Ontario
Within the OPHS and its 26 protocols, the terms “equity”, “equities” and “inequity” are seldom mentioned alone, but rather in combination with specific reference to health equity or inequities. The key terms used are “health inequalities”, “health inequities” or “inequities in health”, which are each defined explicitly. In the OPHS, health inequalities are defined as “differences in health status or in the distribution of health determinants between different population groups”[
17](p. 4). Some of these are “attributable to the external environment and conditions mainly outside the control of the individuals concerned” and may “lead to inequity”. Health inequities are health inequalities that are deemed “unnecessary and avoidable as well as unjust and unfair”[
17] (p. 4). This definition is derived from the World Health Organization[
22] and consistent with an influential discussion paper by Whitehead and Dahlgren[
23].
The goal of reducing health inequities is very prominent in the Introduction to the OPHS and the Foundational Standard, which underpins all other standards. Achieving health equity is presented as being as important as the improvement of overall population health. The Foundational Standard outlines Board of Health requirements to use data on population health, determinants of health and health inequities to tailor programs to meet local needs, including those of priority populations. There is a suggestion that public health units can achieve both goals of public health simultaneously, i.e. “reduce inequities in health while at the same time maximizing the health gain for the whole population”[
17] (p. 13). Reducing health inequities can also be a means of achieving better overall population health with an emphasis on priority populations, defined below. For example, “By tailoring programs and services to meet the needs of priority populations, boards of health contribute to the improvement of overall population health outcomes” and “population health outcomes are often influenced disproportionately by sub-populations who experience inequities in health status”[
17](p. 12). Two of the four principles that underpin the OPHS,
need and
impact, emphasize the reduction of health inequities. The Population Health Assessment protocol also emphasizes the need to reduce health inequities.
However, this explicit focus on reducing health inequity is not evenly maintained throughout the OPHS. The broad vision of public health presented in the Introduction does not explicitly mention health inequities stating, “the primary focus of public health is the health and well-being of the whole population”[
17] (p.2). Few of the specific protocols, which were developed to provide further direction where standardization was identified as needed, actually name reducing inequities as a goal. The strong theoretical commitment to achieving health equity appears to be reconciled with this lack of specificity by identifying the reduction of health inequities as a societal outcome, rather than as a Board of Health outcome. As a societal outcome, it is not solely the responsibility of local public health, but public health is to work with community partners to achieve this goal.
Within the OPHS, the term “priority populations” is often used as a proxy for the need to address health inequities. Priority populations are defined as “those populations that are at risk and for whom public health interventions may be reasonably considered to have a substantial impact at the population level”[
17] (p.2). Almost all Protocols refer to priority populations and some explicitly identify certain groups. For example, in the Tuberculosis Prevention and Control Standard, they are identified as “those incarcerated in correctional facilities, Aboriginal peoples and First Nation communities, refugees, recent arrivals to Canada, homeless persons, and those who work closely with these groups” (p. 37). Other ways of implicitly referring to health inequities occur in protocols that call for “all” to have healthy lives, or that label some groups as being “at risk”. For example, the goal of the Child Health Standard is “to enable all children to attain and sustain optimal health and developmental potential” (p. 27). In the Healthy Babies, Healthy Children Protocol, “at risk” is defined as “some risk that a child may not reach his or her full potential”, and “high risk” as “a serious risk that a child may not reach his or her potential”. Addressing the needs of such populations is referred to in the goals of several standards, with the emphasis on the development of individual skills, provision of a safe and supportive environment and influencing the development of health-promoting public policy.
The determinants of health play a prominent role in relation to reducing health inequities in the OPHS. “Addressing determinants of health and reducing health inequities are fundamental to the work of public health in Ontario”[
17](p. 2). The determinants of health are also important in identifying priority populations. For example, the Nutritious Food Basket Protocol makes a concrete link, “consider the determinants of health to assist in identifying priority populations and use population health data and information to focus public health action”[
17] (p. 1). There is some exploration in the OPHS of why health inequities exist. The Foundational Standard notes, “It is evident that population health outcomes are often influenced disproportionately by sub-populations who experience inequities in health status and comparatively less control over factors and conditions that promote, protect, or sustain their health.”[
17](p. 12). These statements highlight the specific need to identify what is unfair and how inequities arise, implicitly acknowledging a commitment to social justice within public health[
24].
Three categories of actions to reduce health inequities are discussed in the OPHS. First, there is a focus on surveillance and measurement. For example, the Foundational Standard states, “Population health assessment includes measuring, monitoring, and reporting on the status of a population’s health, including determinants of health and health inequities.”[
17] (p. 15). Many protocols discuss the need to identify priority populations through surveillance, but very few discuss taking specific action if health inequities are found. An assumption implicit within the OPHS is that measuring health inequities will lead to action to reduce them.
