Policy and Position Statements

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Achieving Optimal Health for All - Policy Statement

As a nation, the United States must take decisive action to achieve health equity by eliminating the health inequities and disparities experienced by significant segments of the population and creating opportunities for optimal health for all individuals. Every public health professional should undertake eliminating health disparities as a critical part of their job. ASTHO believes that eliminating health disparities is an American and global challenge that affects all people.

In Healthy People 2020, the U.S. Department of Health and Human Services (HHS) acknowledged the central importance of addressing health inequities and disparities to achieve overall improved health when it established "a renewed focus on identifying, measuring, tracking, and reducing health disparities through a determinants of health approach".1 The goals and mission of federal initiatives such as HHS's National Stakeholder Strategy to Achieve Health Equity and HHS's Action Plan to Reduce Racial and Ethnic Health Disparities stress the commitment to achieving health equity for the nation from the highest levels of the government. Health reform offers the opportunity to address the needs of racial and ethnic minority and other  populations by reducing the cost of healthcare, increasing the investment in prevention and wellness, supporting primary care improvements, and creating partnerships between public health, the health care field, and social services. In addition, ASTHO elevated "promoting health equity" from a crosscutting goal of the organization to our strategic map's central challenge in recognition of the fact that we cannot improve health outcomes without improving health equity. We are in alignment with the World Health Organization's (WHO) position that: "The objective of good health is…twofold: the best attainable average level - goodness - and the smallest feasible differences among individuals and groups - fairness."2

At present, significant inequities and disparities exist in key health indicators, such as infant mortality rates, life expectancy and rates of disease; in key risk factors, such as smoking rates, access to care, nutrition and physical activity; and in the social determinants of health, such as poverty, inadequate housing and unsafe working conditions. Health disparities that have their roots in social determinants of health are referred to as health inequities; these are a reflection of the persistent barriers to health that exist in American society. According to the Joint Center for Political and Economic Studies report, the combined direct and indirect costs of health inequities in the US were $1.24 trillion between 2003 and 2006.3

Recognizing the relationship between health disparities and health inequity, ASTHO advocates for policies and strategies that achieve health equity by eliminating health disparities and socially-determined barriers to positive health outcomes. These underlying disparities have great costs to the American people as well.

1.  DETERMINANTS OF HEALTH

ASTHO recognizes that:

  1. Health inequities exist among groups based on factors such as: poverty, income, race, ethnicity, education, disability, geographic location, gender, and sexual orientation.
  2. The following are major determinants of health status: environmental and social exposures, education and economic opportunities, health behaviors, access to and quality of healthcare, and genetics.
  3. Contributors to health inequities are interconnected and must be addressed through multifaceted and multi-sector approaches.
  4. Structural and individual racism and other forms of discrimination affect health outcomes.4  
  5. Exposure to risk factors for health inequities is intergenerational and can occur even prior to conception.5

2.  ROLE OF ASTHO

ASTHO acknowledges that the United States has made progress towards achieving goodness and fairness in health but realizes that there is more work to be done in order to mobilize leadership to promote health equity. In response, ASTHO proposes to accomplish the following to promote health equity for all:

  1. Provide national and state leadership to achieve optimal health for all. Foster societal understanding and the will to achieve health equity.
  2. Promote public health and population health approaches to achieving health equity, such as the core public health functions of assessment, assurance, and policy development. 
  3. Track state and territorial practices, policies, and scientific research that promote health equity.
  4. Educate decision-makers on health equity and its relationship to health disparities and ensure that health equity remains a priority issue in public health policies and programs.
  5. Assist with the evaluation of state and territorial practices to develop an evidence-base for effective health promotion activities.
  6. Develop and disseminate information and tools to state/territorial health agencies to support the replication of promising practices and policies. Strengthen organizational effectiveness in support of health equity.
  7. Convene and facilitate collaboration among state, territorial, local, federal, tribal and private-sector decision-makers to both reduce health disparities and increase health equity. Leverage and engage broad public/private partners in health equity solutions.
  8. Support state and territorial health agencies in advocating for policies that integrate health equity into their state strategic plans, priorities, and policies. Leverage existing and new funding for health equity.
  9. Expand primary care and community prevention efforts related to specific populations such as those with low socioeconomic status.

