Assignment 1: Exposing the Gaps—How Does the United States Compare in Key Determinants of Health?

EDITORIAL Open Access

Looking forward to the next 15 years: innovation and new pathways for research in health equity Ana Lorena Ruano1,2* , Efrat Shadmi3, John Furler4, Krishna Rao5, Miguel San Sebastián6, Manuela Villar Uribe5

and Leiyu Shi7

Abstract

Since our launch in 2002, the International Journal for Equity in Health (IJEqH) has furthered our collective understanding of equity in health and health services by providing a platform on which academics and practitioners can share their work. Today, we celebrate our fifteenth anniversary with an article collection that presents a call for new and novel research in equity in health and we invite our authors to use new approaches and methods, and to focus on emerging areas of research related to health equity in order to set the stage for the next fifteen years of health equity research. Our anniversary issue provides a platform for expanding the conceptualization, diversity of populations and study designs, and for increasing the use of novel methodologies in the field. The IJEqH has helped to support the wider group of researchers, policymakers and practitioners with a commitment to social justice and equity but there is still more to do. With the help of the highly committed editorial team and editorial board, the innovative work of researchers worldwide, and the countless of hours dedicated by hundreds of reviewers, we are confident in the IJEqH’s ability to continue supporting the dissemination of health equity research for years to come.

Keywords: Equity, Indigenous peoples, Right to health, Refugees, Non-Nationals, SDGs, Qualitative methods, Social justice, Cooperation

Since our launch in 2002, the International Journal for Equity in Health (IJEqH) has furthered our collective un- derstanding of equity in health and health services by pro- viding a platform on which academics and practitioners can share their work. Our mandate continues to be the publication of political, policy-related, economic, social and health services research that focuses on the systematic differences in the distribution of one or more aspects of health in population groups defined demographically, geo- graphically or socially. Our commitment to giving voice to authors from high-, middle- and low-income countries re- mains just as strong today as when Prof Barbara Starfield founded the journal fifteen years ago.

Understanding and acting on global and local inequity remains one of the greatest issues of our times, and our efforts to collect and publish research on particular topics of concern are reflected in our three long-running thematic series. The first of these, which focuses on mul- timorbidity (MM), studies the co-occurrence of health conditions in individuals and populations who experi- ence high burdens of disease and who already find them- selves in disadvantaged circumstances. The series is edited by Prof Efrat Shadmi, our co-Editor-in-Chief [1], and stems from Prof Starfield’s work showing that ‘only a person-focused (rather than a disease-focused) view of morbidity, in which multiple illnesses interact in myriad ways, can accurately depict the much greater impact of illness among socially disadvantaged people and the nature of the interventions that are required to ad- equately manage the increased vulnerability to and inter- actions among diseases’ [2]. The series contributes to

* Correspondence: [email protected] 1Center for the Study of Equity and Governance in Health Systems, CEGSS, Guatemala City, Guatemala 2Center for International Health, University of Bergen, Bergen, Norway Full list of author information is available at the end of the article

© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Ruano et al. International Journal for Equity in Health (2017) 16:35 DOI 10.1186/s12939-017-0531-0

the growing body of knowledge on MM and equity and presents an international perspective on the prevalence of MM in diverse population groups [3], its determi- nants [4] and outcomes [5]. Our second thematic series deals with the unprece-

dented economic crisis that has affected Europe, mainly in the southern countries, and is edited by our Associate Editor, Prof Miguel San Sebastián, and Guest Editor Dr Antonio Escolar-Pujolar. While certain macroeconomic recovery has been observed in the last couple of years, the economic situation remains unstable. This is particu- larly true for the Mediterranean countries, which still face numerous social and economic challenges [6]. This series aims to raise awareness of the impacts of the eco- nomic crisis on population health and, especially, on health inequalities. The articles within the series show- case the diversity and complexity of the impact of the crisis on health [7], but further studies are needed to better understand the link between health and the pol- icies emanating from a dominant socioeconomic model that continuously generates socioeconomic inequalities that affect the most vulnerable groups in society [8]. Finally, our thematic series on interventions in primary

health care that improve equity of outcomes in health showcases the potential contributions of continuous, comprehensive, and coordinated primary health care. Prof Starfield’s seminal work demonstrated that effective primary care is associated with improved access to health care services, reduced hospitalizations, cost- effectiveness and enhanced equity [9–12]. In recent years, many countries, organizations, communities, and world agencies have implemented primary care reforms and interventions to improve healthcare access, quality, health outcomes and equity in health. This series aims to create a space where we can document and analyze primary health care reforms and interventions that com- munities, organizations, countries and world agencies have undertaken [13] and is edited by our Associate Editor, Dr John Furler; our Managing Editor, Dr Ana Lorena Ruano; and Prof Leiyu Shi, co-Editor-in-Chief. Today we celebrate our fifteenth anniversary with an

