What Can Public Health Programs Do to Improve Health Equity?

Ritu Sadana, ScDa Erik Blas, DrPHb Health inequalities are disparities in health, reflecting either differences in access to a range of promotional, preventive, curative, or palliative health services or differences in outcomes including disability, morbidity, and mortality spanning physical, mental, and social health. The causes of inequalities in health are dynamic and reflect multiple determinants. Health inequities, however, are differences in health that are judged to be avoidable, unfair, and unjust.1 Health inequities are often revealed through systematic patterns or gradients in access or outcomes across populations with different levels of underlying social advantage or disadvantage—that is, wealth, power, prestige, or other markers of social stratification.2 Numerous reviews across low-, middle-, and high-income countries continue to document that health inequalities are related not only to biological or genetic factors, but also to social factors that are amenable to policy and are potentially avoidable given cross-group or cross-population comparisons. Studies most often document differential access to health services based on an individual’s socioeconomic position or place of residence, rather than on need,3–6 although other approaches exist.7 The place in the social hierarchy that individuals and groups occupy, combined with the epidemiological environment, then determines exposure and vulnerability to health-enhancing or health-damaging conditions in daily life (e.g., where people are born, grow, live, work, and age).8 The underlying causes are complex, often reflecting systematic social, political, historical, economic, and environmental factors that also interface with biological factors. The term “social determinants” is often used as shorthand for all of these factors and is relevant to communicable and non-communicable conditions alike.9 An added complexity is that negative or positive impacts of social determinants of health (SDH) can be accumulated during a lifetime, alter health trajectories across the life course, and be transferred across generations.10 Moreover, labeling an inequality as an inequity also reflects a value judgment. This labeling is sometimes made explicit by deliberating on facts, clarifying underlying values, and designing remedial actions. Often, however, there is no