed in this review are intervention-focused 

frameworks. One of their limitations is their lack of an explicitly elaborated conceptual model that gives scientific 

and theoretical details of the multi-level, causal pathways of health in/equity. 

Suggested Features of a Health Equity Framework 

An ideal health equity framework should have certain features or characteristics. For example, it: 

• Combines an evidence-based conceptual/causation model of health determinants with a practical intervention 

framework; 

• Focuses on disparities in health status, broadly conceived, yet begins from the standpoint of the health care 

system and its strategic levers of power (while also seeking to collaborate with other stakeholders in other 

sectors wherever possible); and 

• Takes a patient-centred approach that addresses issues of cultural and linguistic competence as a fundamental 

health care quality and access issue, while also being sensitive to issues of power and the intersecting nature of 

marginalization. 

Health Equity Policies 

Internationally, policy interventions are fundamentally shaped by the three frameworks discussed above. Debate 

over health equity policy revolves around justifications, objectives, scope, use of evidence, and points of 

intervention (adapted from Mackenbach et al., 2002b). 

Justification: The two main justifications for health equity policies are: 

• Health inequalities are in contradiction of the values of fairness and justice; and 

• Reducing inequalities in health leads to better average health outcomes for the population as a whole. 

Objectives: The goal of health equity policy tends to be framed in one of two ways, as either the achievement of 

absolute health equity or simply the reduction of health inequities. If the latter, it must then be defined whether this 

is a reduction of inequalities in health status or in the health care system access more narrowly. 

Scope: The main differences in health equity policies in this respect concern the breadth and scope of diversity 

groups considered (e.g., race, ethnicity, gender, and/or socioeconomic status, etc.); and the breadth and scope of 

organizational/system functions engaged through health equity policies (e.g., merely human resources, or strategy 

and policy, services, procurement, leadership, etc.) 

Use of Evidence: Policies can be further differentiated according to the degree to which scientific ‘evidence’ plays 

an influencing role. 

Entry Points for Intervention: Health equity policy interventions can be focused ‘upstream’ (e.g. intersectoral 

action on broad social determinants of health such as housing, employment etc.) or ‘downstream’ (e.g. health care 

access issues). This, and whether to prioritize universal and/or targeted (selectivist) approaches (e.g., focusing 

interventions on the most disadvantaged populations, or supporting ethno-specific service provision etc.), are part of 

an ongoing debate. 

International policy trends in these and other respects are covered in this literature review, along with case studies of 

good practice. 

The United Kingdom government is the leader among nations tackling health inequalities through a concerted, 

broad, whole-of-government approach that is informed by a health equity policy framework. The United States, on 

the other hand, is leading the way in cultural competence policies and standards, though approaches rarely reach 

beyond a health care equity framework. 

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Canada, although an intellectual leader in research on health equity (from a health promotion and population health 

perspective), has failed to develop concrete health equity policies and political leadership on the issue of health 

disparities. There are promising developments in this respect however, such as the formation of an intergovernmental 

Health Disparities Task Group and growing attention to health equity in the Ontario Provincial 

Ministry of Health and Long Term Care (MOHLTC) and Local Health Integration Networks (LHIN) contexts. 

Policy Lessons From Around the World 

A review of international health equity policy literature provides a number of key policy lessons: 

• Academic, governmental, and community collaboration in the realm of health in/equity is critical to advancing 

health equity policy. 

• The most effective approaches to health equity combine and incorporate, in varying degrees: 

• Health equity and health care equity policy objectives; 

• Upstream, midstream and downstream (‘all stream’) policy interventions; and 

• Universalist and selectivist approaches. 

This is partly due to the political acceptability of such broad, compound approaches which can appeal to 

multiple audiences and constituencies across the political spectrum (depending on their emphases). Health 

equity policies should strategically align themselves, wherever possible, with national and local political/policy 

contexts to gain traction; 

• Policy objectives should be clearly articulated in achievable, measurable terms; 

• Policies should base themselves on evidence of what causes health inequity and what remedies or prevents 

health inequity (i.e., appropriate and successful interventions). In the absence of evidence, pilot demonstration 

projects, and their evaluation, are crucial. However, evidence is not enough, and policy choices must also be 

made upon ethical priorities and commitments; and 

• The health care sector should play a leading role in advancing a broad intersectoral health equity policy agenda 

that addresses social determinants of health. Intersectoral collaboration has been shown to be fundamental to the 

success of a comprehensive health equity policy. 

Part 2: Accountability, Compliance and Quality Assurance 

Part II examines the means of ensuring accountability and compliance with respect to health equity policies and 

objectives, and quality assurance strategies. 

The ways in which health equity policies and strategies are formulated can greatly impact their realization and how 

accountability is established. It is particularly important to: 

• Articulate clear and realistic policy objectives in terms that can be measured and made operational; 

• Establish concrete action plans that clarify what will be done, by when and by whom, and how success will be 

measured; 

• Include diverse stakeholders (including community stakeholders) in the policy development process; and 

• Ensure compliance and accountability through leadership and governance arrangements. 

Governance for health equity strategies should extend to the highest authority in the health care service system (‘the 

tree top’) to ensure: 

• Coherent integration of health equity concerns across all policy, program, service/function areas; 

• Effective performance management across the system; and 

• Local relevance of decisions, services, and public accountability by involving and supporting the ‘grassroots’ 

and building on their insights and experience. 

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To ensure system-wide compliance and accountability, health equity policies and strategies should be integrated into 

existing performance management systems. In this regard, health equity impact assessments are a promising tool for: 

• ‘Mainstreaming’ accountability across an entire organization (versus siloing responsibility only with 

specialists); and 

• Ensuring that all policy/program areas consider the impact of their interventions on various diverse groups (not 

just the one that the policy/program is focused on). 

Policies should also be monitored by a corporate level oversight body to assure and monitor progress and coordinate 

efforts for eliminating disparities. 

The Role of the LHINs 

The major ‘levers’ currently available to the LHINs for managing performance are their: 

• Funding and allocation powers; 

• Local health system planning and contracting role (e.g., Integrated Health Service Plans; LHIN-Provider service 

accountability agreements etc.); and 

• Potential oversight role regarding compliance with health equity policy objectives as reflected in service plan 

agreements. 

Establishing accountability and quality assurance depends on continuing measurement, evaluation, and reporting of 

progress in relation to health equity policy objectives. As part of its service plan agreements, the LHIN can, for 

instance, require: 

• Annual targets per health equity policy goals and objectives; 

• Ongoing performance monitoring and control action; and 

• Regular reporting on progress to both the LHIN and the public (e.g., annual report cards). 

The LHINs could play a critical role in delivering the capacity that makes compliance possible: 

• Provide and/or support training initiatives; 

• Develop health equity/cultural competence ‘guidelines’ and standards for care; and 

• Assist and coordinate existing health equity researchers and research units in intelligence gathering and 

exchanges. 

The health care system’s licensing and accreditation agencies, although beyond the direct control of the LHINs, can 

also play a quality assurance role. For example, they could require health care providers to meet health 

equity/cultural competence ‘standards’ as a condition of licensing and/or accreditation (Exworthy et al., 2006; 

Betancourt et al., 2002; Office of Minority Health, 2001). 

Part 3: Cultural Competence Education and Training 

While there is significant variation in the specific content of cultural competence training initiatives, they tend to 

focus on three main areas: 

• Attitudes; 

• Knowledge; and 

• Skills (Sue et al., 1992, 1996; Curtis, Dreachslin, & Sinioris, 2007; California Endowment, 2003; Haarmans, 

2004). 

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Though not all training frameworks cover all of these areas equally, this tripartite framework for cultural 

competence training has been likened to a three-legged stool: “the structure would fail if one ‘leg was missing” 

(California Endowment, 2003). 

Educational initiatives and curriculum for medical/health-care professionals, in US post-secondary institutions, 

increasingly incorporate cultural competence standards. This contrasts with the trend in continuous education and 

professional training for existing health care professionals. 

A 2004 paper in the Journal of the American Medical Association, for instance, found that among nearly 8,000 

graduate medical educational programs surveyed in the United States, 50.7 percent offered cultural competence 

training in 2003–2004. This was up from 35.7 percent in 2000–2001 (Brotherton, 2004 cited in Betancourt et al., 

2005). Unfortunately, no corresponding study exists in the Canadian context. 

The reason for this transformation may be a combination of ‘stick’ and ‘carrot’ approaches that the LHINs would do 

well to adopt in its continuing educational initiatives for health professionals (Betancourt et al., 2005). 

The ‘stick,’ in this respect, has taken the form of increasing regulatory pressures and the introduction of cultural 

competence accreditation standards since 2002. In that year, the US Liaison Committee on Medical Education 

(LCME) introduced the first official cultural competence accreditation standard requiring that all medical schools 

integrate cultural competence into their curricula. 

The US Accreditation Council of Graduate Medical Education (ACGME) has also introduced cultural competence 

standards for residency programs (see ACGME, 2004). New Jersey has gone even further with the ‘stick approach,’ 

passing legislation in 2005 requiring cultural competence education as a condition for licenses to health care 

professionals (see Salas-Lopez et al., 2007; also see Baquet et al., 2004). 

The ‘carrot approach’ has also helped to move cultural competence forward in the medical education field. In 2004, 

the New York State of Health modified its $33 million per year Graduate Medical Education Reform Incentive Pool 

to “reward residency programs that provide eight hours of cultural competence training to at least 80 percent of 

residents” (New York State Dept of Health, 2004 cited in Betancourt et al., 2005). Demonstrating the effectiveness 

of this ‘carrot’ approach, “[i]n the first year, 66 of the 104 residency programs in New York State proposed new 

cultural competence curricula” (ibid.). A similar method could be used by the LHINs by means of their funding 

leverage. 

Cultural competence training for practicing health care professionals, by contrast, remains “haphazard and varying 

in quality.” This is largely due to the lack of agreed-upon evaluative criteria for assessing cultural competence 

training (California Endowment, 2003). 

The development of training standards in continuous educational contexts is a key area for future research. In the 

meantime, standards and evaluative tools (such as the Tool for Assessment of Cultural Competence Training) for 

medical school cultural competence education could be adapted to continuous learning contexts. 

One of the greatest limitations of the existing cultural competence training literature is the lack of empirical 

evidence substantiating the effectiveness of cultural competence training interventions. The impact of training is 

rarely evaluated, and is done so using poor methodological design. Without scientific evidence it remains difficult to 

determine which cultural competence training most effectively improves health outcomes for disadvantaged, 

marginalized and/or ethno-racial minority clients. 

While there is evidence that diversity and cultural competence training can change attitudes, research suggests that 

this alone does not translate into behavioural change or better client health outcomes. According to recent 

assessment by Curtis et al (2007), too many of the existing cultural competence training initiatives for health care 

professionals still begin and end with awareness-building. 

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Moreover, the literature suggests that: 

• Cultural competence training needs to guard against teaching strategies that stereotype and therefore minimize 

the complexities of individual social and cultural identification; and 

• Training must not be treated as a substitute for real organizational change. 

Best practices and recommendations relating to cultural competence training include: 

• Focus on skills in training modules and not only attitudes and knowledge. The cultural competency 

literature underlines the importance of employing a practice oriented, skills-based training approach, one that 

focuses on the specific skill sets needed to function in a culturally competent manner in one’s work 

environment (Engerbretso et al., 2008; Curtis et al., 2007; Haarmans, 2004); 

• Take a systems approach to cultural competence training. This means connecting and integrating training 

with the cultural competence strategic goals of the organization. A systems approach, in this respect, requires 

the following steps: 

• [1] Determine diversity and cultural competence goals in the context of strategy; 

• [2] Measure current performance against needs; 

• [3] Design training to address the gap; 

• [4] Implement the training; 

• [5] Assess training effectiveness; and 

• [6] Strive for continuous improvement” (Curtis et al., 2007). 

• A systems approach to training helps to ensure that training objectives focus on the specific skills and 

behaviours (i.e., not just attitudes) required to achieve organizational-level cultural competence. 

• Evaluate training programs for their impact on trainees’ behaviour/performance and clients’ health outcomes 

using validated evaluation tools (Gozu et al., 2007; Curtis et al., 2007). Evaluation methodologies should use 

experimental (i.e., control groups) designs and/or, at a minimum, pre/post-test designs (testing for skills, 

knowledge and attitudes before and after training). 

• Keep up to date with the training literature and develop evidence-based standards and evaluative tools 

for cultural competency training and skills assessment (Office of Minority Health, 2001; Betancourt et al., 

2005). 

Finally, training modules should be developed more explicitly around health equity, as this would engage skill sets 

beyond cultural competence. 

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Table of Contents 

EXECUTIVE SUMMARY 2 

Part 1: Health Equity Frameworks and Policies 2 

Frameworks 3 

Part 2: Accountability, Compliance and Quality Assurance 6 

Part 3: Cultural Competence Education and Training 7 

HEALTH EQUITY LITERATURE REVIEW 11 

INTRODUCTION 11 

Scope 11 

Methods 11 

Outline of Contents 12 

PART 1: HEALTH EQUITY FRAMEWORKS & POLICIES 13 

PART 2: ACCOUNTABILITY, COMPLIANCE AND QUALITY ASSURANCE 77 

PART 3: CULTURAL COMPETENCE TRAINING AND EDUCATION 99 

Appendix 1: 108 






REFERENCES 129 

Produced by: Dr. Remi Warner (January 2009) on behalf of Munger Consulting 

The Project Charter Committee approved this document on January 20, 2010 

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HEALTH EQUITY LITERATURE REVIEW 

INTRODUCTION 

Background 

This literature review forms an initial part of a wider 1.5-year project of the Central East LHINS to develop policy, 

accountability, and education frameworks regarding culture, diversity, and health equity. The overall objective of 

the project is to: 

• Develop planning policy framework for Cultural Competence, Diversity, & Equity from which future and 

current initiatives, policies, and projects can be assessed. 

• Articulate standards for cultural competence for service providers; 

• Address compliance and quality assurance through accreditation, accountability agreements, and other auditing 

tools; and 

• Facilitate enhanced access to culturally competent, sensitive, and appropriate health services through education. 

Scope 

Three main bodies of intersecting literature were reviewed: 

1. Policies and frameworks regarding health equity and cultural competence; 

2. Documents on compliance, quality assurance, accountability agreements, and other auditing tools and methods 

to help ensure effective implementation of policies ; 

3. Frameworks and Standards for cultural competence education and training. 

While local, national and international bodies of literature were reviewed, focus was on the multicultural global 

North (North America, Europe, Australia and New Zealand) for reasons of transferability to the Ontario LHINS 

context. Public sector health equity strategies at regional, provincial/state and national levels were also privileged for 

similar reasons. 

Methods 

Grey and academic literature was reviewed using York University and University of Toronto library catalogues and 

various internet search engines (primarily Google). 

Academic Journal Databases searched included: 

• Medline (PubMed and Ovid); Proquest; Evidence Based Medicine Reviews; Scopus; Sociological Abstracts; 

Social Sciences Abstracts; Social Work Abstracts; PsychINFO; PsychARTICLES; Web of Science; Expanded 

Academic (ASAP); and PAIS. 

Grey Literature was primarily culled from google internet searches, in addition to a variety of online sources, 

including: 

• Government Sources: Government Health Ministry/Department websites (Canada, UK, US, Australia, New 

Zealand); GovInfo: Government on the Web; Government of Canada Publications Catalogue; Canadian 

Institutes of Health Research; Canadian Health Research Collection; National Institute of Mental Health (US); 

Office of Minority Health and Health Disparities (US); National Institute of Mental health (US); Substance


Abuse and Mental Health Services Administration (US); Agency for Health Care research and Quality (US); 

World Health Organization; 

• Other Public Health/Policy Think Tank Sources: The Wellesley Institute; Canadian Policy Research 

Network; Centre for Equity in Health and Society (CEHS); Canadian Institute of Health Research; Canadian 

Policy Research Network (CPRN); Canadian Healthcare Association; Canadian Institute for Health 

Information; Canadian Health Network; Health Care Information Resources (McMaster University); Centre for 

Health Promotion (University of Toronto); Conference Board of Canada; Canadian Health Network; National 

Anti-Racism Council of Canada (Health Section); CERIS/Metropolis website (Canada); Cultural Diversity 

Institute (CDI) [Canada]; National Centre for Cultural Competence (US); Commonwealth Fund (US); Institute 

for Public Policy Research (UK); National Research Register (Department of Health, UK); Open 

University/Resources/reports & grey literature (UK); Health Issues Centre (AUS) – An Independent Australian 

Health Policy and Research Action Center; Health Policy Monitor – International Network Health Policy and 

Reform. 

Library catalogues, databases and internet search engines were searched using the following search terms: 

• (health) or (mental health) or (healthcare) AND (equity) or (equality) or (inequality) or (disparity) or (inequity) 

AND/OR (cultural competence) or (cultural competency) or (linguistic competence) or (linguistic competency) 

or (cultural) or (multicultural) or (competence) or (diversity) or (inclusion) or (anti-oppression) AND/OR 

(system) or (organization) or (agency) AND/OR (policy) or (framework) AND/OR (standard) or 

(accountability) or (compliance) or (quality assurance) AND/OR (training) or (education) or (accreditation) 

In the case of academic journal databases, search areas were restricted to the title and/or keywords and/or abstract. 

Snowball methods were used to expand and focus the search throughout. Attention was, moreover, accorded to the 

number of citations of a journal article in a journal database as an index of the importance or prominence of a 

particular author or article in a subject area. 

Search results and marked references were recorded and saved in RefWorks and Reference Manager. Articles and 

book chapters were converted into pdf files and Microsoft Word files and imported into NVIVO 7 (qualitative 

coding software program) for further thematic coding and analysis. NVIVO 7 coding results informed the 

organization and writing up of the final literature review. 

Outline of Contents 

The literature review is organized into three main sections: 

• PART 1: HEALTH EQUITY FRAMWORKS & POLICIES 

• PART 2: ACCOUNTABILITY, COMPLIANCE & QUALITY ASSURANCE 

• PART 3: CULTURAL COMPETENCE TRAINING & EDUCATION 

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PART 1 

HEALTH EQUITY FRAMEWORKS & POLICIES 

1.0 TOWARDS A DEFINITION OF HEALTH IN/EQUITY 

1.1 Defining the Problem: Health Inequity, Inequality, Disparity 

The academic and grey literature on health disparities contains numerous, competing, overlapping, yet distinct, 

terms for its subject of study, variously termed health disparity, health inequality, health inequity and/or, positively 

conceived, health parity, health equality, and/or health equity. A necessary starting point for this review is the 

untangling of the different meanings and uses of these terms, not only for the sake of conceptual clarity but because 

of the significant policy implications and consequences deriving from such varying definitions, as discussed in 

subsequent sections. 

While health inequity, health disparity and health inequality are sometimes used interchangeably in the literature, 

each term tends to carry its own distinct set of implied meanings. Terminologies, and their distinct conceptual 

orientations and connotations, tend to vary along national lines, reflecting differing national political/policy 

contexts. Health disparity, for instance, is the term commonly used in the US literature, whereas in the UK and 

European contexts health inequality is the more commonly used term. 

All three terms appear in the Canadian literature, though there is a relatively more frequent and intentional use of the 

term health in/equity and/or health disparity. While each of these terms have a national valence partially reflecting 

differing national approaches, they are also used differently in different (e.g. academic vs. government) contexts, 

which makes any such exercise in conceptual definition and clarification at best tentative and partial. 

In a formative Discussion Paper entitled Reducing Health Disparities: Roles of the Health Sector, prepared by the 

Health Disparities Task Group of the Federal/Provincial/Territorial Advisory Committee on Population Health and 

Health Security for the Public Health Agency of Canada, health disparities is defined as “differences in health 

status that occur among population groups defined by specific characteristics” (2004). The paper goes on 

to define “the most useful characteristics [for] policy purposes”, in keeping with its population health approach, as 

being “those consistently associated with the largest variations in health status”, which in Canada, it is argued, relate 

to “socio-economic status (SES), Aboriginal identity, gender, and geographic location” (Health Disparities Task 

Group 2004). 

In the US context, there is a much greater focus on race/ethnicity and health care-specific issues, owing in part to the 

greater significance and pronounced history of racial cleavages there, and the large numbers of persons without 

health insurance (45 million in 2003). The Institute of Medicine’s landmark (2003) report, Unequal Treatment: 

Confronting Racial and Ethnic Disparities in Healthcare, for instance focuses on healthcare disparities (in accord 

with this US tendency), defining the latter as “differences in the quality of health care that are not due to accessrelated 

factors or clinical needs” (Smedley et al., 2003). By screening out access-related factors attributable to 

socioeconomic status, this definition and report foregrounds the significant contributing role of racial and ethnic 

disparities attributable to cultural incompetence, bias, prejudice, and stereotyping in the US healthcare system as a 

major explanation for healthcare disparities. 

Exworthy et al. (2006) use the term health disparities in their (2006) article to refer, comprehensively, to “both 

disparities in health care and inequalities of health status (unless there is a specific instance referring to inequalities 

of health and health care).” 

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Health Inequality 

The term health inequality is used in European contexts to focus the lens more specifically on health inequalities 

relating to socio-economic status. This terminology has been ‘officially sanctioned’ in the United Kingdom since the 

coming to power of Tony Blair’s Labour government in 1997. It came to replace the much more neutral then in use 

term of ‘health variations’ which predominated (when discussed at all) under the Conservative government’s of 

Margaret Thatcher and John Major (Exworthy, Blane, and Marmot, 2003). 

In keeping with the UK/European perspective, Exworthy et al. (2006) define health inequalities as ‘systematic 

disparities in health [status] (or in the major social determinants of health) between groups with 

different levels of underlying social advantage/disadvantage,’ including wealth, power, or prestige” (citing 

Braveman and Gruskin 2003, p.4). Reflecting European approaches more generally, Mackenbach et al. (2002a) 

similarly focus on and define socioeconomic inequalities in health as “systematic differences in morbidity and 

mortality rates between individual people of higher and lower socioeconomic status to the extent that these 

are perceived to be unfair.” 

The (2004) Health Disparities Task Group Discussion Paper for the Public Health Agency of Canada draws a finer 

distinction between health inequality and health inequity, describing health inequality as ”the generic term used to 

designate differences, variations, and disparities in the health achievements and risk factors of individuals 

and groups…that need not imply moral judgment” (Health Disparities Task Group citing Kawachi et al., 2002, 

p.56). Health inequalities due to individual biological endowment or the consequences of personal choices would 

not qualify, in this view, as health inequities, but rather, count as health inequalities. What should concern public 

policy, this discussion paper goes on to suggest, is “health inequalities attributable to modifiable factors, 

especially those that are perceived as inequitable” (see more definitions and descriptions of health inequity 

below). 

Health Inequity 

Of all the terms used, health inequity most consistently and strongly implies health disparities that are unjust and/or 

thus of moral and political concern. Gardner (2008b) in this light defines health inequities (which he uses 

interchangeably with health disparities) as “differences in health outcomes that are avoidable, unfair and 

systematically related to social inequality and disadvantage”. The link between health equity, social justice and 

ethics is made even more explicit in the World Health Organization’s (2008) Closing the Gap report: 

Where systematic differences in health are judged to be avoidable by reasonable action they are, quite 

simply, unfair. It is this that we label health inequity. Putting right these inequities and the huge and 

remediable differences in health between and within countries is a matter of social justice. Reducing 

health inequities is, for the Commission on Social Determinants of Health (hereafter, the Commission), 

an ethical imperative (WHO, 2008). 

The Health Disparities Task Group (2004) similarly links inequity and injustice, defining health inequities as “those 

inequalities in health that are deemed to be unfair or stemming from some form of injustice”. It is the 

normative judgement implied by the terminology of health inequity, they argue, that distinguishes it from health 

inequality. Precisely because of the normative nature of such judgements the Health Disparities Task Group 

emphasize that “science alone cannot determine which inequalities are also inequitable, nor what proportion of an 

observed inequality is unjust or unfair” (Health Disparities Task Group, 2004 quoting Kawachi et al., 2002, p.647- 

8). For such normative judgements depend upon, among other things,”(a) one’s theories of justice; (b) one’s theories 

of society; and (c) one’s reasoning underlying the genesis of health inequalities” (ibid.). An ethical theory of social 

justice is thus ultimately required to differentiate unfair from fair differences in health status. 

Inequitable distributions of health are most commonly and consistently described and defined as those health 

differences that are avoidable, unnecessary and unfair (Whitehead, 1998). Examples of the latter include 

“differences in health resulting from health-damaging behaviour not freely chosen, or from exposure to health 

hazards in the environment, or from impaired access to healthcare services” (Mackenbach et al., 2002a). Since these 

14


are potentially avoidable, they are widely perceived as unfair. “Differences in health which arise as a result of 

natural, biological variation, or of freely chosen health-damaging behaviour,” contrastingly, “will not commonly be 

perceived as 'unfair'” for the inverse reason (ibid.). 

Mackenbach et al. (2002a) draw on Whitehead’s (1998) scheme for judging the fairness of socioeconomic 

inequalities in health based on avoidability and common senses of justice (See Table 1.1. below). 

Table 1.1: Whitehead’s scheme for judging the fairness of socioeconomic inequalities in health 

Source: Mackenbach et al., 2002b. Adapted from Whitehead, 1990. 

Mackenbach et al. (2002b) nevertheless note the increasingly complex and fading borderline between avoidable and 

unavoidable health inequalities with the advancement of medical technologies. Public senses of just and unjust 

health disparities are also continually evolving, making any such judgement historically conditioned, and, at times, 

far from black and white. 

Of all the terms used, health in/equity appears the least ensconced in particular national frameworks and the most 

consistently and strongly defined in terms of health inequalities that are deemed socially and morally unjust. It is 

thus especially critical, when using such terminology, that normative and ethical presuppositions are clearly 

elucidated (see Policy debates section). 

1.2 Defining the Goal: Health Equity 

A greater portion of the literature on health in/equity is concerned with defining and confronting the problem of 

health disparities than with the more difficult task of positively defining the nature and meaning of health equity, 

equality or parity, 

15


Noting the variety of definitions of health equity in use in various jurisdictions across Ontario, Lettner (2008a) 

stresses the importance of crafting “consensus on a working description of health equity to inform the development 

and implementation of programs, services and projects by both government and communities, as well as community 

engagement strategies.” 

Most definitions of health equity/parity/equality vary in accord with, and contradistinction to, how authors have 

variously defined health inequity/inequality/disparity. Health equity is more often than not defined as a negative 

goal to be striven after - the reduction or elimination of health inequities or disparities/inequalities that are deemed 

unjust, unfair and avoidable. 

Rachlis (2007) explores some of the definitions of health equity in currency in the Ontario context: 

“[The goal of] reduc[ing] disparities in the health of those groups who may be disadvantaged by social or 

economic status, age, gender, ethnicity, geography, or language” (Ontario Health Quality Council 2006). 

or 

“The goal of…minimiz[ing] systematic and remedial disparities in health and social well-being between 

groups of people who have different levels of underlying social advantage” (The Ontario Project; cited in 

Rachlis 2007; see Table 3.1 for more definitions of health equity) 

Healthy equity definitions and approaches also vary in the scope of groups targeted (see Policy section 3.1 under the 

‘scope’ subsection). 

Other definitions of health equity are framed in more positive terms. Examples include Gardner’s (2008a) definition 

of health equity as “ensuring equal opportunities for good health for all” and Lettner’s (2008a) definition of 

health equity as “equal opportunity for good health”. The Ontario Health Equity Council has more recently (2007) 

and positively defined the goal of health equity in plain language terms as follows: “People should get the same 

quality of care regardless of who they are and where they live.” This definition, unlike the former two, however 

restricts the purview of health equity to healthcare services, as is common in the US (where healthcare equity is 

more often than not the explicit focus of attention, rather than health equity per se, as discussed in the framework 

section below). 

The varying terms, premises and definitions of health in/equity discussed above find fuller expression and 

divergence in the varying frameworks that have been developed in the literature and among health policy-makers 

and practitioners interested in tackling health disparities. 

2.0 FRAMEWORKS FOR TACKLING HEALTH DISPARITIES 

Health Equity-related frameworks for public policy-making may be divided into two main conceptual camps. The 

first, here termed ‘Health Equity’, take a broader view of the challenge to be confronted by healthcare systems and 

agencies – that is disparities in health status, relating to the full spectrum of health determinants, including those 

beyond the healthcare system. 

The second approach, here termed ‘Health care Equity’, is more narrowly concerned with examining disparities that 

have origins, and thus solutions, within healthcare services more specifically. Cultural Competence frameworks 

may be situated within this latter stream of approaches. 

In between these two framework approaches is ‘Health Equity in Healthcare Frameworks’, which begin with a 

fundamental concern with inequities in health status, yet frame solutions more specifically within the context, and 

from the perspective, of the healthcare system. 

These frameworks each have particular ways of diagnosing the problem to be confronted and solution to be pursued 

by governmental healthcare authorities, in a manner significantly shaping the policy and strategic options pursued 

16


by those operating within their respective purviews. Health equity and healthcare equity frameworks, nonetheless, 

need not be, and should not be seen, as necessarily mutually exclusive. 

The diagram below depicts two different genealogies of approaches tackling inequities in health and social services, 

and recent attempts to bridge these two approaches in healthcare (see Janzen & Ochocka, 2006 for more on the 

genealogy and synthesis of these approaches). 

The distinction drawn between power-oriented and culture-oriented approaches maps partially onto the distinction 

drawn in this review between health equity and healthcare equity (cultural competence in specific) approaches. 

Figure 2.1: Contending diagnoses of the sources of inequitable healthcare service 

Source: Janzen & Ochocka, 2006. 

Health Equity approaches are generally more power-oriented, focusing much more directly on structural inequities 

in power in society as these impact upon health status among disadvantaged population groups. Margot Lettner’s 

(2008a) analysis of the roots of health inequity is exemplary of this power-oriented approach. As she argues: 

The clear research consensus is that the roots of health disparities lie in broader social and economic 

inequality and exclusion. The most effective conceptual framework for health disparities is therefore 

grounded in a determinants of health approach, i.e., it looks beyond the traditional definitions of health, as 

well as beyond the historical analyses of the causes of illness and injury, and focuses on a broad range of 

socio-economic influences and outcomes that affect both individual and community or population health, 

such as income/wealth distribution and poverty, early child development, education, employment and 

working conditions, housing, gender, race and ethnicity, citizenship and immigration status, language, 

ability, sexual orientation, age, racism and discrimination, social exclusion, and natural and built 

environments. 

Most researchers and policy-makers working within a health determinant, health equity framework, nevertheless, 

also recognize the important, albeit less determining role, of healthcare services in mitigating the effects of health 

inequities (healthcare itself being one determinant of health among others). 

  

17


Cultural competence approaches - the dominant framework of healthcare equity found in the literature - derive from 

a longer genealogy of culture-oriented approaches (as mapped out in Figure 2.1) which share a focus on the role of 

cultural bias and misunderstanding in explaining healthcare inequities. The genealogy of cultural competence is 

discussed in Section 2.4. Nothing prevents such approaches from also considering and acknowledging the formative 

role of broader (power inequity-related) determinants of health. 

Below I discuss some of the more notable and salient examples of health equity and healthcare equity frameworks 

fashioned and pursued by governmental bodies seeking to tackle health disparities. This discussion of frameworks 

helps to set the stage for the review of international health equity policies in subsequent sections, enabling the reader 

to better understand and situate health equity policy interventions in the context of contending, overarching 

frameworks. 

2.1 HEALTH EQUITY FRAMEWORKS 

Health Equity Frameworks are most distinguished by their fundamental concern with inequities in health status. 

Such frameworks define the problem to be confronted (‘health inequity’) in broad terms to include all possible 

(social, political, environmental etc.) determinants of health/health inequity, including many which are beyond the 

healthcare sector proper. Most such frameworks depict the root sources of health inequity as lying in unjust sociopolitical 

relations in society. 

Health Equity Frameworks are also distinguished by their focus on health, as opposed to merely the treatment and 

eradication of disease. Figure 2.2 below describes the nature of the proposed shift from an illness orientation to a 

wellness orientation often advocated for in health equity frameworks. 

Figure 2.2: Towards a Wellness Orientation - Ontario’s Chronic Disease Prevention and Management 

Framework 

Source: Meera Jain (2007). Ontario’s Chronic Disease Prevention and Management Framework. 

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The broad and positive understanding of health in health equity approaches is frequently informed by the positive 

definition of health employed by the World Health Organization (WHO), which remains widely adopted as a 

working standard in the health equity frameworks and approaches reviewed here: 

[Health is] a state of compete physical, mental and social well being, and not merely the absence of disease 

or infirmity. It is a fundamental human right and that the attainment of the highest possible level of health 

is a most important world-wide social goal whose realization requires the action of many other social and 

economic sectors in addition to the health sector. (WHO, Alma Ata, 1978) 

This paradigm-shifting definition challenges the more traditional, conventional modern western definition of health, 

as merely the absence of disease. 

The health equity frameworks reviewed here can be further subdivided between those that explicitly base themselves 

on theoretical causal models of the determinants of health/health inequity and those (here dubbed ‘Strategic 

Intervention Frameworks’) that focus instead on intervention strategies, without explicitly linking such strategies up 

to a theoretical model or evidence-based framework 

A. Health Determinant Frameworks 

Etiological 2 Health Determinant Frameworks provide a theoretical model of the determinants and causes of health 

and health in/equity, on the basis of assessments of the empirical evidence. They moreover use such causal models 

to aid and inform the development of policy/intervention strategies. Some examples include the Canadian Institute 

of Health Research’s (2002) Population Health Framework, New Zealand’s (2002) Framework for Reducing 

Inequalities in Health, and the WHO’s (2008) Closing the Gap Framework. 

Rather than elaborate in detail the theoretical bases and underpinnings of these framework models (which is beyond 

the scope of this literature review), some of the more common theoretical approaches to explaining inequalities in 

health in the literature are outlined below. 

All of these perspectives find expression, to greater and lesser degrees, in the frameworks discussed below. 

Mackenbach et al. (2002a) distinguish four theoretical perspectives in particular: 

• Selection versus causation perspectives which “imply that health determines socioeconomic position, 

instead of socioeconomic position determining health”. This perspective focuses on the ways in which poor 

health results in downward socio-economic mobility which in turn has further negative consequences for health 

(See for instance van de Mheen et al., 1999; Wadsworth, 1986; Stern, 1983; Illsley, 1955). 

• Specific determinants perspectives which view various socio-economic factors as directly and indirectly 

shaping health inequities, in the latter case, mediated through a range of individual health-related behaviours. 

Such perspectives vary in emphasis on causes of health inequities, emphasizing, to differing degrees, (a) 

material factors (e.g. low income), (b) psycho-social factors and stressors (which are more and less related to 

material factors) and (c) health-related behaviours such as smoking, diet, alcohol consumption and physical 

exercise, which are related to (a) and (b) as proximal determinants of inequalities in health. 

