Paths to Success: Optimal and Equitable Health Outcomes for All

The World Health Organization (WHO) is a specialized agency of the United Nations (UN) that takes on global health challenges. In April 2016, the WHO released their new Global Strategy and Action Plan for Health in 2030, which sets out their vision for a world where people live longer and healthier lives without discrimination.

1. Optimal health and well-being for all

The World Health Organization (WHO) defines health as "a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity." The WHO also identifies three key elements to attain optimal health: living a healthy lifestyle, access to healthcare, and robust community support.

2. Equitable quality, universal coverage and access

The U.S. healthcare system is failing to provide equal quality, universal coverage and access to all populations. When Barack Obama ran for president in 2008, he promised reform of the American healthcare system. He was able to push through the Affordable Care Act (ACA), which has expanded access to health services for millions of Americans and improved quality of care.

3. Effective governance and partnerships

The business world is changing. As the world becomes more competitive, organizations are looking for ways to differentiate themselves from their competitors. One way to do that is by partnering with other business entities. Rather than being in direct competition with one another, these partnerships can have a mutually positive impact on both parties involved. The most successful partnerships will be those that have strong governance structures and solid communication channels between both partners.

This section will explore the components that might be needed to achieve optimal and equitable health outcomes for all.

The first component is a commitment to equity. Equity is a socially just society where all people have the opportunity to participate in and benefit from society’s resources and opportunities. Equity requires that we work to eliminate disparities in health and health care, which are the result of social determinants such as income, education, employment or race/ethnicity.

The second component is universal access to high-quality, affordable care for all people at every stage of life. Access means that everyone can get care when they need it without being turned away or charged more because they lack insurance coverage or other types of financial support.

The third component is ensuring that everyone has an equal say in decisions that

Paths to Success for Overall U.S. Health

What might be the components of achieving such success? We have previously published

analyses demonstrating the essential components that have led to success in most of

the major breakthroughs in U.S. health status, as measured by substantial reductions

(more than 50%) in mortality rates within leading causes of death over the past 50

years.30 We were able to identify innovations that enabled these successes, and then

to identify mechanisms of diffusing those innovations to achieve survival success. We

now must find similar paths to success for achieving health equity.

The triangulating on success model (research innovation spread through dual-channel

diffusion of public health plus medical care) has both advantages and disadvantages.

On the one hand, it explains America’s success for seven of nine leading causes of death

that have seen a 50% mortality reduction in the past 50 years (Table 1). The model also

reminds us that all three stakeholder groups—researchers, public health professionals,

and medical practitioners—share a success story and have a common stake in improving health outcomes for the American people, but must increasingly work together in

common purpose, in partnership rather than in parallel.

On the other hand, many of these seven success-story categories of disease are the

very conditions which have seen widening disparities, because life-saving innovations

do not appear to diffuse equally through all segments of the population.31 Specifically,

Phelan et al. have shown that disparities in mortality are greatest for those conditions we know most about treating and/or preventing.32 In general, advantaged segments of the population may adopt lifesaving innovations more quickly and more completely than disadvantaged communities. While social determinants provide a root cause explanation of health disparities, the cure is not always the inverse of the cause. The path out is not always the same as the path in. Identification of paradoxically successful

Recommendations

We start by recognizing that culturally sensitive, racially appropriate care is essential for achieving equal outcomes, and that treating everyone the same way is not sufficient. For example, English-speaking professionals providing the same care to all patients will clearly disadvantage patients who are fluent only in other languages, resulting in disparate outcomes. Lifesaving innovations made equally available in terms of cost, but without attention to non-cost barriers faced by vulnerable populations, may actually have increased racial-ethnic health disparities in breast cancer and HIV-AIDS outcomes. Possibly, this is because non-minority, well-educated, and well-insured segments of the population have been better able to take advantage of the innovations.

A greater investment of professional time and energy may be required to achieve the same outcome in a patient with low health literacy or limited resources to spend on self-management. Building a playground may be enough to encourage physical activity in a crime-free neighborhood, while a neighborhood plagued by drug-related crime may need a playground and increased crime prevention and increased substance use treatment centers before there can be a safe place for children to play. To achieve health equity, different segments of our diverse U.S. population may require linguistically and culturally-specific community interventions or treatment strategies. This will usually require a greater investment of resources in the disadvantaged setting, in order to overcome historic and structural inequities. We propose these steps to follow a health equity path toward improved health for all Americans:

1. Measure disparities explicitly.

2. Expect success. Make health equity an explicit objective not only for public health, but also for Medicare and Medicaid programs, managed care contracts, hospital accreditation, and employer-based coverage.

3. Measure local-area variation in disparities to find models of success in achieving health equity.

4. Ask how and why these communities have succeeded. Shift from studying risk factors and causes of disparities, to studying common elements, patterns, and paths to success.

5. Test multi-dimensional interventions based on common characteristics of successful communities, until health disparities are dramatically reduced. Worry about which element worked once a successful portfolio of interventions has been built.

6. Build health equity coalitions in high-disparity communities. A core coalition of organizations and advocates committed to health equity may require secondtier technical support from health departments, clinics, or hospitals, as well as a third tier of support from community groups such as business and professional organizations, civic groups, fraternities, sororities, and faith-based groups. These larger coalitions should be able to set goals, develop implementation plans, and have regular surveillance data on disparities and equity metrics at the local level.

7. Create rapid-cycle feedback loops with real-time surveillance of health disparities at the local community level. Multidimensional interventions become ineffective and diffuse in purpose unless focused by attention to a single, a priori bottomline outcome measure. This requires adequate public health infrastructure in each community for surveillance and support to track racial, ethnic, and socioeconomic health equity as a core public health measure.

8. Involve all sides of health. Foster the integration of public health, mental and behavioral health, primary care, specialty care, and hospital-based care within a larger health system, through a comprehensive and balanced model of primary, secondary, and tertiary prevention (i.e., the right care in the right setting at the right time to achieve best-practice outcomes for all)

9. Build explicit community development, economic development, and social determinant interventions in high-disparity communities, involving and building on the wisdom and concerns of the involved or targeted community.

10. Integrate all elements described above into cohesive, organized initiatives that routinely assess and act to improve their own effectiveness based on health outcome feedback loops (quarterly neighborhood health equity reports based .on health behaviors, health care utilization, health outcomes, and community perceptions of equity).

Conclusion

There is mounting evidence that disparities can be overcome and that health equity is achievable, but it will require investment of resources in explicit, coordinated strategies at local, state, and national levels. Most effective will be multi-dimensional interventions designed in partnership with communities and continuously improved by real-time surveillance and rapid-cycle feedback loops of community-level disparities measures.