Towards Equity-Centered Care

A “Health in All Policies” framework has been touted in the past few years as a strategy to illuminate the intersections between public health and other areas of civic life. It’s one way to incorporate health metrics into existing and proposed public policy – from education to transportation. But the question is, will it work?

It seems fairly obvious that health-centric framing may obstruct interdisciplinary collaboration. But at a more fundamental level, will replacing multivariate, silo’d interests with the singularity of health effectively capture the complexity necessary to create shared agendas across public sectors?

The short answer is no. Here’s why and how we got here.

The former structure of medical education and training was rooted in the idea that the greatest knowledge in medicine was best revealed through individual patient inquiry and the greatest challenges in the field were best understood and addressed through individual clinician excellence. So clinicians were evaluated based on their individual aptitude, patients were assessed based on their isolated symptoms, and each sector of the health and human service network operated in silos, training and treating pieces of the problem, without ever quite appreciating the inter-connected whole.

This paradigm of education and practice placed clinicians at the center of care and patients and allied partners at the periphery. Allied learners were taught separately and systems communicated poorly, both of which resulted in fragmentation – in how problems were evaluated and in how care was delivered.

A more recent iteration of this care ecosystem, like the “Health in All Policies” approach, now places patients and health at the center of delivery models and public policy strategies to treat disease and advance wellness. These patient-driven, health-specific metrics ensure that systems are oriented to serve and public policies are structured to mitigate health impacts.

However increased focus on individual patient outcomes may obscure population-level drivers of health disparities and unilateral dependence on health as the primary outcome, may ostracize allied disciplines, institutions, and learners whose work or study contributes to advanced understanding of human behavior and the complex relationships between structural environments and the pathophysiology of disease.

The bottom line is: the intricate problems that threaten child and community health will not be solved by the individual capacity of excellent clinicians or public servants, but rather by the ability of leaders to organize interdisciplinary teams that learn, work, communicate ideas, translate interventions, and are evaluated across shared infrastructures, in the service of shared outcomes.

If identifying health as the primary outcome of interest or individual patients as the primary drivers of systemic priorities, alienate important partners and dilute the input of minority populations, it is time for a new centering principle. In my mind, that principle should be equity.

Placing equity at the center of the care ecosystem ensures each sector of the health and human service network and each provider and recipient of care has a role and contributes to the shared societal realization of public safety, economic security, and wellness.

Shared values, like equity, are important foundations for building integrated public systems. And integrated public systems are important to create parity in resource dissemination and improve productivity through partnership with allied disciplines and institutions. Although the process of integration may generate new financial costs, it will hopefully save money on the back end by aligning incentives and improving efficiency.

In the end, equity will be the framework for the future of care and policy that aims to improve health. So as we move towards the future, let equity be our guide.

* In appreciation for their wisdom: I want to acknowledge Dr Rajiv Bhatia who’s novel work on The Civic Engine, and Dr. Damon Francis whose generously shared expertise, informed the ideas presented in this piece.*

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