By Jasmine Bihm, DrPH, MPH, Director, Health Equity Innovation and Implementation, and Hawi Teizazu, PhD, Associate Director, Health Equity Innovation & Implementation, Association of Maternal & Child Health Programs (AMCHP)

Defining Health Equity

Health equity, or equity of any type, can seem like the buzz phrase of the day. Although the recent interest in health equity is to be celebrated, it is important to recognize that health equity is not a new concept. It has been 21 years since the landmark report Unequal Treatment: Confronting Racial and Ethnic Disparities in Health was published. This report catalyzed conversations about health disparities and inequalities in health care. Furthermore, addressing population health differences has been a priority area in the Centers for Disease Control and Prevention’s Healthy People Initiative since its inception in 1979. Fast forward to 2024, this work continues, and our collective understanding of health equity continues to grow. The Association of Maternal & Child Health Programs, and other leading health organizations, have expressed their vision of health equity through the following statements:

“…the unfettered well-being of women, children, youth, families, and communities…” –Association of Maternal & Child Health Programs

“Health equity is the absence of disparities or avoidable differences among socioeconomic and demographic groups or geographical areas in health status and health outcomes such as disease, disability, or mortality.” – Health Resources and Services Administration

“The state in which everyone has a fair and just opportunity to attain their highest level of health.” – Centers for Disease Control and Prevention

“Health equity means everyone has the opportunity to attain their highest level of health.” – American Public Health Association

“Health equity is the absence of unfair, avoidable, or remediable differences among groups of people, whether those groups are defined socially, economically, demographically, and geographically.” – World Health Organization

“Health equity means that everyone has a fair and just opportunity to be as healthy as possible.” – Robert Wood Johnson Foundation

The underlined and italicized text denotes the shared elements across definitions and describes the core aspects of health equity. Health equity rests on the assumption that differences in health outcomes between groups could be eliminated if everyone had the opportunity to live their healthiest lives.  Moreover, health equity is an outcome: it is the absence of disparities and the existence of robust opportunity environments.

Theory of Change: Steps Towards a More Equitable Society

If health equity is an outcome, how do we get there? The National Academies of Sciences, Engineering, and Medicine provides a theory of change that lays out what is required to advance from the current situation to a more equitable society. Essential steps include power building, systems transformation, and measurement.

• Power building involves building a broad base of support for structural interventions and policies by mobilizing the communities directly impacted by inequities and engaging with a diverse range of stakeholders. The goal is to build and foster community capacity to develop and advance structural interventions.
• Systems transformation focuses on improving the environments in which people live, work, and play. In other words, it requires intervening in the social determinants of health by promoting better opportunities for all.
• Measurement is needed to track progress and promote accountability. The theory of change recognizes the time it takes to move from improved opportunity environments to measurable changes in population health outcomes. Thus, it is essential to incorporate both short- and long-term measures to capture health equity efforts and their downstream effects. The expectation should not be to see immediate results, but gradual change that promotes the health status changes of the future.

Intervening Along the Change Spectrum

The theory of change framework can be leveraged to advance health equity in two primary ways.

• Establish: Assist in establishing community engagement, power building, systems transformations, and time-sensitive approaches to evaluation as priority areas.
• Reinterpret: Assist in reinterpreting existing efforts through an equity lens. Simply put, how do an organization’s current efforts advance progress towards equity?

Although advancing health equity requires novel solutions and actions, it also requires us to reimagine traditional public health services through an equity lens. For example, data collection is a core public health function. It is important to recognize how stakeholders use data to identify inequities and advocate for solutions in their power building efforts. Understanding the relationship between core public health functions and health equity can help maximize the equity impact of traditional public health services.

Navigating Contemporary Challenges 

Whether advancing equity through novel efforts or existing efforts reinterpreted through an equity lens, there are formidable barriers. Below are some of these barriers, along with strategies to address these obstacles and persist despite them:

• Health equity as discourse: conversations that build knowledge and sensitivity around issues of equity are a necessary first step in advancing health equity but cannot be the sole focus of our efforts to create an equitable society. To move beyond this first step, it is imperative to define desired outcomes through concrete and specific metrics, and work collaboratively to promote accountability across organizations.
• Resource limitations: efforts to center equity in public health are challenged by limitations in the resources needed to understand and address inequities (e.g., data, workforce, evidence-based practices, etc.). Nonetheless, it is possible to move the needle by approaching community engagement through a strengths-based framework. In doing so, it is important to recognize that communities have long addressed their own needs in the absence of the public health community’s attention or intervention and can advocate for resource investments in ways that public health cannot.
• Politicization of health equity: the existing narrative surrounding health equity erroneously assumes that it is financially burdensome or benefits only a subset of our nation’s population. Public health professionals can actively reframe this narrative in health communication efforts by educating others about the evidenced cost of health inequalities and the cost of inaction.

Conclusions

The definitions, framework, and strategies shared in this article emphasize two equally important needs in public health efforts to promote health equity: the need to embrace new ideas and the need to remember familiar lessons. Achieving health equity requires incorporating novel practices and carrying out traditional public health services using new perspectives. Achieving equity also requires us to get back to the basics. This means ensuring that the outcomes embedded across definitions of health equity remain our end goal: the absence of health disparities and robust opportunities for everyone.