Second, there is a focus on addressing the accessibility of public health programs and lowering barriers to them. For example, there is a need to “tailor public health programs and services to meet local population health needs, including those of priority populations” (p. 16) and provide “outreach to priority populations to link them to information, programs, and services”[
17] (p. 26). For example, products such as vaccines should be distributed in an equitable manner, clinical care should be accessible, and injury prevention and harm reduction services should be targeted to high-risk populations.
Third, the OPHS focuses on partnerships and collaboration to reduce health inequities. “The scope of these standards includes a broad range of population-based activities designed to promote the health of the population as a whole, and with community partners to reduce health inequities”[
17] (p. 1). This reflects an understanding that “the ability to influence broader societal changes is the responsibility of many parties.”[
17] (p. 13). There are multiple calls for community engagement and to increase the capacity of partners. There is a focus on supporting civil society organizations and engaging them in setting priorities and in implementing programs.
In certain areas of the OPHS, the need to reduce health inequities is absent where it may be anticipated, given what is known about health inequities in Canada[
2]. There is little mention of First Nation, Métis and Inuit populations, with the exception of the Tuberculosis Prevention and Control Standard. The Environmental Health and Infectious Disease Program Standards do not discuss health inequities beyond the general concept of certain populations being at greater risk. This is also found in the areas of health promotion and emergency management.
In summary, the OPHS presents a theoretical framework to address health inequities and provides some mechanisms by which local public health can work to reduce them. Most discussion of inequities occurs within the introductory materials. The responsibility of local public health is pragmatically outlined as identifying priority populations, meeting their needs “to the extent possible based on available resources.”[
17] (p. 16) and reporting on health inequities to the community, representing one aspect of accountability. Collaboration is seen as central to any effort to reduce inequities. There is a stated need to balance prescriptiveness with autonomy for local public health. Finally, while the OPHS does not delve into why inequities exist, there is a clear recognition of the importance of the SDOH.
British Columbia
The BC Core Functions Framework and the 15 available MCP papers were included in the analysis and reviewed. Within these documents, a variety of terms are used to discuss health inequities. “Inequalities in health” is the most common, followed by “equitable” and “equity”. The Equity Lens Evidence Review provides the following definition, which is similar to the OPHS, “When inequalities are unfair and avoidable, even unjust, then they become inequities.”[
19] (p. i). Related, “vulnerable populations” are defined as “those with a greater-than-average risk of developing health problems… by virtue of their marginalized sociocultural status, their limited access to economic resources, or personal characteristics such as age and gender”[
25](p. 3). A number of other terms are used in the BC documents that refer to vulnerable populations. These include “vulnerable groups”, “vulnerable populations of children” and the need to address “health disparities”. Specific groups are named in the Resource Document[
19](p. 49) and in several MCP papers (Table
2).
Table 2
A comparison of priority groups identified in the BC Core Functions Framework and select Model Core Program Papers
Aboriginal people | Adults in care | Teen mothers | Aboriginal people | Residents of group homes | Aboriginal communities |
Ethno-cultural communities and people of colour | Low income people | Aboriginal people | People with limited income | Elderly (especially the frail elderly) | Mental health groups |
Women, where they are at special risk, or for female-specific conditions | Pregnant women and families | Immigrants, refugees and diverse cultural groups | Immigrant populations | People with physical and mental disabilities | Immigrant groups |
Men, where they are at special risk, or for male-specific conditions | People with developmental disabilities | | Seniors in care | Ethnic minorities | Low-income seniors |
People with disabilities | | | | | |
Infants and children | | | | | |
Youth | | | | | |
Seniors | | | | | |
People with low incomes | | | | | |
Residents of remote, rural, or northern communities | | | | | |
Lesbian, gay, bisexual, and transgendered people | | | | | |
The goal of reducing health inequalities is prominent throughout. As noted in the Framework, “public health has a duty, as one of its fundamental tasks, to work to reduce inequalities in health”[
19] (p. 48). Similar to the OPHS, this task is seen to be as important as improving the overall health of the entire population. This is rooted in the concept of “population health”, which underpins the BC Core Functions Framework[
19](p. 8). As noted in the Healthy Living MCP, population health “is an approach to health that aims to improve the health of the entire population and to reduce health inequities among population groups.”[
26](p. 3).
An equity lens, along with a population lens, is a cross-cutting feature of the BC Core Functions Framework. The equity lens, which is referenced throughout the documents, is “in place to ensure the health needs of specific populations are addressed”[
19](p. 20). The lens is also used for “gathering statistical information from a range of sources on the health status of specific at-risk groups and sub-populations” and to identify “meaningful priorities”[
27].