• Life-course perspectives which pay much more attention to the cumulative effect of disadvantage on 

individual health over the life-course, often stressing or identifying particular ‘windows of susceptibility’ - 

“those periods of life when the individual is more susceptible to the effects of certain exposures, malnutrition 

and infections [for example] during the fetal period, emotional attachment during infancy, and so on.” Lifecourse 

perspectives have the advantage of bringing into view the 'co-evolution' of social position and health in a 

manner “taking away the sharp contradiction between 'selection' and 'causation' explanations” (citing van 

de Mheen et al., 1998; Vigero & Illsley 1995). 

2 Etiology refers to the study of causation, in this context, the study of causes and determinants of health and illness, health equity and health 

inequity. 

19


• Integrated models which attempt to synthesize the aforementioned approaches through the construction of a 

‘layered’ or ‘chain-like’ causation theory of health inequity (e.g. see Figure 2.3). Each of the layers or links 

represents different potential entry points for policy interventions. Such integrated models vary in the extent to 

which they (1) take into account a life-course perspective (some models only focusing in on adult stage), (2) 

represent individual biological pathways (some models only representing determinants that are external to the 

individual), and (3) address macrosocial factors and policies (some models limiting themselves to what happens 

at the individual level). 

Most of the frameworks discussed below draw on integrated models and understandings of the sources of health 

inequity. 

Figure 2.3 Canadian Institute of Health Research Population Health Framework 

Source: Rachlis (2007). Adaptation of CIHR-IPPH (2002). Mapping and Tapping the Wellsprings of Health: 

Strategic Plan 2002-2007. http://www.cihr-irsc.gc.ca/e/institutes/ipph/13789.shtml. 

Health Canada has defined the “overall goal of the population health approach” as “to maintain and improve the 

health of the entire population and to reduce inequities in health between population groups” (Health Canada, 1998). 

The Federal, Provincial and Territorial Ministers of Health officially adopted a population health approach in 1994 

in the report, Strategies for Population Health: Investing in the Health of Canadians (see Health Canada, 1994). 

Population health frameworks, such as the one modeled above by the Canadian Institute of Health Research, are of 

much relevance and use to policymakers concerned with tackling health inequalities, particularly due to their 

concern with health status at the population group level, and attention to the multiple, interacting determinants of 

health, which provide multiple sites for policy intervention. 

Raphael & Bryant (2006) present another Health Canada population health framework that is geared more towards 

guiding specific population health interventions (see Figure 2.4). 

20


Figure 2.4 Health Canada’s population health template 

Source: Raphael & Bryant, 2006, p.42. 

The approach modelled in Figure 2.4 emphasizes the critical importance of gathering data and measuring population 

health status and bringing evidence-based analyses of the determinants of health to bear upon policy decisionmaking 

processes. Also emphasized in this model is the importance of upstream interventions which, by their very 

nature, demand considerable intersectoral collaboration. The model/framework furthermore stresses the importance 

of public involvement and accountability through recursive measurement and evaluation strategies. 

New Zealand Framework for Reducing Inequalities in Health 

The New Zealand Health Strategy on ‘health inequalities’ is elaborated in a (2002) New Zealand Ministry of Health 

strategic paper entitled Reducing Inequalities in Health. The paper “provides a framework for the health sector to 

improve the overall health of New Zealanders and to reduce inequalities amongst New Zealanders, with a focus on 

Maori, Pacific peoples and low-income New Zealanders” (p.1). This framework is informed by a population health 

approachwhich “takes into account all the factors that influence health and how they can be tackled to improve 

health” (ibid.). 

The various components of this framework are elaborated in significant detail below, due to the exemplariness of 

this framework, in combining theory and a concern with practical intervention strategies. 

Underlying the Reducing Inequalities in Health framework is the following ‘integrative’ determinant of health 

model featured below (Figure 2.5). 

21


Figure 2.5 Dahlgren & Whitehead Model of the Determinants of Health 

Source: New Zealand Ministry of Health, 2002. Adapted from Dahlgren and Whitehead (1991). 

The integrative model accounts for a host of health determinants including: 

• Individual lifestyle factors – for example, whether we smoke, exercise, how much alcohol we drink 

• Social and community influences – for example, whether we belong to strong social networks, feel valued and 

empowered to participate in decisions that affect our health and wellbeing 

• Living and working conditions – for example, whether we live in safe housing and have decent working 

conditions 

• Culture, ethnicity and gender – for example, women, Maori and Pacific peoples are over-represented in lower 

paid jobs 

• General socioeconomic and environmental conditions – for example, our position in society, including income, 

education and employment, which affects our ability to participate (Ministry of Health, 2002, p.1-2). 

A more developed causal model of the determinants of health is elaborated in the body of the (2002) New Zealand 

Ministry of Health Strategy paper, as featured below (see Figure 2.6): 

22


Figure 2.6: New Zealand integrative model of the determinants of health 

Source: New Zealand Ministry of Health, 2002, p.16; Adapted from Howden-Chapman and Tobias, 2000. 

Most distinguishing of this top-down causality model is the way in which it envisions “the structure of society” as 

strongly conditioning individual health and health-related behaviour (p.16-17). 

New Zealand Intervention Framework 

The (2002) New Zealand Ministry of Health Strategy paper goes on to elaborate an intervention framework on the 

basis of the determinant of health models in Figure 2.5 and Figure 2.6. The intervention framework also draws on an 

intervention framework developed by Mackenbach (1998), which identifies four possible points of intervention to 

reduce socioeconomic inequalities in health (as shown in figure 2.7). 

23


Figure 2.7: Four possible targets for interventions to reduce socioeconomic inequalities in health (New 

Zealand Ministry of Health) 

Source: New Zealand Ministry of Health, 2002, p.18. Adapted from Mackenbach in National Advisory Committee on 

Health and Disability, 1998. 

This framework seeks to reduce health inequalities by targeting: 

• Underlying social and economic determinants of health impacting socioeconomic status 

• Factors that are intermediate between socioeconomic determinants and health, such as behaviour, environment 

and material resources 

• Health and disability support services (i.e. Disability and healthcare services); and/or 

• The feedback effect of ill health on socioeconomic position (drawing on insights from the selective perspective 

discussed in section 2.1a above). 

Figure 2.8 below models the New Zealand Ministry of Health’s Intervention Framework to Improve Health and 

Reduce Inequalities on the basis of this synthesis of intervention and determinants of health frameworks (see next 

page): 

24


Figure 2.8: New Zealand Intervention Framework to Improve Health and Reduce 

Inequalities 

Source: New Zealand Ministry of Health, 2002, p.19. 

25


This intervention model cascades down from top to bottom from the more to less determining causes of health and 

health in/equity, emphasizing the role of structural system factors and conditions in particular. 

The model is both theoretically informed and comprehensive in scope, considering the full range of factors 

influencing health inequalities, whilst illuminating potential sites and entry points for intervention. 

Below is a listing of the corresponding sites for intervention and types of initiatives envisioned on the basis of this 

intervention framework: 

Level 1: Structural – social, economic, cultural and historical factors fundamentally determine health 

“The most fundamental approach to reducing inequalities in health is to tackle their root cause; that is, 

address the social, cultural, economic and historical inequalities themselves. This requires policies directly 

concerned with education, occupation, income and the Economy” (Ministry of Health 2002, p.20). 

The New Zealand Framework for Reducing Inequalities in Health lists the following potential roles for the health 

sector in reducing inequalities that are ‘upstream’ from the health system: 

• Health sector workers can contribute by drawing attention to the social and economic determinants of health 

and advocating for policies in other sectors that will improve health and reduce health inequalities. 

• We [the health sector] should also work collaboratively with other sectors to develop and implement a more 

comprehensive range of strategies to tackle specific health problems than we could apply relying on health 

services alone. [The example of health impact assessment across Ministries is given as a potential strategy; see 

Accountability section for more on uses of health equity impact assessment tools in this and other respects] 

• The health sector also has a direct role at the strategic level; namely, it should ensure that its own policies are 

directed towards a more equitable distribution of health resources in relation to inequalities in health status. 

Specific examples of the types of action that may be taken at this level include: 

• Systematic implementation of the provisions of the Treaty of Waitangi in policy, planning and service delivery 

• Health funding arrangements that distribute resources according to need 

• Exploration of health impact assessment tools 

• Monitoring of health inequalities, social determinants and the relationship between the two 

• Development of Maori and Pacific providers and workforce (p.20-21) 

Level 2: Intermediary pathways – the impact of social, economic, cultural and historical factors on health 

status is mediated by various factors 

“The effect of socioeconomic position on health is mediated by a number of material, psychosocial and 

behavioural factors, which may provide effective intervention points” (p.21). 

The following examples of potential actions at this level are provided: 

• Housing initiatives 

• Community development programmes 

• Settings-based programmes, such as healthy cities and health-promoting schools 

• Workplace interventions (for example, occupational safety and health) 

• Local authority policies (for example, in relation to cycleways, lighting, playgrounds 

• And transport) 

• Health education and the development of personal skills 

• Health protection. 

26


Level 3: Health and disability services – what services can specifically do 

This level of action focuses in on “the significant part to play” of disability and health care services in reducing 

inequalities, namely by: 

• Ensur[ing] equity of access to care by distributing resources in relation to need, as defined in collaboration with 

local communities; and 

• Remov[ing] barriers, however defined, that inhibit the effective use of services for all ethnic and social groups 

(p.21; citing Benzeval et al., 1995). 

Examples provided of actions and interventions at this level include: 

• Improved access to appropriate, high-quality health care and disability services 

• Collection of accurate ethnicity data 

• Implementation of the elective services booking system based on need 

• Monitoring of service delivery to ensure equitable intervention rates according to ethnicity, gender, 

socioeconomic status and region 

• Primary care initiatives that reduce access barriers for maori, pacific peoples and other disadvantaged groups 

• Ethnic-specific service delivery 

• Community participation in the health sector at a governance level and in resource allocation decision-making 

• Equitable resource allocation by district health boards as funders and by providers, including hospitals 

• Collaborative partnerships within the health sector and intersectorally (pp.21-22). 

Level 4: Impact – minimising the impact of disability and illness on socioeconomic position 

“[T]hose who are chronically ill, or have a disability or mental illness, face higher risks of downward 

mobility through lower educational achievement, greater problems in finding and keeping a job and fewer 

opportunities for upward mobility within a job” (New Zealand Ministry of Health, 2002:22). 

Examples provided of remedial actions at this level include: 

• Income support (for example, sickness benefits) 

• Disability allowance 

• Accident compensation 

• Antidiscrimination legislation and education; and 

• Support services for people with disabilities, chronic illness and mental health illness 

WHO Closing the Gap Framework 

The Commission on Social Determinants of Health was set up by former World Health Organization Director- 

General JW Lee and given the task “to collect, collate, and synthesize global evidence on the social determinants of 

health and their impact on health inequity, and to make recommendations for action to address that inequity” (WHO 

2008). The findings from this inquiry are reported in the WHO’s (2008) report, Closing the Gap in a Generation: 

Health equity through action on the social determinants of health. 

As suggested by the title, the WHO Commission takes a holistic determinant of health approach in its effort to 

identify and remedy inequities in health status which go far beyond the health care system. The ‘principles of action’ 

and corresponding interventions recommended in this report are “underpinned by an aetiological conceptual 

framework” that is modeled below (Figure 2.9). 

27


Figure 2.9: WHO Commission on Social Determinants of Health conceptual framework 

Source: WHO, 2008, p.43. Amended from Solar & Irwin, 2007. 

While the WHO Report does not elaborate further upon its underlying conceptual framework modeled above 

(referring readers instead to the original source), the model clearly brings a wide range of health determinants into 

scope. Like the New Zealand model, it too stresses the more determining role of structural socio-political and 

economic factors and contexts in shaping health inequities. The Commission for instance argues in this respect: 

Strengthening health equity globally and within countries means going beyond contemporary concentration 

on the immediate causes of disease. More than any other global health endeavour, the Commission focuses 

on the ‘causes of the causes’ the fundamental global and national structures of social hierarchy and the 

socially determined conditions these create in which people grow, live, work, and age (WHO, 2008). 

The framework, moreover, implicitly adopts a “life-course perspective on how the social determinants of health 

operate at every level of development - pregnancy and childbirth, early childhood, childhood, adolescence, and 

adulthood - both as an immediate influence on health and to provide the basis for health or illness later in life” 

(WHO, 2008:49). 

The Commission uses this framework to discern two fundamental kinds of interventions that are aimed at taking 

action on: 

The circumstances of daily life, including: 

• Differential exposures to disease-causing influences in early life, the social and physical environments, and 

work, associated with social stratification. Depending on the nature of these influences, different groups 

will have different experiences of material conditions, psychosocial support, and behavioural options, 

which make them more or less vulnerable to poor health; 

• Health-care responses to health promotion, disease prevention, and treatment of illness; 

28


And the structural drivers, including: 

• The nature and degree of social stratification in society – the magnitude of inequity along the dimensions 

listed; 

• Biases, norms, and values within society; 

• Global and national economic and social policy; 

• Processes of governance at the global, national, and local level (p.42). 

Three overarching ‘principles of action’ are derived from the Commission’s analysis of the determinants of health. 

These structure the report’s chapters and provide the overarching framework for the large number of 

recommendations contained in this report. These three ‘principles of action’ include: 

1. Improve the conditions of daily life - the circumstances in which people are born, grow, live, work, and age. 

2. Tackle the inequitable distribution of power, money, and resources - the structural drivers of those conditions of 

daily life - globally, nationally, and locally; and 

3. Measure the problem, evaluate action, expand the knowledge base, develop a workforce that is trained in the 

social determinants of health, and raise public awareness about the social determinants of health. 

The Commission emphasizes and draws attention to the solid evidence-base informing these principles of action, 

which it explains are: 

• Underpinned by an aetiological conceptual framework, 

• Supported by a vast global evidence base that demonstrates an impact of action on these social determinants of 

health and health inequities (effectiveness), 

• Supported by evidence on feasibility of implementation in different scenarios, and 

• Supported by evidence showing consistency of effects of action in different population groups and countries 

with different levels of national economic development (p.43). 

A second public health conceptual framework/model identifying the causal pathways of health in/equity is 

elaborated in the body of the (2008) WHO Report (see Figure 2.10). 

29


Figure 2.10: WHO model of causal pathways for health action 

Source: WHO 2008, p.175. 

This conceptual model more readily lends itself to policy intervention insofar as it more explicitly identifies possible 

entry points for intervention. The model suggests beginning with the evidence of differential individual health 

outcomes as a starting point for analysis, and then proceeding from there to explore consequences of this, followed 

by an explanatory account of the determinants of these differential individual health outcomes and consequences, 

which can then be used to guide strategic policy interventions (see Figure 2.10). 

B. Evidence-Based Health Equity Intervention Frameworks 

Global/Ottawa Equity Gauge Framework 

The Ottawa Equity Gauge is the outcome of a project that has brought together researchers, community leaders, 

NGOS and various public stakeholders with the objective of bridging the gap from evidence to action in reducing 

health inequalities (see Tugwell 2006). The 8 year-old Ottawa Equity Gauge is informed by the Global Equity 

Gauge (GEGA) initiative which describes itself as a “strategy that links measurement and analysis with the 

identification and evaluation of inequity reducing policies and actions” (GEGA, 2009). The Ottawa Equity Gauge 

has recently become an official GEGA associate. 

30


GEGA’s work places health squarely within a larger framework of social justice, focusing on health inequalities that 

are “avoidable and associated with unjust social constructs” (GEGA, 2009). More positively, GEGA describes its 

goal and perspective as “striving towards a world in which disadvantaged population groups (whether defined 

by age, gender, race-ethnicity, socio-economic class or residence) can better achieve their full health potential, 

as indicated by the health standards of those groups in society who are most advantaged” (ibid.). In this effort 

GEGA calls for “affirmative and preferential action to improve the health of those with the poorest health when they 

face unjust obstacles to achieving that potential” (ibid.). 

GEGA describes an equity gauge as “a health development project that uses an active approach to monitoring and 

addressing inequity in health and health care” in a manner that “moves beyond a mere description or passive 

monitoring of equity indicators to a set of concrete actions designed to effect real and sustained change in reducing 

unfair disparities in health and health care” (ibid.). 

The Equity Gauge framework is explicitly based on 3 broad spheres (called ‘pillars’) of action which are each 

accorded equal importance in ensuring a successful outcome. These three pillars are: 

1. Assessment and Monitoring: Research and monitoring to measure and describe inequities 

2. Advocacy and public participation to promote the use of information to effect change involving a broad range 

of stakeholders from civil society working together in a movement for equity 

3. Community empowerment and involvement: to involve the poor and marginalized as active participants rather 

than passive recipients. 

The Ottawa Equity Gauge adds and emphasizes a fourth 'Intervention" pillar to the Global Equity Gauge based upon 

‘Cochrane and Campbell systematic reviews’ 3 of the evidence-base around the impact of specific interventions 

(Tugwell et al., 2006). 

Figure 2.11 below represents the Ottawa Equity Gauge, as applied to the study of food security in Ottawa (see next 

page): 

3 The Campbell Collaboration (named after Donald Campbell, an American psychologist and thinker) is a sibling organisation to The Cochrane 

Collaboration which has been formed “to prepare, maintain and promote the accessibility of systematic reviews in areas such as education, 

criminal justice, social policy and social care”, and, most recently, health equity (Retrieved March 9, 2009 form 

http://www.cochrane.org/docs/campbell.htm). 

31


Figure 2.11: Ottawa Equity Gauge 

Source: Tugwell et al., 2006, p. 8. 

The first pillar, Measurement and monitoring, involves the “analysis, description and understanding of health 

inequities through the collection and collation of qualitative and quantitative data information [so as to] identify 

targets for action and enable later evaluation on whether change has occurred” (Tugwell, 2006, p.7). 

The Intervention pillar “aims to address the lack of evidence that exists on the effectiveness of interventions 

to reduce health disparities through the accumulation and synthesis of research. Most notably this…involve[s] 

systematically reviewing the evidence for public health interventions on low socio-economic groups, rather than just 

that of population averages”. 

Finally “Advocacy [is] combined with a bottom up approach of community empowerment and capacity 

building. This pillar places importance on working with communities to help them speak more effectively for 

themselves, and building the capacity of individuals and community groups to improve their own health” (Tugwell, 

2006, p.7; emphasis mine.). 

One of the particular strengths of the Ottawa Gauge is its combining of expert evidence and community 

empowerment within its framework (against the problematic trend of purchasing one at the expense of the other). 

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2.2 HEALTH EQUITY IN HEALTHCARE FRAMEWORKS 

Health Equity in Healthcare Frameworks form a bridge between (1) health equity frameworks and (2) healthcare 

equity frameworks. This class of frameworks shares with (1) health equity frameworks a focus on disparities in 

health status broadly conceived; and (2) a situated, healthcare-system-perspective on how such disparities in health 

status can be addressed primarily within the confines of the health care system. 

Gardner Health Equity Framework 

Exemplifying this intermediate type of (‘health equity in healthcare’) framework is the intervention framework 

developed by Bob Gardner in a (2008a) discussion paper for the Toronto Central LHINs. Developed as part of a 

highly informative series of Health Equity Roundtables organized by the Wellesley Institute in 2007,4 Gardner’s 

(2008a) Health Equity Discussion Paper identifies its overall goal as “to reduce or eliminate socially and 

institutionally structured health inequalities and differential outcomes”. 

Gardner’s Executive Summary (2008b) and Discussion Paper (2008a) commences with a definition of health 

disparities/inequities as “differences in health outcomes that are avoidable, unfair and systematically related to 

social inequality and disadvantage” (2008a, p.2). Gardner’s discussion paper goes on to discuss the multiple roots 

and causes of such inequities, the most determining of which, he argues (citing research), “lie in broader social and 

economic inequality and exclusion” (Gardner 2008b, p.4). 

While retaining this wider concern with health inequities (as opposed to solely healthcare inequities), the paper 

proceeds to focus more specifically on “how inequitable access to care and differential quality are shaped by social 

inequalities and institutional barriers, and how the damaging impact of this structured inequality can be reduced 

within priorities identified in the IHSP [Integrated Health Service Plan]” 5 (Gardner 2008b, p.4). The approach taken, 

in effect, marries a concern with the broader determinants of health status (structural social inequalities and 

institutional barriers etc.) with a concern with inequities in healthcare settings which reproduce and/or fail to 

adequately redress such wider inequities in health status. 

In keeping with this strategically focused, yet holistic health determinants perspective, Gardner (2008a) recommends 

six “main directions in which the healthcare system can address health disparities”. These six main directions, which 

together form a strategic intervention framework, are by: 

1. Identifying and reducing barriers to access to services; 

2. Ensuring all receive the high-quality and responsive care they need, regardless of their social position and 

conditions; 

3. Targeting investments and interventions towards the most health disadvantaged communities and populations; 

4. Building equity, diversity and gender analysis into all service delivery and planning; 

5. Enhancing equity-focused primary, chronic and preventive care, and other healthcare investments that will have 

the most impact in reducing disparities; 

6. Building cross-sectoral collaborations beyond the healthcare system to address the wider determinants of health. 

4 “The Health Equity Roundtables were held on December 5 and 6, 2007, hosted by The Wellesley Institute, Toronto, Ontario. Thirty five 

participants, bringing together service providers, policymakers, researchers and advocates active in health equity, met to talk about current policy 

openings and opportunities to move health equity forward to action in Ontario – with the provincial government and/or the LHINs” (Lettner 

2008). 

5 The Local Health System Integration Act requires the Local Health Integration Networks (LHINs) to each develop an Integrated Health 

Service Plan (IHSP), with input from the community, and in accordance with the provincial (MOHLTC) Health System Strategic Plan. 

33


Each of these ‘directions’ are elaborated and fleshed out with prospective actionable initiatives and existing good 

practice examples in Gardner’s (2008a) Discussion Paper, which provides a comprehensive and concrete series of 

recommendations for action planning over the short, medium and long term in the LHINs context. 6 

Ontario Health Quality Council Equity Framework 

Rachlis (2007; 2008) has consistently advocated for Ontario governmental health bodies (MOHLTC, LHINS) to 

adopt the Ontario Health Quality Council’s (OHQC) 7 equity framework in order “to operationalize its policy work 

on health equity” (Rachlis, 2008). This framework is elaborated in the OHQC’s second (2007) Report, which 

promotes a three-pronged approach to developing a more equitable health system: 

1. Improve the accessibility of the health system through outreach, location, physical design, opening hours, 

and other policies. 

2. Improve the patient-centeredness of the system by providing culturally competent care, interpretation 

services, and assisting patients and families surmount social and economic barriers to care. 

3. Cooperate with other sectors to improve population health. 

Rachlis recommends broadening or fleshing out this framework further to include anti-racism/anti-oppression issues 

and approaches (2007). 

While the first and second intervention themes of this framework for action are pre-occupied with healthcare equity, 

that is reducing health inequities in and through healthcare services, the third framework theme retains a broader 

concern with population health and health status beyond the healthcare system (hence the call for intersectoral 

cooperation, and this framework’s characterisation, here, as a ‘health equity in healthcare’ framework). 

6 Created by the Ontario government in March 2006, Local Health Integrated Networks are “14 not-for-profit corporations who work with local 

health providers and community members to determine the health service priorities of [14 designated] regions. As Local Health Integration 

Networks (LHINs), [the Ontario LHINs] plan, integrate and fund local health services [in their region], including: 

Hospitals 

Community Care Access Centres 

Community Support Services 

Long-term Care 

Mental Health and Addictions Services 

Community Health Centres. (http://www.lhins.on.ca/; retrieved January 5, 2009). 

7 The Ontario Health Quality Council (OHQC) is an independent agency funded by the Government of Ontario, established in September 2005, 

under The Commitment to the Future of Medicare Act, 2004. The Council is an Operational Service Agency that reports to the Minister of 

Health and Long-Term Care. Section 4 of the Act sets out its mandate as: “to monitor and report to the people of Ontario on: 

1. access to publicly funded health services; 

2. health human resources in publicly funded health services; 

3. consumer and population health status; and 

4. health system outcomes; and 

5. to support continuous quality improvement (http://www.ohqc.ca/en/mandate.ph). 

Section 5 of the Act further requires the Council to deliver a yearly report to the Minister on the state of the health system in Ontario, and any 

other reports required by the Minister. Since its inception in 2005, the Council has published three reports on Ontario's health system (entitled 

QMonitor). 

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2.3 HEALTHCARE EQUITY FRAMEWORKS 

Healthcare Equity frameworks, as conceived here, begin and end with healthcare disparities that have their roots 

and remedies within the healthcare system. Distinguished by their more narrow focus on healthcare inequities, such 

approaches can be further subdivided between those that consider structural socio-economic factors in healthcare 

disparities (e.g. OHQC, 2007), and those that focus more narrowly on the role of culture (most often focusing on 

ethno-racial dimensions of culture) in explaining and remedying healthcare inequities. A majority of cultural 

competence frameworks discussed in the literature may be situated in this latter camp. 

A. Cultural Competence – An Overview 

American health agencies, service providers and professional organizations have been addressing issues of 

culture in healthcare services since the 1970s and 1980s as part of a broader effort to reduce health disparities 

(Betancourt et al., 2002; APA 2003). 

‘Culture-centred’ approaches to healthcare have increasingly come to challenge and displace (albeit still dominant) 

‘culture-blind’ approaches based on standardized (‘cookie cutter’) services for all, regardless of colour, culture or 

class (see Figure 2.1 for genealogical map of cultural competence in this respect). 

Proponents of ‘culture-centred’ approaches argue that such ‘culture-blind’ approaches, while sometimes wellintended, 

wittingly or unwittingly privilege dominant cultural norms and health practices in health care settings in 

ways ignoring and/or minimizing the specific healthcare needs and concerns of cultural minorities with deleterious 

consequences for their health outcomes (APA, 2003). 

The first generation of ‘culture-centered’ approaches to health emphasized the importance of increasing ‘cultural 

awareness’ and ‘cultural sensitivity’ among healthcare practitioners. Whereas cultural awareness has been defined as 

“being conscious of one’s own cultural background and how it relates to our behaviours, thoughts and emotions” 

(Sue et al., 1998), cultural sensitivity has been defined as “the recognition of personal attitudes, values, beliefs, and 

practices within one’s own culture and insight into the effect of self on others” (Schim et al., 2005; italics mine). 8 

Cultural competence approaches and frameworks, while incorporating such insights, are widely represented as an 

advance over this earlier focus on attitudes and awareness due to their more ‘action-oriented’ emphasis on 

‘competence’ defined in terms of required skills and behaviours (Hernandez et al., 1998; Chestang, 1998). The 

Ontario Ministry of Children and Youth Services (2005) Achieving Cultural Competency toolkit conveys this 

distinguishing feature of cultural competence: 

The term ‘cultural sensitivity’ implies that diversity work is just about people being nice to one another. While 

having good interpersonal skills is certainly positive, cultural competency involves much more than that. Cultural 

competency is a professional skill that enables staff and organizations to serve their clients effectively and 

competently. Beyond simply treating diverse clients with sensitivity, culturally competent organizations actively 

identify and remove any barriers that prevent them from accessing and participating in the organization’s programs 

and services. 

Despite the abovementioned need to examine organizational-level service barriers often mentioned in the cultural 

competence literature, a majority of this literature continues to focus primarily on individual-level cultural 

competencies. However, there is a growing body of research on the institutional and systemic dimensions of cultural 

competency (Cross et al.,’s 1989 being among the first; see for instance Smedley, 2008; Chrisman, 2007; Dreachslin 

et al., 2007; California Endowment, 2007; Conviser, 2007; Pyles & Kim’s, 2006; Cashin et al., 2006; Beach et al., 

2006; Hayes-Bautista, 2003; Anderson et al., 2003; Chin, 2002). 

8 Hernandez et al. further add to this definition of cultural sensitivity, “the ability to empathize and identify with the 

emotional expressions, values and beliefs of someone from a different cultural group” (1998, p.13). 

35


Towards a definition of Cultural Competence 

Definitions of cultural competence vary in regards to (1) the extent to which they include levels of analyses beyond 

the individual level (e.g. considering agency and system-levels of analysis and practice); (2) whether they describe 

cultural competency in static or dynamic terms (as an ongoing process); and (3) the scope of diversity groups and 

cultural practices considered or implied under the umbrella of cultural competence. 

The most widely cited and adapted definition of cultural competence is that of Cross et al. (1989), who define 

cultural competence as “a set of congruent behaviors, attitudes and policies that come together in a system or 

agency or among professionals that enables that system, agency, or professionals to work effectively in crosscultural 

situations” (Cross, Bazron, Dennis, & Isaacs, 1989). 9 Notably, this definition informs the (2001) 

National Standards for Culturally and Linguistically Appropriate Services (CLAS) issued by the US Department of 

Health and Human Services’ Office of Minority Health. 

Other definitions of cultural competence addressing agency/system-levels of analysis include the following: 

• The ability of systems to provide care to patients with diverse values, beliefs and behaviors, including tailoring 

delivery to meet patients’ social, cultural, and linguistic needs (Betancourt, 2002). 

• “The ability of organizations and systems to function and perform effectively in cross-cultural situations” 

(Vancouver Ethnocultural Advisory Committee of Ministry for Children and Families, 1998; GTA Diversity 

and LHINS Working Group, 2008a). 

• “Behaviors, attitudes, and policies that can come together on a continuum: that will ensure that a system agency, 

program or individual can function effectively and appropriately in diverse cultural interactions and settings” 

(US Department of Health and Human Services, 2002). 

• “Ongoing commitment or institutionalization of appropriate practices and policies for diverse populations” 

(Brach and Fraser, 2000). 

• “The ability to demonstrate skills and knowledge which enable a person to work effectively across cultures; the 

ability to provide mental health treatment within the cultural framework of the consumer; the ability to provide 

effective services to people of a specific cultural background, including one different from the provider” 

(Substance Abuse and Mental Health Services Administration, 1997, p.27).10 

Michael Goh (2005) describes the Substance Abuse and Mental Health Services Administration’s definition 

as ‘the most comprehensive definition of cultural competence’ to date. 

Another comprehensive definition of cultural competence is offered by the Cultural competence workgroup for the 

projects for assistance in transition from homelessness. They define cultural competence as: 

an ongoing and evolving process that comprises knowledge attainment and the development of 

behaviors, attitudes, policies, and practices that come together in a system of care enabling agencies, 

programs, and individuals to increase access to services and to develop or adapt services that are 

appropriate to specific cultural needs (2002, Report of the Cultural Competence Workgroup for the 

Projects for Assistance in Transition from Homelessness). 

9 The original 75 page monograph published by the Child and Adolescent Service System Program (CASSP) National Technical 

Assistance Center at the Georgetown University Child Development Center was entitled Towards A Culturally Competent System of 

Care, Volume I: A Monograph on Effective Services for Minority Children Who Are Severely Emotionally. Cross et al.’s (1989) definition 

also informs a recent (2005a) Canadian study by Olavarria et al. entitled Standards of Organizational Cultural Competence for 

Community Health and Social Service Organizations. 

10 Michael Goh (2005) describes the Substance Abuse and Mental Health Services Administration’s definition as ‘the most 

comprehensive definition of cultural competence’ to date. 

36


This definition has the benefit of explicitly foregrounding the multiple necessary levels of cultural competence 

praxis while also accounting for the ongoing, always-in-process nature of becoming culturally competent. The 

definition, moreover, informs the (2008) Supportive Housing and Diversity (SHAD) Toolkit and report on culturally 

competent best practice for supportive housing provision. 

A minority of cultural competence frameworks and definitions have tried to expand the meaning of cultural 

competence to more directly address issues and inequities of power. The American College of Health Association’s 

definition of cultural competence is exemplary in this respect (albeit remaining restricted to an individual-level of 

analysis). According to the ACHA: 

The term "cultural competency" refers to a long-term, developmental process that moves beyond "cultural 

awareness" (the knowledge about a particular group primarily gained through media resources and 

workshops) and "cultural sensitivity" (knowledge as well as some level of direct experience with a cultural 

group other than one's own). Cultural competency is an engaging, life-long journey of expanding your 

horizons, thinking critically about power and oppression, and behaving appropriately. Culturally 

competent individuals have a mixture of beliefs/attitudes, knowledge/experience, and skills that help them 

to establish trust/rapport and communicate effectively with others (Retrieved 29-01-2009 from 

http://www.acha.org/about_acha/culture_comp_alist.cfm; emphasis mine). 

This definition also depicts cultural competence as an ongoing process and continuum rather than destination that 

can be finally achieved or arrived at once and for all (Anand, 1999; see also Rosenjack Burchum, 2002; Campinha- 

Bacote, 1999). The literature contains several organizational developmental models of cultural competence outlining 

the evolutionary stages along this continuum (see Jordan, 1998; Wong, 2007; Anand, 1999). The cultural 

competence continuum model of Cross et al. (1989) remains the most formative among these. 

Another comprehensive definition of cultural competence, in terms of the scope of diversity groups mentioned, is 

the Child Welfare League of America’s definition which defines cultural competence as the “ability of individuals 

and systems to respond respectfully and effectively to people of all cultures, classes, races, ethnic 

backgrounds, sexual orientations, and faiths and religions, in a manner that recognizes, affirms, and values 

the worth of individuals, families and communities, and protects and preserves the dignity of each” (cited in 

Ontario Ministry of Children and Youth Services 2005 Achieving Cultural Competency). This definition is clearly 

articulated within a human rights moral-political idiom and a larger social service context. It is also distinguishable 

from most other cultural competence definitions and approaches by its attention to non-ethno-racial dimensions of 

cultural difference. 

In the clinical and nursing literatures, cultural competence is primarily defined in terms of individual competencies, 

attitudes, skills and behaviours (see Campinha-Bacote, 1999; Leininger, 1999; also see Haarmans, 2004 for 

summary of this literature). Jirwe et al. (2006), in this respect, describe cultural competence as “the multi-cultural 

knowledge base that nurses need, together with the ability to apply such knowledge in practice”. Bush (2000) 

likewise defines cultural competency as a “respect for, and understanding of, diverse ethnic and cultural groups, 

their histories, traditions, beliefs, and value systems” in the provision and delivery of services. 

Leong (1998) further distinguishes between cultural competence and “cross-cultural competence”, defining cultural 

competence as “[t]o be able to adapt and function effectively in one’s [own] culture.” (p.3; cited in Haarmans 2004). 

Leong makes the argument that what is really at issue in much of the cultural competence literature is “cross-cultural 

competence, i.e., the knowledge and skills to relate and communicate effectively with someone from another culture 

different from your own” (ibid.). Other theorists and scholars have argued that all encounters are cross-cultural in 

nature, due to the multiple axes of culture and difference (e.g. race, gender, class, sexual orientation, religion, 

differential abilities etc.) that culturally separate persons from one another in general, and the differing insights and 

aptitudes of clinicians and clients, in specific, owing to the formal training and education of the former (Dolhun, 

Munoz & Grumbach, 2003; APA, 2002; Tsang & George, 1998; Sue, 2001). Such training, critics suggest, amounts 

to a distinctive form of enculturation in itself. 

