NURSING CHALLENGES TO ENACT HEALTH EQUITY IN PRACTICE: A BRAZILIAN- CANADIAN NURSING DIALOGUE DESAFIOS DA ENFERMAGEM NA PROMOÇÃO DE PRÁTICAS DE EQUIDADE EM SAÚDE: UM DIÁLOGO ENTRE A ENFERMAGEM NO BRASIL E NO CANADÁ RETOS DE ENFERMERÍA EN LA PROMOCIÓN DE PRÁCTICAS DE EQUIDAD EN SALUD: DIÁLO

In this paper we develop a reflective dialogue about health equity, drawing a parallel between selected challenges to enact equity in Nursing practice in Brazil and Canada. The concept of health equity implies the recognition of injustices suffered by some population groups, considering that a distribution of goods and services to individuals requires recognition of their differences and distinct needs. The principle of health equity emerges in light of inequalities in health and access to health care services. Living and social conditions are critical factors in the development of health inequities that affect population groups. These factors are modifiable and controllable by public policies. Health inequities are considered unnecessary, unjust, and avoidable differences in the health status of populations. Nursing practices can be understood as social practices that seek to enable people to enact their autonomy and citizenship. A proposal for health equity practices, from the perspective of Nursing, requires that we tackle complex challenges that can be analyzed from the perspective of five domains: clinical practice, Nursing education, research, administration and political engagement.


RESUMEN
En este artículo llevamos a cabo un diálogo reflexivo sobre la equidad en salud, trazando un paralelo entre los retos propios de la práctica de enfermería con equidad en Brasil y Canadá. El concepto de equidad en salud implica el reconocimiento de INTRODUCTION Inspired by the theme discussed during the 80 th Brazilian Nursing Week in 2019 -Nursing and the meanings of equity -we took on the challenge of reflecting together on what it means to enact health equity in the practices of Nursing. Our reflection builds on the analysis of a practice rooted in social justice and environmental sustainability, for socially diverse and vulnerable groups. 1 To accomplish this, we reflect on what it means to enact health equity in the practice of Nursing through a dialogue between Brazilian and Canadian Nursing.
Health equity originates in equity principles of contemporary times associated with the rights of socially diverse and vulnerable groups in the public space. 2 Equity includes the need to recognize injustices suffered by population groups and the impact of these on their lives and wellbeing. From an equity perspective, the distribution of goods and services in society needs to take into account individual differences as well as the distinct needs of population groups. 2 The principle of health equity emerges in the face of severe health disparities as evidenced in significant and yet avoidable differences in the health status of population groups as well as in inequalities in access to and utilization of health care services. Health equity endorses the need to deliver health care in a way that recognizes the unique needs of population groups and the severe health disparities they embody. 3 A health equity approach raises awareness of the social conditions as the underlying roots of health disparities. These social conditions are modifiable and controllable through public policies. 4 This awareness implies the need to recognize that health inequities comprise avoidable and unnecessary differences that are, at the same time, unjust and undesirable. In this sense, the term 'health equity' entails a social and ethical dimension. 5 Under a sociological perspective, Nursing practices are understood as social practices that seek to enable persons to enact their autonomy and citizenship. In this line, we raise the question, is it possible to act as health care professionals under an equity perspective? 6 We need to highlight that quality Nursing care and equitable health outcomes implies equitable working and living conditions. This requires an integrated health care team work approach that includes a Nursing team. 7 From a Nursing perspective, enacting health equity in our practices presupposes that we overcome complex challenges. In this article, we reflect on these challenges in the context of five dimensions, namely, clinical practice, Nursing education, research, administration and political engagement. In what follows, we offer a reflective dialogue concerning selected Nursing challenges to enact equity in practice in Brazil and Canada.

