Equity at all cost—and any price—for research funding in Canada?

Abstract

This commentary is in response to the May 2018 announcement by the Canadian Institutes of Health Research (CIHR) of a new procedure to ensure fairer access to health research funding for participants. As such, all applicants to CIHR’s funding programs will now be required to complete a five-question questionnaire covering the dimensions of gender, age, Indigenous origin, visible minorities, and disability. On this basis, CIHR intends to gain a better understanding of the performance of its funding programs in terms of equity. In this commentary, we wish to question the theoretical and conceptual assumptions of a vision of equity framed principally in terms of diversity upstream from the research process as a founding principle of more equitable health research in Canada. We draw attention to the fact that diversity policies do not necessarily challenge inequity in research funding or in research projects. Having established the urgent need for action on equity to improve the health of populations, we recall the ethical responsibility of research and researchers to better take the various facets of equity in research into account. We recommend expanding efforts to understand and reflexively address both equity and diversity when considering the performance of population health research programs.

In May, CIHR informed Canada’s health research community of a new procedure for more equitable access to health research funding.1 This action stems from the Government of Canada’s commitment to promote equity, diversity, and inclusion in federal research activities and reflects CIHR’s goal of “ensuring that its programs, funding opportunities, and evaluation systems result in the fair treatment of all participants.” Applicants to all CIHR programs will now be required to complete an equity and diversity questionnaire in order to submit a funding application. CIHR interprets equity and diversity through five dimensions, selected and adapted from the self-declaration form of members of designated employment equity groups2: gender, age, Indigenous origin, visible minority status, and disability. While we can only welcome progress on this front, one cannot help but be concerned about the theoretical and conceptual assumptions of a vision of equity framed principally in terms of diversity upstream of research as a founding principle of more equitable health research in Canada. Echoing CIHR’s mandate to improve the health of all Canadians, we wish to advocate in this text, which is not intended to be polemical, for a broader vision of equity in publicly funded health research. In doing so, we hope to encourage the scientific and political community to expand efforts to more reflexively address both equity and diversity with respect to the performance of public health and population health (PH) research programs.

Equity for whom in relation to whom and according to what?

Although equity is emphasized in the wording of this new measure, it is very quickly set aside in the text in favour of diversity, which reduces life course to age, socio-cultural identity (gender and membership in visible or Indigenous minorities), and health status (disability) to a binary vision (yes/no). The reductionism in the measurement of these components of diversity also raises questions about the thinking and vision that guided the choice of categories and dimensions of diversity within the research community. Why these five dimensions, and not religion, type of affiliation, income level, geographical area of residence, to suggest just a few examples? While the logic of combating the forms of discrimination that have historically led to the exclusion of certain subgroups of the population from positions of power and privilege is well understood, these choices, while potentially contributing to—somewhat—more equality, are by no means fundamentally equitable.

Within the field of PH, significant efforts have been made to distinguish between the concepts of equality (which falls more within the domain of morality) and equity (which refers to the notion of social justice and falls within the domain of ethics) (Arcaya et al. 2015; Potvin et al. 2007; Whitehead and Dahlgren 2006; Commission on Social Determinants of Health 2008), something which has not been clarified by CIHR. Significant literature exists for each of these concepts, the exploration of which goes far beyond the scope of our text. Nevertheless, these conceptual distinctions are important because, while diversity is an equality issue, it is only one (small) facet and adopting the principle of equity for moral purposes of diversity and equality (without social justice) in research funding should not mask the fact that diversity policies do not necessarily challenge inequity and, in their most simplistic form, might simply make inequity “fairer” (Malik 2018).

Thus, for an unambiguous message referring to equity, whatever terms are used, a minimum prerequisite for identifying these inequalities and ways to address them is to divide the population into subgroups and compare these subgroups on the basis of one condition causing harm to another. In other words, it is the way in which the division into whom and in relation to what is defined, and the way in which the selected elements are combined and crossed, which make it possible to speak of inequalities by underlining the various stakes and constituents of these inequalities, suggest explanations for their emergence, and propose means of acting (Bellefleur 2013).

The opacity of the referents and of the treatment that will be made of these sensitive individual data, which will be retained for an unspecified period, is disturbing. The reduction of the question of equity to the representation of certain subgroups of the scientific population, however legitimate it may be, presents the risk of ethical excesses, by shifting the inequalities to which some are subjected to or among other subgroups.

While it is clearly stated that this information will in turn guide future actions, no details are given on how this personal data will be analyzed, weighted, cross-referenced or aggregated, processed in the allocation of funding. Will they favour the lead applicant? The co-applicants or the team? Who will set thresholds and on what basis? Has anyone anticipated the impact of this measure on the behaviour of evaluators, who are conveyors of values and who are known to be subject to biases and conflicts of interest (Tamblyn et al. 2018)? Should personal information be anonymous to avoid double penalties or positive discrimination bonus effects? In what group does the rest of the scientific community fall, having answered “no” to these questions?

But what ethical thinking or vision guides the research funding process? In the announcement, the ethical issues of this measure are reduced to the security of individual data and confidentiality of the identity of participants. In the promotional video, we are told that “although completion of the questionnaire is mandatory for each applicant, your self-identification information is provided on a voluntary basis, and a ‘Prefer not to answer’ option is available for each question.” How can we expect this optional obligation to be interpreted by researchers whose careers depend on such funding?