article collection that presents a call for new and novel research in equity in health. The papers presented here invite our authors to use new approaches and methods, and to focus on emerging areas of research related to health equity. This is the case of the article by Fridman and Gostin [14], who use the Framework Convention on Global Health to call for a profound questioning of health policies at the global, national and local levels and who ask for research to guide actions geared towards truly reducing inequity in health through activism that can help reshape power dynamics. This is in line with Rasanathan and Diaz’s commentary [15], which focuses on Sustainable Development Goals (SDGs) and the need

for strengthened development, testing, and implementa- tion of possible solutions for improving equity levels around the globe. Brolan et al. [16] use a rights-based approach and state that the SDGs can be truly trans- formative if they are made operational in all countries and if they include nationals and non-nationals alike. This is especially urgent given the conflicts in the Middle East and Africa, as well as the escalating violence in Central America, which has forced hundreds of thou- sands of adults and unaccompanied minors to flee in perilous conditions and with little immediate hope of improving their lives and those of their loved ones. Using systems thinking and engaging in complexity

studies, Hernánez et al. [17] call for a novel approach to improving the health status of indigenous peoples, who remain among the most excluded and marginalized population groups all over the world [18]. The authors invite us to move from reductionist approaches that frame indigenous health as a set of poor health indica- tors and instead focus on holistic, integrated approaches that address the root causes of inequity both inside and outside the health sector. This approach raises the need to expand our methodological and theoretical toolbox, particularly when it comes to social sciences and qualita- tive approaches. Hannefeld et al., on behalf of the SHAPES thematic working group from Health Systems Global, also focus on the role of different methodologies and approaches to enriching our understanding of in- equity [19]. Without a network of researchers of diverse backgrounds and methodological interests, our compre- hension of issues that are central to improving the qual- ity of health services and the tools we have at our disposal to strengthen health systems would be greatly diminished. Because of this, our anniversary issue en- shrines our commitment to publish high-quality qualita- tive and social science research. Social justice is at the heart of improving equity in

health, and Devia et al. [20] examine the role of community-based participatory research in addressing the social determinants of health through working with the underlying causes of the inequitable distribution of resources and power structures. Flores et al. [21] show the urgent need for health professionals to be better equipped to address the cultural diversity of the popula- tions seeking care in many countries today. Providing adequate support and training to new physicians and other health cadres can not only help ensure academic and professional success but also improve the quality and equity of care provided. The last paper in our anniversary issue focuses on the

role of competition and collaboration in achieving greater levels of health equity. Chang and Fraser [22] argue for an agency-based approach, and warn that a zero-sum mentality with respect to competition leads to

Ruano et al. International Journal for Equity in Health (2017) 16:35 Page 2 of 3

ethically questionable and less effective cooperation. Market-driven approaches to healthcare contribute greatly to the growing inequities around the world. Setting the stage for the next fifteen years of health

equity research, our anniversary issue provides a plat- form for expanding the conceptualization, diversity of populations and study designs, and for increasing the use of novel methodologies in the field. Recent global changes that instigate major demographic [23] and eco- nomic transformations [7] call for expanding the role of research in illuminating injustice, developing and testing interventions to expand the evidence base on how to eliminate inequity in health and health care, and guiding policy that will lead to better outcomes for diverse popu- lation groups worldwide. Fifteen years on, much has been achieved. The journal has helped support the wider group of researchers, policymakers and practitioners with a commitment to social justice and equity. There is still more to do. With the help of the highly committed editorial team and editorial board, the innovative work of researchers worldwide, and the countless of hours dedicated by hundreds of reviewers, we are confident in the IJEqH’s ability to continue supporting the dissemin- ation of health equity research for years to come.

Acknowledgements Not applicable.

Funding Not applicable.

Availability of data and materials Not applicable.

Authors’ contributions ALR drafted the first version of this manuscript. ALR, ES, JF, KR, MSS, MVU and LS all contributed equally. All authors approve this paper.

Competing interests The authors declare they have no competing interests.

Consent for publication All authors consent to publication of this paper.

Ethics approval and consent to participate Not applicable.

Author details 1Center for the Study of Equity and Governance in Health Systems, CEGSS, Guatemala City, Guatemala. 2Center for International Health, University of Bergen, Bergen, Norway. 3The Cheryl Spencer Department of Nursing, Faculty of Socail Welfare and Health Sciences, the University of Haifa, Haifa, Israel. 4Department of General Practice, Faculty of Medicine, Dentistry and Health Sciences University of Melbourne, Melbourne, Australia. 5Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA. 6Department of Public Health and Clinical Medicine, Unit of Epidemiology and Global Health Umeå University, SE-901 87 Umeå, Sweden. 7Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.