3.  ROLE OF THE STATE AND TERRITORIAL HEALTH AGENCY

State and territorial health agencies play a critical role in setting and promoting a health equity agenda. However, promoting health equity and reducing disparities is not solely the responsibility of the state or territorial health agency. Partnerships between communities, states, and national organizations should incorporate a "health in all policies" approach that includes agencies involved in not only health, but education, housing, labor, justice, transportation, agriculture, and the environment. The healthcare delivery system also needs to be involved in reducing unequal treatment in the quality of clinical services received by different populations.6

ASTHO encourages its member agencies to perform the following:

  1. Provide leadership at the executive level to ensure that health equity and related health disparities are integrated at the strategic, policy and programmatic levels. Use the prominent authority of the state and territorial health official to raise public awareness of health inequities and increase the focus on solutions.
  2. Build infrastructure within their organizations to implement and sustain health equity activities by ensuring health equity is fully integrated into all state and territorial strategic priorities and plans.
  3. Serve as a resource on health equity and health disparities to the governor, legislators and other agencies in their states and territories.
  4. Advocate for cross-cutting "health in all policies" approaches across all programmatic areas.
  5. Proactively form partnerships with agencies and organizations in sectors beyond public health and clinical care (business, transportation, housing, public safety, corrections, etc.) in advancing a "health in all policies" strategy to address the social determinants of health.
  6. Standardize data collection at the state and local level. Collect data and develop reports that support decision-making on programs and policies for impacted populations.
  7. Evaluate the feasibility of harmonizing state data collection with HHS data collection on race, ethnicity, gender, primary language, and disability status as required by Section 3101 of the Public Health Services Act.
  8. Invest and implement integrated data systems that collect data from various health and human service agencies. Data should include program activities as well as resource and funding allocation.
  9. Coordinate programs to ensure equitable distribution of health resources throughout the state/territory.
  10. Sponsor and promote programs that ensure that the health workforce in the states/territories reflects the ethnic and racial mix of the populations served.
  11. Train and provide resources to health care and public health professionals to ensure cultural and linguistic competency and quality health care through the National Culturally and Linguistically Appropriate Services (CLAS) Standards in Health and Health Care.7
  12. Engage communities and organizations that serve diverse populations (community- and faith-based organizations, local health departments, tribal governments, community health centers) to develop and implement strategies to achieve health equity.
  13. Design the grant-making process to advance health equity. Encourage the promotion of health equity as a component of the work under grants, funding, and procurement by state health agencies.
  14. Evaluate innovative programs and strategies that promote health equity and reduce related health disparities.
  15. Encourage and provide resources for cross-agency collaboration on the social determinants of health, such as transportation, housing, education, environment, labor, etc.
  16. Establish goodness and fairness goals for state health agency initiatives and share promising and best practices with and between other states.
  17. Consult and collaborate with their state Office of Minority Health, Centers of Excellence in health disparities, and other entities whose mission is health equity.

4.  ROLE OF GOVERNORS, FEDERAL, OR NATIONAL STAKEHOLDERS

To support the state/territorial health agency in its efforts to achieve health equity, ASTHO encourages governors, executive offices and agencies of the federal government, research institutions and others to:

  1. Provide leadership, financial and administrative support for information and analysis on underrepresented population groups. Raise awareness of health equity and health disparities as national and state priority.
  2. Evaluate and promote successful state and territorial health equity promotion practices at the national level including the practice of engaging those most impacted by health inequities.
  3. Lead all state/territorial government agencies in evaluating and optimizing the impact that agencies' policies and programs have on population health status and ensure interagency collaboration to end health inequities.
  4. Engage all sectors of state, territorial, tribal and federal executive government in health equity promotion efforts, including the application of solutions that directly address the social determinants of health.
  5. Use the opportunities provided through health reform to increase access to health care for racial/ethnic minorities and other underserved populations, reduce discrimination based on medical history, increase cultural and linguistic competency among providers and increase diversity in the workforce.

