Introduction

Health equity is a central concept in the fields of public and global health, with organizations like the World Health Organization (WHO) signalling their aim to improve health equity since their inception [1] and solidifying these commitments in subsequent declarations (e.g., the Alma-Ata Declaration [2, 3]). What differentiates a health inequity from an inequality in the public health literature is the social justice aspect, in other words, a moral component entailing a need to act [4]. This builds on a widely cited definition of inequity in health, which is defined as “differences which are unnecessary and avoidable, but in addition are considered unfair and unjust” [5]. However, the different ways in which public policy can tackle these unnecessary, avoidable, unfair, and unjust differences is less defined.

A recent scoping review investigating how the peer-reviewed literature understands the WHO’s approach to health equity found that the WHO conceptually approached action in two ways: (i) striving for a baseline level of health and (ii) striving for a baseline level of health and reducing inequality [6, 7]. Drawing on this finding, empirical analysis of key texts of the WHO found that the WHO presents “three main approaches to reduce health inequities” (or “three main approaches to reducing urban health inequities” in Hidden Cities) [8, 9]. These three approaches are: “targeting disadvantaged population groups or social classes” (or “targeting disadvantaged groups” in Hidden Cities), “narrowing the health gap”, and “reducing inequities throughout the whole population” (or “reducing inequities throughout the entire urban population” in Hidden Cities) [8, 9]. Aligned with the WHO’s “three main approaches” discussed above, a briefing note, Policy Approaches to Reducing Health Inequalities, produced by the Canadian National Collaborating Centre for Healthy Public Policy, also presents three similar approaches: “focus on disadvantages”, “focus on gaps”, and “focus on gradient” [10]. However, with the slight difference of “focus on gaps” discussing the lowest income group with respect to all other groups, whereas the WHO “narrowing the health gap” focuses on closing the gap between the richest or best off with the poorest or worst off 20% (or quintiles).

In addition to these outlined conceptual approaches, recent analysis demonstrated that the WHO’s discourses also presented four additional ways action could be conceptualized [11]. These approaches were construed through investigating the discourses and language employed in key WHO texts. However, these approaches were not explicitly presented and discussed by the WHO in the way the above three approaches were.

Moving beyond investigations into the WHO, understandings of how health equity can be acted on or sought, or alternatively, how health inequity can be tackled, are limited. For instance, it is commonplace for literature to discuss addressing health inequity as synonymous with targeting one group, as seen by sweeping concluding statements in journal articles to address health equity in this way. This view neglects other approaches, such as those discussed above, which both means that certain populations will be ignored and that different understandings of what health equity entails will not be considered. Failing to consider different conceptual approaches for acting on health equity is particularly problematic in global health, where there is both widespread attention paid to health equity and there are cross-country differences in understandings of social justice and health equity [12]. Further, taking such a narrow view of health equity also tends to lend itself to a focus on methods or technical strategies to improve health equity, such as distributing resources. Although such strategies can be helpful, these actions are often not associated with broader equity considerations, such as reflecting on the unique needs of individuals that may result in different outcomes, given individuals’ differing capabilities [13]. Thus, the focus of this work is to collate information on what conceptual approaches exist, rather than specific methods or strategies which may or may not come through in the discussion of such conceptual approaches. This work is important because a lack of conceptual clarity on the differing approaches to action can prevent united action and potentially inhibit public policy action altogether.

Methods

A scoping review will be undertaken to compile English-language hits from numerous sources, including from the peer-reviewed and grey literatures. This scoping review protocol was developed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) [14], PRISMA guidelines for protocols (PRISMA-P) [15], the updated methodological guidance for the conduct of scoping reviews [16], and in consultation with a research librarian with expertise in library science.

Discussion

Despite health equity being mainstream and commonplace in the fields of global and public health, discussions around health equity tend to remain vague, as noted in a critical discourse analysis of key WHO texts [22]. This lack of clarity also translates into policy and practice. This was observed in a recent study of key informants with experience with the WHO’s Urban Health Equity Assessment and Response Tool (Urban HEART) [12]. Urban HEART is a tool for cities to address health inequities [23] and has been designed to be comprehensive, inclusive, operationally feasible, among other things [24, 25]. Despite key informants accepting health equity as a central concept, they defined the concept in different ways and found the concept to be vague [12]. This study demonstrates that the concept of health equity can be unclear even to individuals whose work has focused on health equity.

Therefore, we anticipate discussing the nuances inherent in each conceptualization and developing a foundational document to promote clarified and united action. This study has widespread relevance for work at various levels, including: population-level efforts that are directly and indirectly focused on improving health equity, such as the Health in All Policies approach and Healthy Cities [26]; individual-level efforts that seek to improve health equity, such as clinicians working on poverty screening [27]; organizational efforts, particularly in light of the persistence of inequities in global health institutions [28]; and others. This work is not only unique, it is particularly timely given COVID-19, where there has been a call for focusing on achieving equitable outcomes instead of cutting spending [29] and observations that the pandemic may afford an opportunity to refocus on the social determinants of health and health equity [30].

Supporting information