August 3, 2022 | Jessica Zeff

5 min read

Making Health Equity An Essential Component of Healthcare Delivery

In a previous blog, I mentioned that the Population Health Institute found that social determinants of health (SDoH) account for more than 70% of health outcomes.1 So, when we talk about building health systems and delivering care that results in measurable improvement, it’s vital that we also consider a patient’s or population’s economic and social circumstances, access to education and health care, or even neighborhood and environmental conditions.  In fact, government policy is increasingly focused on incorporating SDoH into all aspects of the health delivery system, from individual patient care planning to quality measures to population health objectives, as part of the government’s strategy for tackling health disparities.

So what are health disparities? Health disparities are preventable differences in the burden of disease, injury, and violence, or opportunities to achieve optimal health that are experienced by populations that have been disadvantaged by their social or economic status, geographic location, and environment.2

What’s An Example of a Health Disparity?

Here’s a recent example of a health disparity related to ethnicity: BIPOC people (black, indigenous and people of color) in the U.S. are more likely to contract and die from COVID-19 than white people. But there’s no known physiological basis for this difference.  Instead, the evidence points to the health disparity being related to social factors that make it more likely for BIPOC people to contract and die from COVID-19. For example: 

  • BIPOC people are more likely to have jobs that are considered essential (and therefore can’t be done from home) – this can range from food service to vocational nursing. Those jobs are also likely to involve more direct interaction with the public, increasing their chances of exposure.3  
  • Black and Hispanic people are more likely to take public transportation to work, making exposure more likely.4
  • BIPOC people are at higher risk for developing conditions, such as Type II diabetes, which increases the risk of developing severe COVID-19 symptoms.5
  • BIPOC people are more likely to face cost-related barriers to regular medical care.6

So, How Can We Move Towards Health Equity?

There are many different ways that the healthcare community can influence health equity.  And how individual providers address this important issue will depend on available resources, funding, access to expertise, community support, and any number of other factors.  The suggestions below offer a high-level starting point and are intended as conversation starters to be debated and developed based on each provider’s organizational needs and resources, but the basics all come back to the collection and analysis of SDoH data.

Step 1:  Collect basic demographic and social information about your patient population.  This can include gender, age, ethnicity, disability, communication needs, and even veteran status.  (The truth is, you probably already do this!)  

Step 2: Adopt or develop a professionally recognized SDoH assessment tool for your organization.  

Step 3. Use data analytics based on the patient information already available to you to better understand your patient population and their needs.  

Step 4: Develop objectives, goals, processes, and maybe even metrics based on improvements your organization would like to see based on the patient population needs identified.   

Step 5: Monitor and review for effectiveness.  

Step 6:  If you’re really game, see if your organization can align its health equity efforts with the priorities set out in the government’s Healthy People 2020 strategy and its goals around reducing health disparities by addressing SDoH.

Health Equity & Data Analytics

Step 3 above emphasizes the use of Data Analytics to influence health equity in individual organizations.  A key step in progressing health equity is to use data analytics to identify patterns and trends in the patient population, particularly around social determinants, that may impact health equity.  Insights gained from these analytics should be used to allocate resources where they’re needed most. The right tools, for example, can help predict which patient populations may need more resources, but finding ways to offer them can be challenging. It may involve hiring more healthcare workers, tailoring public health information to specific populations, providing more assistance in filling out forms or finding transportation to healthcare facilities, or even enhancing clinical education so they can better understand the needs of the different populations they serve.

In the end, health equity means providing enough resources to those at a disadvantage so that everyone can be raised up to the same level of health and wellness whenever possible. 

If you’re interested in learning more about the social determinants of health and how they affect health equity, Net Health recorded a webinar on the topic. And if it’s time for you to incorporate SDOH analytics into your practice, you can schedule a demo of our analytics tool here.


1 Population Health Institute. “The Other Half of Health: An Introduction to Social Determinants.” November 14, 2017.

2 Office of Disease Prevention and Health Promotion. (2021, August 11). Healthy People 2020: Disparities. U.S. Department of Health and Human Services. Retrieved August 13, 2021, from 

3 PLoS One “Racial and Ethnic Differentials in COVID-19-Related Job Exposures By Occupational Standing in the US,” April 6, 2021. 

4 Substance Abuse and Mental Health Services Administration (SAMHSA), “Double Jeopardy: COVID-19 and Behavioral Health Disparities for Black and Latino Communities in the U.S.,” Accessed July 30, 2022. 

5 Pew Research Center, “Who Relies on Public Transportation in the U.S.,” April 7, 2016.

6 The Commonwealth Fund, “Achieving Racial and Ethnic Equity in U.S. Health Care,” November 18, 2021.

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