Received: 7 February 2017 Accepted: 13 February 2017

References 1. Shadmi E. Multimorbidity and equity in health. Int J Equity Health. 2013;

12(1):59. 2. Starfield B. The hidden inequity in health care. Int J Equity Health. 2011;

10(1):15. 3. Boutayeb A, Boutayeb S, Boutayeb W. Multi-morbidity of non

communicable diseases and equity in WHO Eastern Mediterranean countries. Int J Equity Health. 2013;12(1):60.

4. Reis-Santos B, Gomes T, Macedo LR, Horta BL, Riley LW, Maciel EL. Prevalence and patterns of multimorbidity among tuberculosis patients in Brazil: a cross-sectional study. Int J Equity Health. 2013;12(1):61.

5. Alaba O, Chola L. The social determinants of multimorbidity in South Africa. Int J Equity Health. 2013;12(1):63.

6. Escolar-Pujolar A, Bacigalupe A, San SM. European economic crisis and health inequities: research challenges in an uncertain scenario. Int J Equity Health. 2014;13(1):59.

7. Escolar Pujolar A, Bacigalupe A, San SM. Looking beyond the veil of the European crisis - the need to uncover the structural causes of health inequalities. Int J Equity Health. 2016;15(1):39.

8. Bacigalupe A, Escolar-Pujolar A. The impact of economic crises on social inequalities in health: what do we know so far? Int J Equity Health. 2014; 13(1):52.

9. Macinko JA, Starfield B. Annotated bibliography on equity in health, 1980–2001. Int J Equity Health. 2002;1(1):1.

10. Macinko J, Starfield B, Shi L. The Contribution of Primary Care Systems to Health Outcomes within Organization for Economic Cooperation and Development (OECD) Countries, 1970–1998. Health Serv Res. 2003;38(3): 831–65.

11. Starfield B. Is primary care essential? The Lancet. 344(8930):1129–33 12. Starfield B. Primary care: balancing health needs, services, and technology.

USA: Oxford University Press; 1998. 13. Ruano AL, Furler J, Shi L. Interventions in Primary Care and their

contributions to improving equity in health. Int J Equity Health. 2015;14(1): 153.

14. Friedman E, Gostin LO. From local adaptation to activism and global solidarity: framing research and innovation agenda towards true health equity. Int J Equity Health. 2017;16(18)

15. Rasanathan K, Diaz T. Research on health equity in the SDG era: the urgent need for greater focus on implementation. Int J Equity Health. 2016;15(202)

16. Brolan C, Forman L, Dagron S, Hammonds R, Waris A, Latif L, et al. The right to health of non-nationals and displaced persons in the sustainable development goals era: challenges for equity in universal health care. Int J Equity Health. 2017;16(14)

17. Hernández A, Ruano AL, Marchal B, San Sebastian M, Flores W. Engaging with complexity to improve the health of indigenous people: a call for the use of systems thinking to tackle health inequity. International Journal for Equity in Health. 2017;16(XX).

18. Cerón A, Ruano AL, Sánchez S, Chew AS, Díaz D, Hernández A, et al. Abuse and discrimination towards indigenous people in public health care facilities: experiences from rural Guatemala. Int J Equity Health. 2016;15(1):1.

19. Daniels K, Loewenson R, George A, Howard N, Koleva G, Lewin S, et al. Fair publication of qualitative research in health systems: a call by health policy and systems researchers. Int J Equity Health. 2016;15(1):98.

20. Devia C, Baker E, Shanchez-Youngman S, Barnidge E, Golub M, Motton F, et al. Advancing system and policy changes for social and racial justice: comparing a rural and urgan community-based participatory reserach partnership in the U.S. Int J Equity Health. 2017;16(17)

21. Flores G, Mendoza FS, Fuentes-Afflick E, Mendoza JA, Pachter L, Espinoza J, et al. Hot topics, urgent priorities, and ensuring success for racial/ethnic minority young investigators in academic pediatrics. Int J Equity Health. 2016;15(1):201.

22. Chang W, Fraser J. Cooperate! A paradigm shift for heatlh equity. Int J Equity Health. 2017;16(12)

23. Kousoulis AA, Ioakeim-Ioannidou M, Economopoulos KP. Access to health for refugees in Greece: lessons in inequalities. Int J Equity Health. 2016;15(1):122.

Ruano et al. International Journal for Equity in Health (2017) 16:35 Page 3 of 3

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