Image courtesy of Bold Goals Coalition of Central Alabama.
The realities of health inequities may be too well known to shock us any longer. People in richer countries live longer than those in poorer countries. And within countries, people who are rich live longer than people who are poor, people with more education longer than people with little schooling. Practically everywhere, certain populations, like indigenous peoples, fair badly when it comes to the potential to live long, healthy lives.
Yet the tremendous nature of this injustice ought to shock us still. It ought to shock us that the residents of one mostly white suburb of St. Louis can expect to live to be over 91 years old – 35 years more than residents of another St. Louis suburb, where most residents are black. It ought to shock us that South Asian women who are among the poorest segment of the population are almost five times less likely to be attended by a skilled birth attendant – one of the most important interventions for reducing maternal mortality – than they would be if they were part of the wealthiest segment. And it ought to shock us that the TB incidence in Canada’s indigenous Inuit people is more than 270 times that of non-indigenous Canadians.
Such inequities coexist with a new political commitment to address them, as the world entered the Sustainable Development Goals era of Leave No One Behind several years ago. Redressing these health inequities is a momentous task, a challenge for our generation if Leave No One Behind is to avoid joining the ranks of Health for All by 2000 – the promise of the 1978 Alma-Ata Declaration on primary health care – as a noble promise that proved fatally empty. Indeed, even the Millennium Development Goals, lacking a focus on equity, failed to substantially and consistently reduce health inequities.
Certainly many efforts, from local to global initiatives, are underway to support the goal of leaving no one behind when it comes to health – and indeed, when it comes to life itself. The O’Neill Institute and a number of partners would like to add one more: that all countries develop National Health Equity Strategies. Through a partnership with Stop TB and USAID, and many others, we are developing a guide on National Health Equity Strategies.
What are National Health Equity Strategies? Some wealthier countries have these – if not quite as we propose. They delineate ways, in the health sector and beyond, to narrow health disparities, with particular attention and strategies to address health needs of certain marginalized populations.
Under National Health Equity Strategies as we are proposing, countries would tailor their responses to health inequities to the particular circumstances of all populations experiencing such inequities – not only some populations – and with extensive analysis to ensure that resulting strategies can address all major contributors to health inequities. The National Health Equity Strategy would include specific actions to take across populations and across the many causes of health inequities, seeking to narrow, and ultimately close entirely, these disparities – these injustices. The National Health Equity Strategy would not exist as a stand alone initiative. These actions should then be integrated into national strategies in health and other sectors.
Of course, good strategies alone cannot change the social and political dynamics that have led to persistent marginalization. Accordingly, the action plans would be backed by comprehensive accountability strategies. These would include regular monitoring and evaluation of measurable, time-bound targets; ongoing structures for continued, high-level political and community engagement in reviewing progress and recommending changes (these could build on existing structures), and; additional accountability strategies.
For example, targets might include reducing the proportion of migrants reporting mistreatment at health facilities by 50% within three years, narrowing the gap in life expectancy between indigenous and non-indigenous populations by four years within four years, reducing the number of people experiencing long-term homelessness by 80% within five years, reducing child marriages by 60% within five years, and reducing the number of people with mental disabilities in long-term mental health institutions by 100% within five years. Additional accountability strategies, meanwhile, could encompass human rights education and training, regular local and national health assemblies, legislation requiring public participation in health-related policymaking, and health equity impact assessments.
Integral to the concept of and proposal for these health equity strategies, linked to one of their central goals of empowering populations experiencing health inequities, members of marginalized populations would be in leadership positions in the process of developing the strategies and in follow-on structures. This would be at least one concrete opportunity for populations who are frequently sidelined from decision-making processes to instead be central to them.
Where are we in the process of developing this guide? An initial draft is nearly complete, with the assistance of a global Advisory Committee, with more than a dozen members. It includes people who are themselves members of marginalized communities, individuals who are work for international organizations, and a former minister of health, among others.
We believe it vital that our process of developing this guide be as broad and inclusive as possible. Accordingly, beginning in March and lasting for approximately two months, we will be holding an open, primarily online, consultation on the guide. Along with the opportunity to read and provide us feedback on the draft of the guide and related summary material, we plan to hold several webinars, and may have other means of engagement as well (such as possibly an online discussion group). We hope that you will participate.
Besides receiving feedback on the guide to improve its quality and accessibility, we aim to raise interest in putting this approach into practice, from governments that could spearhead these strategies to civil society organizations and communities experiencing health inequities that could advocate for them. Therefore, we would welcome your sharing information on the guide – such as this blog – with anyone whom you think might be interested in this initiative.
In addition, we would welcome your input in several areas:
Statistics that demonstrate the extent of health equities in particular countries or for particular populations.
Examples (particularly short examples or statistics) of improvements in health equity.
For any marginalized population, what are successful strategies for improving health equity – whether initiatives within or beyond the health sector?
Successful processes or mechanisms for engaging marginalized communities (in general or specific populations) in health-related decision-making.
Are you aware of individuals in governments or international organizations that would likely be interested in developing or promoting these health equity strategies that we should be in contact with?
If you have anything you would like to share in these areas, please email me (firstname.lastname@example.org). And if you would like to participate, you can email me or have a look as March nears at the O’Neill Institute’s event page, which will provide more information on the timing and process for the consultation as soon as it is available. We look forward to your thoughts and participation.
The views reflected in this expert column are those of the individual authors and do not necessarily represent those of the O’Neill Institute for National and Global Health Law or Georgetown University. This blog is solely informational in nature, and not intended as a substitute for competent legal advice from a licensed and retained attorney in your state or country.