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

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The Culture, Diversity and Equity Project: Literature Review 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). 60
The Culture, Diversity and Equity Project: Literature Review 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). 61
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Appendix 1: Health Equity Literatur
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The Culture, Diversity and Equity P
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REFERENCES ACAS [Advisory Conciliat
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