37


Culture 

The term ‘culture’ in cultural competence is meant to “direct attention to the role that culture plays in shaping 

human behavior”, in particular, health related behaviours, practices and perceptions (Hernandez et al.,1998; citing 

Cross et al., 1989). 

Definitions of culture in the cultural competence literature vary surprisingly little, most relying on classical modern 

anthropological conceptions of culture which foreground ethnic and racial forms of cultural difference. Cross et al.’s 

(1989) definition of culture, which remains the most widely cited in the literature, is exemplary in this respect. 

They define culture as “the integrated pattern of human behavior that includes thoughts, communication 

styles, actions, customs, beliefs, values, and institutions of a racial, ethnic, religious or social group” (1989, 

p.13). The CLAS (Culturally and Linguistically Appropriate Service) standards developed by the Office of Minority 

Health employ an almost identical definition. 11 

Other definitions of culture contained in the literature include: 

• “The learned, shared and transmitted values, beliefs, norms and life practices of a particular group of people” 

(Leininger & McFarland, 2002; cited in Jirwe et al., 2006) 

• “The structure of behaviors, ideas, attitudes, values, habits, beliefs, customs, language, rituals, ceremonies, and 

practices of a particular group of people that provides them with a general design for living and patterns for 

interpreting behavior” (US DHHS, 2001). 

• “An integrated pattern of learned beliefs and behaviors that can be shared among groups [that] includes 

thoughts, styles of communicating, ways of interacting, views on roles and relationships, values, practices, and 

customs” (Betancourt, 2002). 

• “The unique characteristics that all of us possess that distinguish us as individuals and identify us as belonging 

to a group or groups” (The GTA Diversity and LHINS Working Group, 2008a). 

More often than not, despite references to groups in general in such definitions, non-ethnic and intra-ethnic forms of 

cultural difference go unexamined in cultural competence frameworks. 

Betancourt’s (2002) work is exceptional in this respect, to the extent that it regards culture as being “shaped by 

multiple influences, including race, ethnicity, nationality, language, and gender” as well as “extend[ing] to 

socioeconomic status, physical and mental ability, sexual orientation, and occupation, among other factors” (ibid.). 

Competence 

Competence is defined by the US DHHS as “having the knowledge, skills, and abilities to be effective in a 

particular area” (2001, p.2) or having attained a level of mastery (US DHHS, 2001, p. 3). In cross-cultural 

situations, competence implies “having the capacity to function effectively as an individual and an organization 

within the context of the cultural beliefs, behaviors, and needs presented by consumers and their communities” 

(OMH, 2001 [CLAS Standards]; Adapted from Cross, 1989). The International Council of Nurses defines 

competence as “a level of performance, which demonstrates effective application of knowledge, skills, attitudes and 

judgements” (ICN, 2005). 

Key Components of Cultural Competence 

The literature contains numerous portraits of what a culturally competent health care setting looks like and how it 

functions. In one of the few systematic reviews of the cultural competence literature, Anderson et al. (2003) 

conclude that a culturally competent healthcare setting should include an appropriate mix of: 

11 

Culture is defined in the CLAS standards as “integrated patterns of human behavior that include the language, thoughts, communications, 

actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups” (Office of Minority Health, 2001). 

38


• A culturally diverse staff that reflects the community(ies) served; 

• Providers or translators who speak the clients’ language(s); 

• Training for providers about the culture and language of the people they serve; 

• Signage and instructional literature in the clients’ language(s) and consistent with their cultural norms; and 

• Culturally specific healthcare settings. 

More locally, in the context of the LHINs, the GTA Diversity and LHINs Working Group contend: 

• A local health integration network (LHIN) that is culturally competent establishes diversity as a corporate 

strategic priority; reflects the principles of diversity, equity and inclusion in its organizational culture; mirrors 

the community’s diversity in its governance and staffing; and cultivates inclusive relationships with 

communities. 

• Indicators of success for a diverse and culturally competent LHIN include commitment from the top, clarity on 

what needs to be changed; process internally managed, knowledge-based, and supported by training; 

commitment reflected in policies and procedures; goals action-oriented and measurable; resources targeted; and 

built-in accountability in action plan (2008a). 

Other key components of cultural competence are elaborated in the cultural competence frameworks discussed 

below. 

B. Cultural Competence Frameworks 

Cultural competence frameworks can be broken down into two main kinds: individual core competency-defined 

frameworks, and intervention-area/level/domain defined frameworks. Whereas the former are generally oriented 

towards individual health practitioners, outlining the core individual-level competencies comprising ‘cultural 

competency’, intervention-area/level/domain frameworks are generally oriented towards organizations and systemlevel 

players, outlining the key domains, areas and levels for health care organizational/system cultural competence 

intervention. 

The latter intervention frameworks can be further subdivided between those that are thematically organized and 

those that are organized by domains for culturally competent intervention I. Individual Competency-Defined 

Frameworks 

Sue et al. (1996) Tripartite Framework 

D. W. Sue, Ivey and Pederson (1996) developed the most widely cited cultural competence conceptual framework 

for outlining the specific nature of knowledge and skills required to become culturally competent at the individual 

health practitioner/counsellor level. Their conceptual scheme includes three general competency areas, defined more 

specifically in the context of counsellor-client relations: 

• Cultural awareness and beliefs, which pertains to “[p]rovider’s sensitivity to her or his personal values and 

biases and how these may influence perceptions of the client, client’s problem, and the counselling 

relationship”. 

• Cultural knowledge, which pertains to [c]ounsellor’s knowledge of the client’s culture, worldview, and 

expectations for the counselling relationship”; and 

• Cultural skills, which relates to “[c]ounsellor’s ability to intervene in a manner that is culturally sensitive and 

relevant” (Sue, 2006). 

This tripartite framework informs the American Psychological Association’s Multicultural Guidelines (2003) and 

numerous other cultural competency training modules and standards of culturally competent care (see Part III on 

Training and Haarmans, 2004 for more detailed elaboration of competencies within this tripartite framework). 

39


Many variations of this framework appear in the literature (Campinha-Bacote, 1999; Rosenjack Burchum, 2002; 

Kim-Godwin et al., 2001). For instance, the American College Health Association (ACHA) elaborates the following 

individual competencies within the context of Sue et al.’s (1996) basic conceptual framework on their website. 

With regard to beliefs/attitudes, the culturally competent individual is: 

• Aware of and sensitive to her/his own cultural heritage and also respects and values different heritages; 

• Aware of her/his own values and biases and how they may affect the perception of other cultures; 

• Comfortable with differences that exist between her/his culture and other cultures' values and beliefs; and 

• Sensitive to circumstances (personal biases, ethnic identity, political influence, etc.) That may require seeking 

assistance from a member of a different culture when interacting with another member of that culture. 

With regard to knowledge, the culturally competent individual must: 

• Demonstrate good understanding of the power structure in society and how non-dominant groups are treated; 

• Acquire specific knowledge and information about the particular group(s) s/he is working with; and 

• Recognize institutional barriers that prevent members of disadvantaged groups from using organizational and 

societal resources. 

With regard to skills, the culturally competent individual must: 

• Generate a wide variety of verbal and nonverbal responses (body language) when communicating with 

individuals of different backgrounds or culture; 

• Send and receive both verbal and nonverbal messages accurately and appropriately; and 

• Intervene appropriately and advocate on behalf of individuals from different cultures (i.e., serve as an ally) 

(american college health association, 2009). 

The ACHA framework is distinguished by its attention to power relations in society and how this impacts upon 

client-clinician/health practitioner relations and interactions. 

Jirwe et al.’s (2006) Framework 

In their (2006) article, Jirwe, Gerrish, & Emami (2006) systematically reviewed and analysed the core competency 

components found in the nine most frequently cited theoretical frameworks of cultural competence in the nursing 

literature. 

The nine reviewed frameworks originated from three different continents: seven from the USA, one from the United 

Kingdom and one from New Zealand (in many ways representing the global distribution of such cultural 

competence frameworks). 

Synthesizing the core cultural competencies elaborated in these nine theoretical frameworks, Jirwe et al. identify 

four main recurring themes relating to cultural competence. These include: 

1. An awareness of diversity among human beings: Under this theme, two underlying sub-themes are 

identified: (A) Awareness of Oneself and; (B) Awareness of the Other. 

2. An ability to care for individuals: In this theme, three underlying sub-themes are identified: (A) to be 

skilled in performing cultural assessments, (B) to be knowledgeable about other cultures, and (C) to be able 

to meet specific cultural needs. 

3. Non-judgmental openness for all individuals: This competency revolves around the health practitioners’ 

“willingness to overcome prejudices and ethnocentrism and [demonstrate] a genuine interest in people from 

other cultures” informed by a sense of equality, empathy and sensitivity. 

40


4. Enhancing cultural competence as a long-term continuous process: This theme depicts cultural 

competence as a step-by-step process where the health practitioner becomes culturally aware and makes an 

ongoing effort to continuously develop and improve his/her knowledge. 

II. Domain-Organized Intervention Frameworks 

Betancourt et al. Framework for Cultural Competence in Health Care (2002) 

One of the most widely cited cultural competence intervention frameworks in the literature is that developed by 

Betancourt, Green & Carrillo in their (2002) report for the Commonwealth Fund, Cultural Competence in Health 

Care: Emerging Frameworks and Practical Approaches. This (2002) report identifies various models of culturally 

competent care, all of which, they argue, are ultimately aimed at improving the quality of health care for all. 

The framework organizing Betancourt et al.’s report is distinguished by its attention to, and description of, the key 

components of culturally competent care at three operational levels of intervention: clinical cultural competence, 

organizational cultural competence and system cultural competence. 

Below some of the recommendations offered by Betancourt et al. within this framework are elaborated. 

(1) Clinical Cultural Competence 

To attain clinical cultural competence, health care providers must: (1) be made aware of the impact of social and 

cultural factors on health beliefs and behaviors; (2) be equipped with the tools and skills to manage these factors 

appropriately through training and education; and (3) empower their patients to be more of an active partner in the 

medical encounter. Organizations can do this through: 

• Cross-cultural training as a required, integrated component of the training and professional development of 

health care providers; 

• Quality improvement efforts that include culturally and linguistically appropriate patient survey methods and 

the development of process and outcome measures that reflect the needs of multicultural and minority 

populations; and 

• Programs to educate patients on how to navigate the health care system and become an active participant in 

their care (Betancourt et al., 2002, p.x). 

(2) Organizational Cultural Competence 

To achieve organizational cultural competence within the health care leadership and workforce, it is important to 

maximize diversity. This may be accomplished through: 

• Establishing programs for minority health care leadership development and strengthening existing programs. 

The desired result is a core of professionals who may assume influential positions in academia, government, and 

private industry. 

• Hiring and promoting minorities in the health care workforce. 

• Involving community representatives in the health care organization’s planning and quality improvement 

meetings (Betancourt et al., 2002, p.viii). 

(3) System Cultural Competence 

To achieve systemic cultural competence (e.g., in the structures of the health care system) it is essential to address 

such initiatives as conducting community assessments, developing mechanisms for community and patient 

feedback, implementing systems for patient racial/ethnic and language preference data collection, developing quality 

measures for diverse patient populations, and ensuring culturally and linguistically appropriate health education 

materials and health promotion and disease prevention interventions. 

41


Programs to achieve systemic cultural competence may include: 

• Making on-site interpreter services available in health care settings with significant populations of limited- 

English-proficiency (LEP) patients. Other kinds of interpreter services should be used in settings with smaller 

LEP populations or limited financial or human resources. 

• Developing health information for patients that is written at the appropriate literacy level and is targeted to the 

language and cultural norms of specific populations. 

• Requiring large health care purchasers to include systemic cultural competence interventions as part of 

their contracting language. 

• Identifying and implementing federal and state reimbursement strategies for interpreter services. Title VI 

legislation mandating the provision of interpreter services in health care should be enforced and institutions held 

accountable for substandard services [see International Policy section 3.2. on the US for elaboration of content 

and import of US’ Title VI legislation] 

• Using research tools to detect medical errors due to lack of systemic cultural competence, including those due to 

language barriers. 

• Incorporating standards for measuring systemic cultural competence into standards used by the Joint 

Commission on Accreditation of Healthcare Organizations (JCAHO) and by the National Committee for 

Quality Assurance (NCQA) [see Accountability section for more on this]. 

• Collecting race/ethnicity and language preference data for all beneficiaries, members, and clinical encounters in 

programs sponsored by the federal government and private organizations. The data should be used to monitor 

racial and ethnic disparities in health care delivery, for reporting to the public, and for quality improvement 

initiatives (Betancourt et al., 2002, p.ix). 

The Registered Nurse’s Association of Ontario’s (RNAO) recent (2007) publication, Embracing Cultural Diversity 

in Health Care: Developing Cultural Competence is similarly organized – in a manner resembling Betancourt et 

al.’s (2002) framework - by three main levels or contexts for culturally competent care and analysis. 

Each of these levels or ‘contexts’ for culturally competent care form a chapter containing various recommendations 

and guidelines based on a review of best and ‘promising practice’. 12 The chapters include: 

• Individual Context: Best Cultural Competence Practices; 

• Organizational Context: Best Cultural Competence Practices for Employers and Unions; and 

• External Context: Best Cultural Competence Practices for Academia, Governments and Regulators, and 

Professional Association. 

Betancourt et al.’s (2002) framework was among the first to systematically elaborate such organizational and 

system-level cultural competencies based on existing evidence. Such attention to systems-levels analyses of cultural 

competence remains a fairly recent but growing development. Other notable system-level approaches to cultural 

competence include: 

• Cross et al.’s (1989) pioneering “Towards a Culturally Competent System of Care”; 

• Hayes-Bautista (2003), “Research on culturally competent healthcare systems”; 

• Anderson et al.’s (2003), “Culturally competent healthcare systems: A systematic review”; Pumariega et al.’s 

(2005), “Culturally Competent Systems of Care for Children’s Mental Health”; 

• Pyles & Kim’s (2006), “A Multilevel Approach to Cultural Competence”; 

12 The guidelines aim ‘to help nurses, employers and those in the broader system understand the urgency of the need to act [on cultural 

competence], and to suggest directions based on evidence’ (RNAO, 2007, p.56). 

42


• Cashin et al.’s (2006), “Transformation of the California Mental Health System”; 

• Dreachslin et al.’s (2007), “A Systems Approach to Culturally and Linguistically Competent Care”; 

• Chrisman’s (2007), “Extending Cultural Competence Through Systems Change”’; 

• The California Endowment’s (2007) Conference Summary Report, “Building Culturally Competent Health 

Systems in California”; 

• Conviser’s (2007), “Catalyzing System Changes to Make HIV Care More Accessible”; and 

• Jean Lau Chin’s (2002), “Assessment of Cultural Competence in Mental Health Systems of Care for Asian 

Americans”. 

Health Resources and Services Administration’s (2002) Organizational Cultural Competence Assessment 

Framework 

Many of the cultural competence intervention frameworks are designed with organizational self-evaluation purposes 

in mind. 

In 2002, the Health Resources and Service Administration (HRSA) of the U.S. Department of Health and Human 

Services embarked upon an ambitious project with three main objectives in mind. These included “to: 1) develop an 

analytic framework for assessing cultural competence in health care delivery organizations; 2) identify specific 

indicators that can be used in connection with this framework; and 3) assess the utility, feasibility and practical 

application of the framework and its indicators” (HSRA, 2002). 13 

The project culminated in the production of An Organizational Cultural Competence Assessment Profile which 

was the end result of an extensive literature review, consultation with a Technical Expert Panel of cultural 

competence specialists and practitioners, and research findings from site visits to best practice settings for cultural 

competence in health care settings. 

Building upon previous work in the field, including most notably the (2001) National Standards for Culturally and 

Linguistically Appropriate Services (see CLAS framework below), the Assessment Profile is designed to function as 

an “analytic or organizing framework and set of specific indicators to be used as a tool for examining, 

demonstrating, and documenting cultural competence in organizations involved in the direct delivery of health care 

and services” (HRSA 2002). 

The Assessment Profile has three major components: 1) domains of cultural competence; 2) focus areas within 

domains; and 3) indicators relating to focus areas, by type of indicator. 

Domains and Focus Areas 

Seven domains – i.e. ‘performance areas’ or ‘critical arenas or spheres in which cultural competence should be 

evident or manifest in an organization’ – are identified in this assessment framework: 

• Organizational Values: An organization's perspective and attitudes with respect to the worth and importance 

of cultural competence, and its commitment to provide culturally competent care. 

• Governance: The goal-setting, policy-making, and other oversight vehicles an organization uses to help ensure 

the delivery of culturally competent care. 

• Planning and Monitoring/Evaluation: The mechanisms and processes used for: a) long- and short-term 

policy, programmatic, and operational cultural competence planning that is informed by external and internal 

consumers; and b) the systems and activities needed to proactively track and assess an organization's level of 

cultural competence. 

13 The HRSA’s (2002) cultural competence assessment project was implemented through a contract with The Lewin Group, Inc. with input and 

oversight from the HRSA's Office of Minority Health and Office of Planning and Evaluation. 

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• Communication: The exchange of information between the organization/providers and the clients/population, 

and internally among staff, in ways that promote cultural competence. 

• Staff Development: An organization's efforts to ensure staff and other service providers have the requisite 

attitudes, knowledge and skills for delivering culturally competent services. 

• Organizational Infrastructure: The organizational resources required to deliver or facilitate delivery of 

culturally competent services. 

• Services/Interventions: An organization's delivery or facilitation of clinical, public-health, and health related 

services in a culturally competent manner (SAMHSA Assessment Tool developed by The Lewin Group, 2002; 

Retrieved on January 12, 2009 from http://captus.samhsa.gov/national/resources/resources.cfm) 

Within each of these domains, ‘focus areas’ are identified, i.e. ‘substantive topic areas’ within a domain that 

comprise more specific arenas to examine for evidence of cultural competence’ and from which to develop 

indicators. These domains and their corresponding focus areas are outlined in Box 2.1 below: 

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Box 2.1: Organizational Cultural Competence Assessment Profile: Domains and Focus Areas 

DOMAIN 

FOCUS AREAS 

Organizational Values: 

An organization's perspective and attitudes 

regarding the worth and importance of cultural 

competence, and its commitment to providing 

culturally competent care. 

• Leadership, Investment and 

Documentation 

• Information/Data Relevant to Cultural 

Competence 

• Organizational Flexibility 

Governance: 

The goal-setting, policy-making, and other oversight 

vehicles an organization uses to help ensure the 

delivery of culturally competent care. " 

• Community Involvement and 

Accountability 

• Board Development 

• Policies 

Planning and Monitoring/Evaluation: 

The mechanisms and processes used for: a) longand 

short-term policy, programmatic, and operational 

cultural competence planning that is informed by 

external and internal consumers; and b) the systems 

and activities needed to proactively track and assess 

an organization's level of cultural competence. 

• Client, Community and Staff Input 

• Plans and Implementation 

• Collection and Use of Cultural 

Competence-Related Information/Data 

Communication: 

The exchange of information between the 

organization/providers and the clients/population, 

and internally among staff, in ways that promote 

cultural competence. 

• Understanding of Different Communication 

Needs and Styles of Client Population 

• Culturally Competent Oral Communication 

• Culturally Competent Written/Other 

Communication 

• Communication with Community 

• Intra-Organizational Communication 

Staff Development: 

An organization's efforts to ensure staff and other 

service providers have the requisite attitudes, 

knowledge and skills for delivering culturally 

competent services. 

• Training Commitment 

• Training Content 

• Staff Performance 

Organizational Infrastructure: 

The organizational resources required to deliver or 

facilitate delivery of culturally competent services 

• Financial/Budgetary 

• Staffing 

• Technology 

• Physical Facility/Environment 

• Linkages 

Services/Interventions: 

An organization's delivery or facilitation of clinical, 

public-health, and health related services in a 

culturally competent manner. 

• Client/Family/Community Input 

• Screening/Assessment/Care Planning 

• Treatment/Follow-up 

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The HRSA project team moreover identified more specific indicators of cultural competence in health care delivery 

organizations in relation to these domains and focus areas. The indicators are classified into four types: 1) structure 

indicators, 2) process indicators, 3) output indicators, and 4) intermediate outcome indicators. 14 

As indicators, these are designed to “directly answer the question: ‘How can cultural competence be monitored and 

assessed?’ by identifying the specific items on which information is to be gathered” (HSRA, 2002). 

A grid chart, developed by the HRSA, aligning these four kinds of indicators with the abovementioned domains and 

focus areas is elaborated in Appendix 1. 

Such performance assessment and evaluation frameworks are in line with more recent ‘diversity management’ 

trends in North America, which seek to embed and mainstream diversity issues and competencies within the core 

operations and strategic functions of organizations (as opposed to the tendency of older approaches to silo diversity 

within human resources departments, in the hands of specialists). 

Among the numerous intervention frameworks geared towards cultural competence organizational self-assessment 

are: 

• The GTA Diversity and LHIN’s Working Group’s (2008) “A Diversity Self-Assessment Tool for Local Health 

Integration Networks; 

• Olavarria et al.,’s (2005), “Organizational Cultural Competence: Self-Assessment Tools for Community Health 

and Social Service Organizations”; 

• Vancouver Ethnocultural Advisory Committee of Ministry for Children and Families (1998) “Cultural 

Competency Assessment Tool”; and 

• SHAD’s (2008) Home for All: How to make supportive housing more culturally competent and anti-oppressive. 

Thematically Organized Intervention Frameworks 

Office of Minority Health’s (2001) CLAS Standards Framework 

A third class of cultural competence intervention frameworks in the literature are distinguished by their organization 

around themes for intervention, which are designed to inform action across organisational/system domains. 

The Office of Minority Health’s (2001) National Standards for Culturally and Linguistically Appropriate Services 

(CLAS) in Healthcare is a primary example of such a thematically organized framework for guiding health 

interventions. 

The 14 standards proposed therein are organized by three broad themes: 

14 Defining indicators as “the particular observable or measurable characteristics of an organization that signify cultural competence”, the HRSA 

further elaborate the specific content of these four different kinds of indicators. As they explain: 

Structure indicators are used to assess an organization's capability to support cultural competence through adequate and appropriate 

settings, instrumentalities, and infrastructure, including staffing, facilities and equipment, financial resources, information systems, 

governance and administrative structures, and other features related to the organizational context in which services are provided. 

Process indicators are used to assess the content and quality of activities, procedures, methods, and interventions in the practice of 

culturally competent care and in support of such care. 

Output indicators are used to assess immediate results of culturally competent policies, procedures, and services that can lead to 

achieving positive outcomes. 

Intermediate outcome indicators are used to assess the contribution of cultural competence to the achievement of intermediate 

objectives relating to the provision of care, the response to care, and the results of care (2002). 

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• Culturally Competent Care (Standards 1-3); 

• Language Access Services (Standards 4-7); and 

• Organizational Supports for Cultural Competence (Standards 8-14). 

The specific standards within these three themes are elaborated in Section 4.3 (see Box 4.3 for listing of CLAS 

standards). Standards 1-7 address interventions that have the most direct impact on clinical care while Standards 8- 

14 address organizational structures, policies and processes that support the implementation of these. 

Joint Commission’s (2008) ‘One Size Does Not Fit All’ Framework (Hospitals, Language, Culture Study) 

Another good recent example of a thematically organized intervention framework is that elaborated in the Joint 

Commission’s (2008) recent report, One Size Does not Fit All: Meeting the Health Care Needs of Diverse 

Populations. 

The Report, authored by Wilson-Stronks et al. (2008), draws on the findings of the Hospitals, Language, and 

Culture (HLC) study. This study set out to better understand how the challenges associated with cultural and 

language (C&L) barriers are being addressed at 60 hospitals across the country, and to initiate the development of 

the first ever hospital accreditation standards for culturally and linguistically appropriate health care. 

The recommendations of the One Size Does not Fit All Report may eventually become officially adopted as (or 

translated into) standards that are required for hospital’s to get accreditation from the Joint Commission on 

Accreditation of Healthcare Organizations (see Section 5.2 for more on growing role of accreditation agencies in 

healthcare quality assurance of culturally competent care). 

The thematic framework developed in One Size Does Not Fit All is derived from current best practices that hospitals 

are employing to provide care and services to their diverse patient populations. This framework is presented below 

in Figure 2.12. 

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Figure 2.12: One Size Does Not Fit All Framework 

Source: One Size Does Not Fit All. Retrieved January 24, 2009 from 

http://www.jointcommission.org/NR/rdonlyres/5AA54D85-0879-4C29- 

B5171241365581AF/0/One_Size_Report_One_Pager.pdf 

Wilson-Stronks et al. (2008) provide a host of recommended actions within these four themes, which are briefly 

summarized as follows: 

Theme 1: Building a Foundation 

• Establishing a foundation of policies and procedures that systemically support cultural competence is a crucial 

component of meeting the needs of diverse patient populations. The role of leadership is inherent to these types 

of activities — leadership support is required to recognize, prioritize, and often drive efforts that establish 

policies and procedures to improve care and to better meet patient needs. 

• Integrating C&L [Culture and Language] considerations into organizational policy and procedure requires a 

demonstration of commitment. Without an organizational commitment to cultural competence and 

subsequent action at the policy and procedure level, these initiatives can often be over-shadowed by other 

organizational priorities. In order to resolve challenges such as lack of funding and resources for C&L services, 

it is important for organizations to clarify their commitment to providing culturally competent care by creating a 

supportive infrastructure of policies and procedures that help staff put these ideals into action. 

Theme 2: Collecting and Using Data to Improve Services 

• The collection and use of community- and patient-level data is essential to developing and improving services 

in health care, including services developed to meet the needs of diverse patient populations. Instituting 

practices to systematically collect data allows the effectiveness and utilization of C&L services to be monitored, 

measured, and evaluated. This can be useful for planning so that services can be designed to meet the specific 

needs of the organization. 

• While many hospitals across the United States already collect community- and patient-level data, few hospitals 

have developed systems for using them to guide service development and improvement. A thorough 

understanding of the need for C&L services, dependable information regarding the use of those services, and 

the usefulness of those data to improve C&L services can all contribute to a hospital’s ability to identify and 

monitor health disparities and provide safe, quality health care to culturally and linguistically diverse patients. 

The data collected may also be used to inform short- and long-term organizational planning, help develop C&Lspecific 

services and programs, and identify limitations in staffing and resources that collaborative partnerships 

may alleviate. 

Theme 3: Accommodating the Needs of Specific Populations 

• Accommodating the needs of specific populations includes practices aimed at providing safe, quality care and 

decreasing health disparities for particular populations in the service community. Accommodations targeted to 

48


the needs of specific populations evolve as hospitals search for solutions to the challenges of providing care to 

their diverse patients. 

• To ensure organizations meet changing staff and patient needs, the development of services and activities 

tailored for specific populations should be a continuous process. While the practices outlined in this chapter 

show positive steps toward the delivery of culturally and linguistically appropriate care, they also indicate the 

complicated reality of the long road ahead. Although knowledge, field experience, and technology have 

improved the delivery of C&L services, hospitals need to consider the balance between convenience, cost, 

patient safety, and quality. 

Theme 4: Establishing Internal and External Collaborations 

• Collaborative practices encompass those that bring together multiple departments, organizations, providers, and 

individuals to achieve objectives related to culturally and linguistically appropriate care. Within each hospital, 

different stakeholders should be brought together to develop, implement, evaluate, and improve initiatives 

aimed at meeting the needs of diverse patients. External collaborations can help hospitals engage their 

community and share information and resources. 

• Collaboration, whether internal or external, may provide new avenues for hospitals currently undertaking 

cultural competence initiatives. There is no doubt that collaboration needs to play a role in all the practices 

outlined in this report. Building active relationships with cultural brokers, traditional healers, chaplains, 

religious leaders, and other individuals may enhance and extend the hospital’s existing C&L services. While 

collaborative efforts come with their own challenges, building partnerships that bring together the champions of 

culturally and linguistically appropriate care has the potential to move the entire field forward. 

2.4 STRENGTHS AND LIMITATIONS OF RESPECTIVE FRAMEWORKS 

Health equity frameworks 

Strengths 

A particular strength of the health equity frameworks discussed in this literature review are their promotion of 

holistic understandings of ‘health’ and ‘health status’ which enables them to suggest a wider range of health 

promotion and prevention-based, remedial policy interventions beyond traditional medical model approaches 

concentrating solely on treating individual illness in healthcare contexts. 

Health equity frameworks engagement with health equity issues at the population level of analysis in these respects 

is also critical to redressing structural inequities between social groupings in society, as this impacts upon health 

status, within and beyond healthcare service contexts. 

Another particular strength of the health equity frameworks discussed here is their strong evidence-base, informed 

by various causal models of the determinants of health and health in/equity. Such causal models not only provide 

and suggest empirically and theoretically defensible sites for policy intervention and collaboration, on the basis of 

empirical evidence, they also lend themselves to more realistic and objective assessments of what healthcare equityfocused 

interventions may achieve in preventing and alleviating health disparities, appreciating the constraints 

imposed by various ‘upstream’ determinants of health. 

Limitations 

One of the difficulties or challenges of adopting a health equity framework that considers (if not foregrounds) 

broader social determinants of health, from the perspective of the healthcare sector, is the fact that many of these 

social determinants of health inequity are beyond the direct control of the healthcare sector (Benzeval et al., 1995). 

Addressing broader social determinants of health effectively, moreover, often requires considerable intersectoral 

collaboration (for example, through ‘whole-of-government’ approaches and strategies). This, in turn, can pose many 

49


challenges due to the sectoral frameworks within which governments are designed and accustomed to operating in 

(see WHO, 2008, p.111; PHAC, 2007; PHAC & WHO, 2008). Such whole-of-government approaches, moreover, 

where these do exist in practice, most often require coordination at the highest levels of government. 

Another challenge of the more ‘evidence-based’ health equity models and frameworks employing causal models of 

health in/equity revolves around the contested nature of ‘causes’ and ‘evidence’ in the literature. As the WHO 

reports in the former respect: 

By their nature many of the social determinants considered by the Commission are relatively distant, 

spatially and temporally, from individuals and health experience. This is challenging, both conceptually 

and empirically, when trying to attribute causality and demonstrate effectiveness of action on health equity 

(2008, p. 42). 

Part of the challenge of evidence-based approaches in this respect is what kinds of evidence are considered to 

‘count’ in the scientific literature (too often, critics argue, only experimental quantitative evidence that can be 

counted). Many ‘upstream’ determinants of health, such as global or national economic arrangements and social 

policies, however, do not lend themselves to randomized controlled trials etc. Applying overly strict and narrow 

rules of evidence in this respect could lead to many of the most important health determinants falling off the 

analytical radar. 

When it comes to suggesting appropriate intervention strategies, moreover, health equity frameworks and models 

have less of an evidence-base to stand on. This is in no small part due to the dearth of existing research evaluating 

the impact and effectiveness of various kinds of health equity interventions on the ground (Exworthy et al., 2006; 

Gardner, 2008a; Mackenbach et al., 2002a). 15 

Theoretically informed, evidence-based health equity models and frameworks, moreover, have to guard against 

being too complex for policy-makers to understand, as this will inhibit effective translation into policy interventions. 

Those health equity frameworks complementing their theoretical causal models with corresponding practical 

intervention frameworks, in this respect (e.g. WHO 2008; New Zealand Min of Health, 2002), hold out the most 

promise and potential, since they already provide guidance on this translation from theoretical models to sites for 

policy intervention. 

Many of the identified causes of health inequity in such frameworks and models, moreover, are of a more politically 

contentious nature, since they ultimately rely on normative theories of differentiating just from unjust social 

arrangements and health outcomes. Scientific ‘evidence’, in this respect, is no substitute for ethics. Some of the 

health equity frameworks are thin on the ethical bases of their commitments. 

Finally, many of the health equity frameworks encountered in the literature focus near exclusively on socioeconomic 

status as a bases for health in/equity, failing to take adequate stock of intersecting dimensions of social 

exclusion and health inequity such as race, ethnicity, gender, and sexual orientation (Galabuzi & Labonte, 2002). 

15  Mackenbach et al.’s (2002a) survey of the field of health inequalities remains very much true to this day in this respect: 

most publications about socioeconomic inequalities in health have focused on the description of socioeconomic inequalities in health in 

countries, comparisons between countries and the explanation of these inequalities. From these studies we have learnt much about 

the different factors which influence socioeconomic inequalities in health. However, in practice it seems hard to translate these factors 

into interventions in health. 

50


The (2004) Discussion paper of the Health Disparities Task Group for Public Health Canada, for instance, 

commendably recommends examining the health status of Aboriginal peoples, single mothers in poverty, women, 

homeless people, and refugees, but lacks a more explicit ethno-racial lens of analyses. 

Health Equity in Healthcare Frameworks 

Strengths 

Forming a bridge between health equity and healthcare equity frameworks, health equity in healthcare framework 

have the benefit of keeping within their analytical and strategic purview determinants of health and health inequity 

that lie beyond the healthcare system, and employing such analyses to effectively and creatively inform appropriate 

(holistic, prevention-based) strategies to address such inequities within the healthcare system (as illustrated in 

Gardner’s many recommendations which share a holistic, community-empowerment perspective focusing 

‘upstream’ on prevention and health promotion). 

In concerning themselves with the broad determinants of health status, yet from the situated standpoint of the 

healthcare system, and what it can do to reduce inequities in health status, health equity in healthcare frameworks 

have the added appeal and benefit of being more easily operationalized within local/regional healthcare contexts and 

settings such as the LHINs. 

Limitations 

The two health equity in healthcare frameworks engaged in this literature review did not explicitly base themselves 

upon any etiological model or evidence-base of the causes of health in/equity and the most effective solutions. 

While these frameworks (e.g. Gardner, 2008a) offer many concrete recommendations for LHINs action, it would be 

useful to more explicitly wed such intervention frameworks to a more self-consciously elaborated, evidence-based, 

conceptual framework and model. 

Healthcare Equity Frameworks 

Strengths 

Healthcare equity frameworks taking a more narrow and focused approach on healthcare inequities have, as a 

particular strength, their ‘do-ability’ and ‘translatability’ into action in and by the healthcare sector. 

Cultural competence frameworks – the main form of healthcare equity frameworks discussed in this review - are 

particularly commendable for their close attention to the ways in which cross-cultural dynamics within healthcare 

settings can seriously and negatively impact upon the accessibility and quality of healthcare services received by 

cultural minorities (Registered Nurses Association of Ontario, 2007; Stampino, 2007; Simich et al., 2006; Basok, 

2007). 

Cultural competence frameworks have as a particular strength their close attention to the cultural ingredients of 

successful interpersonal relations, exchanges, and communication, all of which are critical to successful, patientcentred, 

health outcomes in healthcare contexts. 

In plural, immigrant-based, multicultural societies such as Ontario, where there is a significant level of ethnocultural 

diversity, cultural competence frameworks may be of particular use, given their focus on inter-ethnic 

relations. 

