Filling gaps to improve health outcomes
Despite significant will and isolated advances, the public health sector has not been able to embed a systemic approach to improving health equity in Canada.  The NCCDH looked at why this may be in a recent gap analysis, which uncovered a wide range of issues that impede public health’s capacity to improve or mitigate social determinants of health (SDH).
Looking at SDH broadly, the NCCDH identified gaps and actions in 14 NCCDH resources (2011–2015, plus the 2017 environmental scan) in the areas of Evidence & Knowledge, Workforce Development, Organizational Capacity and Societal Context/Environment. The analysis goes further, identifying a variety of actions to fill these gaps among researchers, policy- and decision-makers, and practitioners. The actions do not reflect all the possible activities noted in the resource documents, nor are they limited to those mentioned in these sources. Resources to support the actions identified reflect materials available now, and not only those named in the documents reviewed. (Please see the full report for details on the methodology.)
A number of common elements emerged among the gaps:
- There is limited evidence and few knowledge-to-action models for effective action in interventions, programs, policies and intersectoral action.
- Both data (measurement, indicators and monitoring) and evaluation methods are lacking or, where they exist, are not well applied.
- There is inconsistency in health equity terminology, definitions and public health roles. Public health struggles to communicate complexity, social determinants of health and health equity to its wide range of audiences, including the media and politicians, whose understanding is required to support change.
- Public health leadership in health equity is inconsistent, with inadequate public health requirements and organizational vision, and few expectations that leaders must address systemic barriers to health inequities. For example, equity has not been integrated into many provincial/territorial public health standards, Canada’s core competencies or most discipline-specific competencies.
- Systemic barriers include a lack of resources, workforce diversity and supportive structures, such as dedicated SDH or health equity offices, teams and specialist staff, coupled with eroding independence of public health staff and programs.
- Few equity-focused policies or strategies exist that cross sectors, jurisdictions and levels. With drivers for health equity resting outside the public health system, higher-level and cross-cutting mechanisms are need for change.
- There is a lack of political support, attention and investment upstream, with a continued overemphasis on individual lifestyle change.
- Staff competencies and training, as well as expectations regarding their roles in health equity, are not seen as priorities, with insufficient support and integration within health organizations. This is reflected in diminished funding for professional development, few opportunities for mentorship and a devaluing of practice-based learning.
Applications to specific roles
There is, of course, significant crossover among the actions of researchers, policy- and decision-makers, and practitioners. For example, some of the evidence gaps highlighted for researchers are reflected in knowledge gaps among practitioners. Specific actions for each group include:
- Researchers can obviously fill gaps in evidence and knowledge. However, they can also take the lead in clarifying public health roles and terminology. Researchers can be powerful forces in translating research into practice, through collaboration with practitioners and decision-makers.
- Policy- and decision-makers are key players in system modification — the area identified by NCCDH as having the most influence on healthy equity. Those who make policy or program decisions have significant power to transform the public health environment to focus on upstream factors influencing health. They can help establish structures supportive of health equity, set priorities to be achieved and advocate for increased public health capacity.
- Public health practitioners are in an excellent position to shift organizational focus upstream. Their first-hand stories of people whose health suffers through social or economic vulnerability can go a long way towards influencing health policies and programs. Input to job descriptions and levels of autonomy that integrate upstream approaches would also put practitioners in a much better position to act on health inequities. Change within organizations can come from above, through great leadership, but also from change agents at the front lines.
All public health actors can contribute to the broad systemic changes required for health equity, by bringing better evidence, clear language and their credibility to bear on societal and political will. Politicians and the public need to be able to see the tangible health outcomes that can result through strong, sustainable and appropriate health equity policies and actions.
This gap analysis is based on the perspectives of the researchers who contributed to the 14 documents assessed. Critically, they have not been reviewed by those actively working in the field. To be truly effective in highlighting priority action, your input is required.
How do you feel barriers within public health systems, structures, culture and leadership can be addressed? How can you contribute to improved health equity outcomes? What can we do as a sector to diminish the emphasis on lifestyle and focus more on the structural changes required to advance equity?
To read the full analysis, and how it affects all groups, please see the full report.
 Critical Public Health (2013): Epistemological barriers to addressing the social determinants of health among public health professionals in Ontario, Canada: a qualitative inquiry, Critical Public Health, DOI: 10.1080/09581596.2013.820256