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

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
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