DEFINITIONS

ASTHO relies on the following definitions for work related to health inequities, health disparities and health equity:

  1. Equity: "A just and fair inclusion in a society where we can all prosper."8
  2. Health disparity: "a particular type of health difference that is closely linked with social and/or economic disadvantage. Health disparities adversely affect groups of people who have systematically experienced greater social and/or economic obstacles to health and/or a clean environment based on their racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation; geographical location; or other characteristics historically linked to discrimination or exclusion."9
  3. Health equity: "attainment of the highest level of health for all people. Achieving health equity requires valuing everyone equally with focused and ongoing societal efforts to address avoidable inequalities, historical and contemporary injustices, and the elimination of health and healthcare disparities."10
  4. Health inequity: "differences in health which are…unnecessary and avoidable…unfair and unjust."11 Also, "…systematic disparities in health, or in the major social determinants of health, between groups with different levels of underlying social advantage/disadvantage (for example, by virtue of being poor, female, and/or members of a disenfranchised racial, ethnic, or religious group)."12
  5. Social determinants of health: where we live, learn, work and play or "the economic and social conditions that influence the health of individuals, communities and jurisdictions as a whole."13

Approval History:

Access Policy Committee Review and Approval:
Board of Directors Review and Approval: July 2014
Ratified by the ASTHO Assembly of Member: December 2014
Policy expires: December 2017

ASTHO policies are broad statements of enduring principles related to particular policy areas that are used to guide ASTHO's actions and external communications.

Related ASTHO Documents:

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Access Policy Statement


References

  1. Healthy People 2020. http://www.healthypeople.gov/2020/about/DisparitiesAbout.aspx. Accessed on 12/4/2013.
  2. World Health Organization. The World Health Report 2000. Health Systems Improving Performance. http://www.who.int/whr/2000/en/index.html. Accessed on 12/4/2013.
  3. TA. LaVeist, DJ. Gaskin, P. Richard. The Economic Burden of Health Inequities in the United States. Washington D.C.: Joint Center of Political and Economic Studies; September 2009.
  4. CP. Jones. Levels of Racism: A Theoretical Framework and a Gardener's Tale. American Journal of Public Health. August 2000, vol 90. No.8. Available at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1446334/pdf/10936998.pdf. Accessed 4-16-2014.
  5. Centers for Disease Control and Prevention. Recommendations to improve preconception health and health care-United States. Morbidity and Mortality Weekly. April 21, 2006; 55( RR-6).
  6. Institute of Medicine. Unequal Treatment: What Healthcare Providers Need to Know About Racial and Ethnic Disparities in Healthcare. Available at http://www.iom.edu/~/media/Files/Report%20Files/2003/Unequal-Treatment-Confronting-Racial-and-Ethnic-Disparities-in-Health-Care/Disparitieshcproviders8pgFINAL.pdf. Accessed 2/6/2014.
  7. The Office of Minority Health. National Culturally and Linguistically Appropriate Services (CLAS) Standards in Health and Health Care. Available at https://www.thinkculturalhealth.hhs.gov/Content/clas.asp. Accessed 12/9/2013.
  8. PolicyLink. About Us. Available at http://www.policylink.org/site/c.lkIXLbMNJrE/b.7977453/k.FBB8/PolicyLink_About_Us.htm Accessed 12/3/13.
  9. Office of Minority Health. National Stakeholder Strategy to Achieve Health Equity. Available at http://minorityhealth.hhs.gov/npa/templates/content.aspx?lvl=1&lvlid=33&ID=286. Accessed 1/13/2014.
  10. Office of Minority Health.
  11. M. Whitehead. The Concepts and Principles of Equity and Health; Copenhagen: World Health Organization. Regional Office for Europe, 1990 (EUR/ICP/RPD414).
  12. P. Braveman, S. Gruskin. Defining Equity in Health. Journal of Epidemiology and Community Health. 2003; 57:254-258.
  13. D. Raphael (ed).) Social Determinants of Health: Canadian Perspectives. Toronto: Canadian Scholars Press; 2004:1.