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

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The Culture, Diversity and Equity Project: Literature Review 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. 4
The Culture, Diversity and Equity Project: Literature Review 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. 5
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REFERENCES ACAS [Advisory Conciliat
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