Health inequities are the result of many and varied factors that are often outside people’s direct control. It is not enough to identify the big issues that need addressing but to identify a range of tools, actions, investments, policies and practical solutions for improving health and well-being and reducing inequalities.
Health inequities are not inevitable; they can be reduced or prevented. Solutions are required that address the unmet needs of populations made vulnerable by systemic inequity. Real health benefits can be attained at an affordable cost and within resource constraints if effective strategies are adopted.
Healthcare alone cannot close the health inequity gap. Health inequities are multi-faceted, often demonstrating the interlinked nature of multiple factors, not least avoidable social inequalities in factors such as where we live, our household earnings, and our opportunities for good work.
This complexity means there is no simple ‘one size fits all’ solution to reduce health inequities. Rather, efforts to reduce health inequities requires action on all the social determinants of health – the five essential conditions – across the life course. As such, actions in all areas of government policy affect health.
Coordinated policy action on the determinants of health, combined with well-designed and implemented governance and policy approaches can have effect on 1) reducing the health gap; 2) improving overall population health and well-being; and 3) achieving inclusive and sustainable economic growth and prosperity for all.
Ongoing challenges – not least the COVID-19 pandemic, the cost of living crisis and climate change – emphasise that we live in an increasingly changing and globalised world, posing both challenges and opportunities. Despite its catastrophic consequences, the pandemic has opened a window of opportunity to adopt and accelerate new approaches and solutions to achieve healthier and more resilient people, societies and economies. As well as potential solutions to ‘build back fairer’ from the pandemic, there is also potential for a ‘green recovery’ by identifying opportunities to support population health through sustainable means and to put health in all policies to identify and influence the health and equity impacts of policy decisions.
The Programme for Government commits the Welsh Government to ‘move to eliminate inequality in all its forms’. Making the case and advocating for investment in well-being and health equity are essential to enable evidence-informed, sustainable and fair policy and action for the benefit of people, communities, societies, the economy and the planet. The scale and nature of the challenge calls for a co-ordinated, whole-sector response, making a strong case for community-centred approaches to public health and whole-system approaches to health equity.
How public policy and decision making responds to persistent and new challenges in uncertain times will rely heavily on the ability to shape responses to big trends. The challenge is how to implement change across a complex system so that it endures over time.
Futures work is about thinking and planning for the long term. It can help when considering the challenges we are likely to face in Wales that could influence and shape the future, as well as those that are unforeseen or uncertain, while supporting the development of policies or strategies that will prove robust in the face of many different futures. The Future Trends Report 2021 and associated Evidence Pack can support decision-makers understand Wales’ future better and make more informed decisions for current and future generations. The Three Horizons Toolkit can also help public bodies to think and plan for the longer term. Efforts to consider what inequality in a future Wales might look like can be supported by the framework established by the Well-being of Future Generations (Wales) Act 2015, which compels us to think differently about our approach to health inequalities. The Future Generations Commissioner has set out case studies and big ideas from Wales and further afield on what individuals, communities and public bodies are doing to meet the well-being goals.
The Five Essential Conditions
Understanding ‘what works’ can inform decisions about public services. There are many tools, resources, practical frameworks and software applications to help measure and understand health inequalities. Also, the WHO Europe Health Equity Status Report Initiative (HESRi) has brought together case studies of success stories, promising practices and lessons learned from the local, national and European levels. The case studies show how countries have overcome the challenges related to disinvestment in policies and approaches that impact on health equity, and maximised new opportunities for advancing objectives to increase equity in health.
This section brings together information on potential solutions and good practice, and directs those attempting to tackle health inequalities to reports, practical guides, toolkits and techniques that have been implemented. Different tools and techniques are appropriate at different stages of development. For example, when a new service is being planned it might be relevant to undertake a Health Impact Assessment, whereas if services have been in place for some time but are under review, tools such as Multi-Criteria Decision Analysis or Programme Budgeting and Marginal Analysis may be more appropriate.
The solutions-focused resources in this section are presented within a broader context, which acknowledges the underlying factors driving health equity. The WHO Regional Office for Europe report Driving forward health equity – the role of accountability, policy coherence, social participation and empowerment, suggests that evidence increasingly demonstrates that addressing one or a combination of the conditions that are crucial to giving people an equal chance in life (e.g. living environment, education, employment) in isolation from broader social and institutional factors in society has led to progress not being as fast as expected. Rather, to scale up action on health equity and enable the conditions necessary to lead healthy and prosperous lives, action needs to be taken on underlying factors driving health equity. The report presents the findings of a scientific expert review that identified four key drivers of health equity – accountability, policy coherence, social participation and, underlying them, empowerment – as social and institutional factors that drive health equity on their own, but are also dynamic and interact with each other. Work on these drivers has informed the Health Equity Status Report initiative and has resulted in independent companion papers each elaborating further on accountability, policy coherence and social participation as drivers of health equity. A further policy brief presents evidence showing that political participation, representation, accountability and transparency are also important preconditions for health equity.
The role of behavioural science in addressing health inequalities
Increasing health equity requires both the social and behavioural causes of health inequalities to be addressed in parallel. Behavioural science, the scientific study of behaviour, provides evidence-based approaches to understanding and influencing behaviour in specific populations in a given context. This scientific approach ensures an accurate understanding of behaviours and what drives them rather than relying on assumptions of what is believed to influence behaviour. It also facilitates consideration of both conscious and automatic processes that have an influence on our behaviour.
Behavioural science methods support the identification of populations/sub populations most at risk of, or affected by, health inequalities and provides evidence base frameworks for exploring the determinants of behaviour from the perspective of the population of interest. This enables targeted intervention for segments of the population experiencing health and/or social inequalities. The systematic approach offered by behavioural science prompts consideration of equity at every stage in process of developing and implementing policies, services, and communications.
A guide to using behavioural science, which comes from a Public Health Wales and UCL Centre for Behaviour Change partnership, Improving health and well-being: a guide to using behavioural science in policy and practice offers an introduction to behavioural science and a step-by-step process for developing/optimising interventions (policy, service or communications) designed to start, stop, continue or change behaviours.
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