Limitations 

Healthcare equity frameworks have been critiqued for failing to consider and engage the most important and 

consequential determinants of health that are situated ‘upstream’ from the healthcare sector. Though not within the 

direct control of the healthcare sector, critics argue that the healthcare sector can play a lead role in advancing and 

advocating a more holistic approach to health that better addresses and accounts for the broader social determinants 

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of health upstream from the healthcare sector (Gardner, 2008a; Raphael & Bryant, 2006; Exworthy & Washington, 

2006; Lettner, 2008a; Jain, 2007; Rachlis, 2008). 

By focusing analyses and solutions exclusively on healthcare service inequities, critics argue, healthcare equity 

frameworks limit themselves to improving the treatment of individual illness in healthcare service contexts 

(precluding more preventative, population-level interventions as afforded, for instance, by a population-health 

perspective) (Raphael & Bryant, 2006). 

As Mackenbach et al. argue, such ‘downstream’ healthcare focused solutions and interventions “can never totally 

eliminate the problem, because people will have to fall ill before [better] healthcare can repair the damage” 

(2002b). 

Research consistently shows, moreover, the relatively minor role played by health care in explaining health 

disparities. Exworthy et al. (2006) for instance cites research attributing to healthcare inequities “perhaps only 10 

percent to 15 percent of the variation in health outcomes among different groups” (see also Adler et al., 1993; 

McGinnis, Williams-Russo, and Knickman, 2002). Policy intervention frameworks focusing exclusively on 

healthcare inequities, in this light, provide limited potential for fundamentally reducing inequities in health status. 

Cultural competence frameworks, more specifically, have often been critiqued for their: 

• Neglect of broader structural, socio-economic determinants of health and inattention to inequities of power 

more generally, as these impact upon health and heath care (Raphael & Bryant 2006; Kumas et al., 2007; 

Sakamoto 2007); 

• Neglect of supra-individual, systemic levels of analyses (Sakamoto 2007); 

• Perpetuation of cultural stereotypes and cultural essentialism, in part due to a reliance on static and 

homogenising concepts of culture that fail to adequately account for cultural hybridity (‘cross culture’), fluidity, 

and intersectionality (Engerbretson et al., 2008; Turner, 2008; Carpenter-Song et al., 2007; Kumas et al., 2007; 

Wong et al., 2003); 

• Faulty epistemological premises depicting culture as a stable object of knowledge that can be known and 

‘mastered’ (which, critics suggest, can result in a lack of ‘cultural humility’ towards ‘others’) (Wong et al., 

2003; Tervalon and Garcia, 1998) 

• Narrow focus on racial and ethnic dimensions of ‘culture’ and failure to account for and conceptualize other 

intersecting cultural identities, patterns and experiences (SHAD, 2008; Raphael & Bryant, 2006) 

• Lack of evidence-base substantiating the positive impact of cultural competence interventions on the ground 

(Beach et al., 2006; Anderson et al., 2003; Whitley, 2007); and 

• Abstract postulations which lack operational specificity or translatability (Sue, 2006). 

Counterexamples, nevertheless, can be found for each of these critiques demonstrating the continuing evolution and 

maturation of the cultural competence literature. 

2.5 RECOMMENDED FEATURES OF A HEALTH EQUITY FRAMEWORK 

Key features of a health equity framework recommended based on this review of the literature are listed below: 

• Combines an evidence-based conceptual model of the causes/determinants of health and health in/equity with a 

practical intervention framework (e.g. New Zealand’s Framework for Reducing Inequalities in Health and the 

WHO’s Closing the Gap Framework). Conceptual models most useful to policy-making balance conflicting 

priorities: they help to illuminate the multiple relevant causal pathways for health in/equity and entry points for 

intervention, on the one hand (i.e. integrated models), yet, are not too complex for policy-makers and the wider 

public to understand, on the other hand (Mackenbach, 2002a); 

52


• Concerned with health status, broadly conceived, yet from the situated standpoint of the healthcare system and 

its strategic levers of power (e.g. the health equity in healthcare approach of Gardner, 2008; Rachlis, 2008); 

• Patient-centred, addressing and incorporating issues of cultural and linguistic competence as a fundamental 

healthcare quality and access issue. ‘Culture’, however, should be broadly construed to include and address 

intersecting forms of cultural difference beyond ethnicity (e.g. addressing cultural differences relating to age, 

gender identity, class, geography etc.). It is also important that cultural-linguistic competence approaches 

engage issues of power inequity, as these impact social and cultural relations, e.g. race/racism, gender/sexism, 

socio-economic marginalization etc. 

3.0 HEATH EQUITY POLICIES 

The following section examines some of the key terms of debates in the health equity policy literature (section 3.1), 

before surveying international health equity policy trends (section 3.2) and drawing out some of the key lessons 

from international health equity policy experiences, successes and failures (section 3.3). 

3.1 KEY POLICY DEBATES 

Health equity policy debate revolves primarily around five main areas: Justification, Objectives, Scope, Use of 

Evidence, and Strategic Options & Priorities. This section draws extensively on the framework of analyses of 

Mackenbach et al (2002b), which elucidates many of the key debates in these respects. Health equity policy-makers 

would do well to consider and clearly articulate positions within these five fields of debate, taking cognisance of 

existing policy trends and variations in these respects. 

Justification 

The first critical question any health equity policy must address is why should health inequities be reduced in the 

first place? What is the justification and rationale for committing public resources to this goal? 

Mackenbach et al. (2002b) discern two main justifications in the health equity policies they reviewed: 

1. Because inequalities in health contradict values of fairness and justice; and 

2. Because reducing inequalities in health may lead to better average health in the population as a whole. 

These varying justifications for health inequity policy are discussed below. 

I. Because inequalities in health contradict values of fairness and justice 

The first justification begs the question of how one decides which health distributions in a population are unfair. In 

other words, as earlier discussed, what health differences are health inequities. This is where ones definition of 

health inequity becomes essential, as it can help to clarify the issue from the beginning, as exemplified in 

Whitehead’s earlier definition of health inequities as unequal distributions of health that are avoidable, unnecessary 

and unfair. 

However, even such a seemingly precise definition of health inequity begs the further question of the specific ethical 

premises informing the inevitably normative nature of such judgements distinguishing fair and unfair health 

disparities (see Section 1.1. and Table 1.1 for more on normative nature of such judgements). In their article, ‘Ethics 

frameworks in Canadian health policies: Foundation, scaffolding, or window dressing’, Giacomini et al. (2009) 

consider a range of definitions and ethical justifications for commitments to health equity (see for example Table 

53


3.1), and take Canadian policy-makers to task for failing to sufficiently elaborate clearer ethical foundations for 

health equity policies. 16 

Table 3.1: Different interpretations of the same ethical ideal: “Equity” 

(a) “Equity: access to health services should be based on need and need alone, not on other factors such as wealth, origin, 

the region where people live, their gender or age” (Commission on the Future of Health Care in Canada, 2002, p. 48). 

(b) “Equity: all Canadians are equally entitled to access our health system based on health needs, not ability to pay” (ibid., p. 

50). 

(c) “Equity: no one should face financial hardship because of illness, disease or disability. Wealth should not be able to buy 

better treatment, higher-quality care or a better chance at a cure” (British Columbia Ministry of Health Planning, 2002, 

p. 15). 

(d) “Equity: every person has a fair opportunity to attain his/her full health potential. Policies and services are developed to 

reduce the differences in health status that are associated with factors such as socio-economic status, gender, age, 

ability, and culture” (Department of Health and Community Services, 2002, p.10) 

(e) “Equity: no one should face excessive financial hardship or possible bankruptcy because of illness, disease or disability. 

Access to timely and medically necessary health services should be available to all, regardless of income. These two 

access issues are fundamental to Canadian health care and are tenets almost all British Columbians would agree with. 

This does not mean, however, that British Columbians should not bear some responsibility to keep healthy or to 

contribute to the future sustainability of the health care system, which will be discussed in more detail further in the 

report. Rather, it means that any funding mechanism or financial involvement should be equitable and fairly distributed. 

No one disease profile, demographic or sector of society should bear a disproportionate burden of the health care 

costs” (Legislative Assembly of British Columbia, 2001, p.13). 

(f) “Equity: participation, access, and the sharing of benefits and risks, taking into account the characteristics of each 

population” (Reseau de Medecine Genetique Appliquee du Quebec 2002, p. 2). 

Source: Giacomini et al., 2009 

Anthony Culyer (2007) similarly encourages Canadian policymakers to be more explicit about their ethics in order 

to better manage and translate ethical positions “into policy action in reasonable and doable ways”. Failing to do 

this, by leaving ethics largely implicit, he argues, 

means that the huge differences between us that might otherwise remain submerged could become 

underwater reefs with the potential to rip the bottoms out of well-meaning policies for equity in practice - 

as soon as it becomes clear that one person's notion of equity is not also another's. We need to be clearer 

about what we mean and where we might differ in what we mean (p.12). 

Mackenbach et al. (2002b) likewise stress the importance of “explicitly justify[ing] policies to reduce 

socioeconomic inequalities in health, not only because it is important to convince policy-makers of different 

political convictions that something needs to be done, but also because one's choice of justification will partly 

determine which policies should receive priority” (see Mackenbach et al., 2002b for examples of the implications of 

different policy justifications). 

16 Surveying a bewildering array of definitions and interpretations of ‘equity’ as a value in healthcare policies (see Table 3.1 above), Giacomini 

et al. (2009) for instance argue: 

[t]he instrumental role of the ethics framework should be made clear, particularly its relationship to the development, 

interpretation, and implementation of the policy it accompanies. Currently, many ethics frameworks seem detached from policies, 

floating alongside in special text boxes or appendices. They are also set apart by vague, platitudinous language; imperatives are 

typically expressed in terms that are inspirational, positive, nonspecific, and non-operational. The language offers vast license in 

interpretation and discretion in response. Some degree of flexibility is appropriate and necessary in ethical analysis. However, expansive 

ethical terms with little definition or operationalization become weak rhetoric, and apparent agreements (e.g., to include 

“accountability” among guiding principles) may mask fundamentally different aims (e.g., involving public participation vs. 

transparent reporting). 

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II. Because reducing inequalities in health may lead to better average health in the population as a whole. 

The second frequent justification for health equity policies also emphasizes, sometimes for pragmatic political 

reasons, the ways in which health equity policies can improve the health of all populations (and certainly not lead to 

a worsening of health for any group as a consequence). 

Oftentimes, such justifications also recognize (if not explicitly acknowledging) that the same health equity policies 

frequently lead to a differential improvement in the health of lower socioeconomic groups, as compared to other 

groups. 

Such justifications tend to generate less controversy, since they appear to be clearly in the interest of all citizens and 

healthcare recipients. Stronks (2002) for instance attributes part of the success of the Dutch health authorities’ ability 

to get health equity on the political agenda to their definition of the problem to be tackled in ‘politically neutral 

terms’. 

As she argues: “Most of the time the public health argument was used as a rationale for the policy of reducing 

inequalities in health (i.e. 'diminishing inequalities will improve the average health status of the population'), instead 

of the more political argument of 'unfairness'” (2002). 

Of course these two policy rationales need not be mutually exclusive, and many health authorities (such as Health 

Canada) appeal to both of these justifications in their advocacy for and implementation of health equity policies. 

Aims and Objectives 

While the objectives of health equity policies may appear obvious at first sight – e.g. to reduce health inequities – it 

is not always clear what this entails. As Mackenbach et al. (2002b) explain of the varying possible interpretations of 

this seemingly obvious objective: 

Do we intend to reduce relative or absolute inequalities in health? To redistribute health from the higher to 

the lower socioeconomic groups? Or to differentially improve the health of the lower socioeconomic 

groups? Does 'health' refer to the occurrence of specific health problems or to integrated health measures 

such as health expectancy (p.29)? 

Objectives, no less than justifications, should as such be articulated clearly and in operationalizable terms in order to 

provide policy-makers and the wider public with clear yardsticks with which to measure success or failure (see Box 

4.1, 4.5 and 4.6 for good examples of clearly articulated, realistic, and operational health equity goals and 

objectives). 

The main debates in relation to health equity policy objectives revolve around: 

• Whether the goal or objective is the absolute or relative reduction in health inequalities; and 

• Whether the goal or objective is the reduction of inequalities in health status and/or healthcare 

These two major areas of divergence in views in relation to health equity objectives are discussed below. 

I. Absolute or relative reduction in health inequality as objective 

Mackenbach et al. (2002b) highlight the fact that objectives aimed at improving the health of lower socioeconomic 

groups in absolute terms (using absolute measures), for instance through universal healthcare provision, do not 

necessarily or always reduce (indeed they may sometimes increase) relative measures of health inequality between 

SES (socioeconomic status) groups. 

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Stating health equity policy goals in absolute terms, Mackenbach et al. (2002b) however argue, increases the range 

of potential policy options, since any policy initiative that universally reduces, for instance, average rates of 

mortality or morbidity (even if not changing the size of relative inequalities between population groups), will be 

justifiable in service of this objective. 

Objectives aimed at decreasing the relative ratio of inequality between SES groups, on the other hand, often require 

health equity policy interventions that exclusively target the most disadvantaged. It is precisely because “[s]trategies 

to maximize improvement in overall population health may have little or no impact on relative disparities or, indeed, 

may cause them to increase” (Keppel et al., 2007), that many argue (including Gardner, 2008a and the Canadian 

Health Disparities Task Group) that “[t]he most appropriate and effective way to improve overall population 

health status is by improving the health of those in lower SES groups and other disadvantaged populations” 

(Canadian Health Disparities Task Group, 2004). 

Mackenbach et al. (2002b) recommend pursuing health equity policy objectives on both fronts – i.e. investing in 

overall improvements in overall population health, as well as seeking to reduce health gaps between higher and 

lower socio-economic groups. This has been the approach adopted in the UK (see Section 3.2.B and 3.3 for more on 

UK health equity policies). 

The WHO’s (2008) Closing the Gap framework also includes elements of both of these two (absolute and relative) 

objectives: on the one hand, aiming to ‘improve living conditions for all’, and on the other hand, ‘to reduce 

inequitable distributions of power, money and resources’. 

II. Reduction of health status inequalities and/or healthcare inequalities as objective 

The various frameworks discussed in the preceding section on Frameworks were largely organized around their 

differing objectives: healthcare equity and/or health status equity. It is important not to confuse disparities in health 

care with disparities in health status. Disparities in health status are widely agreed to be rooted in socioeconomic 

circumstances that extend far beyond the health care system. As Exworthy and Washington (2006) argue: 

Disparities in health care cannot remedy all the disparities in health status, because of the wider 

determinants of health shaping the latter. Indeed, health care may only have an ameliorative effect on 

disparities in health status and in some cases may even exacerbate them (see for instance McGinnis et al., 

2002). 

Exworthy et al. (2006) provide some tangible examples (see Table 3.2 below) of the different kinds of measures 

involved in assessing disparities in health status versus disparities in healthcare, drawing on statistics from the UK 

and US contexts. 

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Table 3.2: Examples of Disparities and Inequalities in Health and Health Care 

Source: Exworthy et al., 2006 

Ultimately, it is recommended by Mackenbach et al. (2002b) that both kinds of disparities (health status and 

healthcare) feature as objectives in any policy concerned with reducing health inequities. 

Scope 

Health Equity policies also vary considerably, internationally and intra-nationally, by the scope of ‘disadvantaged 

groups’ they consider and target, and the breadth of system areas or domains engaged by health equity policy 

initiatives. 

I. Breadth of disadvantaged groups considered 

The scope of disadvantaged groups targeted by health equity policies depends greatly on local histories and politics, 

and statistical/census data. US healthcare equity policies for instance tend to focus, almost exclusively, on racial and 

ethnic minorities, and rarely if ever speak in terms of socioeconomic status or class position, as is the norm in the 

European healthcare context. 

In the UK context, Strategic Health Authorities and the UK Department of Health focus in particular on six ‘equality 

strands’ – race, gender, disability, age, sexual orientation and gender identity, and religion and belief – and human 

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rights. New Zealand’s health equity policies focus more narrowly on ethnicity – in particular the Maori – and 

socioeconomic status. 

In the Canadian context, the inter-governmental Health Disparities Task Group views socio-economic status (SES), 

gender, Aboriginal status and geographical location as the ‘strongest predictors of disparities’ (2004), and 

recommends that these factors in particular be monitored and measured. Tugwell et al. (2006), argue that “equity 

gradients relevant to informing policy and decision makers on the effectiveness of interventions include not only 

socioeconomic gradients but also gender, race, workforce, rural-urban, education and social capital 

gradients.” Lettner (2008b) furthermore stresses the importance, in the Toronto and Ontario context, of looking at 

race/ethnicity as a determinant of health (also see Robertson & Swan 2005 in this respect). 

The first (2006) report of the Ontario Health Quality Council argued that “[t]here should be continuing efforts to 

reduce disparities in the health of those groups who may be disadvantaged by social or economic status, age, 

gender, ethnicity, geography, or language”. 

Whilst commending this definition as ‘providing a good starting-point for shaping health care policy and delivery,” 

Rachlis (2007) argues that it should be “broadened further to include health disparities related to racism and 

discrimination, culture, citizenship status, sexual orientation, and ability”. 

Gardner (2008a) puts the focus on ‘disadvantaged populations’, and recommends that “inequitable access, treatment 

and outcomes be measured by race, country of origin, sexual orientation [and, elsewhere, gender] or any other 

line of discrimination and oppression”. In keeping with their earlier definition, the Health Disparities Task Group 

specifies more precisely what they mean by ‘disadvantaged population’ in their health equity discussion paper: 

Disadvantaged populations: populations that share a characteristic associated with high risk of adverse 

health outcomes (e.g. Aboriginal peoples, single mothers in poverty, women, homeless people, refugees) 

(2004). 

Focusing on ‘disadvantaged populations’ – depending on the empirical evidence in this respect (where this is 

adequate to begin with) - is a useful starting point, as it has the merit of enabling a contextual analysis that is fluid 

enough to evolve with changing circumstances and power relations and health inequities (e.g. religion rising to the 

foreground as a basis of discrimination post-911). 

II. Breadth of system domains engaged through health equity policies 

Health equity policies also vary in the scope of organizational and system are functions they engage and seek to 

intervene in. Among the differing health system domains frequently discussed in the literature, and engaged through 

health equity policy initiatives are: 

• Leadership (including vision statements, policies, strategies etc.) 

• Governance (including stakeholder engagement issues) 

• Services and Service Delivery 

• Research and Evaluation 

• Human Resources 

• Contracting & Procurement 

• Communications 

Research and policy experience from various jurisdictions suggests the critical importance of ‘mainstreaming’ 

diversity and equity issues across all of these various health system functions and domains (see especially Exworthy 

2003 for importance of mainstreaming equity considerations). 

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Use of Evidence 

Health Equity policies can be distinguished by the extent to which they use and incorporate evidence into their 

policies and policy-making processes. Global momentum has grown considerably in recent years for evidencedbased 

policymaking and evaluation (see Exworthy et al., 2006; Whitley, 2007; Davies, Nutley, and Smith, 2000; 

Walshe and Rundall, 2001). Among national governments, the UK government has come closest to living by its 

motto of ‘what counts is what works’ (Exworthy and Berney, 2000). 

Exworthy et al. (2006) emphasize the importance of prioritizing interventions and policies on the basis of evidence 

of their potential effectiveness in reducing health inequalities. Mackenbach et al., (2002b) stress the importance of 

two types of evidence more specifically: 

[1] evidence that the determinant addressed by the intervention or policy plays a key role in the causation 

of socioeconomic inequalities in health; [and] 

[2] evidence that the proposed intervention or policy can be expected to effectively reduce exposure to 

that determinant in the lower socio-economic groups (or to reduce socioeconomic inequalities in 

exposure to that determinant) (p.32). 

This is where choice of framework is important, as discussed earlier, since it can more or less provide an evidencebased 

theoretical model and framework for intervention. 

Both of the above two types of ‘evidence’ discussed by Mackenbach et al. (2002b) can be difficult to definitively 

obtain (see Section 2.4). Mackenbach et al. (2002b) and Gardner (2008a) recommend a certain degree of measured 

pragmatism in advancing health equity policy and practice in areas where evidence may not be readily established or 

forthcoming. 17 

Evidence alone, moreover, as earlier discussed, cannot singlehandedly determine health equity policies since the 

goals and objectives of such policies also presuppose and require staking out particular normative/ethical positions 

(which may be more or less compelling). 

The WHO (2008) Closing the Gap report suggests the need to expand conventional definitions and conceptions of 

what constitutes ‘evidence’ beyond experimental designs and randomized controlled trials etc. (for instance by 

including qualitative measures, community accounts etc.). 

Judge and Mackenzie (2002) also elaborate the important potential role of theory-based evaluations when dealing 

with broad determinants of health that do not lend themselves to experimental manipulation. (For more on some of 

the difficulties in furnishing ‘evidence’ for policies and their impact also see Exworthy et al., 2006 and Judge & 

Mackenzie, 2002). 

17 Mackenbach et al. argues in this respect: 

it may take decades to build up a reasonably extensive evidence base. It is therefore better to be pragmatic and to be prepared to decide for the 

implementation of policies and interventions in the absence of full documentation of their effectiveness. Sometimes, effectiveness can reasonably 

be expected on the basis of experience in another setting, or evidence of effects on intermediate outcomes. In such cases it is all the more 

important that while the policies or interventions are being implemented, evaluations are carried out so that their effectiveness can be determined 

at a later stage, and changes made if effectiveness remains below expectations. In reality, all this implies that it will usually be difficult to 

prioritize policies and interventions on the basis of scientific evidence only. Other considerations, for example, on the (political) feasibility of 

certain strategic options, are likely to have a profound influence on priority setting in this area (2002b, p.33). 

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Strategic Options & Priorities 

Variations in policy justifications and objectives are (or should be) closely related to variations in the strategic 

options pursued by health policymakers. Mackenbach et al. (2002b) discern the two main lines of division in this 

respect as revolving around 

1. Entry points for intervention, namely upstream vs./and/or downstream intervention sites; and 

2. Universalist or Selectivist Approaches 

These are discussed below. 

I. Upstream' versus 'downstream' policy options 

Health equity (versus healthcare equity) approaches generally emphasize and aim for upstream solutions dealing 

with the fundamental causes of health inequalities beyond the healthcare system. Policy interventions concerned 

with equity exclusively in healthcare contexts are very much a downstream solution since they deal more with the 

effects of upstream determinants of health. 

Upstream solutions, “[b]y addressing the fundamental causes of inequalities in health…avoid 

the possibility that after one of the more immediate causes has been eliminated, other immediate causes take its 

place because the same fundamental causes are still in operation” (Mackenbach et al., 2002b). On the other hand, as 

earlier discussed, health policymakers have less direct leverage over such root causes of health disparities like socioeconomic 

distributions. 

Downstream solutions in healthcare services, contrastingly, are more within the direct control of health 

policymakers, and the effects of such policy interventions more easily lend themselves to measurement and 

documentation (Mackenbach et al., 2002b; Exworthy et al., 2006). On the other hand, Mackenbach et al., argue, 

such policy interventions “are usually expensive and can never totally eliminate the problem, because people 

will have to fall ill before extra healthcare can repair the damage” (2002b). 

Research consistently shows the relatively minor role played by health care in explaining health disparities. 

Exworthy et al. (2006) for instance cites research that attributes healthcare inequities as accounting for “perhaps 

only 10 percent to 15 percent of the variation in health outcomes among different groups” (see also Adler et al., 

1993; McGinnis, Williams-Russo, and Knickman 2002). Downstream policy interventions in healthcare contexts 

thus hold out limited potential for fundamentally reducing health inequities. 

Between these two (downstream and upstream) policy options are ‘midstream’ interventions: “for example, reducing 

exposure to unfavourable specific material living conditions, psychosocial factors and behavioural risk factors in the 

lower socioeconomic groups” (Mackenbach et al., 2002b). 

Such policy interventions “combine some of the advantages and disadvantages of both upstream and 

downstream solutions: the leverage and decision-making power of health policy-makers may be limited, but the 

health effects of changing the socioeconomic distribution of some of the more powerful determinants, such as 

smoking and work environment, can be expected to be substantial” (p.36). 

Both Mackenbach et al. (2002b) and Exworthy et al. (2006) ultimately recommend a combination of upstream, 

midstream and downstream policy interventions (i.e. an ‘all stream’ solution). 

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II. Universalist vs. Selectivist Approaches 

Policy options also vary in terms of whether they take a universalist or selectivist approach to intervention. 18 

Universalist approaches target all individuals without distinction in pursuit of universal standards and goals for all. 

Such approaches often frame health equity policy objectives, where such commitments exist, in absolute versus 

relative terms (see Objectives section above). 

Selectivist approaches, on the other hand, target services and benefits to specific population groupings, often 

depending on degree of need. Cultural competence and health equity approaches targeting particular disadvantaged 

populations exemplify selectivist approaches. 

Patterson and Judge (2002, p.180) cite research evidence substantiating the effectiveness of both of these kinds of 

interventions (universalist and selectivist) in reducing health inequities. 

While encouraging specific strategies targeting the most disadvantaged populations, the (Canadian) Health 

Disparities Task Group furthermore draws attention to the difficulty of clearly separating out these approaches (at 

least in terms of their effects). As they argue: 

It is rarely, if ever, possible to address these [health disparity] problems in a specific, identifiable population without 

altering factors that affect the entire community. Furthermore, health disparities are not isolated phenomena that can 

be excised with surgical precision. They are, rather, a function of the whole operation of society, and the “treatment” 

must be more fundamental and all-encompassing (2004). 

The Task Group nevertheless maintains its (earlier cited) position that “[t]he most appropriate and effective way to 

improve overall population health status is by improving the health conditions and health services for those in lower 

SES groups and other disadvantaged populations” (2004, p.4). 

In the cultural competence literature this debate between universalist and selectivist approaches plays itself out in 

the context of debates over whether the focus of cultural competence policies and interventions should be on 

developing autonomous ethno-specific health services or reforming mainstream services to make them more 

culturally appropriate (see SHAD 2008b, p.14 for review of this debate in the cultural competence literature). 

Most agree that the best way forward involves some combination of both of these approaches (Mackenbach et al., 

2002b; SHAD, 2008b). 

3.2 INTERNATIONAL HEALTH EQUITY POLICY TRENDS 

A. Margaret Whitehead’s Action Spectrum on inequalities in health 

Margaret Whitehead (1998) elaborates a useful schema to compare and characterize the readiness and willingness of 

various governmental bodies around the world to take action on socio-economic inequalities in health. Her ‘action 

spectrum’ on health equity begins at one pole with the complete absence of measurements of inequalities in health, 

and moves from there progressively along a continuum from ‘measurement’, ‘recognition’, ‘awareness’, 

‘denial/indifference’, ‘concern’, to ‘will to take action’, ‘isolated initiatives’, ‘more structured developments’ and 

‘comprehensive coordinated policy’ (See Figure 3.1 below). 

18 “The question arises as to whether public policy should frame the issue in terms of specific populations at greater risk of health disparities 

or focus on the underlying determinants and conditions that are the causes of health disparities”, the Health Disparities Task Group in this 

respect observes, in a variation of this debate (2004). 

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Figure 3.1 Whitehead’s Action Spectrum on inequalities in health 

Source: Mackenbach et al. (2002b). Adapted from Whitehead (1998) 

Whitehead counsels her readers not to view this action spectrum as a linear evolutionary process as not all countries 

will necessarily go through the same sequence of stages and there is always the possibility of abrupt regress and/or 

progress along this health equity action spectrum or continuum. 

While different jurisdictions within countries may differ in their positioning along this action spectrum, it provides a 

useful means of generalizing, situating and comparing international and intra-national policy developments in the 

area of health equity, as explored below. 

The policy trends examined in this section are necessarily selective in nature, in part due to the uneven reporting of 

these in the literature, difficulties of accessing policies ‘internal’ to various state/provincial and national health 

authorities and in part due to the sheer scope of equity-related policies in those jurisdictions actively pursuing health 

equity (e.g. the UK context, with its many policies and strategies). 

The policies addressed below, as such, are largely those that have either been written about in the academic 

literature and/or are accessible in university/public libraries and/or posted on the worldwide web. Not infrequently, 

only aspects of various health policies are addressed in the academic literature, which further made it difficult to 

compare policies on the basis of a consistent comparative schema. 

B. Cross-national survey of health equity policies 

Canada 

In part due to the piecemeal and selective reporting of health equity policies made available to the public, the 

following section does not claim to comprehensively represent all or the most recent health equity policy 

developments internationally. It does however seek to offer, at minimum, a general picture of major policy trends, 

primarily within Europe and North America. 

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Policy/Strategy Developments 

The Health Disparities Task Group (HDTG) of the Federal/Provincial/Territorial Advisory Committee on 

Population Health and Health Security for the Public Health Agency of Canada describes Canada as having “few 

comprehensive, integrated efforts to address known health disparities and the factors and conditions that lead to 

them” (2004). Their formative (2004) Discussion Paper, Reducing Health Disparities: The Role of the Health 

Sector, tempers this observation with a measure of optimism, noting the recent launching of “some 

promising…initiatives to reduce disparities” (Health Disparities Task Group, 2004). 

The HDTG (2004) breaks down Canadian interventions around health equity into four main categories: 

1. Leadership and policy development, e.g. the development of the Healthy Living initiative, establishing 

population health units in Health Ministries, wellness and health promotion programs, strategic plans 

that include disparities reduction priorities, primary health care innovations, etc. In Quebec the Health 

Ministry is required by law to examine the health impact of policies across the government. 

2. Intersectoral collaboration and partnerships, e.g. child health initiatives, nutrition programs, prevention and 

harm reduction strategies, intra-governmental awareness-raising task groups, targeted programs for highrisk 

groups, etc. 

3. Building community capacity, e.g. community development activities at regional health authority level, 

primary health care outreach, staff training in a population health approach, core area rehabilitation 

initiatives in cities, comprehensive school health programs, etc. 

4. Knowledge development and exchange, e.g. widely publicized health status reports, detailed community 

profiles, health atlases, workshops for staff, health status indicators, specific research support programs, etc. 

(HDTG 2004:16) 

Among the more promising contemporary policy/strategy developments in Canada are: 

• The 2002 and 2003 First Ministers’ Health Accords which make national commitments to reducing 

disparities, more specifically through the adoption and promotion of a national Healthy Living Strategy. The 

Healthy Living Strategy’s two overarching goals are (1) to improve the health of Canadians and (2) to reduce 

health disparities (see Healthy Living Task Group 2003). 19 

The Federal-Provincial-Territorial Advisory Committee on Population Health’s establishment of a Health 

Disparities Task Group in 2002 with the mandate of providing advice on the role of the health sector in addressing 

health disparities. 

The Task Group, which includes policy-makers and researchers from the health and social service sectors (within 

and beyond government), has identified four roles for the health sector in the reduction of health disparities. These 

include to: 

1. Make the reduction of health disparities a health sector priority (establish a national leadership capacity; set 

goals and targets; use Health Impact Assessment; collaborate with jurisdictions, develop priority areas); 

2. Integrate disparities reduction into health programs and services; 

3. Engage with other sectors in health disparities reduction; 

19 The February 2003 Health Accord of the First Ministers states in this respect: “First Ministers direct Health Ministers to continue their work 

on healthy living strategies and other initiatives to reduce disparities in health status.” 

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4. Strengthen knowledge development and exchange activities (develop indicators to measure the impact of 

health disparities; continue to support research; improve health information systems; share evidence on 

health disparities). 

The adoption and promotion of a ‘10 year plan to strengthen health care’ at the (2004) First Minister’s Meeting 

on the Future of Health Care. First Ministers at this meeting agreed on an action plan based on the following 

principles: 

• Universality, accessibility, portability, comprehensiveness, and public administration; 

• Access to medically necessary health services based on need, not ability to pay; 

• Reforms focused on the needs of patients to ensure that all canadians have access to the health care services 

they need, when they need them; 

• Collaboration between all governments, working together in common purpose to meet the evolving health 

care needs of canadians; 

• Advancement through the sharing of best practices; 

• Continued accountability and provision of information to make progress transparent to citizens; and 

• Jurisdictional flexibility. 

Many of the principles affirmed in this 10 year plan synchronize with, and are fundamentally informed by, 

principles of equity in health status and health care. The 2004 First Minister’s Meeting also featured a special 

meeting with Aboriginal leaders which resulted in the development of specific measures to address disparities in the 

health status of Aboriginal peoples: 

• The Quebec Public Health Act which requires all ministries and agencies to consult with the Ministry of 

Health and Social Services when they are formulating policies that could have an impact on health (see PHAC 

& WHO 2008 Report) 

• The provincial Ontario Ministry of Health and Long-Term Care’s (MOHLTC) recent development of a tenyear 

strategic vision and plan for Ontario’s health care system which is expected to feature equity as a 

prominent direction (Lettner, 2008a; Gardner, 2008a). The fact that the Ministry has already established a 

health equity unit to coordinate policy activities on health equity is particularly encouraging in this respect. In 

light of such developments, Lettner suggests that “the new Local Health Integration Networks (LHINs) will 

need to operationalize health equity as part of their mandate in response to the new provincial strategy” (2008a). 

• The policy developments and strategic commitments made by various Local Health Integrated Networks at the 

regional level, in particular the Toronto Central LHIN’s successful August 28, 2007 motion to insert health 

equity and diversity performance indicators into the CEO's Annual Performance Plan and requirement, for 

all 18 hospitals in the Toronto Central LHIN, to provide action plans. 

• The formation of the GTA Diversity and LHINs Working group, specifically addressing diversity and equity 

issues in the LHINs context. 

Limitations and Challenges 

Some of the challenges and limitations of Canadian health equity policy developments are discussed below. 

• There is a substantial discrepancy between official Canadian governmental avowed commitments to health 

equity, health promotion and population health and government policy and action on such matters. The 

Canadian Population Health Initiative in this respect observes: 

Canada has led the world in understanding health promotion and population health …However in recent years, 

as the costs and delivery of health care has dominated the public dialogue, there has been inadequate policy 

development reflecting these understandings. In fact, Canada has fallen behind countries such as the United 

Kingdom and Sweden and even some jurisdictions in the United States in applying the population health 

knowledge base that has been largely developed in Canada (2002, p.1). 

This observation is reiterated by Raphael & Bryant (2006), Williamson et al. (2003), Williamson (2001), and 

Sutcliffe et al. (1997). 

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• There is a dearth of “comprehensive, integrated efforts to address known health disparities, and the 

factors and conditions that lead to them. Although health ministries in all jurisdictions, often in 

collaboration with other sectors, have launched a variety of initiatives to improve health and reduce 

health disparities, these efforts could benefit from a more coherent, system-wide approach” (Health 

Disparities Task Group, 2004). 