The equity performance of CIHR-funded programs is everyone’s business

On the basis of these five elements, CIHR intends to develop “a better picture of the equity performance of [its] funding programs.” The video concludes that “countless studies show that this diversity leads to more creativity, more innovation and more meaningful outcomes.” Here again, we are surprised at the reading of the CIHR, which positions the equity performance of its programs within individual funding program processing parameters rather than considering the importance of the social or cultural validity (Francisco and Butterfoss 2007) of its programs in terms of meaningful and expected population health outcomes.

In population health, social inequalities in health (SIH) are systematic and unfair differences in health within and between social groups. They arise from social and political circumstances and are therefore potentially avoidable (Arcaya et al. 2015; Whitehead and Dahlgren 2006; Commission on Social Determinants of Health 2008). To combat these inequalities, health actors and researchers have a wealth of evidence at their disposal, in particular thanks to the report of the World Health Organization’s (WHO) Commission on Social Determinants of Health (CSDH) (Commission on Social Determinants of Health 2008). For the Commission, “reducing health inequities is (…) an ethical imperative. Social injustice is killing people on a grand scale” (p.1). In 2008, Canada’s Chief Public Health Officer released a report highlighting these inequalities and concluding with a call to move forward proactively and across sectors to achieve the common goals of a healthy Canadian population (Agence de santé publique du Canada 2008). Since then, national (Public Health Agency of Canada and Pan-Canadian Public Health Network 2018) and provincial reports on SIH have multiplied, and many provinces have included the reduction of SIH in their public policies. However, the data and repeated calls for action have apparently failed to generate urgency (Centre de collaboration nationale des déterminants de la santé 2018a). And while there is often a tendency to lay the responsibility at the feet of health professionals, here we have the opportunity to challenge researchers—whether affiliated with public health or population health, it makes little difference (Roux 2016)—so that each may reflect and, in all conscience, assume their share of responsibility for the shortcomings observed in terms of equity.

It seems that research is not setting the example, and that it struggles to generate useful knowledge for actions that integrate equity (Centre de collaboration nationale des déterminants de la santé 2018b). And research that does not take equity into account in its various aspects certainly generates partial, insufficient, inconsistent, or even erroneous knowledge from an equity perspective.

While diversity should not mask or replace a genuine consideration of equity and SIH, the integration of these issues into CIHR programs should be subject to more in-depth reflection so as not to become counterproductive. Indeed, in the last Spring 2018 Project Grant competition, an instruction message to all principal applicants encouraged them to “integrate sex and gender into their research designs when appropriate.” While this expectation is legitimate and not new, CIHR is now asking competition evaluators to assess whether sex or gender integration is a strength or weakness of the proposal or not applicable. They must also recommend ways in which applicants can improve their application in this regard. Experience leads us to question whether evaluators always have the necessary skills and expertise to judge “when appropriate” and to know how to provide advice…just as we wonder whether online training can reasonably equip researchers on these issues that are so complex to identify and study. One can only underline the perverse effects of a criterion, perceived de facto as obligatory by the candidates, which pushes researchers to “sex” or “gender” their research objects and plans at all costs—and at any price—whether or not the team possesses the skills needed to rigorously address those issues, in order to satisfy expectations.

Expanding the efforts to reflexively address both equity and diversity when considering performance of health research programs

Thus, without going into a dogmatic vision of equity at all cost—and any price—in research, a complementary reading of the equity performance of CIHR-funded programs and meaningful results should require particular attention from the CIHR to this fundamental dimension of population health within research projects, processes, and outputs. Given the longstanding absence of both equity and diversity in health research in Canada in terms of research topics explored/funded, we welcome efforts in this direction. But equity and diversity are not synonymous, and emphasizing only some of the components of diversity in the policies for the allocation of research funding cannot guarantee more equitable research implementation processes or outcomes on population health.

It is not a question of rejecting one in favour of the other, let alone espousing an anti-diversity stance with respect to CIHR’s initial incursions into the field of equity and diversity, but of drawing attention to a better balance in priorities that must necessarily involve an in-depth reflection of the issues in our research contexts that today tend to make diversity the main indicator of equity (Malik 2018). It is clear that upstream and downstream approaches are needed to deepen our understanding of equity and diversity in funding as well as in research projects and teams, which is why we call for expanding the efforts to reflexively address both equity and diversity.

To gauge the state of research on equity for the health of Canadians, we recommend that the CIHR issue to all researchers involved in PH according to their database a survey consisting of the following four questions:

• Is the research problem based on a literature review that took into account the socio-environmental determinants involved in its subject of study?

• Are the research design, approaches, and methods appropriate for addressing equity issues?

• Do the research questions and evaluation methods reveal the effects of inequity (e.g., presentation of results in the form of disaggregated indicators, search for counterproductive effects for certain subgroups of the population, etc.)?

• Does the team have the expertise to address equity issues in the research?

A negative answer to even one of these questions could point to a vast disconnect between the research and its social responsibility in terms of PH. Based on these results (that should be shared with all the respondents), CIHR (or a federal body of PH researchers) could set up a deliberative reflexive working group to create a guide or a framework to sensitize and support researchers in better considering equity in their projects. The reflection process could be inspired by the Reflex-ISS model developed to structure and guide action in partnership from a perspective of equity in population health (Guichard et al. 2018a, b).