Annex 10. Using data to advance health equity: general policy responses

Used with other forms of evidence, disaggregated data can help to inform appropriate policy responses. The following general policy responses – policies targeted towards disadvantaged groups, policies aiming to narrow health gaps, and policies aiming to reduce health gradients – are described as a starting point to illustrate considerations that may arise as part of equity-oriented policy-making processes. Although these responses may be roughly associated with patterns of inequality in disaggregated data, equity-oriented policy-making process are complex and iterative, often relying on a combination of responses and approaches tailored to the context for which they are designed.

Targeting disadvantaged groups

One general policy response entails a specific focus on population subgroups experiencing disadvantage (1, 2), such as policies targeted towards a particular region, households experiencing poverty, workers in a particular employment sector, or adolescent parents. Policies targeted towards groups experiencing disadvantage may correspond to the marginal exclusion patterns of inequality, where one subgroup has been systematically or purposefully “left behind”.

With a relatively limited scope and focus, such policies may be efficient to roll out (if the population subgroup is easily identified) and may provide clear criteria for subsequent monitoring. Improvements in the targeted population may be evident in the shorter term, albeit within a small proportion of the overall population. Such policies may be aligned with wider efforts to promote social inclusion and improve opportunities for better health and living conditions.

There are potential drawbacks to this response (1, 3). Policies targeted towards improving the lives of people from subgroups experiencing disadvantage tend to conflate inequality and disadvantage (acknowledging, however, that fundamental structural changes may be an important part of advancing health equity). Progress may be measured based solely on the situation of the subgroup experiencing disadvantage. This perspective does not account for potentially accelerated improvements in the more advantaged groups. Such policies also risk unintentionally perpetuating stigma or legitimizing economic or other forms of disadvantage. Indeed, policies may intentionally or unintentionally introduce harms. Targeted policies also risk failing to reach people outside of the group who may be experiencing disadvantage.

Narrowing health gaps

Approaches that concentrate on narrowing health gaps aim to promote improvements among groups experiencing disadvantage at a rate that is faster than improvements among more advantaged groups (1–3). Although this response continues to emphasize improvements in subgroups experiencing disadvantage, it also maintains a focus on the rest of the population by highlighting changes in inequality. Such policy responses facilitate target setting, and health inequality monitoring is part of assessing the impact. The implementation of responses based on this approach may be technically challenging.

A limitation of this response is that, in focusing on the subgroup experiencing disadvantage, it may ignore or obscure the situation in intermediary groups, especially those that fall slightly above the most disadvantaged. Additionally, it may encourage responses that focus on lifestyle factors rather than embedded structural determinants of health.

Addressing inequality gradients

Policy responses based on gradient approaches consider health inequalities as a population-level issue, simultaneously considering the gap between the least and most advantaged, and the distribution of health across all subgroups (1–3). It widens the policy focus from seeking improvements among the subgroup experiencing disadvantage to understanding the circumstances and forces that produce and perpetuate inequality across the population overall. Accordingly, a differential rate of improvement is required for each subgroup, corresponding to its situation. Thus, gradient approaches may be part of inclusive policy goals.

Responses oriented towards addressing inequality gradients “locate the causes of health inequality not in the disadvantaged circumstances and health-damaging behaviours of [subgroups experiencing disadvantage], but in the systematic differences in life chances, living standards and lifestyles associated with people’s unequal positions in the socioeconomic hierarchy” (2). Gradient approaches, however, present certain technical and political challenges (1). Health gradients are deep-rooted and may be complex and costly to address. Long time periods may be required to see improvements.

References

1. Solar O, Irwin A. A conceptual framework for action on the social determinants of health: social determinants of health discussion paper 2 (policy and practice). Geneva: World Health Organization; 2010 (https://iris.who.int/handle/10665/44489, accessed 23 September 2024).

2. Graham H, Kelly MP. Health inequalities: concepts, frameworks and policy. London: Health Development Agency; 2004.

3. Mantoura P, Morrison V. Policy approaches to reducing health inequalities. Montreal: National Collaborating Centre for Healthy Public Policy; 2016 (https://www.ncchpp.ca/docs/2016_Ineg_Ineq_ApprochesPPInegalites_En.pdf, accessed 23 September 2024).