• Existing health equity strategies, more specifically the Integrated Pan-Canadian Healthy Living Strategy, 

limits areas of emphasis to individual health-related behaviours such as physical inactivity, unhealthy eating, 

and tobacco use (even if acknowledging that broader determinants of health shape individual health-related 

behaviour). No mention is made of the conditions of daily life as determinants of health, nor is it deemed 

important to specifically address such health determinants through public policy initiatives (Raphael & Bryant, 

2006). 

• “Canada has yet to develop policies to require systematic cultural sensitivity in the health care regimes of all 

provinces. While some hospitals have begun to develop ad hoc programs and adapt practices to enhance 

delivery of culturally competent health care services, they have been developed in isolation” (Oxman-Martinez 

& Hanley, 2004, quoting Bowen, 2002). 

• Current frameworks developed by the Canadian Institute for Health Information and Statistics Canada have 

insufficient indicators of health disparities (Health Disparities Task Group, 2004). 

• The structural design of the LHINs, in particular the exclusion of public health authorities from the LHINS (in 

contrast to the situation in all of Canada’s other provinces’ Regional Health Authorities), could complicate 

and/or compromise its ability to collaboratively address broader determinants of health and health equity 

(Moloughney, 2007). 

Dominant Framework 

• In Canada, Health Equity/Population Health frameworks are dominant in the academic and grey literature. 

In practice, however, approaches adopted tend to take a narrower focus on issues of healthcare equity. While 

cultural competence research initiatives are growing (particularly toolkits and best practice guidelines etc.), the 

operationalization of such frameworks in practice, organizationally and systemically, remains limited and 

sparse. 

Rating on Whitehead’s Action Spectrum 

• Between ‘Concern’ and ‘Isolated initiatives’ 

USA 


Exworthy and Washington (2006) distinguish four main features of US policies tackling health-care disparities in 

their review of US organizational strategies to reduce healthcare disparities. 

Table 3.3: Features of US policy on healthcare disparities 

Source: Exworthy and Washington, 2006, p. 46. 

65


They further describe the aims and objectives of US policies and initiatives to tackle healthcare disparities as falling 

into three categories: 

1. To raise awareness among various stakeholders; 

2. To eliminate disparities; and 

3. To improve cultural competency. 

Examples of notable US policies, legislative acts, and interventions in these three areas are explored below. 

1. To raise awareness among various stakeholders 

Examples of policies and legislative acts drawn up with this aim in mind include: 

• The Minority Health and Health Disparities Research and Education Act of 2000 (P.L. 106-525), which 

was signed into law on November 22, 2000. The Act created a National Center on Minority Health and 

Health Disparities at the National Institutes of Health (NIH). Activities and functions of the Center include 

to fund research programs on health disparities and minority health; support training of members of health 

disparity populations as researchers; and provide education loan relief for health professionals who commit 

themselves to perform health disparities research. The Center also coordinates all NIH research efforts in this 

area. The Act also authorizes the Agency for Healthcare Research and Quality (AHRQ) to conduct and support 

activities and research to measure health disparities and to identify causes and remedies. Finally, it authorizes 

the Health Resources and Services Administration (HRSA) to support research and demonstration projects to 

train health care professionals on reducing health care disparities (see Beal 2004). 

• The commissioning of the federal Agency for Health Research and Quality (AHRQ) to draw up what 

became the National Healthcare Disparities Report (NHDR) by Congress in 1999, which addresses lowincome 

groups, minority populations, women, children, the elderly, and those with special health needs (AHRQ 

2002, 2003). The preliminary measure set for NHDR was published in 2002, and the final draft was published 

in December 2003 (AHRQ, 2003). This report, since published annually, monitors trends in health care 

disparities, measures progress toward their elimination, and raises awareness of racial, ethnic, socioeconomic, 

and geographic disparities in health care so as to help guide health policymakers in designing strategies to 

eliminate them (Swift, 2002; Exworthy et al., 2006). 

• The Institute of Medicine’s (IOM) landmark (2002) report commissioned by US Congress, entitled Unequal 

Treatment: Confronting Racial and Ethnic Disparities in Healthcare. Documenting extensive research 

evidence relating to health-care disparities between racial/ethnic populations, this report is seen as a landmark in 

US policy, insofar as it convinced many agencies to introduce policies addressing healthcare disparities (for 

more on content and impact of report, see Smedley et al., 2008; Smedley, 2002). 'I don't think the Bush admin 

was very interested in disparities until it was forced on them by that [IOM] report’, a Federal agency 

interviewee is quoted as stating, underlining the impact of this report (cited in Exworthy & Washington, 2006). 

The report found that “even among the better-controlled studies, the vast majority indicated that minorities are 

less likely than whites to receive needed services, including clinically necessary procedures” (Smedley, 2002). 

2. To ‘eliminate’ disparities 

Examples of U.S. policies and legislative acts drawn up with this aim in mind include: 

• ‘Healthy People 2010’, a nationwide public health plan and federal policy, was launched in January 2000 by 

the Department of Health and Human Services (DHHS). Its two overarching goals are “to eliminate health 

disparities among specific segments of the population” and “to increase quality and years of health life”. These 

goals inform the policy’s 467 objectives which, organized into 28 public health focus areas, are designed to 

serve as a framework for improving the health of all people in the United States over the course of the first 

decade of the 21st century. A selected set of 10 objectives – including physical activity, overweight and obesity, 

tobacco use, substance abuse, responsible sexual behaviour, mental health, injury and violence, environmental 

quality, immunization, and access to health care - known as the Leading Health Indicators, were created to 

monitor progress on these goals and objectives (see section 4.3D below). The Health People 2010 Policy is 

theoretically informed by the following model: 

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Figure 3.2: Healthy People 2010 Theoretical Model 

Source: Raphael and Bryant, 2006, p.45. 

Critics argue that while the Healthy People 2010 plan mentions broader determinants of health (as reflected in 

the above health model), the prioritized indicators and concrete strategies pursued in practice neglect broader 

determinants of health, being ‘firmly planted in the biomedical and behavioural public health model’ (Raphael 

& Bryant, 2006). 

• The ‘Steps to a Healthier US’ is another major US Federal policy aimed at health promotion and disease 

prevention that was launched in 2003 by the US Department of Health and Human Services. This policy also 

refers to health disparities, yet like Healthy People 2010, neglects structural factors, placing the emphasis 

instead on ‘physical fitness, prevention, nutrition and health lifestyles’ (see DHHS, 2003 www. 

healthierus.gov/steps/index.html; also see Exworthy et al., 2006). 

• One of the more ambitious avowed aims of the US Federal Bureau of Primary Health Care is‘100% access 

and 0 disparities’ (Exworthy & Washington, 2006) 

3. To improve cultural competency 

Culturally and Linguistically Appropriate Service (CLAS) Standards: The Office of Minority Health of the US 

Department of Health and Human Services developed 14 National Standards for Culturally and Linguistically 

Appropriate Services (CLAS) in healthcare in 2001. The CLAS Standards were developed with several purposes in 

mind including: 

• “To correct inequities that currently exist in the provision of health services and to make these services 

more responsive to the individual needs of all patients/ consumers… especially…the needs of racial, ethnic, 

and linguistic population groups that experience unequal access to health services”; 

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• To provide “a common understanding and consistent definitions of culturally and linguistically appropriate 

services in health care…Ideally, the issuance of national standards for CLAS should result in the 

replacement of the patchwork of different definitions and requirements with one universally understood set 

of guidance”; and finally 

• To “offer a practical framework for the implementation of services and organizational structures that can 

help health care organizations and providers be responsive to the cultural and linguistic issues presented by 

diverse populations” (Office of Minority Health 2001). 

The ‘ultimate aim’ of the standards is “to contribute to the elimination of racial and ethnic health disparities 

and to improve the health of all Americans” (Office of Minority Health, 2001); 

The 14 CLAS standards are thematically organized around three themes: 

Culturally Competent Care (Standards 1-3), Language Access Services (Standards 4-7), and Organizational 

Supports for Cultural Competence (Standards 8-14). Federally funded health care organizations are 

mandated to meet four of these standards (Standards 4-7) relating to language access services. This 

mandate derives from Title VI legislation of the 1964 Civil Rights Act which mandates that all institutions 

receiving federal funds provide adequate means of communication between English-speaking 

providers and individuals with limited English proficiency (LEP). The federal Office of Civil Rights 

defines an LEP individual as “someone who is unable to speak, read, write, or understand the English 

language at a level to interact effectively with health and social service agencies and providers” (cited in 

Rice 2007; also see Martinez et al., 2004). 

Promising state level policies, legislation and/or initiatives include: 

• New Jersey Senate Bill S-144, which was introduced in 1999 and signed into law in 2005. It requires that 

physicians in New Jersey to take cultural competency training as a condition of licensure by the State 

Board of Medical Examiners (see Salas-Lopez et al., 2007; also see Baquet et al., 2004); 

• The proposed Illinois Covered Act introduced into Illinois’ state legislature which would, among other 

things, establish a State Healthcare Workforce Council to provide an assessment of health care workforce 

trends with a focus on cultural competence and minority participation in health professions education 

(Smedley, 2008); 

• Pennsylvania’s governor, Ed Rendell's, proposed Cover All Pennsylvanians legislation which, if enacted, 

would similarly establish a Pennsylvania Center for Health Careers, among whose duties would be to 

develop recruitment and workplace tools that aim to improve health professional workforce diversity and 

promote the delivery of culturally appropriate care. In addition, this legislation would require charitable 

hospitals to produce a community needs assessment in consultation with community groups and local 

government officials (Smedley, 2008). 

• Various private, governmental, and non-profit organizations in the US have also increasingly come to adopt 

cultural competence policies, standards and training. Exworthy & Washington summarize the nature of such 

strategies and policies in Table 3.4 below: 

Table 3.4: Strategies to improve cultural competence at different levels in the US 

Source: Exworthy & Washington, 2006. Adapted from Betancourt et al., 2002. 

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• Private health insurers such as Kaiser Permanente, Aetna, and BlueCross BlueShield of Florida, have been 

particularly active in developing cultural competence initiatives (see Betancourt et al., 2005 for more on these 

initiatives). The California Endowment, a private, state-wide health foundation that was created in 1996 as a 

result of Blue Cross of California's creation of WellPoint Health Networks (a for-profit corporation) has been 

especially active in developing research and initiatives aimed at improving the cultural and linguistic 

competence of the US healthcare system. 

Also of particular note in this respect is the Institute for Culturally Competent Care of the Kaiser 

Permanente - America's leading nonprofit integrated health plan, serving approximately 8.2 million people in 

nine states and the District of Columbia – which has established numerous ‘'Centers of Excellence' for 

different racial/ethnic groups in their efforts to raise the profile of cultural competency within their health-care 

provision. Various other philanthropic foundations, such as the Robert Wood Johnson Foundation and 

Commonwealth Fund in particular, have also actively pursued agendas seeking to widen access to health care 

through research and demonstration projects. 

Limitations and Challenges 

Among the challenges and limitations of American policy developments addressing health and healthcare disparities 

discussed in the literature are the following: 

• Failure to address broader determinants of health and structural patterns of socio-economic inequality and 

disadvantage as these impact upon health disparities (Raphael and Bryant, 2006; Exworthy et al., 2006; 

Exworthy & Washington, 2006); 

• Overly exclusive focus on ethnic and racial disparities in healthcare service, to the neglect of other bases and 

forms of disparity (Raphael & Bryant, 2006); 

• Narrow and exclusive focus on healthcare disparities and/or confusion or conflation of healthcare disparities 

with disparities in health status (Exworthy & Washington, 2006); 

• Dominance of medical model and individual-behavioural approaches to the neglect of broader public policy 

solutions to disparities. Fundamental reluctance to view such broader social inequities and determinants of 

health as a public policy matter (Raphael & Bryant, 2006); 

• Flawed tendency to ascribe all health inequalities to biological or cultural causes as a result of official US 

statistics near exclusive reporting of health inequalities by race rather than by socioeconomic status (Howden- 

Chapman & Kawachi, 2002). 


• Healthcare Equity Frameworks, more specifically, cultural competence frameworks focusing on issues of 

race/ethnicity and accessibility to healthcare services. 


• The dominant state of affairs, as concerns health equity efforts in the broad (social determinants of health 

inclusive) sense, ranges from Awareness Raising to Denial/Indifference and Mental Block 

• As concerns healthcare equity and cultural competence in particular, the dominant state of affairs could be 

characterised as isolated initiatives and awareness raising. 

England 


Over a short period of time following the election of the Labour government in 1997, the UK has rapidly become a, 

if not the, leader in governmental health equity policy and action aimed at not only the healthcare system but also 

addressing wider determinants of health/health equity. Among the landmark UK policies, strategies and initiatives 

described in the literature are: 

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• The (1980) Black Report, which is described by Benzeval (2002) as “by far the most significant event in recent 

history” in the UK’s “long [150 year] history of conducting research on health inequalities”. This formative 

report described how “lowest employment-level groups showed a greater likelihood of suffering from a wide 

range of diseases and dying prematurely from illness or injury at every stage of the life cycle” and concluded 

that “the material conditions under which people live their lives: availability of income, working conditions, and 

quality of available food and housing, etc. were the primary determinants of these findings” (Raphael & Bryant, 

2006; see Black & Smith, 1992). While the Report had little immediate impact under the Thatcher and Major 

Conservative Governments (1979-1997), it would later come to play a significant role in shaping research and 

policy developments in the succeeding Labour Government era (1997-present). 

• One month into the new Labour Government’s first tenure, the first-ever Minister for Public Health in England 

launched the development of a new health strategy - Saving Lives: Our Healthier Nation - that had 

'tackling inequalities’ at its heart. Having as one of its two aims “to improve the health of the worst-off in 

society and to narrow the health gap'” , the final Saving Lives policy document of July 1999 not only 

addressed the social causes of ill-health and inequalities but specifically noted that “tackling inequalities 

generally, is the best means of tackling health inequalities in particular” (cited in Benzeval, 2002, p.205; see 

Saving Lives 1999). In response to criticisms that this strategy failed to set national targets for the reduction of 

health inequalities, a new and revised strategy - NHS Plan: a Plan for Investment, a Plan for Reform - was 

developed by the Department of Health in July 2000 that introduced its first national target: 'to narrow the 

health gap in childhood and throughout life between socioeconomic groups and between the most 

deprived areas and the rest of the country' (ibid.; citing UK Department of Health, 2000). 

• In July 1997, Sir Donald Acheson was asked to chair an Independent Inquiry into Inequalities in Health to 

'identify priority areas for future policy development…to reduce health inequalities' (Acheson, 1998). The 

subsequent Acheson Report, published in 1998, considered a wide range of evidence on contributing health 

determinants and concluded in its synopsis, in a manner echoing the findings of the (1980) Black Report: 

• The weight of scientific evidence supports a socioeconomic explanation of health inequalities. This traces the 

roots of ill health to such determinants as income, education and employment as well as to the material 

environment and lifestyle (Acheson, 1998; cited in Raphael & Bryant, 2006). 

The Report offered 39 main recommendations over 13 areas which spanned a range of health determinants including 

“poverty, income, tax and benefits; education; employment; housing and environment; mobility, transport and 

pollution, among others” (ibid.). Of these recommendations, the Inquiry Committee argued that three were 

particularly crucial: 

• All policies likely to have an impact on health should be evaluated in terms of their impact on health 

inequalities. 

• A high priority should be given to the health of families with children. 

• Further steps should be taken to reduce income inequalities and improve the living standards of poor 

households (Acheson, 1998). 

Among the major policy initiatives to arise in response to the Acheson Report was the UK Department of Health’s 

(1999) Reducing Health Inequalities: An Action Report. Benzeval (2002) distinguishes this action plan as the first 

UK government action plan to officially acknowledge the wide range of social policies influencing health 

inequalities and the first to treat such policies as suitable arenas for government action. Reducing Health Inequalities 

for instance emphasized the need to tackle 'the causes of poverty and social exclusion, not just the symptoms' 

(Department of Health, 1999).The major themes and corresponding policy initiatives pursued in this action strategy 

are listed in Box 3.1 as follows: 

70


Box 3.1: Reducing Health Inequalities: An Agenda for Action 

The current government's strategy is organized into the nine themes set out below. Some of the 

specific policies it cites as action under each theme are also listed to illustrate its approach. 

Raising living standards and tackling low income by introducing a minimum wage and a 

range of tax credits and increasing benefit levels. 

Education and early years by introducing policies to improve educational standards, creating 

'Sure Start' - preschool services in disadvantaged areas, free to those on low incomes. 

Employment by creating a range of welfare to work schemes for different priority groups. 

Transport and mobility by setting targets to reduce road traffic accidents, developing safe walking 

and cycling routes, and standardizing concessionary fares for older people. 

Issue for the NHS include working in partnership with local authorities to tackle the wider 

determinants of health, reviewing the resource allocation formula to local healthcare agencies, 

developing national service frameworks to standardize care across the country for particular 

conditions, and broadening the performance management framework for the NHS to include fair 

access and improving health. 

Building healthy communities by investing in a range of regeneration initiatives in disadvantaged 

areas, including Health Action Zones. 

Housing by changing capital financial rules to promote investment in social housing and 

introducing special initiatives to tackle homelessness. 

Reducing crime by investing in range of community-led crime prevention schemes and tackling 

drug misuse. 

Public health issues - the first-ever Minister for Public Health is overseeing a range of 

initiatives to encourage healthy lifestyles, strengthen the public health workforce and tackle 

specific problems such as fluoridation of water supplies. 

Original Source: Department of Health, 1999. Adapted by Benzeval, 2002 

An extensive evaluation of these initiatives – published in report form by Exworthy et al.’ (2003) as Tackling health 

inequalities since the Acheson inquiry – found significant progress in UK efforts to tackle health inequalities. As 

Raphael & Bryant report of Exworthy’s (2003) findings: 

Evidence concerning health inequalities had been gathered, health inequalities had been placed on the 

policy agenda to a significant extent, and a diverse range of activities with increasing integration and 

coherence had been developed. Indicators of outcomes and policy implementation were beginning to 

emerge though impacts upon health status were not yet apparent. The authors concluded: “Many 

challenges remain but the prospects for tackling inequalities are good” (p. 52; cited in Raphael & Bryant, 

2006). 

More recent evaluations (e.g. Hills & Stewart, 2005) further credit the Labour government with taking issues of 

poverty and social exclusion seriously, for instance, reducing child poverty through concerted whole-of-government 

strategic policy action. 

• In 2003 the Department of Health and the Treasury developed a comprehensive Programme for Action which is 

discussed in some detail below in Box 3.2 

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Box 3.2: Cross-Government Action on Health Inequities, the United Kingdom 

In 2002, as part of the formal government-wide spending negotiations, the Department of Health and the Treasury led 

discussions between 18 departments to inform a delivery plan for the targets and identified the contribution required from each 

part of government. The Treasury’s financial and political authority was instrumental and brought departments to the table to 

engage in a cross-cutting goal. It facilitated agreement between departments to combine expertise and resources behind 

government priorities. 

The 2003 Programme for Action identified 82 funded commitments, owned by 12 government departments, which in the 

following 3 years would lay a foundation for achieving the 2010 targets and provide a sustainable impact on the wider 

determinants of health. The Programme for Action provided a strategic framework to direct all actions towards a single goal. This 

prescribed coordination at both national and local levels of government and strong performance management systems to drive 

delivery. An open process of regular audit, reporting, and review provides understanding of the target trajectory and the ability to 

refine the approach. Status reports were published in 2005 and 2008. The target has put pressure on the government to 

coordinate activities. This has required good communication between departments and Treasury leadership. National 

frameworks now mandate health inequities as a top priority for health planners and local government, while central guidance and 

support has targeted underperforming areas and promoted best practice. The current Secretary of State for Health has made 

health inequities his priority, challenging the National Health Service, which has its 60th anniversary in 2008, to live up to its 

founding principles of universality and fairness. 

Source: Hayward, 2007, as featured in WHO’s (2008) Closing the Gap Report 

. 

Other unique and innovative features of the UK policy and strategy landscape include: 

• The introduction of Health Action Zones (HAZs). See Box 3.3 below for more information on these 

innovative pilot projects. 

Box 3.3: Health Action Zones 

The introduction of Health Action Zones (HAZs) in selected areas as 7-year pilot projects “'to explore mechanisms for breaking 

through current organizational boundaries to tackle inequalities and to deliver better 

services'. Local partnerships between health and local authorities were invited to bid for HAZ status. Forty-one bids were 

received; 11 areas were successful in achieving HAZ status in April 1998, and a further 15 in April 1999. Together these areas 

cover 13 million people in England and include some of the most disadvantaged areas of the country./ Tackling inequalities in 

health is central to HAZs' agenda, with Ministers frequently describing them as being in the 'vanguard' or 'frontline of the war on 

health inequalities'….The foundation 

of this new way of working is a partnership between health and local authorities, voluntary and community groups and, in some 

places, other agencies. The way in which these partnerships are formed and work together to assess their needs, develop their 

strategies and deliver their services is fundamental to the success of the HAZ initiative. Crucially, they must develop a strategy to 

achieve their goal of improving health and reducing health inequalities, and ways of monitoring and learning from what they 

achieve” 

Source: Judge et al., 1999; cited in Judge and Mackenzie, 2002, p.306. 

• Another particularly distinguishing feature of the UK governmental/policy landscape is the statutory 

‘equality’ duties and legally enshrined obligations to not only eliminate discrimination but promote equality 

along multiple dimensions, including race, gender and ability, and, more recently, age, sexual orientation 

and religion or belief. Current duties require all public bodies (including the NHS) to develop and put into 

place ‘equality schemes’ which are essentially action plans outlining measures and initiatives being 

undertaken to promote equality in the abovementioned areas. The recently created Equality and Human 

Rights Commission (which brings together the work of the three previous equality commissions around 

race, sex and disability) is currently working with the UK government to move towards single equality 

72


legislation. Such legislation will legally require public bodies to conduct equality impact assessments (see 

Box X) and develop equality schemes (see Box X below) relating to not only gender and race but also other 

dimensions of inequality including age, sexual orientation and religion or belief. The Department of Health 

has already proactively developed two Single Equality Schemes - SES (2007-2010) and, more recently, in 

updated and revised form, SES (2008-2011) – in anticipation of this requirement. The DOH SES’s set out 

the Department’s public commitments and plans for action across six ‘equality strands’ of race/ethnicity, 

gender, disability, age, sexual orientation and religion or belief (see 

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_0754 

63 for downloadable copy of the latest 2008 Department of Health Single Equality Scheme). 

Policy commitments within the UK Department of Health are also guided by an overarching (2003) 

Equality Framework which commits the Management Board of the DOH to “improving the health and 

well-being of the population through a health and social care system which: 

• Is provided equally to those who need it, free at the point of need 

• Offers a personal service which is truly patient-centred 

• Has sufficiently increased capacity to enable choice and diversity to be offered to patients 

• Is fair and provides equity of access to care. 

The National Health Service (NHS) has also developed an Equality Framework -The Vital Connection: An 

Equalities Framework for the NHS - that has oriented work in the health sector since 2003.The (2003) 

Vital Connection Framework has three strategic equality aims that all parts of the NHS are required to work 

towards through a series of priorities, objectives and targets. These three strategic equality aims are: 

1. A workforce for equality and diversity - To recruit, develop and retain a workforce that is able to 

deliver high quality services that are accessible, responsive and appropriate to meet the diverse needs 

of different groups and individuals. 

2. A better place to work - To ensure that the NHS is a fair employer achieving equality of opportunity 

and outcomes in the workplace. 

3. A service using its leverage to make a difference - To ensure that the NHS uses its influences and 

resources as an employer to make a difference to the life opportunities and the health of its local 

community, especially those who are shut out or disadvantaged. 

Such NHS and Department of Health Strategic Frameworks and objectives are primarily enforced at the 

local level by Strategic Health Authorities (see Appendix 2 and Box 4.1, 4.2, 4.4, and 4.7 for more on 

functions and governance of Strategic Health Authorities). 

• In their international review of public health policy, Raphael & Bryant draw attention to five ways in which 

such UK policy developments differ from what is happening in the Canadian and US contexts: 

• The first is the recognition that health inequalities are a cause for serious concern. 

• The second is the serious use of available research evidence by government authorities. 

• The third is the recognition that these areas are cause for concern not only by health ministries and 

departments but also the entire government. 

• Fourth, there is a commitment to action through the development and implementation of public policy. 

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• And fifth, there is a goal for the National Health Service to promote equitable access to services in relation 

to need and they’re taking the lead in working with other agencies to tackle the broader determinants of 

health. In addition, goals were set for the elimination of health inequalities (Raphael & Bryant, 2006). 20 

Limitations and Challenge 

Some of the limitations and challenges of UK policies and strategies discussed in the literature are outlined below: 

• It has proven difficult to reorientate the health service to focus on health rather than healthcare issues at the 

local level. “To achieve this,” Benzeval argues, “local agencies require consistent and clear messages, 

reinforced by a range of policy levers such as performance management systems” (2002, p. 212). 

• There have been challenges collaborating intersectorally; though reducing health inequalities requires a broad 

social policy response, other sectors sometimes have more pressing goals and priorities that may be 

fundamentally out of sync with efforts to improve living standards, employment conditions and social security. 

Such inconsistencies in priorities can make it difficult to make substantial inroads in reducing health inequities 

(Judge & Mackenzie, 2002). 

• There have been challenges attributing causes and effects to interventions and policies that are aimed at broad 

health determinants and developing appropriate indicators to measure progress on intersectoral initiatives 

(Exworthy et al., 2006; WHO, 2008). 21 

• There is a less progressive trend in more recent reports (e.g. Wanless 2004; Dept of Health, 2004) to focus more 

narrowly on individual health behaviours and healthcare service access issues to the exclusion of broader social 

structural determinants of health (Raphael & Bryant, 2006). 

• There remains a gap between the state of knowledge and analyses, and the implementation of the latter (Raphael 

& Bryant, 2006 ) 

• Objectives and targets are not always clearly linked and/or articulated (specifically in relation to the Health 

Action Zones) and “pathways of expected change” are not always “specified in sufficient detail for it to be 

possible to make a reasonable judgement about whether the target is feasible” (Judge & Mackenzie, 2002). 


• Whole-of-government Health Equity Framework that considers broad socio-economic determinants of health. 

20 

Raphael & Bryant give the example, in this respect, of “the 2002 Spending Review Public Service Agreement – a kind of business plan – 

for the Department of Health which contained the goal ‘By 2010 to reduce inequalities in health outcomes by 10% as measured by infant 

mortality and life expectancy at birth’. To facilitate and support action, the government set up ‘cross-cutting spending reviews’ focused 

on health inequalities. These reviews are to be used by departments to inform spending plans for the 2003–2006 period. 

21 Though it is perhaps too early to judge, there appear to be few visible, attributable impacts of such broad policy interventions in the UK context 

thus far, and existing time trends show little evidence of narrowing health gaps (e.g. poverty rates for working aged adults without children reach 

all-time high levels by 2002-2003) (Raphael & Bryant, 2006). Exworthy et al. (2006) draw attention to some of the difficulties in measuring 

success of such interventions due to the length of time required for such interventions to take effect. As they argue: 

the causal pathway between policy and outcome may be apparent only in the long term [years or decades], if at all. …[ Yet] the period in 

which the policy interventions are expected to deliver results and over what time periods these effects should be measured often are not 

clear” (Exworthy et al., 2006). 

74



• Comprehensive Coordinated Policy 

Other International Developments (Netherlands, Sweden, New Zealand, Barcelona) 

The following section lists some of the promising government policy/strategy developments and interventions 

relating to health equity encountered in the literature emanating from other parts of the world. 

Australia 

• Australian health authorities have developed, implemented, and provided training on health equity impact 

assessment (see Section 4.3E for more on the origins, development, employment, and usefulness of Health 

Equity Impact Assessment tools in various jurisdictions). 

Box 3.4: Health Equity Impact Assessments in Australia 

The Australian Better Health Initiative is part of a Council of Australian Governments Reform Package, which 

aims to improve health for all Australians. As part of the development of the Implementation Plan for New South 

Wales, a Rapid Equity Focussed Impact Assessment was conducted. Eight initiatives were assessed on their 

potential equity impacts, looking at inequities by age, gender, place of residence, ethnicity, and socioeconomic 

status. Concrete recommendations were formulated on how to improve the equity focus and potential positive 

impacts on health equity of the Initiative. 

Original Source: Harris, Harris & Kemp, 2006; Taken from WHO, 2008. 

Box 3.5: Expanding Capacity for Health Equity Impact Assessment in Australia: Learning by 

Doing 

An example of capacity building for health impact assessment is the “Learning by Doing” approach that was part 

of the New South Wales Health Impact Assessment Project. Learning by Doing includes formal training, access 

to resources and technical support, and continued building of consensus on the scope of health impact 

assessment. An equity focus needs to be incorporated into all training on health impact assessment. 

Original Source: Harris, 2007; Taken from WHO, 2008 

The Netherlands 

• The Netherlands has been successful in putting health equity issues on the political agenda, having achieved 

broad consensus on the need to reduce health inequalities (See Stronks 2002 for summary of policy 

developments in the Netherlands from 1980 to 2000; also see Stronks & Gunning-Scheper, 1993). 

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New Zealand 

Box 3.6: Monitoring Health Inequities in New Zealand 

New Zealand has initiated a whole-of-government approach to reducing inequities in health, especially with 

regard to the ways in which ethnicity and socioeconomic inequities interact. Key policy documents released in 

2000 and 2002 have embedded a health inequity focus into all levels of the work of the health sector and have 

provided a template (the Reducing Inequalities in health Framework) for how action to reduce health inequities 

could be achieved. New Zealand has performed particularly well in steadfastly monitoring inequities and 

reporting those inequities in ways that best facilitate action. This has been achieved through a number of 

mechanisms, including a strong emphasis on ethnicity recording in the health sector, the routine matching of 

census with mortality records, and widespread use of a census-based small area deprivation measure, the New 

Zealand Deprivation Index. These approaches have boosted cross-sectoral interest in inequities, facilitated 

discussion in academic and policy circles about the root causes of inequities, and provided social agencies with 

evidence on which they can plan programmes and policies to address health inequities in their respective areas. 

Original Source: WHO & PHAC, 2007; Taken from WHO, 2008. 

Sweden 

• “Sweden has a decentralized form of federalism and a political culture compatible with a broad, 

determinants-based strategy. The motivation to address health disparities in Sweden led to a sustained national 

dialogue on the determinants of health and their consequences. The government pursued a consensus-building 

process that involved all political parties, an evidence-based approach and extensive public consultation. The 

result was a strongly supported strategy that focuses almost exclusively on the non-medical determinants of 

health” (Health Disparities Task Group, 2004). 

3.3 SOME KEY LESSONS & RECOMMENDATIONS 

This section concludes with some key lessons and recommendations discerned from this review of the grey and 

academic literature on international health equity policies. 

• Knowledge development (especially the development of appropriate health equity measures and indicators) and 

dissemination through partnerships and (community-government-academic) collaboration is critical to putting 

health equity on the public policy agenda and advancing health equity strategies. 

• Comprehensive approaches that combine and incorporate, in varying degrees, (1) health equity and healthcare 

equity policy objectives, (2) upstream, midstream and downstream (‘all stream’) interventions, and (3) 

universalist and selectivist approaches have proven most effective, in part due to their design and analysis of 

causal pathways of health inequity, and in part due to the politics of such multi-pronged approaches which can 

appeal to multiple audiences and constituencies (depending on their emphases) across the political spectrum. 

• The healthcare sector can and should play a lead role in advancing a broad inter-sectoral health equity policy 

agenda that addresses social determinants of health. Intersectoral collaboration is critical to the success of a 

truly comprehensive health equity policy agenda seeking to effectively reduce health inequities. 

• Political will and a conducive policy/political environment is critical to the advancement of the health equity 

policy agenda. Policies should thus strategically align themselves, wherever possible (i.e. while maintaining 

their integrity) with local policy contexts and drivers to gain traction and fruition. 

• Policies should be guided by evidence regarding the nature of the problem (health inequity) and the appropriate 

intervention solutions to the greatest extent possible. In the absence of evidence (particularly in the latter 

respect), pilot demonstration projects, and their evaluation, are critical. Evidence alone, however, cannot inform 

and steer policy choices, as ethical views and priorities, too, play a key role. It is thus critical that ethical 

commitments and foundations for policies are clearly spelled out in ways that can help inform difficult policy 

choices. 

• Policy objectives should be clearly articulated in realistic, operationalizable terms. 

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PART 2 

ACCOUNTABILITY, COMPLIANCE AND 

QUALITY ASSURANCE 

Having considered various health disparity frameworks, policy options, debates and trends, Part II of this review 

examines ways and means of ensuring accountability and compliance with such policies and providing quality 

assurance, as discussed in the health equity literature. Case studies profiling good practice are interspersed 

throughout this section. Most of the good practices profiled are drawn from the UK governmental context, as the UK 

government has made the most progress in tackling health inequalities among governments surveyed in Part I, 

Section 3. 

Part II is organized into three sections: 

• Policy and Strategy; 

• Leadership and Governance; and 

• Performance Management 

4.1 POLICY AND STRATEGY: Essential Components and Dimensions of policy and strategy 

development to ensure compliance and accountability 

To ensure compliance across the system, equity policies and strategic goals need to be adopted at the highest levels 

of the organisation/system as an essential and integral component of the organization/system’s strategic goals, vision 

and mandate. It is moreover essential that such organizational strategic goals be performance managed by senior 

management (see Governance section below). 

The Local Health System Integration Act requires the Local Health Integration Networks (LHINs) to each develop 

an Integrated Health Service Plan (IHSP) - with input from the community, and in accordance with the provincial 

(MOHLTC) Health System Strategic Plan. The MOHLTC’s strategic plan is expected to contain a commitment to 

equity as a strategic priority and goal. It is essential that the vision statement, integration strategy and specific 

priorities laid out for the local health system in such IHSPs include and reflect a strong commitment to health equity. 

As discussed in Part I, clearly articulating one’s equity vision, policy goals and objectives, in terms that can be 

operationalised and measured, is critical to ensuring accountability. The more vague the vision and corresponding 

policy objectives, the less able are policymakers and other stakeholders (including the public) to measure and gauge 

progress, which is critical to ensuring accountability and responsibility for the performance of such policies. 

Strategic goals around equity need not only be clear and measurable but also achievable (versus merely aspirational) 

in order to ensure continued momentum on the basis of early and sustained achievements (see Box 4.1, 4.5 and 4.6 

for good examples of clearly articulated, realistic, and operational health equity goals and objectives). 

It is also critical that policymakers elaborate the ethical foundations of their policy commitments (if not in the policy 

itself, then in policy guideline materials), so as to help guide tough decisions regarding which goals and strategies to 

pursue (see Section 3.1 for more on the importance of elaborating ethical premises, under the subsection, Policy 

Justification). 