References to the SDOH occur repeatedly throughout the BC Framework and a number of lists of determinants are provided. For example in Health Emergency Management, “disaster vulnerability has been linked to the determinants of health, in particular, income, social status, social supports and personal health”[
28](p. 11). This focus on the SDOH is linked to the overarching concept of population health, “which takes into account social, economic, environmental determinants of health, including protective factors, risk factors and vulnerable populations”[
25](p. 16). There is an emphasis on the need for each health authority to “assess and report on the determinants” for their population[
19] (p. 45). However, there is also an emphasis on taking action. While there is recognition of the limits of the evidence supporting action on SDOH, “this does not diminish the importance of the broader determinants of health and the strategies need (sic) to address them”[
19](p. 19).
Actions to reduce health inequities discussed in the BC documents fall into five categories. First, there is a need to quantify health inequities by “gathering statistical information from a range of sources on the health status of specific at-risk groups and sub-populations”[
27](p. 18). “The task of public health is to participate in the identification of populations at risk and work to reduce their risk”[
19](p. 41). There is also the mention of “developing profiles or snapshots of high-risk populations and sub-groups on a health authority and community level”[
26](p. 27).
Second, there is an emphasis on taking action on the SDOH. Examples include addressing housing, community food policies, strengthening community services, local action on urban design and transportation, and bylaws. The Food Security MCP paper is a good example of the idea of taking action to reduce health inequities by focusing on the SDOH. “It is well known that poverty is a major determinant in food insecurity. Significant improvements in food insecurity can be achieved through collaborative efforts to address community food security and poverty issues”[
29] (p. 12).
Third, advocacy is identified as key to “addressing fundamental issues such as community poverty, environmental sustainability, social development and economic vitality”[
27](p. 4). This is tied to the recognition of the need for “political commitment throughout” and a connection to social justice. In the Resource Docment,[
19](p. 9), one figure lists a number of items that relate to social justice under conditions that influence health. These include, “achieving an equitable distribution of income”, “an adequate income for all” and “reduction in the number of families living in poverty”. Further, in the Food Security MCP paper, there is a reference to “fairness and openness” as well as the need for an “equitable distribution of food”[
29](p. 26). The Healthy Infant and Child Development MCP is perhaps the most explicit, by calling for public health “to address and work to change the broader community and societal factors that influence child health”[
19](p. 26).
Fourth, intersectoral action is seen as key to reducing health inequities, so empowered communities can “take control of the factors that determine their well-being”[
27](p. 2). Public health can “build strong social networks and social support” and the idea of collaboration with government, other organizations and with “vulnerable populations”, occurs in several MCP papers. Such collaboration is often for the purpose of affecting policy change. Many papers mention the need to develop partnerships, develop “community coalitions” and take “a leadership role in initiatives that address the determinants of health”.
Fifth, several MCP papers emphasize the need to have general interventions and “targeted interventions” to specific, at-risk or vulnerable groups. The need for access to specific, directed services is noted within Dental Health, “Advocacy for access to dental treatment for vulnerable populations is recognized as a best practice”[
30](p. 6). There is also some mention of “equitable access”, “accessible to all” and “improving access/removing barriers” in the Resource Document, but few specifics are given. Providing information to specific groups is noted within the Dental Public Health and the Healthy Infant and Child Development MCP. Related to this, the BC documents have a strong focus on Aboriginal populations, which are mentioned throughout the Framework. They are often cited as a high-risk group or vulnerable population. The Healthy Infant and Child Development MCP specifically lists health inequities between Aboriginal communities and the general population, including higher infant mortality rates, food insecurity and anemia. Similarly, the Unintentional Injury Prevention MCP mentions specific inequities and provides figures. It also mentions the need to use OCAP (ownership, control, access, possession) principles when working with Aboriginal communities[
31]. The emphasis is that "Specifically, "it is important that Aboriginal groups have full involvement in the planning and delivery of early childhood health and development programs to families on First Nation reserves as well as Aboriginal families in other communities”[
25](p. 14).
There is an emphasis on accountability within the Framework and how it can be achieved. “Consideration may be given, in consultation with the health authorities, to an accountability framework for reducing these inequalities. This may involve reporting on core publicizing health program activities by documenting and making public regional inequalities; by analyzing the factors that contribute to such inequalities; and by reporting on their involvement in advocacy coalitions, agency partnerships, community development, and similar efforts directed at reducing inequalities in access to the basic determinants of health”[
19] (p. 49). Similar to the OPHS, there are limitations emphasized as to what public health can do to address health inequities. The determinants of health “may be beyond the control of public health staff or health authorities”[
19](p.56). In the Healthy Infant and Child Development MCP, “areas such as income and education levels, housing conditions, and access to child day care programs are outside the authority of the health authority”[
25](p. 23). However, this is immediately followed by an emphasis on the advocacy role of public health.
In summary, the importance of addressing health inequities occurs throughout the BC Core Functions Framework and related documents. The use of an equity lens is explicit and has seemingly led to very specific actions outlined in the MCP papers with most naming vulnerable or 'at risk' population. Health inequities between Aboriginal and non-Aboriginal populations are particularly highlighted. There is an emphasis on taking action on the SDOH, particularly through advocacy, which is central to and based on community collaboration.