Week 13 Health Equity and Equality

Question 1

Equality refers to

Answer 1

sameness or equal distribution

Question 2

Equity refers to

Answer 2

justice, rightness or fairness

Question 3

While everyone may be in favour of equity,
they might not be for the same definition of
equity
Debates around equity of who gets what,
when, and how fall into three dimensions:

Answer 3

◦ Recipient
◦ Item
◦ Process

Question 4

Recipient-based challenges

Answer 4

Membership: who gets to be a recipient
◦ Unequal invitation but equal slices
Merit: reward for individual accomplishment
◦ Equal merit, equal slices; unequal merit, unequal slices
Rank: relevant differences between segments of a larger group, and resources
should be allocated based on subgroups rather than individual differences
◦ Equal ranks, equal slices; unequal ranks, unequal slices
Group-based distribution: similar to rank, but assigns people into groups based
on traits that have nothing to do with individual qualifications or achievement
(e.g. race, sex, age etc)
◦ Equal blocs/unequal slices

Question 5

Item-based challenges

Answer 5

Boundaries of the item: redefining an item as part of a larger whole
◦ Equal meals/unequal slices
Value of the item: redefining the value of an item from a standardized value to a customized, individualized value
◦ Equal value/unequal slices

Question 6

Process-based challenges

Answer 6

Competition (opportunity as starting resources)
◦ Equal forks/unequal slices
Lottery (opportunity as statistical chance)
◦ Equal chances/unequal slices
Voting (opportunity as political participation)
◦ Equal votes/unequal slices

Question 7

Vertical equity

Answer 7

those who are different are treated differently
◦ Virtual equity in care: care is provided on the basis of need. Greater needs should receive
more or more rapid access to health care.
◦ Virtual equity in financing: those greater wealth should make greater contributions to the health care system (rather than those with greater needs!)

Question 8

Horizontal equity

Answer 8

those who are equal are treated equally
◦ Horizontal equity in care: those with the same need for health care receive the same amount
or access to treatment
◦ Virtual equity in financing: people with equal incomes make equal contributions to the
healthcare system (regardless of health status or use of services)

Question 9

Relevance for Health Policy
Recipient-based:

Answer 9

◦ Membership: who is entitled to a health service?
◦ Rank: which physician specialities should be paid higher wages?
◦ Group: group-distributions are used to compensate for systemic inequity and
injustice
◦ Medical school slots specifically allocated for Indigenous students

Question 10

Relevance for Health Policy
Item based:

Answer 10

◦ Boundaries of item: Income-based programs like public drug and dental plans.
offered to low income individuals for whom drug costs would otherwise represent a significant percentage of their income.
◦ Value of the item: Healthcare is not a “good”. It has no intrinsic value to users.
Nobody wants equal slices of health care.

Question 11

Why focus on equity/equality in a course
on healthcare systems?

Answer 11

Roots of health inequalities lie in wider social and economic inequities

Question 12

Health system organization and health services delivery have an important impact on health disparities

Answer 12

◦ Reducing barriers to equitable access to care
◦ Targeted interventions that improve the health of socially or economically
marginalized communities
◦ Focused investments in prevention and primary care

Question 13

There are systemic health system inequities that need to be addressed:

Answer 13

◦ Despite the equity principles of the CHA, people in lower socioeconomic
groups have worse access to care, while simultaneously having more and
more complex needs
◦ Health care programs can make health inequalities worse if gaps in access are
sustained or widen
◦ Ties back to parallel private systems
Health disparities are health system cost drivers
Healthcare sector has a clear mandate in this area

Question 14

Health inequalities

Answer 14

differences in health status
or in the distribution of health determinants
between different population groups.

Question 15

Health inequities

Answer 15

subset of health inequalities
that are deemed to be unfair or unjust, that
arise from the systematic and intentional or
unintentional marginalization of certain groups, and that are likely to reinforce or exacerbate disadvantage and vulnerability

Question 16

Health equity

Answer 16

the absence of unfair and
avoidable or remediable differences in health
among population groups defined socially,
economically, demographically or geographically

Question 17

Indicators

Answer 17

Health status
-Life expectancy
-Mortality and disability
-Perceived physical/mental health
-Infectious and chronic diseases

Health determinants
-Health behaviours
-Early childhood development
-Physical and social environment
-Working conditions
-Access to health care
-Social protection
-Social inequities

Question 18

Social stratifiers

Answer 18

SES
-income
-education
-employment
-material and social deprivation

Indigenous peoples
-First Nations
-Inuit
-Metis

Place of residence
-rural/urban

Sex
-Male or female

Jurisdiction
-National or provincial/territorial

Question 19

Indicators

Answer 19

Domains
◦ Health outcomes
◦ Daily living conditions
◦ Structural drivers
Indicators selected based on whether they:
◦ Reveal pronounced inequities across groups
◦ Cover a range of health outcomes
◦ Allow for disaggregation across key population groups
◦ Are policy relevant and actionable
Draws on data from: Canadian Community
Health Survey, Canadian Vital Statistics
Database, the Canadian Cancer Registry & First
Nations Regional Health Survey

Question 20

Structural Drivers:

Answer 20

◦ Developmental vulnerability in early childhood: higher among lower SES
neighbourhoods, individuals identified as Indigenous
◦ Food insecurity: higher in the lowest income groups, First Nations living off
reserve, and Métis, among households with lower educational attainment
◦ Working poverty: higher among First Nations living off reserve, and Métis,
and households with lower educational attainment

Question 21

Daily Living Conditions:

Answer 21

◦ Health behaviours:
◦ Smoking, exposure to second-hand smoke: increased with decreasing levels of income, educational
attainment and occupational skill
◦ High alcohol consumption: higher among men, bisexual or lesbian women, First Nations living off
reserve, Métis and Inuit adults; higher with increasing incomes and those in in skilled, technical, or
supervisory occupations
◦ Physical and social environments:
◦ Housing below standards highest among lowest income groups, decreasing along a gradient; also
higher among recent immigrants, and visible minorities

Question 22

Health outcomes

Answer 22

Canadians as a whole are healthy but health inequalities persist and are growing
As with health determinants, health disparities are not simply a have-have not issue; for most, there is a
gradient
◦ At every step in the SES gradient there are differences in risk factors and risk conditions, health status, incidence of disease
and mortality across a wide range of physical and mental disorders.
Life expectancy and health-adjusted life expectancy are lower, while infant mortality is higher:
◦ In lower-income areas; with lower educational attainment,
◦ In areas with high concentrations of First Nations, Inuit and Métis people
◦ In remote communities
Self-rated mental health:
◦ Lower among those in the lowest income and SES groups, with lower levels of education, or who identify as bisexual or
gay/lesbian
Hospitalization for mental illness:
◦ Similar pattern to mental health (SES gradient) but also higher in areas with high concentration of has similar SES gradient
but also higher in areas with higher concentration of people identifying as Métis, Inuit, or First Nations

Question 23

Key Principles to be adopted

Answer 23

1. Adopt a human rights approach to action on social determinants
   of health and health equity
2. Intervene across life course with evidence-informed policies and
   culturally safe health and social services
3. Intervene on downstream and upstream determinants of health
   and health equity
4. Deploy both targeted interventions and universal policies/
   interventions
5. Address material contexts and sociocultural processes of power,
   privilege, and exclusion
6. Implement a ”Health in All Policies” approach
7. Carry out ongoing monitoring and evaluation.

Question 24

Inequalities are driven by underlying inequities that are the result of explicit policy choices

Answer 24

◦ Doing nothing/maintaining status quo IS a policy choice.