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It is moreover advisable, in the interests of accountability and compliance, that health equity policy statements are 

adjoined with concrete action plans and guidelines for implementation that clearly articulate the means (strategies 

and plans) by which such policy goals and objectives are to be realised, as well as the expected strategic outcomes of 

each action plan initiative. The more fully and transparently such corresponding action plans and desired outcomes 

are elaborated and explained in relation to policy goals and objectives, the more able are stakeholders to monitor and 

debate the feasibility and ‘fit’ of such plans as a means of achieving the espoused goals and objectives. 

Strategic action plans, moreover, should go into detail about what will be done, by when and by whom, clearly 

listing, in this latter respect, the responsibilities of each relevant stakeholder accountable and responsible for 

ensuring policy implementation and compliance. The Plan should thus: 

• Set dates on when you will do the things such as monitoring, reviewing procedures, training and guidance; 

• Expand on how these will be done and by whom; 

• Clarify what will be your measures of success and how you will evaluate these (including how and when you 

will review the overall working of your policy) (ACAS, 2009). 

Clearly articulating the objectives and corresponding action tasks to be performed, as well as the lead role holders 

having carriage over such tasks, is essential to ensuring that the policy is accountably advanced. It is also important, 

as mentioned above, that a process and timeline is agreed upon for regularly reviewing and updating the policy, 

in light of incoming information on progress or lack thereof. 

Policies should also be supplemented by explicit strategies for making the policy known to all stakeholders. 

Dissemination of policy initiatives within and beyond the organisation in question is essential, not only because of 

the public’s right to know, in the case of public health policy, but because bringing such policies into public light 

makes it that much more difficult to get away with doing nothing in support/pursuit of it. It is useful, in this respect, 

to develop policy guidelines to further elaborate and explain policy goals, objectives, strategic plans and desired 

outcomes to concerned stakeholders in more detailed form 

The process of policy development is as critical to its success in implementation as the content of the policy. The 

policymaking process should not only involve knowledge experts, but also all affected and interested 

stakeholders, including, importantly, members of the public, in particular members of vulnerable communities who 

may be targeted by the policy. 

Aside from the intrinsic value of such public/stakeholder involvement in a democratic society, such engagement 

may increase public (and thus political) and staff ‘buy-in’, and help prevent resistance, backlash, and subversion at 

implementation phases (see Sabik & Lie, 2008 for more on the importance but also challenges of stakeholder 

involvement in policymaking processes). 

Policy decisions and outcomes should be transparently communicated to stakeholders at all phases of the policy 

development process. Such transparency in itself helps to increase accountability, since it is much easier to ‘drop the 

policy ball’ when no one is aware of the policy or applying pressure for ‘results’ (Sabik & Lie, 2008). 

Training initiatives in support of the policy are also critical to ensuring compliance, as such initiatives help to equip 

those responsible for implementation with the appropriate skills and competencies required to do so effectively. 

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Box 4.1: NHS London Strategic Plan 2009-2013 

In the UK context, Strategic Health Authorities (SHAs) most resemble the LHINS in terms of their role, function, structure and place 

in the overall UK National Health System (see Appendix 2: The structure of the new NHS in England for more on the configuration of 

the UK health system). Strategic Health Authorities have three main functions: 

(1) developing and implementing strategy for health and healthcare 

(2) holding local organisations to account for the quality of the care which 

they provide; and 

(3) ensuring capacity through the development of the workforce, technology 

and buildings (NHS London, 2007, p.6). 

NHS London, one of 10 national strategic health authorities in England, was formed in July 2006 when the five previous London 

Strategic Health Authorities were combined, bringing together the North West London, North Central London, North East London, 

South East London, and South West London authorities into a single strategic body. NHS London covers 32 London Boroughs with a 

population of approximately 7.2 million and rising. NHS London has overall responsibility for the performance of 31 primary care trusts 

(PCTs), 22 24 acute trusts (hospitals) 23 , three mental health trusts 24 and the London Ambulance Service. 

NHS London’s commitment to reducing health inequalities is reflected in its vision and mission statement and strategic goals. The 

NHS London Vision statement for instance reads: 

Our vision is world-class health and healthcare for Londoners. 

Achieving our vision will mean: 

• improved health as a whole for Londoners 

• reduced health inequalities by delivering greater improvement for the 

most disadvantaged groups 

• higher quality services and enhanced clinical safety for patients 

• sustained financial stability (NHS London, 2008). 

22 Primary Care Trusts (PCTs) are responsible for the provision of health services to the local community across England. Primary care services 

include general medical practitioners (GPs), dentists, pharmacists, opticians, district nursing and numerous other services. PCTs receive budgets 

directly from the Department of Health and commission (i.e. purchase) services from providers, putting in place their own service agreements 

(see Appendix 1: The structure of the new NHS in England for more on the organization of the UK health system). Since April 2002, PCTs have 

taken control of local health care while strategic Health Authorities (SHAs) monitor local performance and standards. SHA’s also commission 

highly specialised services for rare conditions through its National Commissioning Group (NCG) http://www.london.nhs.uk/your-nhs-inlondon/structure-explained, 

Retrieved March 3, 2009). 

23 NHS acute trusts are responsible for running many NHS hospitals. 

24 “Mental health trusts oversee mental health services which can be provided through a General Practitioner, other primary care services, or 

through more specialist care in NHS hospital trusts or local council social services departments” (Retrieved March 3, 2009 from 

http://www.london.nhs.uk/your-nhs-in-london/structure-explained). 

. 

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Box 4.1 continued 

The NHS London Mission (what is NHS London’s role?) reads: 

Our role is to: 

• Provide strategic leadership for the NHS in London 

• Build a sustainable, affordable and innovative health service in London 

• Ensure health resourcing tackles inequalities and shifts the balance of 

resources towards community services 

• Encourage the NHS in London to work in partnership with stakeholders 

(NHS London, 2008). 

The NHS London Strategy to achieve its vision and mission includes, as the first of seven strategy components: 

• “Work in partnership with pan-London organisations to improve 

health and reduce health inequalities” (NHS London, 2008, p.4). 

The NHS London Strategic Plan lists a further three more specific, concrete strategic goals, as desired outcomes over the 

next three to five years, in relation to the above strategy: 

• Average life expectancy of Londoners increased by at least 2 years 

for males and females 

• Number of primary care clinicians per population to increase as a 

function of deprivation so that the most deprived boroughs have more 

primary care clinicians 

• The difference in life expectancy between the best and worst boroughs in 

London is reduced by 10 per cent. 

Source: NHS London, 2008. 

4.2. LEADERSHIP & GOVERNANCE in support of accountability and compliance 

Governance arrangements for health equity policies and strategies are also critical to establishing accountability and 

ensuring compliance. Governance – how decision-making power, authority, accountability/responsibility (reporting 

relationships) and performance management is organized and configured 25 – should extend to the highest authority 

in the health system (‘the tree top’) to ensure coherent integration of health equity concerns across all policy, 

program, service/function areas and effective performance management and coordination across the system. 

25 The Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services defines governance in its 

(2002) cultural competence assessment domain framework as “the goal-setting, policy-making, and other oversight vehicles an organization uses 

to help ensure the delivery of culturally competent care”. 

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Governing entities should also involve and build on the insights and experience of those closest to the ground (the 

‘grassroots’), including frontline service providers, service users and targeted marginalized communities, to ensure 

local relevance of services and accountability to the public (Rachlis, 2007b; Gardner, 2008a; GTA Diversity and 

LHINS Working Group, 2008a). 

The UK’s rapid success in tackling health inequalities bears out the pivotal role of leadership at the highest levels (in 

the UK experience cabinet-level and Secretary of State level) in moving health equity strategies efficiently forward 

in ways establishing accountability and compliance across the system (see WHO, 2008). It is thus essential that 

ultimate responsibility for action on health equity unambiguously rests with the most senior person(s) at the highest 

governing level of the organisation. This helps to ensure legitimacy and buy-in, and coordination, across all 

corporate/program/service areas (WHO, 2008). 

The literature also stresses the importance of establishing an oversight body at the senior corporate level of the 

organisation to monitor progress and coordinate efforts for eliminating disparities on an ongoing basis (e.g. Beal, 

2004; Department of Health, 2007a; WHO, 2008). 26 

This requires dedicating staff and resources. Investing sufficient human and capital resources into the development 

and oversight of health equity policies and plans, corporately, is critical to ensuring compliance with such policies 

and plans (as borne out in the UK experience). 

The grey and academic literature also stresses the importance of mainstreaming accountability and responsibility 

for health equity throughout the organization/system, most notably through performance management systems and 

health equity impact assessment (HEIA) processes (see Section 4.3E for more on use of HEIA as mainstreaming 

tool). 

While it is important to have staff dedicated specifically to addressing health equity issues, it is thus essential that 

responsibility for the latter not be siloed in only one part of the organisation/system amongst ‘specialists’ but also be 

made the responsibility of all. 

Community/stakeholder engagement is another key governance ingredient to ensure public accountability and 

appropriate, quality service provision and resource allocation in tune with community needs on the ground 

(Smedley, 2008; Tugwell et al., 2006; Robertson & Swan, 2005; GTA Diversity and LHINS Working Group, 

2008a). 

Increasing public awareness of health equity issues through public involvement, consultation, advocacy and 

knowledge exchange also helps to ensure that health equity remains on governmental policy agendas, by helping to 

cultivate sufficient ‘push from below’ around health equity issues, which is also essential to sustaining such policies 

(Rachlis 2007; Gardner, 2008a; WHO, 2008). 

26 As the WHO contend, in relation to ensuring gender issues are addressed by health authorities: 

Effective organizational mainstreaming is facilitated by placing responsibility for mainstreaming gender with senior management, and 

by allocating adequate financial and human resources for a central unit with gender expertise (2008, p.149). 

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Box 4.2 Governance & Oversight of Equality issues in the UK Department of Health 

Governance and oversight of Equality issues in the British healthcare system occurs at the highest level. Ultimate responsibility 

for ensuring that the Department of Health fulfills the objectives of its Equalities policy and Single Equality Scheme 27 lies with 

the Department Management Board (DMB). 28 The Board reviews reports of progress on the Single Equalities Scheme annually, 

making recommendations and amendments as necessary. 

On an individual basis, the Permanent Secretary (the highest ranking person) in his role as Accountable Officer is accountable 

for effective implementation of equality. The Permanent Secretary is in turn advised by the Director of Equality and Human 

Rights Group (EHRC). 

The Department of Health’s Equality and Human Rights Group, Equality Delivery Assurance Group (EDAG), and 

Management Board ‘Policy Committee’ are specifically mandated with overseeing Equality issues in the Department. 

Monitoring developments across six ‘equality strands’ - race, gender, disability, age, sexual orientation, gender identity, and 

religion and belief (as well as human rights in general) – the EHRG’s role includes to: 

*give strategic leadership on equality and human rights 

*champion equality and human rights within DH [Department of Health] 

*challenge discrimination across DH, the NHS [National Health Service] and Social Care 

*support DH policy colleagues and advise on proposed legislation 

*identify the ‘business case’ for Equality and Human Rights and provide examples of good 

practice to back it up 

*enable delivery of the equality and human rights agenda across the NHS and Social Care 

through innovative change programmes that test a variety of approaches 

*develop partnerships with stakeholders, regulators, patient and staff groups and other 

colleagues across DH, the NHS and Social Care to facilitate delivery of the above 

(Department of Health 2007). 

27 The Department of Health’s (2007-2010) Single Equality Scheme (SES) describes itself as “a public commitment of how we at the Department 

of Health plan to meet the duties placed upon us by the equality legislation”, which includes the Race Relations (Amendment) Act 2000, 

Disability Discrimination Act 2005 and the Sex Discrimination Act as amended by the Equality Act 2006 (Department of Health, 2007a). The 

SES also includes actions on age, religion and belief, and sexual orientation, and human rights more generally. 

28 The Departmental Management Board supports the Permanent Secretary in the discharge of his/her responsibilities as Principal Accounting 

Officer, within the framework set out by the Secretary of State. The Management Board is responsible for: 

providing advice to Ministers on developing the strategy and objectives for the health and social care system 

setting DH standards 

establishing the framework of governance, assurance and management of risk. 

The Board is also specifically responsible for approving:the Departmental Business Plan 

the DH Resource Account for each financial year 

the Departmental Report 

major expenditure commitments 

(Retrieved March 3, 2009 from http://www.dh.gov.uk/en/Aboutus/HowDHworks/BoardsandCommittees/DH_088623). 

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Box 4.2 continued 

The Equality Delivery Assurance Group (EDAG) functions as an advisory body, whose responsibility is to coordinate and 

provide assurance on compliance with equality legislation and other policy aspects of the DH Single Equality Programme. 29 

The Policy Committee (of the Departmental Management Board) is responsible for “monitoring the SES action plan and the 

continued application of equality screening and equality impact assessments across the DH policy delivery” (DH 2007b). The 

Committee receives quarterly reports from the EDAG on progress against the SES action plan and the programme of policy 

equality screening. The Policy Committee also contributes to the Annual Report of the Departmental Management Board. 

Role of Strategic Health Authorities in equalities planning and monitoring 

Strategic Health Authorities (SHAs) also play a critical role in ensuring that they and the local health providers and purchasers 

that they monitor and oversee fulfill their legal and policy obligations in relation to equality issues. As part of their management 

function, Strategic Health Authorities each produce their own three-year Single Equality Schemes (SES) which set out their 

commitment to promoting equality of opportunity and tackling discrimination in access to health services and in the way that staff 

are treated (NHS London 2007). 

NHS London has developed and is currently implementing its own SES (2007-2010), which has a total of 37 objectives. Each 

objective is broken down into various associated ‘Tasks’, each of which are assigned a Lead person, Target Date for completion, 

and Outcome Measure(s).The NHS London Board 30 is ultimately accountable and responsible for successful implementation of 

the scheme. The Chief Executive of the Board and named Leads are responsible for reporting on progress and ensuring that 

action plan objectives are being met within their areas of responsibility. 

The development of NHS London’s (2007-2010) SES was facilitated by the Equality Steering Group (ESG), which is made up 

of a cross-section of NHS London staff (including senior representatives from Public Health, Corporate Affairs, Human 

Resources, Communications, the Union, and the Research unit). The Equality Steering Group’s purpose is “[t]o manage the 

overall project to produce the Strategic Health Authority’s Single Equality Scheme consultation document, consult on the 

scheme, and all related activities associated with producing the Single Equality Scheme” (NHS London 2007). 

NHS London’s Single Equality Scheme (2007-2010) was also developed through the involvement of an Equality Reference 

Group (ERG). The purpose of the ERG was “[t]o actively participate in determining the scope, content, and presentation of the 

Strategic Health Authority’s Single Equality Scheme consultation document, and to actively participate in determining the scope 

and methodology for the consultation process” (NHS London 2007). In addition to including disabled people within the group, 

other equality strands were also represented within the ERG group membership. 

While all of the monitoring functions described above, in the case of the Department of Health and the Strategic Health 

Authorities, are internal to these organisations, UK equalities legislation also grants “significant powers” to the Equality and 

Human Rights Commission 31 to “enforce the equalities duties of organisations and authorities, including, ultimately, launching 

official inquiries and formal investigations” (Retrieved January 24, 2009 from http://www.equalityhumanrights.com). 

4.3. PERFORMANCE MANAGEMENT LEVERS 

One of the most critical means of ensuring accountability for and compliance with health equity policy and strategy 

is by embedding and monitoring health equity goals and outcomes in performance management systems. Among the 

29 The DH Single Equality Programme incorporates the Single Equality Scheme and SES action plan development and monitoring, the Equality 

Impact Assessment Programme (EIA), Equality Delivery Assurance Group secretariat and Stakeholder Review and Management (for more on the 

Single Equality Programme see http://www.dh.gov.uk/en/Managingyourorganisation/Equalityandhumanrights/index.htm). 

30 NHS London is governed by the NHS London Board, which is made up of 6 non-executive directors (including the Chair), 5 executive 

directors (including the Chief Executive), and 4 non-voting members. The board is responsible for: 

establishing values and standards for NHS London 

agreeing the strategy for the NHS in London 

monitoring our performance against financial and other targets 

ensuring that risk is well managed (Retrieved March 3, 2009 from http://www.london.nhs.uk/who-we-are/people-and-structure/ourboard.) 

31 The Equality and Human Rights Commission is a non-departmental public body (NDPB) established under the Equality Act 2006 – 

accountable for its public funds, but independent of government. 

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major ‘levers’ for managing performance currently available to the LHINS is their (1) funding and allocation 

powers; (2) local health system planning role (Integrated Health Service Plans); and (3) LHIN-Provider service 

accountability agreements. The critical importance of measuring, evaluating and assessing performance on an 

ongoing basis – and reporting on the results - is also discussed in this section as an essential ingredient in 

establishing accountability and compliance and assuring quality services and outcomes. 

A. Funding & Allocation 

A major policy lever for the LHINs is their funding authority to institutions (Moloughney, 2007). One of the 

primary means of ensuring action on and compliance with health equity strategic priorities at the local level is by 

developing LHINs funding criteria that ties funding to service provider performance on health equity. 

Such criteria could range from more general (and context/baseline dependent) criteria of demonstrating improved 

access and service delivery for marginalized communities (GTA Diversity and LHINs Working Group, 2008a), to 

specific performance targets, standards and/or benchmarks as a condition of funding. No small part of the success of 

the British Labour government in tackling health inequalities has been its own vigilance in ensuring that the 

reduction of health inequalities is maintained as a central criteria in the allocation of funds and resources across (and 

indeed beyond) the healthcare sector (Benzeval, 2002). 

In the US context, Title VI Legislation concerning the language rights of ‘persons with limited English proficiency’ 

(part of the 1964 Civil Rights Act) has recently (2001) been interpreted in a manner requiring all federally funded 

healthcare service providers to meet certain Standards for linguistically appropriate service as a condition of their 

funding. The Office of Minority Health of the US Department of Health and Human Services developed these 

National Standards for Culturally and Linguistically Appropriate Services (CLAS) in 2001. The 14 CLAS Standards 

are listed below (see Box 4.3 below). 

Of these, only Standards 4, 5, 6, and 7 are currently enforceable as Mandates, that is as ‘current Federal 

requirements for all recipients of Federal funds’. 32 Standards 1, 2, 3, 8, 9, 10, 11, 12, and 13 are Guidelines, i.e. 

‘activities recommended by OMH for adoption as mandates by Federal, State, and national accrediting agencies’; 

and Standard 14 is a Recommendation, which is ‘suggested by OMH for voluntary adoption by health care 

organizations’ (OMH, 2001). 

32 Federal requirements allow a certain degree of flexibility in implementing the mandated standards, taking into account the unique and 

individual characteristics and circumstances of particular organizations (see OMH, 2001 for more details in this respect). 

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Box 4.3: Culturally and Linguistically Appropriate Services (CLAS) Standards 

Theme I: Culturally Competent Care 

Standard 1. Health care organizations should ensure that patients/consumers receive from all staff members effective, 

understandable, and respectful care that is provided in a manner compatible with their cultural health beliefs and practices and 

preferred language. 

Standard 2. Health care organizations should implement strategies to recruit, retain, and promote at all levels of the organization 

a diverse staff and leadership that are representative of the demographic characteristics of the service area. 

Standard 3. Health care organizations should ensure that staff at all levels and across all disciplines receive ongoing education 

and training in culturally and linguistically appropriate service delivery. 

Theme II: Language Access Services 

Standard 4. Health care organizations must offer and provide language assistance services, including bilingual staff and 

interpreter services, at no cost to each patient/consumer with limited English proficiency at all points of contact, in a timely 

manner during all hours of operation. 

Standard 5. Health care organizations must provide to patients/consumers in their preferred language both verbal offers and 

written notices informing them of their right to receive language assistance services. 

Standard 6. Health care organizations must assure the competence of language assistance provided to limited English proficient 

patients/consumers by interpreters and bilingual staff. Family and friends should not be used to provide interpretation services 

(except on request by the patient/consumer). 

Standard 7. Health care organizations must make available easily understood patient-related materials and post signage in the 

languages of the commonly encountered groups and/or groups represented in the service area. 

Theme III: Organizational Supports for Cultural Competence 

Standard 8. Health care organizations should develop, implement, and promote a written strategic plan that outlines clear goals, 

policies, operational plans, and management accountability/oversight mechanisms to provide culturally and linguistically 

appropriate services. 

Standard 9. Health care organizations should conduct initial and ongoing organizational self-assessments of CLAS-related 

activities and are encouraged to integrate cultural and linguistic competence-related measures into their internal audits, 

performance improvement programs, patient satisfaction assessments, and outcomes-based evaluations. 

Standard 10. Health care organizations should ensure that data on the individual patient’s/consumer’s race, ethnicity, and 

spoken and written language are collected in health records, integrated into the organization’s management information systems, 

and periodically updated. 

Standard 11. Health care organizations should maintain a current demographic, cultural, and epidemiological profile of the 

community as well as a needs assessment to accurately plan for and implement services that respond to the cultural and 

linguistic characteristics of the service area. 

Standard 12. Health care organizations should develop participatory, collaborative partnerships with communities and utilize a 

variety of formal and informal mechanisms to facilitate community and patient/consumer involvement in designing and 

implementing CLAS-related activities. 

Standard 13. Health care organizations should ensure that conflict and grievance resolution processes are culturally and 

linguistically sensitive and capable o identifying, preventing, and resolving cross-cultural conflicts or complaints by 

patients/consumers. 

Standard 14. Health care organizations are encouraged to regularly make available to the public information about their progress 

and successful innovations in implementing the CLAS standards and to provide public notice in their communities about the 

availability of this information 

Source: Office of Minority Health, 2001. 

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While requiring health equity standards and/or benchmarks of health equity performance as a condition of funding is 

one direct and sure means of ensuring action on health equity, making health equity a funding priority and criterion 

for resource allocation more generally – by designating funds to health equity/cultural competence research, 

capacity building, training and evaluation - is also critical to the realisation of health equity as a strategic (IHSP) 

LHINs priority (SHAD, 2008a; Gardner, 2008a; WHO, 2008). 

B. Licensing and Accreditation 

Though largely beyond the direct control of the LHINs, licensing and accreditation agencies within the healthcare 

system also have a critical role to play in assuring quality care standards and providing healthcare providers with 

further incentives to increase their cultural and linguistic competency and commitment to tackling healthcare 

inequities (Exworthy et al., 2006; Betancourt et al., 2002; Office of Minority Health, 2001). 

The US Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is currently developing the 

first-ever accreditation standards for the provision of culturally competent patient-centred care. The standards 

currently being developed will eventually become mandated as a condition of receiving hospital accreditation in the 

near future. Launched in August 2008, the 18-month standards development project builds upon the research 

framework of the Joint Commission’s ongoing Hospitals, Language and Culture: A Snapshot of the Nation study, 

which has been examining how a sample of 60 hospitals across the country are providing health care to culturally 

and linguistically diverse patient populations. 

The study’s findings have been published in reports such as the recent One Size Does Not Fit All: Meeting the 

Health Care Needs of Diverse Populations (see Section 2.3B/III for more on the recommendations and framework 

of One Size Does Not Fit All). A 26-member Expert Advisory Panel has been assembled by the Joint Commission to 

guide this project that is reviewing available evidence-based best practices and identifying principles that can be the 

basis for new and revised standards. (For more information about the Joint Commission’s initiative to develop 

culturally competent patient-centered care standards, visit www.jointcommission.org [click on “Patient Safety,” then 

“Hospitals, Language and Culture”]). 

Quality assurance of culturally competent care in the US has also been promoted, more recently, through medical 

licensing boards. The passing of New Jersey Senate Bill S-144, introduced in 1999 and signed into law in 2005, is 

exemplary in this respect. It requires that physicians in New Jersey take cultural competency training as a condition 

of licensure by the State Board of Medical Examiners (see Salas-Lopez et al., 2007; also see Baquet et al., 2004). 

A considerable portion of the recent cultural competence literature, moreover, focuses on ways to evaluate, improve 

and require cultural competence components in core curricula of various educational institutions educating the next 

generation of doctors, nurses and healthcare workers (see Quereshi et al., 2008; Xu 2007; Shaya et al., 2006; Luquis 

& Perez, 2003; Chevannes 2002). 

C. Contracting and Procurement 

While it is essential that the Ministry of Health and Long Term Care embed health equity accountabilities within its 

own accountability agreements with the LHINs, the service accountability agreements entered into between the 

LHINs and health service providers (HSPs) are another critical means or ‘lever’ by which the LHINs can ensure 

equity considerations and strategic priorities are realized and managed in practice at the local level, in accountable 

ways (GTA Diversity and LHINs Working Group, 2008a; Gardner, 2008a). 

Requiring health equity plans, on the bases of analyses of relevant health equity issues in the local catchment area, 

as part of contractual agreements and obligations between the LHINs and health service providers is another 

essential means of embedding accountability for the furtherance of LHIN health equity strategic goals at the local 

level. 

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Focusing more specifically on hospitals, Gardner outlines some of the key elements the LHINs might expect and 

look for in a hospital health equity plan. An effective and comprehensive hospital equity plan, he argues, would 

include elements such as: 

• A broad overall vision or commitment to reducing health disparities through their service delivery; 

• Demonstrating that the hospital has analyzed health status and disparities in the area in which they are located 

or their broader catchment area - or if they haven’t done the necessary local analysis, how they will; 

• Indicating how they have or will incorporate this data and analysis into program planning; 

• Analysing how closely hospital utilization patterns and service mixes reflect the demography and meet the 

needs of their catchment areas – and if they don’t, indicating critical unmet needs; 

• Describing what current programs, outreach and resources are targeted to addressing health disparities in their 

area, and what additional expanded or new services are needed; 

• Operationalizing a comprehensive commitment to women’s health – not simply sexual and reproductive 

healthcare – but ensuring all research, diagnoses and treatment take gender differences into account; 

• Clear standards for culturally competent care – and consumer satisfaction, evaluation and performance 

management mechanisms to ensure these standards are consistently achieved; 

• Describing how the hospital is reducing physical and other access barriers; 

• Human resources, recruitment, training and other diversity practices to ensure the ‘face’ of hospitals reflects 

their communities; 

• Setting out how internal organizational structures and working cultures such as governance, performance 

management and communications have been or will be changed to prioritize equity and diversity; 

• Indicating how the hospital does or will systemically collect appropriate equity and diversity- relevant data on 

services and patients, and build this into their monitoring and accountability processes; 

• Assessing how the hospital has built solid relationships with community-based service providers in their area, 

and developed networks and partnerships to deliver innovative services to disadvantaged populations; and 

• Community engagement processes and advisory forums to guide and evaluate equity plans and delivery (2008a, 

p.10). 

Community Health Centres and other service providers, Gardner adds, should also demonstrate how they plan to 

meet the abovementioned expectations. Health equity plans developed by hospitals and other local health service 

providers, moreover, would need to also explain, in clear terms, how they relate to the LHINs overall equity vision 

and strategic health equity goals. Granted, there would need to be sufficient flexibility in how such requirements are 

adapted in local organizational settings, in accord with local capacity. 

The LHINs could also play an important capacity building and support role by, for instance, “provid[ing] some 

planning, analysis and other enabling support, especially for smaller agencies” (Gardner, 2008a). For compliance 

cannot be mandated into existence, where there is insufficient capacity to comply with espoused equity goals 

objectives. 

Among the potential capacity building and support roles of the LHINs are: providing or supporting training 

initiatives; developing health equity/cultural competence ‘guidelines’, if not standards, for care; and establishing or 

collaborating with existing health equity researchers, teams and/or corporate research and evaluation units to assist 

in knowledge/data gathering and exchange processes that are critical to ensuring effective implementation and 

accountability (see below). 

The next section describes potential roles for the LHINs in providing health equity research and ‘intelligence’ to 

local health providers, in collaboration with researchers and the MOHLTC-based health equity research unit. 

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Box 4.4: Strategic Health Authority Performance Incentives in the NHS 

Incentives to perform well in the area of ‘equalities’ and health equity in the UK national healthcare system operate, in part, 

through the process by which local Primary Care Trusts (PCTs) apply for and potentially gain NHS ‘Foundation’ status. NHS 

Foundation Trusts are afforded considerably greater autonomy and flexibility than Primary Care Trusts in the way they manage 

their affairs, in reward for demonstrating a strong performance track record over an extended period of time. Trusts may only 

apply for foundation status after being approved by the regional Strategic Health Authority (SHA), 33 which monitors, among other 

things, compliance with equalities legislation and health equality policies, and furtherance of strategic goals (which include the 

reduction of health inequality). Regional-based Strategic Health Authorities, in this capacity, restrict and/or reward primary care 

trusts through performance appraisals on diversity and equity issues, which can affect their ability to gain coveted Foundation 

status. 

D. Measurement and Evaluation 

Research and analyses of health disparities and the development of health equity policy/strategy performance 

indicators is especially critical to ensuring effective interventions, quality care, and establishing accountability for 

performance. A necessary starting point for action on health equity is a basic understanding of the nature, origins 

and causes of health disparities within one’s service area. This requires the development of indicators and data 

collection sufficient enough to inform analyses of the nature of health inequalities in any catchment area. 

“In the face of competing priorities and often scepticism,” Exworthy et al. (2006) argue, “better locally relevant data 

on disparities will help keep the issue on the policy agenda and stimulate further action”. This contention is clearly 

borne out in analyses of government progress on health equity policy around the world (see Section 3.3.; also see 

Mackenbach & Bakker, 2002). 

The WHO’s (2008) Closing the Gap Report elaborates some of the basic ingredients of what a ‘minimum health 

equity surveillance system’ might look like, in this respect (See Appendix 3), as well as a framework for a more 

comprehensive national health equity surveillance system (See Appendix 4). The WHO Commission calls for 

research investment and improvement in three broad areas in particular: 

• Research on determinants of health inequities, rather than determinants of average population health; 

• What works to reduce health inequities in what circumstances, and how best to implement interventions such 

that they contribute to a reduction of these inequities; and 

• Development of methods for measuring and monitoring health inequities and for evaluating the impact of 

population-level interventions (who, 2008, p.186). 34 

33 “NHS foundation trusts are a new type of NHS trust in England and have been created to devolve decision-making from central government 

control to local organisations and communities so they are more responsive to the needs and wishes of their local people… NHS Foundation 

Trusts have greater freedoms and flexibilities than NHS Trusts in the way they manage their affairs e.g. 

Freedom from Whitehall control and performance management by Strategic Health Authorities 

Freedom to access capital on the basis of affordability instead of the current system of centrally controlled allocations 

Freedom to invest surpluses in developing new services for local people 

Freedom of local flexibility to tailor new governance arrangements to the individual circumstances of their community 

In line with the program of reforms set out in The NHS Plan, NHS Foundation Trusts give more power and a greater voice to their local 

communities and front line staff over the delivery and development of local healthcare…NHS trusts work on their foundation trust application 

under the guidance of their Strategic Health Authority (SHA). A formal application will only come to the Department of Health when the SHA is 

confident that a trust is ready” (Retrieved February 29, 2009 from 

http://www.dh.gov.uk/en/Healthcare/Secondarycare/NHSfoundationtrust/index.htm). 

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In the Canadian context, the Health Disparities Task Group has its own set of recommendations for the reform and 

expansion of health indicators and research (e.g. CIHI, Statistics Canada, and the Performance Indicators Reporting 

Committee [PIRC] framework mandated as part of the Health Accords; see Health Disparities Task Group, 2004, 

p.16-17). 

Data systems and Performance measures within the healthcare system 

As a first priority in laying down foundations for longer term change within the Ontario healthcare system, it is 

essential that the LHINs and service providers they fund and oversee begin to integrate disaggregated measures of 

disadvantage (including such variables as race, ethnicity, language, gender, sexual orientation, socio-economic 

status, Aboriginal status etc.) into existing data collection systems within the healthcare system so as to begin to 

better account for potential differences in health status and healthcare treatment and outcome among different 

population groupings (WHO, 2008; Gardner, 2008; GTA Diversity and LHINs Working Group, 2008a; Lettner, 

2008c). 

Where existing information systems fail to capture potential differential service needs and inequities among 

marginalized populations, new data collection systems will need to be developed. In numerous US jurisdictions, as a 

result of Civil Rights Legislation, such disaggregated measures are required by law (see Box 4.5 below). Expanded 

and more accurate disaggregate data is essential because it “can pinpoint where the gaps are and provide the baseline 

for measuring change and improvement” (Health Affairs 2005b, 353). 

Box. 4.5: Acute Care Hospitals Mandated to Collect race/ethnicity based data in Boston, 

Massachusetts 

In 2006, policy changes were implemented in Massachusetts to better measure disparities in the quality of health care provided 

to racial and ethnic minority residents. Regulations were passed by the Boston Public Health Commission (BPHC) and the 

Massachusetts Division of Health Care Finance and Policy (MDHCFP) that require all acute care hospitals in the city and state to 

collect race and ethnicity data from all patients with an inpatient hospitalization, an observation unit stay, or an emergency 

department visit. 

Source: Weinick et al., 2007 

Developing performance indicators and outcome measures in relation to health equity strategic goals and objectives 

is particularly important in order to establish accountability for the reduction of health inequity by stakeholders 

within the (LHIN) healthcare system (see Betancourt et al., 2005). Such performance measurements and 

mechanisms are essential because they “provide the data by which incentives (to reward progress or penalize the 

lack of it) are implemented” (Exworthy et al., 2006). 

Health equity and diversity-related measures should not only be incorporated into the performance evaluation 

systems set up for policies, programs and services – through such means as internal audits, client satisfaction 

assessments, quality assurance data, and outcomes-based evaluations – but also inform the professional performance 

evaluations of individual staff members (e.g. through staff performance development plans and evaluations) (GTA 

Diversity and LHINs Working Group, 2008a). 

It is particularly important that senior managers and Board directors overseeing the development and 

implementation of strategic priorities around health equity are rendered individually and professionally accountable 

for the success of such policies, in their individual performance contracts and evaluations (ibid.). 

34 The broad scope and nature of indicators recommended by the WHO reflects their insistence on the need to significantly broaden the scope of 

current healthcare/public health research to include a stronger focus on the social determinants of health. 

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Exworthy et al., (2006, p.97) offer the following “guiding principles” to help assess existing measurement 

mechanisms and help shape their future development (see Table 4.1 below): 

Table 4.1: Principles to Consider When Designing and Managing Measurement Mechanisms 

Research Capacity Building through partnership and collaboration and/or Establishing a Health Equity 

Research Unit 

One of the key recommended means of enhancing research capacity in the above respects, and thereby equitability, 

effectiveness, accountability and quality of services rendered, is by creating a health equity research unit or 

committee within the LHINs (if not the MOHLTC) dedicated to auditing and monitoring progress on the LHINs 

health equity strategy, and building capacity among service providers in the area of research, strategy 

implementation and evaluation. 

An alternative or additional possible tactic adopted in many jurisdictions is to work in concert with other local 

research institutions and public authorities (see for instance Box 4.6 below on the role of the London Health 

Observatory within NHS London). 

