Health equity refers to the fundamental principle that every person, regardless of their social standing, should have a fair opportunity to reach their highest possible level of health. This definition implies addressing systematic differences in health outcomes that are avoidable, unfair, and unjust. Health inequalities often result from complex interactions of social, economic, and environmental factors that disproportionately affect certain population groups.
Health equity as a multidimensional concept
The necessity to approach health equity using the Cultural Strategic Foresight approach can be substantiated by quantitative data, which at various levels of analysis, illustrate the challenges and structural determinants. Below, I present key numerical facts that emphasize the relevance of the topic and can serve as a starting point for an in-depth CLA.
3%
for 1% of GDP, accepting health-related inequalities costs European economies
Method
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What is Causal Layered Analysis?
Causal Layered Analysis (CLA) is a method of future studies that analyzes complex phenomena through various levels of depth and meaning. Developed by Sohail Inayatullah, it allows us to look beyond the superficial symptoms and understand the deeper structures, worldviews, and narratives that shape our perception of the present and future.
Unlike many traditional analytical methods that focus on visible data and short-term solutions, the CLA guides us through different layers of understanding - from the surface to the deepest cultural foundations.
Be sure to read how we incorporate Causal Layered Analysis in the approach for Cultural Strategic Foresight.
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I am Frank Stratmann – an experienced foresight and communication designer who works with passion for healthcare professionals. Also known as @betablogr.
Health Equity as a Multidimensional Concept
Health equity refers to the fundamental principle that every person should have a fair chance to achieve their highest possible level of health, regardless of their social position 1. This definition implies addressing systematic differences in health outcomes that are avoidable, unfair, and unjust. Health inequalities often result from complex interactions of social, economic, and environmental factors that disproportionately affect certain population groups 1.
The complexity of the phenomenon requires a methodological approach that goes beyond superficial analyses and captures the deeper systemic, cultural, and narrative structures that create and perpetuate health inequalities. The CLA provides a suitable framework for systematically analyzing these multidimensional aspects and developing transformative solutions 3.
Application of CLA to Health Equity
A CLA in the field of health equity would systematically traverse the four levels to gain a comprehensive understanding of the phenomenon:
Litanies Analysis: Visible Manifestations of Health Inequality
At the litany level, empirical data on health disparities would be collected and analyzed. This includes epidemiological data on morbidity and mortality differences between various socioeconomic groups, ethnic communities, or geographic regions. Indicators of access to healthcare, waiting times, or utilization rates of preventive measures could also be considered here 1. These quantitative indicators make the symptoms of health inequality visible, without, however, delving into their deeper causes.
Systemic Analysis: Structural Determinants of Health Inequality
The systemic level would analyze the institutional and structural factors that create or exacerbate health inequalities. This includes the organization of the healthcare system, funding models, legal frameworks, and barriers to access. Also, the structure of medical training, as reflected in the National Competence-based Learning Objective Catalog for Medicine (NKLM), would need to be considered here 2. The systemic analysis would show how institutional arrangements can systematically disadvantage certain population groups.
Worldview Analysis: Discursive Construction of Health and Justice
At the worldview level, the dominant paradigms and discursive constructions of health, illness, and justice would be analyzed. This involves examining how societal discourses shape notions of individual responsibility versus collective care, which health concepts dominate, and how medical knowledge is constructed and legitimized. For instance, the analysis could examine how neoliberal paradigms or biomedical reductionism influence the understanding of health and illness 7.
Myth/Metaphor Analysis: Narrative Deep Structures in Health Discourse
The deepest level of CLA would analyze the fundamental myths and metaphors that unconsciously shape health discourse. This could include metaphors such as “health as a commodity,” “body as a machine,” or archetypal notions of the physician's role. These deeply ingrained narrative structures significantly influence how health, illness, and healing are conceptualized and which approaches are deemed legitimate 6.
The Transformative Dimension of CLA in Health Equity
The unique strength of CLA lies in its transformative potential. Through systematic analysis at all four levels, it can address not only the superficial symptoms of health inequality but also the deeper structural, discursive, and narrative causes 4. This enables the development of comprehensive and sustainable strategies to promote health equity.
The transformation begins at the myth/metaphor level by developing alternative narrative constructions that promote health equity. These alternative narratives can then create new discursive legitimations at the worldview level, which in turn enable systemic changes at the structural level. These systemic transformations ultimately manifest in changed empirical realities at the litany level 5.
An example of this transformative process can be found in the causal layered analysis on health equity conducted by BETABLOGR Cultural Foresight. This aims to deeply understand the systemic and fundamental causes of health inequalities and develop alternative future scenarios 1. Similarly, the example from the municipal sector demonstrates how CLA can analyze and transform the existing narrative “baths are cost factors” into a new, forward-looking narrative 7.
Methodological Challenges and Potentials
The application of CLA in the context of health equity presents both challenges and potentials. Challenges include the complexity of the method, which requires a deep engagement with various domains of knowledge 5. Additionally, CLA demands an interdisciplinary perspective, integrating medical, sociological, cultural, and philosophical knowledge.
The potentials of CLA lie in its ability to provide a deeper understanding of complex problems, promote critical thinking, and develop holistic perspectives 3. By exploring different causal levels, more robust strategies for change can be developed that address not just symptoms but also fundamental causes.
Integration of CLA into Medical Education and Practice
The integration of CLA into medical education and practice could be an important step in promoting structural competence in clinical practice. The National Competence-based Learning Objective Catalog for Medicine (NKLM) defines various roles and competencies for physicians, including the role of health advisor and advocate as well as the role of the professional practitioner 2. CLA could be a methodological tool to strengthen these roles and equip aspiring medical professionals to understand and address the complex social determinants of health.
Through the application of CLA, medical students and practicing doctors could learn to think beyond the immediate biological factors and reflect on the systemic, cultural, and narrative dimensions of health and illness. This would promote a more holistic and context-sensitive medical practice that not only treats individual patients but also addresses the structural determinants of health and illness 2.
CLA as a Tool for Transformative Health Research
The Causal Layered Analysis provides a valuable methodological framework for analyzing questions of health equity in a differentiated and profound manner. By systematically examining the litany, system, worldview, and myth/metaphor levels, CLA enables a comprehensive understanding of the multidimensional determinants of health inequality. This understanding can serve as a foundation for developing transformative strategies that not only address the symptoms but also the deeper causes of health disparities.
For a well-founded CLA in the context of structural competence in clinical practice, a detailed analysis of the specific article from the Ärzteblatt would be required. Nonetheless, the methodological framework developed here offers guidance on how such an analysis could be structured and conducted. The integration of CLA into medical research, education, and practice could make a significant contribution to deepening the understanding of the complex interactions between society, the healthcare system, and individual health, ultimately promoting health equity.