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

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The Culture, Diversity and Equity Project: Literature Review 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
The Culture, Diversity and Equity Project: Literature Review • 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
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