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Box 4.6: The London Health Observatory 

The London Health Observatory (LHO) is part of a network of twelve public health observatories (PHOs) across the UK and 

Ireland that together form the Association of Public Health Observatories (for further information on the LHO and APHO network 

and its work see http://www.lho.org.uk/Default.aspx and www.apho.org.uk respectively).The LHO works closely with the Public 

Health Directorate of NHS London (the regional Strategic Health Authority), as well as other local authorities and bodies, 

including Primary Care Trusts, the Greater London Council, researchers/research institutions, and national agencies. 

As the national lead among UK’s PHOs in monitoring health inequalities, ethnicity and health, the LHO provides NHS London, 

and others, with critical up-to-date information, data and intelligence on the health and heath care of London’s 7.8million citizens. 

Such intelligence includes information on a wider variety of determinants of health and health inequality which assists NHS 

London (and others) with commissioning and policy decisions. The LHO also runs training programmes in health intelligence 

training and capacity-building programmes for health practitioners in London. 

As a hosted organisation within NHS London, the LHO also benefits from NHS London’s core services including facilities, human 

resources and training opportunities, and is governed by its policies on these and other areas. NHS London has the responsibility 

for ensuring that the LHO complies with its legal equality duties. 

Sources: NHS London, 2007; and http://www.lho.org.uk/Default.aspx [Retrieved 02/09/09]) 

Partnerships with research institutions (e.g. Wellesley Institute Health Equity Roundtable) and other governmental 

and arms-length research bodies (e.g. MOHLTC Health Equity Unit, Ontario Health Quality Council, CIHR, etc.) 

are another crucial means of building research capacity in the service of heightening service quality and 

accountability (Exworthy et al., 2006; WHO, 2008; Gardner, 2008a; Rachlis, 2007; Raphael & Bryant, 2006). 

Target Setting 

The development of performance indicators in relation to policy initiatives and strategic objectives also needs to be 

accompanied by the development of concrete performance targets which should include not only process measures 

but also, importantly, outcome measures (Gardner, 2008a; Mackenbach et al., 2002b). Developing appropriate 

methods of measuring progress against targets must be an integral component of any such target setting exercise 

(ibid.). 

Judge and Mackenzie (2002), more specifically, warn against the politically motivated tendency to set unrealistic, 

aspirational goals and targets that ‘promise to change the world before the next election.’ Instead they recommend 

that targets be set only “in terms of the genuinely expected consequences of well specified interventions”, even if 

these look “very modest and rather piecemeal to politicians” (p.310; see also Gardner, 2008a). Persons involved in 

target setting should clearly articulate the specific “pathways of expected change” by which strategic interventions 

are expected to help realize policy targets (ibid.; also see Exworthy et al., 2006). 

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Box 4.7: Examples of health policy targets relating to inequalities in health 

NHS London Strategic Plan 2008-2013 [UK] 

Target 1: Average life expectancy of Londoners increased by at least 2 years for males and females. 

Target 2: Number of primary care clinicians per population to increase as a function of deprivation so that the most deprived 

boroughs have more primary care clinicians. 

Target 3: The difference in life expectancy between the best and worst boroughs in London is reduced by 10 per cent. 

Source: NHS London, 2008. 

The WHO Commission on Social Determinants of Health Closing the Gap (2008) 

Target 1: Reduce by 10 years, between 2000 and 2040, the LEB [Life Expectancy at Birth] gap between the one third of 

countries with the highest and the one third of countries with the lowest LEB levels, by levelling up countries with lower LEB. 

Halve, between 2000 and 2040, the LEB gap between social groups within countries, by levelling up the LEB of lower 

socioeconomic groups. 

Target 2: Halve, between 2000 and 2040, adult mortality rates in all countries and in all social groups within countries. In effect, 

achieving this target means reducing the gap in adult mortality between and within countries by half. 

Target 3: Reduce by 90%, between 2000 and 2040, the under-5 mortality rate in all countries and all social groups within 

countries, and reduce by 95%, between 2000 and 2040, the maternal mortality rate in all countries and all social groups within 

countries. In effect, achieving this target means reducing the gap in under-5 mortality between and within countries by 90%, and 

reducing the gap in maternal mortality between and within countries by 95%. 

Source: WHO, 2008 

Health 21 – Health for All in the 21 st Century [WHO] 

Target 2 – Equality in Health 

By the year 2020, the health gap between socioeconomic groups within countries should be reduced by at least one fourth 

in all Member States, by substantially improving the level of health of disadvantaged groups. 

In particular: 

*the gap in life expectancy between socioeconomic groups should be reduced by at least 25 per cent; 

*the values for major indicators of morbidity, disability and mortality in groups across the socioeconomic gradients should be 

more equally distributed; 

*socioeconomic conditions that produce adverse health effects, notably differences in income, educational achievement and 

access to the labour market, should be substantially improved; 

*the proportion of the population living in poverty should be greatly reduced; people having special needs as a result of their 

health, social or economic circumstances should be protected from exclusion and given easy access to appropriate care. 

Source: WHO, 1999 

Ongoing Monitoring & Assessment 

Health equity policy performance indicators and targets need not only be developed, but also consistently monitored 

and reported on an ongoing basis, in order to ensure accountability and the intelligent (on the basis of evaluation 

evidence) steering and review of policy objectives and strategic interventions. As Exworthy et al. stress, 

policymakers “need to demonstrate the progress of their policies in order to sustain their momentum and to promote 

accountability” (2006, p.76). 

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Box 4.8: Tracking Healthy People 2010 

Launched in 2000, ‘Healthy People 2010’ is a Federal US public health policy and plan developed by the Department of Health 

and Human Services (DHHS) with two primary goals in mind: “to eliminate health disparities among specific segments of 

the population” and “to increase quality and years of health life”. These goals inform the policy’s 467 objectives which are 

organized into 28 focus areas. A selected set of 10 objectives – physical activity, overweight and obesity, tobacco use, 

substance abuse, responsible sexual behaviour, mental health, injury and violence, environmental quality, immunization, and 

access to health care - known as the Leading Health Indicators, form part of a larger ‘tracking’ program that sets targets and 

assesses the progress toward its objectives. 

The National Center for Health Statistics (NCHS) is responsible for coordinating the effort to monitor the Nation's progress toward 

the targets, using data from NCHS data systems as well as from more than 190 different other data sources, from more than 

seven Federal Government Departments (including Health and Human Services, Commerce, Education, Justice, Labor, 

Transportation, and the Environmental Protection Agency), and from voluntary and private non-governmental organizations. To 

the extent appropriate, data for the objectives are provided for subgroups defined by relevant dimensions such as sociodemographic 

subgroups of the population, health status, or geographic classifications. 

Data are made available through DATA2010, an interactive database system accessible through the NCHS web site and the 

CDC WONDER system. 

Source: www.healthypeople.gov/About/ (Retrieved March 3, 2009) 

E. Health Equity Impact Assessment 

Ongoing evaluation and assessment of policy initiatives, programs and services for their health equity impact is 

particularly critical to ensuring effective, efficient and equitable programs and services and accountability for the 

latter. Health Equity Impact Assessment tools, as currently used by various health authorities in the UK, Australia 

and New Zealand, are of particular usefulness in this respect (see Department of Health, 2008a, 2008b [UK]; 

London Health Commission, 2008; Rangahau and Pomare, 2003 [New Zealand]; Simpson, 2005 [Australia]; 

Ritsatakis et al. 2002 [Europe]). Health Canada has adopted Frankish et al.’s (1996) definition of Health Impact 

Assessment as “any combination of procedures or methods by which a proposed policy or program may be judged 

as to the effect(s) it may have on the health of a population”. 

While health impact assessments (HIAs) have a longer history, with origins in environmental impact assessment and 

healthy public policy (see for instance Health Canada 1994), health equity focused impact assessments (also known 

as equity audits) have more recent origins in the UK, owing in part to that countries legislated ‘duties’ around 

equality, which include requirements to assess policies for their impact on various diversity groups. 

The UK Department of Health describes health equity impact assessments as “appraisals of the impact of policies 

or interventions on health disparities” (2002). Health equity impact assessments were a major recommendation of 

the Acheson Inquiry (1998) and have since been operationalized in numerous jurisdictions around the world, most 

notably, at present, Australia, New Zealand and the UK (see Box 3.4, 3.5, 3.6 and Box 4.9 and Box 4.10 for more on 

Australian, UK and New Zealand uses of such Impact Assessment Tools). Canada has developed a similar genderspecific 

methodological tool - Gender-Based Analysis (GBA) - for assessing the gender impact of policies, 

programs and services (see Health Canada, 2000). 

According to an international (‘Gothenburg’) consensus paper deriving from an international seminar in Manchester 

in June 2000, HIA includes “consideration of evidence about the anticipated relationships between a proposed 

policy or project and the health of a population and of the opinions, experience and expectations of those who may 

be affected. 

It aims to provide more informed understanding by decision-makers and the public regarding the effects of the 

proposed policy, and to propose adjustments and options to maximize positive and minimize negative health 

impacts” (Gothenburg, 2001; as paraphrased by Ritsatakis et al., 2002). 

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HIA methodologies involve both community/stakeholder consultation and more ‘expert’-based and derived 

assessments of the research evidence. 

Among the many benefits of Health Equity Impact Assessment are: 

• Its heightening of awareness and reflexivity among policymakers as to the impact of their policies on different 

social groups and the value-ladenness of the policymaking process. 

• Its proactivity - health-disparity-prevention and health-promotion potential - in enabling assessments of 

unintended health impacts of proposed policies on health disparities prospectively. It also enables the 

consideration of ways to enhance health equity promoting factors when weighing or revising policy options. 

• Its mainstreaming of health equity considerations as part and parcel of all policymaking processes 

• Its evidence-basis and emphasis on the rigorous use of evidence regarding actual or potential health equity 

impact. It also generates data for future program/service reform and strategic development and policymaking. 

• Its emphasis on consultation with affected stakeholders and empowerment of marginalized groups in the 

assessment process (which also facilitates knowledge-exchange). 

• Its potential to increase the transparency and public accountability of decision-making processes through public 

involvement and public reporting of results of impact assessments (as is the practice in the UK). 

The scope of health equity impact assessments have been expanded in some jurisdictions to include an assessment of 

not only policies, but also programs, services, projects, and budgeting and allocation processes. The City of Toronto 

has for instance developed an ‘equity lens’ and requires that equity impact statements be included in City Reports 

and budget allocation processes. 

Health impact assessments have also been used in Sweden, England, and the Netherlands to screen and assess 

legislation, policies and initiatives in other sectors that are likely to have a direct or indirect effect on health and 

health inequalities (see for instance WHO, 2008, p.115 and London Health Commission, 2008 for examples of such 

broader uses of health impact assessments by the London Health Commission across policy sectors). HIAs have also 

been commended for their potential to promote intersectoral collaboration through such intersectoral evaluation 

processes. 

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Box 4.9: Equality impact assessment (EqIA) – UK Department of Health 

UK policymakers in the Department of Health are required to screen all new (and eventually, all existing) policies for their impact 

on people from different ethnic backgrounds, people with disabilities, men and women (including transgendered people), people 

with different sexual orientations, people in different age groups, and people with different religions or beliefs. 

Decisions about the potential for impact on these various groups are required to be (qualitative and/or quantitative) evidence 

based (See Department of Health 2008b, p.19-25 for more on sources of evidence). 

EqIA’s form part and parcel of a broader process by which the Department of Health demonstrates its compliance with equality 

legislation in conjunction with the DH Single Equality Scheme. 

The diagram below provides an overview of the process by which policies are screened and assessed: 

Source: Department of Health 2008b, p.8. 

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Box 4.10: A Health Equity Assessment Tool (Equity Lens) for Tackling Inequalities in Health – 

New Zealand Department of Health 

The New Zealand Department of Health (2004) has developed a health equity impact self-assessment tool for the healthcare 

sector that consists of a series of questions to assist health authorities to ‘consider how particular inequalities in health have 

come about, and where the effective intervention points are to tackle them.’ These questions include: 

1. What health issue is the policy/programme trying to address? 

2. What inequalities exist in this health area? 

3. Who is most advantaged and how? 

4. How did the inequality occur? (What are the mechanisms by which this inequality was created, is maintained or increased?) 

5. What are the determinants of this inequality? 

6. How will you address the Treaty of Waitangi in the context of the New Zealand Public Health and Disability Act 2000? 

7. Where/how will you intervene to tackle this issue? Use the Ministry of Health Intervention Framework to guide your thinking. 

8. How could this intervention affect health inequalities? 

9. Who will benefit most? 

10. What might the unintended consequences be? 

11. What will you do to make sure it does reduce/eliminate inequalities? 

12. How will you know if inequalities have been reduced/eliminated? 

Source: Te Roopu Rangahau a Erü Pomare., Ministry of Health and Public Health Consultancy. 2003. A Health Equity 

Assessment Tool. Wellington: Public Health Consultancy, Wellington School of Medicne and Health Sciences. Adapted by 

Ministry of Health in May 2004 from Bro Taf Authority. 2000. Planning for Positive Impact: Health inequalities impact assessment 

tool. Cardiff: Bro Taf Authority 

There are also numerous diversity and cultural competence organizational self-assessment tools and diversity 

performance management frameworks (see for instance the LHINS Diversity Self-Assessment Tool developed by 

the GTA Diversity Group; Wilson-Stronks et al., 2008; Olavarria et al., 2005; Vancouver Ethnocultural Advisory 

Committee of the Ministry of Children and Families, 1998). 

There are nevertheless limitations to relying solely on self-assessment, particularly insofar as these rely upon 

organizations and staff being honest, objective, self-critical and comprehensive. Partly to counter criticisms of an 

over-reliance on self-assessment of previous performance evaluation systems in the UK, the Healthcare Commission 

(an independent healthcare inspection agency in England and Wales) has come to play an expanded role in 

reviewing healthcare provider progress toward national standards (including health inequality targets) (Exworthy et 

al., 2006). 

National and local health authorities in the UK are also subject to external assessments as part of the process of 

applying for the ‘Equality Mark’ – a government sanctioned validation award of ones excellence in meeting the 

Equality Standard for Local Government (ESLG), which includes a 5-level evaluation framework for progress on 

equality (see Improvement and Development Agency website at 

http://www.idea.gov.uk/idk/core/page.do?pageId=5145192). 

NHS London and other strategic health authorities also regularly commission independent research into the degree 

of compliance of London NHS organisations with various equality legislative acts and duties. Trusts within NHS 

London are also required to seek out feedback from their users, employees and partner organisations on their 

performance around equity and diversity issues to ensure that a gap does not exist and open up between their 

perception of the organization’s achievements and the reality. 

Client satisfaction surveys are particularly critical to enhancing public accountability and ensuring that strategic 

policy initiatives and interventions are achieving their intended results, from the perspective of service users. 

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F. Reporting and Transparency 

Finally it is critical, to the establishment and maintenance of accountability, that the results of monitoring and 

assessment are regularly reported, ideally, to the public, and in a manner that allows for comparability of reported 

information across the health system. 

The production and publication of diversity/health equity report cards on an annual basis, available to the public, is a 

particularly good incentive for motivating action, compliance and good performance on health equity issues (GTA 

Diversity and LHINs Working Group, 2008a). 

The use of reports cards or scorecards as a means of measuring the progress of health disparities policies is a 

growing phenomenon in numerous jurisdictions (see Box 4.11 below for example of San Francisco Health Report 

Card; also see Trivedi et al., 2005; Davies, Washington, and Bindman, 2002; Nerenz et al., 2002/2005; Exworthy et 

al., 2006). 

Report cards have been found to be a useful means of sustaining direction and momentum and increasing 

accountability. In the broader UK governmental system of checks, report cards take the simple form of a traffic light 

(red for failure to meet targets, yellow for intermediate outcome, and green for passing or surpassing targets). It is 

important, moreover, that consequences are attached to performance outcomes, whether positive or negative. 

Box 4.11: San Francisco Department of Public Health Report Card on Health Disparities 

The San Francisco Department of Public Health produced the first US public health report card in 2002, focusing on maternal 

and infant health indicators of different ethno-racial groupings in particular. The report card adopted six indicators relating to the 

city’s progress in meeting the national Healthy People 2010 objectives (see Table below). Each indicator was graded as to the 

extent (percentage more specifically) to which it had achieved the Healthy People 2000 objective. A positive or negative symbol 

denoted whether they were “within” or “off” the target for HP-2010, as the example of low birth weight below illustrates (see Table 

below). Each indicator reported also included local comparisons of the rates of “all races” and “African Americans”, as per below. 

_____________________________________________________________________________________ 

San Francisco Report Card: Low Birth Weight 

Indcator: Category All Races African Americans 

Healthy People 2000 Objective 5.0 % 9.0% 

Healthy People 2010 Objective 5.0% 5.0% 

San Francisco Rate, 2000 6.4% 12.4% 

San Francisco Grade* C- D- 

Note: *Grades are linked to the percentage of the 2000 target achieved (A = 90-100%; 

B = 80-89%; C = 70-79%; D = 60-69%; F = less than 60%). 

_________________________________________________________________________________ 

The results highlighted the enormous challenge facing San Francisco’s policymakers and practitioners in reducing disparities 

between African Americans and ‘all races’ as well as between the local rate and national policy objectives. 

Source: Exworthy et al., 2006 

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Summing up the importance and benefits of measuring and monitoring health inequities, the Canadian intergovernmental 

Health Disparities Task Group concludes: 

An essential element of any such strategy [to further prioritize commitments to disparities reduction and 

establish methods of accountability of all stakeholders for improvement] includes the measurement of 

disparities and regular reports on progress. Good data not only advances understanding of what works and 

what does not; good and clear reports also galvanize support for disparities reduction. With the right 

indicator sets, the health sector can achieve a better balance between accountability for providing 

high-quality health care services and accountability for addressing disparities. (Health Disparities Task 

Group, 2004, p.18). 

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PART 3 

CULTURAL COMPETENCE TRAINING AND 

EDUCATION 

While there is significant variation in the specific content of cultural competence training initiatives, these tend to 

fall into three main categories, in terms of their focus: (1) Attitudes, (2) Knowledge and (3) Skills (Curtis, 2007; 

California Endowment, 2003; Haarmans, 2004). Though not all training frameworks cover all three of these areas 

and differ in their emphases (see Limitations for instance), this threefold framework for training has been likened to 

a three-legged stool: “the structure would fail if one ‘leg were missing” (California Endowment, 2003). Further 

stabilizing these three training legs, researchers argue, is “a committed consciousness and receptive attitude” (ibid.), 

without which the knowledge and skills related to cultural competence in health care would be seriously 

compromised. 

This tripartite training framework - applicable at any and all stages of the developmental learning process - is 

discernible, in one form or another, in nearly all of the cultural competence training frameworks and modules 

discussed below. 

5.1 CULTURAL COMPETENCE TRAINING FRAMEWORKS 

D.W. Sue et al. (1992) 

D. W. Sue, Arredondo & McDavis (1992) are widely credited with having developed this tripartite framework for 

cultural competency, which remains the most widely cited and recognized in the cultural competence training 

literature. 

The training framework they have conceptualized and developed (discussed also in Section 2.3B/I) to enhance the 

cultural competence of services and programs, particularly at the client-counsellor interface, revolves around the 

aforementioned three themes: 

• Cultural awareness and beliefs: Training in this ‘affective domain’ of competencies is designed to enhance 

providers’ sensitivity to their personal values and biases and how these may influence perceptions of the client, 

client’s problem, and the counselling relationship. 

• Cultural knowledge: Training in this ‘cognitive domain’ of competencies is designed to increase providers’ 

knowledge of the client’s culture, worldview, and expectations for the counselling relationship. 

• Cultural skills: Training in this ‘practice domain’ of competencies is designed to increase providers’ ability to 

intervene in a manner that is culturally sensitive and relevant in cross-cultural situations (Sue et al., 2006, 1992; 

see Haarmans, 2004 for more detailed elaboration of competencies within this tripartite framework). 

This framework informs the American Psychological Association’s Multicultural Guidelines (2003) and 

numerous other cultural competency training modules, frameworks, and standards (see for instance Miyake Geron, 

2002; Campinha-Bacote, 1996; Rosenjack Burchum, 2002; Kim-Godwin et al., 2001). 

Haarmans (2004) 

In one of the most comprehensive reviews of the cultural competence training literature, Haarmans (2004) further 

develops and fleshes out Sue et al.’s (1992) tripartite framework and adds a critical fourth competency area that 

concerns ‘power/relationship’ issues (discussed below). 

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Haarmans four-field clinical cultural competence training framework consists of the following practice components 

and related competencies: 

• Awareness: 

• Own cultural values & biases; and 

• Client worldview. 

• Knowledge: 

• Culture-specific (Emic); and 

• Culture-generic (Etic). 

• Skills: 

• Pre-engagement; 

• Engagement; 

• Assessment/feedback; 

• Treatment/intervention; 

• Closure/discharge; and 

• Research & Education. 

• Power/Relationship Issues: 

• Client-therapist dyad (Micro-Level); and 

• Client-system (Macro-Level). 

Most distinguishing about Haarmans framework is its attention to issues of power in and beyond the clinical setting, 

as these impact client-clinician relationships. As Haarmans argues: “Power Relationship/Issues is a particularly 

important domain due to the power differential inherent in the client-clinician relationship” (2004, p.8). 

Drawing on the work of Sodowsky et al. (1994), Haarmans fourth domain focuses on power relationships at both the 

micro (client-clinician) and macro (client-system power/relationships issues) level of interaction, drawing attention, 

in this latter respect, to the “impacts of systemic oppression, discrimination, racism and deprivation at the sociocultural, 

institutional, and political levels on psychosocial, political, and economic development” (2004, p.8). 

AMCD Multicultural Counselling Competencies (Arrendondo et al., 1996) 

The Association for Multicultural Counselling and Development (AMCD) is an association of counselling 

professionals that “seeks to develop programs specifically to improve ethnic and racial empathy and understanding” 

(http://www.amcdaca.org/amcd/whatisamcd.cfm; retrieved March 8, 2009). Its website motto is ‘Providing global 

leadership, research, training and development for multicultural counselling professionals with a focus on racial and 

ethnic issues” (ibid.). 

The AMCD’s framework for multicultural counselling training was developed by Arrendondo et al. (1996), largely 

on the basis of the work of Sue & Arrendondo et al. (1992). Sue et al. recommend, in their (1998) work, that this 

series of multicultural competencies and standards be adopted by the American Association for Counselling and 

Development (now simply known as the American Association for Counselling). 

Arrendondo’s AMCD framework very much reflects Sue & Arrendondo et al.’s (1992) tripartite framework. It 

includes three broad content areas, each of which are subdivided by a series of competencies organized by the 

attitudes, knowledge, and skills required. These three broad content areas include: 

1. Counsellor Awareness of Own Cultural Values and Biases; 

2. Counsellor Awareness of Client's Worldview; and 

3. Culturally Appropriate Intervention Strategies. 

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This framework and the specific ternary of competencies within each of these framework pillars are presented in full 

in Appendix 5. 

5.2 CULTURAL COMPETENCE TRAINING STANDARDS & QUALITY ASSURANCE 

US post-secondary educational institutions have been at the forefront of developing and incorporating cultural 

competence modules into the standard educational curriculum for medical/health-care professionals in training. A 

2004 paper in the Journal of the American Medical Association for instance found that among close to 8,000 

graduate medical educational programs surveyed in the United States, 50.7 percent offered cultural competence 

training in 2003–2004, up from 35.7 percent in 2000–2001 (Brotherton, 2004; cited in Betancourt et al., 2005). 

Betancourt et al. (2005) attribute this transformation to a combination of ‘stick’ and ‘carrot’ approaches. 

The ‘stick’, in this respect, has taken the form of increasing regulatory pressures since 2002, particularly in the form 

of accreditation standards. In 2002, the Liaison Committee on Medical Education (LCME) introduced the first 

official cultural competence accreditation standards, and required all medical schools to integrate these into their 

curricula. 

The Accreditation Council of Graduate Medical Education (ACGME) has also introduced cultural competence 

standards for residency programs (see ACGME, 2004). New Jersey has gone even further with the stick approach 

and passed legislation in 2005 that requires cultural competence education as a requirement for the licensure of 

health care professionals (see Salas-Lopez et al., 2007; also see Baquet et al., 2004). 

Exemplifying the ‘carrot’ approach, which has also helped to move the medical education field forward in the area 

of cultural competence, the New York State of Health modified its $33 million per year Graduate Medical Education 

Reform Incentive Pool in 2004 to ‘reward residency programs that provided eight hours of cultural competence 

training to at least 80 percent of residents’ (New York Dept of Health 2004; cited in Betancourt et al., 2005). 

Demonstrating the effectiveness of this ‘carrot’ approach, “[i]n the first year, 66 of the 104 residency programs in 

New York State proposed new cultural competence curricula” (ibid.). 

Cultural competence training outside of post-secondary educational contexts, for practicing healthcare professionals, 

contrastingly, remains “haphazard and varying in quality”, in no small part due to the lack of agreed upon standards 

and evaluative criteria by which to assess cultural competence training in such contexts (California Endowment, 

2003). 

The development of such training standards in continuous professional education and development contexts is a key 

area for future research. In the meantime, educational standards and evaluative tools (such as the TACCT; see 

below) of cultural competence borrowed from post-secondary educational contexts and curricula could be adapted to 

continuous learning contexts. 

Aside from the Association for Multicultural Counselling and Development’s Multicultural Counselling 

Competencies, which have been proposed by Sue et al. (1998) as standards for the American Counselling 

Association but not adopted, the only other proposed ‘standards’ for cultural competency training discovered in the 

literature derive from the California Endowment’s (2003) Report, Principles and Recommended Standards for 

Cultural Competence Education of Health Care Professionals. The recommendations from this report are explored 

below. 

Principles and Recommended Standards for Cultural Competence Education of Health Care Professionals. 

(California Endowment, 2003): The Principles and Standards recommended in the 2003 California Endowment 

report are designed to accompany the Culturally and Linguistically Appropriate Services in Health Care (CLAS 

Standards) adopted by the Office of Minority Health in 2002. Intended for “persons who are charged with direct 

patient care and the delivery of health care services” (CE, 2003), the standards “provide guidance as to the general 

content and organization of educational programs” (ibid.). The Reports authors thus advise that “experts in specific 

health care disciplines” be consulted to integrate relevant subject matter into the suggested framework of standards 

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(CE, 2003). The (2003) Report opens up with the following twelve ‘Guiding Principles’ for cultural competence 

education and training of health care professionals (in no particular order): 

1. The goals of cultural competence training should be: 1) increased self- awareness and receptivity to diverse 

patient populations on the part of health care professionals; 2) clinical excellence and strong therapeutic 

alliances with patients; and 3) reduction of health care disparities through improved quality and costeffective 

care for all populations. 

2. In all trainings, there should be a broad and inclusive definition of cultural and population diversity 

including consideration of race, ethnicity, class, age, gender, sexual orientation, disability, language, 

religion and other indices of difference. 

3. Training efforts should be developmental, in terms of the institution and the individual. Institutions may start 

out simply in their inclusion of cultural competency training as a specific area of study but are 

expected to build in more complex, integrated and in-depth attention to cultural issues in later stages of 

professional education. Trainees should be expected to become progressively more sophisticated in 

understanding the complexities of diversity and culture as they relate to patient populations and health 

care. Both instructional programs and student learning should be regularly evaluated in order to provide 

feedback to the on-going development of educational programs. 

4. Cultural competence training is best organized around enhancing providers’ attitudes, knowledge and skills, and 

attention to the interaction of these three factors is important at every level of the training. It is important to 

recognize the extensive pre-existing knowledge and skill base of health care professionals, and to seek to 

promote cultural competence within this context. 

5. While factual information is important, educators should focus on process-oriented tools and concepts 

that will serve the practitioner well in communicating and developing therapeutic alliances with all types of 

patients. 

6. Cultural competence training is best integrated into numerous courses, symposia and experiential, 

clinical, evaluation and practicum activities as they occur throughout an educational curriculum. Attention 

may need to be directed to faculty, staff and administrative development in cultural competence in order to 

effect this integration. 

7. Following on the above, cultural competence education should be institutionalized within a school 

or health care organization so that when curriculum or training is planned or changed, appropriate 

cultural competence issues can be included. 

8. Cultural competence education is best achieved within an interdisciplinary framework and context, drawing 

upon the numerous fields that contribute to skill and knowledge in the field. 

9. Education and training should be respectful of the needs, the practice contexts and the levels of 

receptivity of the learners. 

10. Education in cultural competence should be congruent with, and, where possible, framed in the context of 

existing policy and educational guidelines of professional accreditation and practice organizations, such 

as the Accreditation Council on Graduate Medical Education, the Liaison Committee on 

Medical Education, the American Academy of Nursing, the National Association of Social Workers, 

the Society for Public Health Education and the Academies and Colleges of Family Practice, 

Paediatrics, Emergency Medicine and Obstetrics and Gynaecology. 

11. Wherever possible, diverse patients, community representatives, consumers and advocates should participate 

as resources in the design, implementation and evaluation of cultural competence curricula. 

12. Finally, cultural competence education should take place in a safe, nonjudgmental, supportive 

environment. While the Principles and Recommended Standards are focused on the education and training 

of health care professionals, the schools and organizations in which they study and work must be 

settings that are conducive to functioning in a culturally competent way and visibly support the goals of 

culturally competent care. 

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More specifically, the (2003) Report offers training-related cultural competency standards in four main areas: 

• Content of Cultural Competence Education 

• Training Methods and Modalities 

• Evaluating Cultural Competence Learning 

• Standards Relating to the Qualification of Cultural Competence Teachers and Trainers 

The Standards for Cultural Competence Education and Training are subdivided into three cultural competency 

categories of Attitudes, Knowledge, Skills (see Appendix 6 for elaboration of Recommended Standards for the 

Content of Cultural Competence Education). 

Tool for Assessment of Cultural Competence Training (TACCT) 

The Association of American Medical Colleges (AAMC) has developed a self-administered “tool for the assessment 

of cultural competence training” (TACCT) to assist medical schools in meeting their accreditation standards, as 

required by the Liaison Committee on Medical Education, and the Accreditation Council of Graduate Medical 

Education (ACGME) (see http://www.aamc.org/meded/tacct/start.htm). The TACCT was designed as a framework 

for evaluating and examining the various components of a medical school’s cultural competence curriculum. It 

could also usefully be adapted to assess and inform the development of cultural competence training programs and 

modules for health care organizations. 

There are two parts to the TACCT. The first part, Domains, is designed to guide the assessment and monitoring of 

overall curricular offerings. It helps to identify any gaps or redundancies in such offerings (see below for framework 

outline). The second part, Specific Components, provides a framework for the identification of education for 

detailed knowledge, skills and attitudes. These two parts of the TACCT are explored in outline form below. 

1. TACCT Content Domains 

The first part of the TACCT – cultural competence domains – outlines five TACCT domains for cultural 

competence education: 

• Domain I: Cultural Competence—Rationale, Context, and Definition 

• Definition and understanding of the importance of cultural competence; how cultural issues affect health 

and health-care quality and cost; and, the consequences of cultural issues; 

• Definitions of race, ethnicity, and culture, including the culture of medicine; and 

• Clinicians’ self-assessment, reflection, and self-awareness of own culture, assumptions, stereotypes, biases. 

• Domain II: Key Aspects of Cultural Competence 

• Epidemiology of population health; 

• Patient/family-centered vs. physician-centered care: emphasis on patients’/families’ healing traditions and 

beliefs [for example, ethno-medical healers]; 

• Institutional cultural issues; and 

• Information on the history of the patient and his/her community of people. 

• Domain III: Understanding the Impact of Stereotyping on Medical Decision-Making 

• History of stereotyping, including limited access to health care and education; 

• Bias, stereotyping, discrimination, and racism; and 

• Effects of stereotyping on medical decision-making. 

• Domain IV: Health Disparities and Factors Influencing Health 

• History of health-care design and discrimination; 

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• Epidemiology of specific health and health-care disparities; 

• Factors underlying health and health-care disparities—access, socioeconomic, environment, institutional, 

racial/ethnic; 

• Demographic patterns of health-care disparities, both local and national; and 

• Collaborating with communities to eliminate disparities—through community experiences. 

• Domain V: Cross-Cultural Clinical Skills 

• Knowledge, respect, and validation of differing values, cultures, and beliefs, including sexual orientation, 

gender, age, race, ethnicity, and class; 

• Dealing with hostility/discomfort as a result of cultural discord; 

• Eliciting a culturally valid social and medical history; 

• Communication, interaction, and interviewing skills; 

• Understanding language barriers and working with interpreters; 

• Negotiating and problem-solving skills; and 

• Diagnosis, management, and patient-adherence skills leading to patient compliance (AAMC, 2005, p. 9). 

2. Specific Components Grid 

The second part (Specific Components) of the TACTT identifies and details the specific knowledge (K), skills (S), 

and attitudes (A) that need to be taught and evaluated for, under each of these five domains. 

5.3. LIMITATIONS OF THE TRAINING LITERATURE, FRAMEWORKS & STANDARDS 

(1) Lack of evidence-base and quality evaluation 

One of the greatest limitations of the existing cultural competence training literature is the lack of empirical data 

concerning what makes diversity training, and linguistically and culturally appropriate health education training in 

particular, effective (Curtis et al., 2007; Anderson et al., 2003). 

Much of this has to do with the poor methodological design and/or rigour of the few evaluations in the literature that 

do examine the impact of cultural competence training on minority health care quality (Beach et al., 2005; Beach et 

al, 2006; and Curtis et al., 2007). Most such studies, for instance, rely on self-administered tools for evaluation that 

have not been validated (Gozu et al., 2007) 35 and base themselves on post-test only or single group pre-test/post-test 

self-reports of knowledge and attitudes acquired in the process (Haarmans, 2004). 

While there is some evidence that properly designed cultural competence training can change trainees attitudes 

(Curtis et al., 2007; Crosson et al., 2004; ), there is a lack of evidence substantiating that such training improves 

‘patient adherence to therapy, health outcomes, and equity of services across racial and ethnic groups’ (Beach et al., 

2005). 

(2) Attitude focus 

A second major limitation of cultural competence training discussed in the literature concerns the continuing overemphasis 

in a lot of cultural competence training designs on awareness-building aimed at attitude change. “The 

literature indicates that current diversity training practices begin and end with awareness building” Curtis et al., for 

instance conclude, in their (2007) review of diversity and cultural competence training literature between 2000 and 

2005. 

35 Curtis et al., (2007) for instance note, in the former respect, a significant discrepancy between the reported results of subjective (self-report) 

measures of attitude change, and the results of survey methods measuring attitude change using standardized instruments, which are much more 

mixed. 

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There is a corresponding neglect or under-emphasis of skills-focused training interventions (Curtis et al., 2007; 

Engerbretso et al., 2008). 

