Health equity

Overview

In the first lesson in this module we introduced the goal of ‘quality of life for all people with HIV.’ We noted that the words ‘for all’ introduce an obligation to check that nobody is being left behind. In the second lesson we covered the different sources of data we can use to monitor HIV outcomes. This lesson covers the concept of health equity, which provides a framework for using data on HIV outcomes to make sure that nobody is being left behind.

What is health equity

Health equity is a framework for bringing our social justice values into our practice in public health and health promotion. It draws on what we learn about the changing epidemic to identify opportunities for further action and intervention.

For a long time, the HIV sector has had a strong commitment to diversity and inclusion, but these concepts are hard to measure. Health equity aims to create measurable change in the world.

To understand health equity, we can ask what counts as a health inequity. We will use a definition from Margaret Whitehead:

• There is a difference in health outcomes between one group and the mainstream population
• The difference is preventable and therefore unfair

The language of health equity can be uncomfortable, since it implies we are failing at some aspects of our jobs. There are two ways of dealing with this. One says managing discomfort is part of the job. The other says health equity helps us identify opportunities for action today and in the future. This is the approach we recommend.

Proactive and reactive action

Health equity has proactive and reactive aspects to it. We can promote health equity and remove health inequities. Removing health inequities is reactive — it means identifying and closing the gaps. Promoting health equity means taking proactive steps to make prevention and service provision fairer. We always need to be doing both things at the same time, even though they may involve different activities.

For example:

• The Fifth National Aboriginal and Torres Strait Islander BBV/STI Strategy identified that in 2016, Indigenous people had a 2.2 times higher chance of having HIV than non-Indigenous people born in Australia. We can develop strategies designed to close this gap and remove the health inequity.
• However, we also need to ensure all our activities and services are culturally safe for people of Aboriginal and Torres Strait Islander backgrounds, including clients, contacts, community members and colleagues. This is an example of promoting health equity.

We always need both aspects — removing inequities and promoting health equity.

Identifying inequities

We can use our understanding of the changing epidemiology of HIV in Australia to identify some of the gaps we might want to target. For instance, we are seeing disproportionate numbers of new HIV cases among overseas-born gay, bisexual and other men who have sex with men (GBM). This represents a difference in health outcomes that we can work to reduce.

When we talk about health outcomes, we are not just talking about HIV diagnoses. There are a large number of possible health outcomes where gaps might emerge. Research doesn’t routinely check for differences in many of these areas. So we also rely on consultation with clients and communities to identify where gaps might exist or emerge.

Examples of outcomes:

• Infections
• Timely diagnosis
• Starting treatment early
• Understanding that U=U (undetectable = untransmittable)
• Feeling okay about diagnosis
• Starting to have sex again
• Thinking about the future
• Good quality of life

Some of these outcomes are subjective, and that’s okay. We can use any one of the different kinds of research and knowledge to identify gaps in the Australian response to HIV. Ideally we use more than one source of knowledge to get a clearer sense of what’s happening. (This is sometimes called triangulation.)

Using consultation and qualitative research is a valid way of identifying gaps, especially with small groups and rare events that don’t generate large enough numbers for statistical analysis.

Closing the Gap

One of Australia’s most well-known health equity initiatives is the federal Closing the Gap strategy. This aims to reduce the differences in health outcomes that exist between Indigenous people in Australia and settler Australians. The strategy has multiple components:

• Defining targets — the outcomes it matters to measure
• Defining methods for measuring targets
• Regularly collecting and capturing data on achievement of targets
• Planning and taking action to Close the Gaps
• Measuring indicators to see if the action taken has been effective

The approach emphasises listening to Indigenous people and communities about their needs, and working in an organised partnership that includes governments (Commonwealth and state/territory), Indigenous peak bodies, and communities themselves.

Exercise

Find out more by visiting the Close the Gap website. Browse through the targets (see link above).

• Is there a target regarding HIV incidence (new cases)?
• Are there targets on experiences that might affect an Indigenous person’s chances of getting HIV?

Anticipating future inequity

Identifying gaps creates an opportunity to think about how differences in outcomes can be prevented in future. It is an opportunity to think about what other needs people affected by a known inequity might have. Meeting these needs can help close the gaps we have identified. Thinking ahead creates opportunities to promote health equity.

In the next lesson we cover the health needs perspective, and how meeting health and other social needs contributes to quality of life and health equity.