Curtis et al., moreover, cite research findings that suggest “even if measurable attitudinal change does occur as a 

reported consequence of [such attitude-based] training, attitudinal change does not necessarily result in 

changed behaviour” (see also Armour, Bain, & Rubio, 2004; Bieschke et al., 2003; Tomlinson-Clarke 2000). 

(3) Stereotyping 

Another limitation associated with knowledge-based approaches to cultural competence training concerns the 

persistence of stereotyping teaching strategies that depict groups in static, homogeneous ways (Betancourt et al., 

2005; Engerbretso et al., 2008). The failure to recognize the complexity of individual cultural identity and 

formation, can lead to misdiagnosis and culturally incompetent care. Frequently, such ‘categorical’ approaches to 

training focusing on the particular cultural norms of particular ethnic groups, moreover, fail to address and account 

for the cultural orientation of the dominant health care system and its providers (Engerbretson et al., 2008). 

(4) Lack of standards and criteria for assessment 

While cultural competence education for medical/healthcare professionals in training in universities and colleges has 

grown in sophistication and consistency as a result of the introduction of accreditation standards, continuing cultural 

competence education for practicing health care professionals has been described as “increasingly haphazard and 

varying in quality” (California Endowment, 2003). One of the major reasons for this is the lack of agreed upon 

standards and evaluative criteria by which to plan or assess cultural competence training for existing healthcare 

professionals (ibid.). 

(5) Training as substitute for organizational change 

A last salient limitation or critique of cultural competence training in the literature is the false sense of 

accomplishment this can bestow on organizations providing it. Cross et al.’s (1989) cultural competence continuum 

for assessing organizations is telling in this respect as it situates organizations at the pre-competence phase as 

frequently and inordinately focussing on training and diverse staff hiring, yet too often to the neglect of more 

fundamental and systemic changes in the way business is conducted in the organization. 

Cultural competence training – most of which tends to focus on improving individual staff attitudes, knowledge, and 

behaviour - is a necessary but insufficient condition (and certainly no substitute) for improving the cultural and 

linguistic appropriateness and accessibility of programs and services. 

5.4. BEST PRACTICES & RECOMMENDATIONS 

Among the salient recommendations and best practices identified in this review of the cultural competence training 

literature are: 

• Evaluating - and properly designing evaluations (e.g. experimental pre/post-test designs using validated 

instruments) of - training programs for their impact on trainees behaviour as well as client health outcomes 

(Gozu et al., 2007; Curtis et al., 2007). 

• Developing greater (evidence-based) consensus on training standards and evaluative criteria for cultural 

competency training and skills assessment. This is a particularly important priority in the field of continuous 

education for existing health care professionals (OMH, 2001; Betancourt, 2005). 

• Focusing on skills versus solely attitudes and knowledge in training modules by employing a practiceoriented, 

skills-based approach to training that focuses on specific competencies and skills required to 

function culturally competently in a particular organizational setting (Engerbretso et al., 2008). 

Taking a systems approach to cultural competence training. A systems approach treats training as a “key 

component of a health care organization’s strategic approach to organizational performance”, and links it to the 

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attainment of these strategic goals for improved quality of care (Curtis et al., 2007). The systems approach as such 

encourages and requires the following steps: 

• Determine diversity and cultural competence goals in the context of strategy; 

• Measure current performance against needs; 

• Design training to address the gap; 

• Implement the training; 

• Assess training effectiveness; and 

• Strive for continuous improvement (Curtis et al., 2007; see Figure 5.1 below). 

Figure 5.1: Curtis et al.’s systems approach to leadership development and organizational competence. 

Source: Curtis et al., 2007. Adapted from the (2005) National Center for Health care Leadership Development 

System. 

• Training of health care policy-makers and practitioners in conducting health equity impact assessments 

(WHO, 2008; See Box 3.5). “In-depth training on the conduct of [Health Equity Impact Assessments] should be 

provided to a minimum of one member of staff from each directorate/section of the organisation so that [health 

equity] expertise is available in each of its specific functions/policy areas” (North Central London Strategic 

Health Authority, 2006). 

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• Ongoing education and training in culturally and linguistically appropriate service delivery is offered to 

staff at all levels and across all organizational functions. 36 Such training, moreover, is tailored to target and 

nurture the appropriate skill-sets required at the relevant organizational level and area of functioning (OMH, 

2001). 

• Training addresses the dynamic, intersectional nature and bases of culture and cultural identity and is 

sensitive to relations of power, both in the immediate client-practitioner relation, and in the larger societal 

context (see Haarmans 2004 in this latter respect). Knowledge-based components of cultural competence 

training, in this respect, should draw on “anthropological theories, epidemiological data, socioeconomic status, 

and the social and historic context of the population” so as to guard against stereotyping teaching strategies 

(Engerbretso et al., 2008). 

• Finally, it is also advisable that training modules be developed more explicitly around health equity, which 

would engage themes and skill sets beyond (albeit including) cultural competence. 

36 The National Standards for Culturally and Linguistically Appropriate Health Care Services (CLAS) suggests that the standard requiring 

training for staff at all levels “may be the single most important element of assuring the cultural competence of an organization, and one of the 

elements most directly related to clinical care and outcomes” (Office of Minority Health, 2001, p.5). 

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HRSA Organizational Cultural Competence Assessment Profile Structure, Process and Output Indicators 

DOMAIN: Organizational Values 

Part I: Structure, Process and Output Indicators 

An organization's perspective and attitudes regarding the worth and importance of cultural competence, 

and its commitment to providing culturally competent care. 

INDICATORS 

FOCUS AREAS 

STRUCTURE 

PROCESS 

STRUCTURE 

PROCESS 

OUTPUT 

Leadership, 

Investment, 

Documentation 

• Individual(s) at executive 

level with responsibility for 

implementing/monitoring 

cultural competence 

plans/initiatives 

• Team/committee of midand 

high-level staff 

responsible for 

coordinating cultural 

competence (and 

diversity) activities 

• Funding related to cultural 

competence activities 

• Overall investment 

in cultural 

competence 

• Mission statement 

addresses cultural 

competence 

• Strategic plan 


competence, 

including a cultural 

competence plan 

• Business plan 


competence 

• Program plans 

address cultural 

competence 

• Staff 

awareness/accept 

ance regarding 

contents of 

relevant plans 

• Client/community 

awareness 

regarding contents 

of relevant plans 

• Materials 

expressing the 

organization's 

commitment to 

cultural 

competence 

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Information/ 

Data Relevant 

to Cultural 

Competence* 

• Mechanisms for collection 

of cultural competencerelated 

information/data 

(client- and populationlevel) 

• Mechanisms for 

appropriate dissemination 

of cultural competencerelated 


• Conducts regular 

organizational selfassessments 

regarding cultural 

competence 

• Requires/facilitates 

regular individual 

provider 

assessments 


competence 

• Obtains client-level 

cultural 

competencerelated 

information 


community/needs 

assessments 

• Evaluates cultural 


activities 

• Flow and feedback 

of cultural 



for use in policy, 

program, 

operations, and 

treatment planning 

and 

implementation 

Organizational 

Flexibility 

• Systematic and 

ongoing 

examination and 

use of 


relevant to cultural 

competence 

• Administrative and 

service delivery 

adaptations 

tailored to 

population in 

service area, 

including 

adaptations to 

improve access to 

care 

*“Information/Data Relevant to Cultural Competence" may include the following: ethnic/racial 

demographics, client language preference, epidemiological data related to various cultural groups served, 

community needs assessment, etc. 

DOMAIN: Governance 

Part I: Structure, Process and Output Indicators (Cont'd) 

The goal-setting, policy-making, and other oversight vehicles an organization uses to help ensure the 

delivery of culturally competent care. 

INDICATORS 

FOCUS 

AREAS 

STRUCTURE PROCESS OUTPUT 

109


Community 

Involvement 

and 

Accountability 

• Diverse governing body or 

policy influencing group, with 

representatives from groups 

served 

• Community advisory 

committee(s), representative of 

groups served 

• Community 

participants are 

provided financial 

and other 

supports for their 

involvement on 

governing board 

and advisory 

committees 

• Percentage and 

retention of 

community 

members on 

governing body and 

advisory 

committees 

• Reports to 

stakeholders on 

cultural 

competence 

activities/issues 

Board 

Development 

• Has ongoing 

education of 

governing body 


competence 

Policies • Formal cultural 


policies 

exist regarding: 

- personnel 

recruitment/retentio 

n 

- training/staff 

development 

-language 

access/communicat 

ion 

-cultural 


grievances/ 

complaints 

- community/client 

input 


DOMAIN: Planning and Monitoring/Evaluation 

The mechanisms and processes used for: a) long- and short-term policy, programmatic, and operational 

cultural competence planning that is informed by external and internal consumers; and b) the system and 

activities needed to proactively track and assess an organization's level of cultural competence. 

INDICATORS 

FOCUS AREAS STRUCTURE PROCESS OUTPUT 

110


Client/ 

Community 

and Staff Input 

• Membership on relevant 

planning committees of 

community participants 

that represent groups 

served 

• Membership on relevant 

monitoring/review 

committees of 

community participants 

that represent groups 

served 

• Process for 

obtaining 

client/community 

input in the 

development of 

cultural 


plans 


obtaining staff 

input in the 

development of 

cultural 


plans 


obtaining 

client/community 

and staff input in 

cultural 


monitoring 

and evaluation 

• Consumer 

participation/satisfa 

ction regarding 

cultural 

competence-related 

planning 

• Staff 

participation/satisfa 

ction regarding 

cultural 


planning 

Plans and 

Implementation 

• Planning 

documents, 

including fiscal 

plan, addressing 

cultural 

competence issues 

• Integration and 

implementation of 

cultural 

competence plan 

Collection and 

Use of Cultural 

Competence- 

Related 

Information/ 

Data* 

• Data sources and 

systems that support 

proactive cultural 

competence planning at 

all levels (policy, 

program, operations, 

treatment) 

• Resources and capacity 

to collect/manage/report 

cultural competencerelated 


• Uses 

community/client 

cultural 


data in 

planning (policy, 

program, 

operations, 

treatment) 

• Monitors/evaluates 

implementation 

and results of 

cultural 

competence 

plans/activities as 

part of quality 

improvement 

activities 

• Timely and 

accurate cultural 


data 

• Monitoring and 

evaluation reports 

related to cultural 

competence 

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*"Information/Data Relevant to Cultural Competence" may include the following: ethnic/racial 

demographics, client language preference, epidemiological data related to various cultural groups served, 

community needs assessment, etc. 

DOMAIN: Communication 


The exchange of information between the organization/providers and the clients/population, and internally 

among staff, in ways that promote cultural competence. 

INDICATORS 

FOCUS AREAS STRUCTURE PROCESS OUTPUT 

Understanding 

of Different 

Communication 

Needs and 

Styles of Client 

Population 

• System for informing 

patients of right to free 

interpretation/translation 

services 

• System for identification and 

recording of population's 

and client's language 

preferences, level of 

proficiency, and literacy 

• System for access to trained 

interpreters 

• Curriculum and training 

programs for interpreters 

and staff 

• Fixed point of administrative 

responsibility for crosscultural 

communication 

support system 

Provides for staff 

training regarding 

cross-cultural 

communication 

" Monitors and 

evaluates cultural 

competence in 

organizational and 

provider 

communications 

• Special 

"communication" 

initiatives 

• Universal" 

language access 

• Linguistically 

competent services 

provided 

• Staff 

demonstrates/appli 

es effective 

communication 

styles with diverse 

groups 

Culturally 

Competent Oral 

Communication 

• Mechanisms for providing 

access to trained 

interpreters 

• Trained bi-lingual staff 

• Protocol(s) for when and 

how to elicit sensitive 

information from clients 

• Policy in place that 

minimizes the use of family 

members as interpreters 

• Provides for 

training and 

testing of 

interpreters 

and bi-lingual 

staff 

• Provides for 

staff training on 

use of 

interpreters 

• Languages/dialects 

of community 

available at point of 

first contact and all 

levels of interaction 

• Extent of use and 

timeliness of 

interpretation 

service, including 

requests and 

fulfillment of 

requests 

• Client 

understanding of 

interpreted material 

• Low interpretation 

errors 

112


Culturally 

Competent 

Written /Other 

Communication 

• Criteria available for 

assessing capability of 

vendors that translate 

materials 

• Uses a quality 

review 

mechanism to 

ensure that 

translated 

materials 

convey 

intended 

meaning 

• Engages in 

culturally 

appropriate 

dissemination 

of written/other 

materials 

• Signage, 

administrative 

documents, health 

information 

materials, and all 

key written/other 

materials in 

language of the 

groups served 

• Written/other 

material 

appropriate to 

literacy level of 

populations served 

• Client 

understanding of 

written/other 

materials 

Communication 

with 

Community 

Mechanism for systematic and 

ongoing communication with 

community 

Engages in twoway 

communication 

with community 

from which 

clients/potential 

clients come/may 

come 

Intra- 


Communication 

• Policies, workplace design, 

and mechanisms in place to 

promote integration of staff 

of various backgrounds 

• Processes to 

promote 

effective 

communication 

among diverse 

staff 

• Staff demonstrates 

cultural 

competence in 

communications 

with co-workers 


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DOMAIN: Staff Development 

An organization's efforts to ensure staff and other service providers have the requisite attitudes, 

knowledge and skills for delivering culturally competent services. 

INDICATORS 

FOCUS 

AREAS 


Training 

Commitment 

• Has training plan for staff 

development in cultural 

competence 

• Training in cultural 

competence linked to quality 

improvement efforts (as core 

competency) 

• Provides 

basic/initial and 

periodic cultural 

competence 

training for all 

staff 

• Incorporates 

cultural 

competence 

training into 

overall staff 

training activities 

• Consultation 

provided on 

cultural 

competence, 

upon request 

• Offers regular 

opportunities for 

staff to interact 

with community 


monitoring and 

periodic 

evaluations of 

cultural 

competence 

training efforts 

• Disseminates 

information on 

staff training 

opportunities and 

policies 

• Investment 

(monetary and 

other) in cultural 

competence 

training 

• All staff complete 

basic/initial and 

periodic cultural 

competence 

training 

Training 

Content 

• Cultural competence curricula 

address key cultural 


knowledge, skills, and attitudes 

(as generally applicable and as 

related to specific relevant 

groups) 

• Cultural competence curricula 

particularized to roles of 

persons trained (e.g., clinical, 

• Assesses cultural 

competence 

training needs of 

staff 

• Obtains 

community input 

regarding staff 

training 

• Assesses the 

quality of staff 

• Staff 

demonstrates 

cultural 

competence in 

knowledge, skills, 

attitudes, and 

behaviors (as 

generally 

applicable and as 

related to specific 

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front-line, administrative, 

marketing, etc.) 

training in cultural 

competence 

relevant groups) 

Staff 

Performance 

• Cultural competence is a part 

of job descriptions 

• System of incentives 

(individual and team) for 

cultural competence 

behaviors/activities 

• Assesses staff 

performance 


competence 

• Staff 

performance 

evaluations are 

conducted in a 

culturally 

competent 

manner 

Staff performance 

(including selfefficacy) 

in 

application of cultural 

competence 

principles/practices 


DOMAIN: Organizational Infrastructure 

The organizational resources required to deliver or facilitate delivery of culturally competent services. 

INDICATORS 

FOCUS 

AREAS 


Financial/ 

Budgetary 

• Person(s) designated to 

monitor the need for additional 

resources or funding 


enhancing 

resources related 

to cultural 

competence 

(e.g., grant 

writing, 

fundraising 

activities) 

• Overall budgetary 

allocation and 

investment in 

cultural 

competence 

activities, aligned 

with strategic 

plan 

Staffing • A plan for recruitment, 

retention, and promotion of 

staff representative of the 

population(s) served 

• Designated staff responsible 

for cultural competence 

implementation/activities 

• Staffing to facilitate 

client/community outreach and 

• Active staff 

recruitment for 

diversity and 

cultural 

competence 

• Active 

retention/promoti 

on of culturally 

diverse workforce 

• Diverse staff at 

all levels 

• Community 

liaisons (e.g., 

ombudspersons, 

community health 

workers, cultural 

brokers) 

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communication • Process for 

assessing the 

quality and 

cultural 

competence of 

relevant 

contractors/vend 

ors 

Technology • MIS that includes/tracks 

cultural competence-related 

information on populations and 

clients served 

• Range of technology that 

facilitates communication 

between clients/population and 

health organization/providers 

• Staff is trained to 

use, collect, and 

input data into 

the organization's 

information 

system in a 

consistent, 

standardized way 

Physical 

facility/ 

environment 

• Culturally inviting and helpful 

environments (e.g., décor, 

color coding, literature, 

posters) 

Linkages • Formal and informal 

alliances/links with community 

and other partners to address 

cultural competence issues 

• Formal internal 

coordination to 

facilitate delivery 

of culturally 

competent care 

• Obtains and 

considers 

information on 

cultural 

competence of 

referral sources 

and partnering 

organizations 

• Evidence of 

appropriate use 

of/referral to 

partners/alliance 

members 


DOMAIN: Services/Interventions 

An organization's delivery or facilitation of clinical, public-health, and health related services in a culturally 

competent manner. 

INDICATORS 

FOCUS 

AREAS 


116


Client/Family/ 

Community 

Input 

• Policies, protocols 

regarding 

client/family/comm 

unity input 

• Obtains client, family, 

patient advocate input 

regarding care 

planning and 

treatment, as 

appropriate 

• Meets, during 

treatment, with client's 

family or advocate (as 

appropriate and with 

client consent) 

• Obtains community 

input regarding 

community-level 

interventions 

• Care and treatment plan 

agreed on by client/family and 

amended with client/family 

input, as appropriate 

• Tailored outreach and 

community health education 

initiatives 

Screening/ 

Assessment/ 

Care 

Planning 

• Community and 

client assessment 

guidelines and 

tools exist to elicit 

cultural and 

demographic 

factors relevant to 

health and health 

behaviors 

• Appropriately 

detailed data 

routinely available 

re 

culture/language 

and needs/assets 

of populations and 

clients served 

• Mechanism for 

keeping providers 

updated on illness 

patterns and 

treatment efficacy 

issues (e.g., 

ethnopharmacolog 

y) relevant to 

groups served 

• Identifies 

community/client 

beliefs, practices and 

culture-related factors 

• Addresses systematic 

cultural/ethnic factors 

in 

screening/assessment/ 

care planning 

• Provider compliance with 

assessment guidelines 

related to cultural 

competence 

• Focused 

prevention/treatment/mainten 

ance plans reflecting cultural 

competence-related factors 

117


Treatment/ 

Follow-up 

• Practice guidelines 

and treatment 

framework that 

account for 

differences related 

to culture 

• Makes 

accommodations to 

and integrates client's 

traditional health 

beliefs and practices, 

as appropriate 

• Utilizes community 

resources as treatment 

partners, as 

appropriate 

• Provides client- and 

population-level health 

education around 

issues that are 

specifically relevant in 

the community 

• Regularly assesses 

treatment processes 

and outcomes related 

to 

ethnic/cultural/languag 

e groups as part of 

quality monitoring and 

improvement program 

• Individualized interventions 

applied in a patient- and 

family-centered fashion 

• Patient instructions (written 

and oral) reflect cultural 

competence 

• Care-facilitating outreach to 

clients/population from 

relevant cultural groups 

• Public health interventions 

reflecting needs of population 

in service area 

" Culture-specific quality 

assurance reports 

Part II: Intermediate Outcome Indicators 

INTERMEDIATE OUTCOME INDICATORS 

ALL DOMAINS 

ORGANIZATIONAL 

PERSPECTIVE 

CLIENT PERSPECTIVE 

COMMUNITY 

PERSPECTIVE 

Organizational Values 

Governance 

Planning and 

Monitoring/Evaluation 

Communication 

Staff Development 


Infrastructure 

Services/Interventions 

• Rate of 

appropriate use 

of services 

relative to need 

• Retention of 

clients/reduced 

attrition rates 

• Reduction in 

rates of broken 

appointments/n 

o-shows 

• Reductions in 

misdiagnoses 

and inadequate 

treatment plans 

• Rates of 

appropriate 

management of 

selected chronic 

conditions 

• Staff 

• Perceptions regarding: 

- cultural competence of 

providers/organization 

- how well organization meets their 

needs 

• Satisfaction with care 

• Knowledge/understanding regarding 

prevention, diagnosis, treatment 

plan 

• Agreement/compliance/adherence 

with treatment plan 

• Medication compliance/reduction in 

misuse of medications 

• Improved management of selected 

chronic conditions 

• Increase in healthy behaviors and 

prevention practices/reduction in 

risky behaviors 

• Opinions 

about the 

organizatio 

n and its 

responsiven 

ess to 

community 

needs 

118


satisfaction 

Source: Health Resources and Service Administration, 2002. 

119



The structure of the new NHS in England 

Source: Talbot-Smith et al., 2006. 

120



A Minimum Health Equity Surveillance System (WHO, 2008) 

Source: WHO, 2008, p.181. 

121



Towards a Comprehensive National Health Equity Surveillance Framework (WHO 2008) 

Source: WHO, 2008, p.182. 

122



AMCD Multicultural Counselling Competencies 

I. Counselor Awareness of Own Cultural Values and Biases 

A. Attitudes and Beliefs 

1. Culturally skilled counsellors believe that cultural self-awareness and sensitivity to one's own cultural heritage is 

essential. 

2. Culturally skilled counsellors are aware of how their own cultural background and experiences have influenced 

attitudes, values, and biases about psychological processes. 

3. Culturally skilled counsellors are able to recognize the limits of their multicultural competency and expertise. 

4. Culturally skilled counsellors recognize their sources of discomfort with differences that exist between themselves 

and clients in terms of race, ethnicity and culture. 

B. Knowledge 

1. Culturally skilled counsellors have specific knowledge about their own racial and cultural heritage and how it 

personally and professionally affects their definitions and biases of normality/abnormality and the process of 

counselling. 

2. Culturally skilled counsellors possess knowledge and understanding about how oppression, racism, 

discrimination, and stereotyping affect them personally and in their work. This allows individuals to acknowledge 

their own racist attitudes, beliefs, and feelings. Although this standard applies to all groups, for White counsellors it 

may mean that they understand how they may have directly or indirectly benefited from individual, institutional, and 

cultural racism as outlined in White identity development models. 

3. Culturally skilled counsellors possess knowledge about their social impact upon others. They are knowledgeable 

about communication style differences, how their style may clash with or foster the counselling process with persons 

of color or others different from themselves based on the A, B and C, Dimensions ,and how to anticipate the impact 

it may have on others. 

C. Skills 

1. Culturally skilled counsellors seek out educational, consultative, and training experiences to improve their 

understanding and effectiveness in working with culturally different populations. Being able to recognize the limits 

of their competencies, they (a) seek consultation, (b) seek further training or education, (c) refer out to more 

qualified individuals or resources, or (d) engage in a combination of these. 

2. Culturally skilled counsellors are constantly seeking to understand themselves as racial and cultural beings and 

are actively seeking a non racist identity. 

II. Counselor Awareness of Client's Worldview 

A. Attitudes and Beliefs 

1. Culturally skilled counsellors are aware of their negative and positive emotional reactions toward other racial and 

ethnic groups that may prove detrimental to the counselling relationship. 

They are willing to contrast their own beliefs and attitudes with those of their culturally different clients in a 

nonjudgmental fashion. 

2. Culturally skilled counsellors are aware of their stereotypes and preconceived notions that they may hold toward 

other racial and ethnic minority groups. 

123


B. Knowledge 

1. Culturally skilled counsellors possess specific knowledge and information about the particular group with which 

they are working. They are aware of the life experiences, cultural heritage, and historical background of their 

culturally different clients. This particular competency is strongly linked to the "minority identity development 

models" available in the literature. 

2. Culturally skilled counsellors understand how race, culture, ethnicity, and so forth may affect personality 

formation, vocational choices, manifestation of psychological disorders, help seeking behaviour, and the 

appropriateness or inappropriateness of counselling approaches. 

3. Culturally skilled counsellors understand and have knowledge about socio-political influences that impinge upon 

the life of racial and ethnic minorities. Immigration issues, poverty, racism, stereotyping, and powerlessness may 

impact self esteem and self concept in the counselling process. 

C. Skills 

1. Culturally skilled counsellors should familiarize themselves with relevant research and the latest findings 

regarding mental health and mental disorders that affect various ethnic and racial groups. They should actively seek 

out educational experiences that enrich their knowledge, understanding, and cross-cultural skills for more effective 

counselling behaviour. 

2. Culturally skilled counsellors become actively involved with minority individuals outside the counselling setting 

(e.g., community events, social and political functions, celebrations, friendships, neighbourhood groups, and so 

forth) so that their perspective of minorities is more than an academic or helping exercise. 

III. Culturally Appropriate Intervention Strategies 

A. Beliefs and Attitudes 

1. Culturally skilled counsellors respect clients' religious and/ or spiritual beliefs and values, including attributions 

and taboos, because they affect worldview, psychosocial functioning, and expressions of distress. 

2. Culturally skilled counsellors respect indigenous helping practices and respect helping networks among 

communities of color. 

3. Culturally skilled counsellors value bilingualism and do not view another language as an impediment to 

counselling (monolingualism may be the culprit). 

B. Knowledge 

1. Culturally skilled counsellors have a clear and explicit knowledge and understanding of the generic characteristics 

of counselling and therapy (culture bound, class bound, and monolingual) and how they may clash with the cultural 

values of various cultural groups. 

2. Culturally skilled counsellors are aware of institutional barriers that prevent minorities from using mental health 

services. 

3. Culturally skilled counsellors have knowledge of the potential bias in assessment instruments and use procedures 

and interpret findings keeping in mind the cultural and linguistic characteristics of the clients. 

4. Culturally skilled counsellors have knowledge of family structures, hierarchies, values, and 

beliefs from various cultural perspectives. They are knowledgeable about the community where a particular cultural 

group may reside and the resources in the community. 

5. Culturally skilled counsellors should be aware of relevant discriminatory practices at the social and community 

level that may be affecting the psychological welfare of the population being served.] 

124


C. Skills 

1. Culturally skilled counsellors are able to engage in a variety of verbal and nonverbal helping responses. They are 

able to send and receive both verbal and nonverbal messages accurately and appropriately. They are not tied down to 

only one method or approach to helping, but recognize that helping styles and approaches may be culture bound. 

When they sense that their helping style is limited and potentially inappropriate, they can anticipate and modify it. 

2. Culturally skilled counsellors are able to exercise institutional intervention skills on behalf of their clients. They 

can help clients determine whether a "problem" stems from racism or bias in others (the concept of healthy 

paranoia) so that clients do not inappropriately personalize problems. 

3. Culturally skilled counsellors are not averse to seeking consultation with traditional healers or religious and 

spiritual leaders and practitioners in the treatment of culturally different clients when appropriate. 

4. Culturally skilled counsellors take responsibility for interacting in the language requested by the client and, if not 

feasible, make appropriate referrals. A serious problem arises when the linguistic skills of the counsellor do not 

match the language of the client. This being the case, counsellors should (a) seek a translator with cultural 

knowledge and appropriate professional background or 

(b) refer to a knowledgeable and competent bilingual counsellor. 

5. Culturally skilled counsellors have training and expertise in the use of traditional assessment and testing 

instruments. They not only understand the technical aspects of the instruments but are also aware of the cultural 

limitations. This allows them to use test instruments for the welfare of culturally different clients. 

6. Culturally skilled counsellors should attend to as well as work to eliminate biases, prejudices, and discriminatory 

contexts in conducting evaluations and providing interventions, and should develop sensitivity to issues of 

oppression, sexism, heterosexism, elitism and racism. 

7. Culturally skilled counsellors take responsibility for educating their clients to the processes of psychological 

intervention, such as goals, expectations, legal rights, and the counsellor’s orientation. 

Source: Arredondo, P., Toporek, M. S., Brown, S., Jones, J., Locke, D. C., Sanchez, J. and Stadler, H. (1996) 

Operationalization of the Multicultural Counselling Competencies. AMCD: Alexandria, VA 

125


Appendix 6: Recommended Standards for the Content of Cultural Competence 

Education 

Attitudes: 

• Similar to all aspects of health care professionals’ continuing education, cultural competence education 

should be a continuous learning process as well. Cultural competence education for health care 

professionals should foster a lifelong commitment to learning and self-evaluation through an ability to 

recognize and question their own assumptions, biases, stereotypes and responses. 

• Health care professionals should be encouraged to adopt attitudes of open-mindedness and respect for all 

patients including those who differ from them socially or culturally. 

• Health care practitioners should be taught techniques that promote patient- and family-centered care, along 

with the understanding that effective therapeutic alliances may be construed differently across patients and 

cultures. 

• As they learn about health care disparities and inequities and the factors that lead to unequal treatment, health 

care professionals should be encouraged to undertake a commitment to equal quality care for all and 

fairness in the health care setting. 

• To actively serve this commitment, educators can teach students ways to identify systemic or 

organizational barriers to access and use of services by their patients and encourage them to be 

proactive within their practice environments to eliminate these barriers. 

Knowledge: 

• Self-awareness and self-knowledge are the first types of knowledge cross- cultural training would seek 

to establish. This involves bringing to the learner’s awareness internalized beliefs, values, norms, 

stereotypes and biases. They should be made aware of how ethnocentrism, that is, the belief that one’s own 

culture is superior to others, operates in all cultures and encouraged to be attentive to the possibility of 

ethnocentrism in their own thinking. They should be made aware of how ethnocentrism may influence 

their own interaction with patients. 

• Essential to their understanding of both themselves and their patients is an understanding of the concept of 

culture. The theory of culture makes clear the connections between worldview, beliefs, norms and 

behaviors related to health, illness and care-seeking in different populations. In this regard, practitioners 

can be taught to explore how their own cultures, including the cultures of biomedicine, inform their 

perceptions and behaviors. All people operate within multiple cultures. 

• Information about local and national demographics would be part of a health professional’s cultural competence 

education. This should include attention to specific populations, immigration and changing demographics, 

such as alterations in age or occupational distributions. Students/trainees should be encouraged to 

draw implications from this information for their current and future professional practices. Organizations 

should have a process in place to reassess relevant demographics on a consistent basis. 

• Practitioners need to know the legal, regulatory and accreditation issues which address cultural and 

linguistic issues in health care. These would include such things as the position of the federal 

Department of Health and Human Services (DHHS) on civil rights and language access, federal and state 

cultural competence contract requirements for publicly funded health care and state legislation around 

the provision of language services and culturally sensitive health care. The DHHS Recommended Standards for 

Culturally and Linguistically Appropriate Health Care Services should be reviewed. 

126


• Health care professionals need to be made aware of any cultural and linguistic policy statements or standards 

espoused by their own or other professional associations, such as the Society for Teachers of Family 

Medicine, the American Academies of Family Physicians, Paediatrics or the American Academy of 

Nursing. They should be given an understanding of how cultural competence fits into the goals of their 

professional education. 

• Health care professionals should know the kinds and degrees of disparities in health status, health care 

access and use of preventive strategies across racial, ethnic, gender and other discrete population groups 

in the United States. This information should be placed in a context that allows the learner to understand 

how class, racial and ethnic discrimination, social variables and structural variables, including the 

structure of health care, contribute to these disparities. 

• Health care professionals should be given a framework for exploring the family structure and dynamics, 

health beliefs, behaviors and health practices demonstrated in different cultures and population groups, 

especially those in the local areas of service. 

• Practitioners should understand the concept of medical pluralism— the concurrent use of both 

traditional and biomedical systems of care. Familiarity with the kinds of healers and healing traditions 

within their communities of practice or those frequently associated with their specialty field should be 

discussed. Interaction with traditional healers, if possible, is recommended. Improved understanding of 

traditional practices does not mean endorsing them, but it can lead to improved provider -patient 

or provider -family interaction. 

• In developing understandings about epidemiology and group health practices, the tendency to make 

inferences from probabilistic, group-level generalizations to individual cases, which, carelessly done, can 

lead to stereotyping, should be addressed. Its clinical risks and benefits should be carefully explored. 

Sources of within-group variation, including class and acculturation need to be clarified. A “recipe” 

approach to cultural and clinical descriptions of groups should be rigorously avoided. 

• Emergent data, such as those being developed in genome research and ethnopharmacology, which apply 

to specific racial and ethnic groups, should be carefully evaluated as to their potential use in enhancing 

the quality of care for these groups. The positive and negative implications of these types of data for the 

care of diverse populations should be discussed and well understood. 

• Practitioners should learn about the epidemiology of disease among specific populations, both nationally 

and within their local areas, and be able to use this knowledge in patient assessment, health promotion and other 

aspects of care. This includes an awareness of the limitations of epidemiological information for diverse 

populations. For example, there is not much data on epidemiological differences for ethnic sub-populations. 

Existing broad ethnic group data may not be able to be applied generally across sub-populations. 

• Knowledge of the dangers of attempting to care for a patient whose language they do not understand well and of 

the problems associated with the use of family members, friends or unskilled interpreters should be part of 

a health professional’s cultural competence training. 

• Without using a recipe approach, health care practitioners should become knowledgeable about crosscultural 

variations in verbal and non-verbal communication and etiquette and be taught techniques for 

recovering, if they discover that they have inadvertently breached a cultural norm. 

• Trainers and teachers should inform trainees of available resources, such as bibliographies, websites, case 

studies and community contacts and resources, so that practitioners can continue to expand their 

knowledge and education around cultural issues while engaging in professional practice. 

127


Skills: 

• Skills that enable health care professionals to assess their own responses, biases and cultural 

preconceptions on an ongoing basis are critical baseline skills to be learned. 

• Providers need to be given communication tools and strategies for eliciting patients’ social, family 

and medical histories, as well as patients’ health beliefs, practices and explanatory models. 

Communication skills for fostering positive therapeutic alliances with diverse patients should be 

taught. These would include ways for assessing patients’ expectations around levels of interactive 

formality with providers, valuing and incorporating the patients’ beliefs and understanding into 

diagnosis, treatment options and preventive health care where possible and negotiating conflicting 

patient/provider perspectives when necessary. 

• Health care practitioners should be taught ways of accessing and interacting with diverse local 

communities for the purpose of understanding their traditional or group specific healthcare practices 

and needs. Collaboration with local communities, for example, is useful in tailoring effective 

outreach, prevention and educational programs and materials. 

• Health care professionals should be able to assess patients’ language skills as they relate to their 

ability to communicate fully with the practitioner and staff and to their understanding of written 

instructions, prescriptions and educational materials. While language and literacy issues may be 

particularly important in working with limited English speakers, they should be considered in relating to all 

patients. 

• Practitioners should be taught methods of realistically assessing their own proficiency in languages 

other than English and should acquire the skills for effective use of interpreters, including working with an 

untrained interpreter, a trained interpreter and telephone interpreting. 

• Skills in accessing translated written materials through their organizations and commercial resources; 

as well as computer programs and web-based resources should be taught. 

• 

• Cultural competence education should foster skills for retrieving data concerning cultural issues in 

health care, population data and epidemiological information on the web. 

Source: California Endowment, 2003. 

128

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