HEALTH EQUITY CHALLENGES IN THE BR AZILIAN AND CANADIAN CONTEXTS
"Health as a Right" was the central theme of the 16 th National Health Conference in 2019 in Brazil. This conference restated health as a universal right, that is, a condition that must be accessible for all citizens, regardless of their socioeconomic status, race, colour, sex, gender, employment status, and housing condition. Equity principles are reaffirmed when special privileges are not granted to some to the detriment of others; when we respect the uniqueness of each individual and thus ensure access to health care based on their particular needs. 8 Brazil, a country of about 210 million inhabitants and profound cultural and social diversity, had its public health care system -Unique Health System (Sistema Único de Saúde -SUS) -established by the 1988 country's Constitution. Even though in principle, SUS endorses a universal public health care system for all Brazilians, in reality, the health care system takes shape in a fragmented form, with the coexistence of three major subsystems: 1) SUS, public and offered to everyone; 2) A private health care system of supplementary medical care, accessed through private health care plans; and 3) A fee-for-service private health care system. One of the major dilemmas faced by SUS is that of having to establish itself as a public health care system for all and at the same time be recognized as a system directed only to those living in poverty. 9 las injusticias sufridas por algunos grupos de población, considerando que la distribución de bienes y servicios a individuos incluye el reconocimiento de sus diferencias y necesidades distintas. El principio de equidad en salud se establece dentro del alcance de las condiciones de salud y del acceso y uso de los servicios en función de un parámetro de distribución heterogénea de estos servicios. Los principales responsables de las diferencias en las condiciones de salud de los diferentes grupos de población son los factores sociales que pueden ser alterados o controlados por las políticas públicas, es decir, las inequidades en salud deben entenderse como diferencias innecesarias y evitables. Con respecto a las prácticas de enfermería, desde una perspectiva sociológica, deben entenderse como prácticas sociales que deberían permitir la autonomía de las personas y el ejercicio de la ciudadanía, y vale la pena preguntarse si es posible actuar como profesionales de la salud desde la perspectiva de la equidad. En este contexto, entendemos que la propuesta de prácticas de equidad en salud, desde la perspectiva de la enfermería, presupone superar retos complejos que se pueden analizar desde cinco dimensiones: asistencia, gestión, capacitación / educación permanente, compromiso político e investigación. Palabras clave: Enfermería; Equidad en Salud; Práctica Profesional; Sistemas de Salud.
the health care network to diverse and complex care areas. 15 Enacting equity in Nursing practice requires that nurses tackle complex challenges that can be examined in light of the four domains that fall within our scope of practice. These are clinical practice, education, research, and administration. 16 We expand these by including political engagement as another domain of our Nursing profession.
As in Brazil, Canadian nurses face multiple challenges to improve equity in clinical practice. We share a common vision that primary health care is a significant strategy to prevent and address health inequities affecting population groups in our countries. The Canadian Nurses Association has called for initiatives to strengthen primary health care as a strategy to increase equitable access to health care. 17 Although initiatives to increase health equity exist, alarming health disparities among Canadians reveal the need to accelerate the development of these.
In the clinical practice domain, we recognize the need to address the challenges imposed by the division of Nursing work by searching that which unites the Nursing team, that is, a Nursing practice that is person-centred, be it for an individual or a group. To achieve this, nurses need to be agents of change by taking on, in an autonomous way, decision-making responsibility in the planning of Nursing care. This implies a professional performance that entails cognitive, psychomotor, and affective qualities (Garcia). In addition, this requires an ongoing need for reflection, flexibility, creativity and innovation in the development of care plans that respond to the human and social needs of those cared for by nurses at the individual, familial, and collective levels. 16 Take for example the care of a woman with breast cancer in Brazil. We highlight that this has become a public health problem in the country. Although breast cancer mortality rates in Brazilian women have shown a tendency to remain stable, when we analyze breast cancer rates in the context of Brazilian States, inequalities among women are remarkable. Studies report an increase in breast cancer mortality rates in states of low socioeconomic status and a decrease or a tendency to remain stable in those of higher socioeconomic status 18 . SUS plays an important role in oncology care with the development of public policies that prioritize preventative actions and timely access to medium and high complexity health care resources for breast cancer diagnosis and treatment. 18 Persons diagnosed with breast cancer under the supplementary health care system are able to migrate to the public system to receive chemotherapy and radiation. 19 Although this approach promotes equity in access to diagnosis and treatment for this type of cancer, cancer care outcomes regarding diagnosis, treatment, and mortality continue to be unequal. Socioeconomic disparities associated with poverty, On the other side, Canada is a country with a population of 37 million inhabitants, with vast cultural, linguistic, geographic, and economic diversity. Public funding and public administration are the hallmark of the Canadian health care system. The Canada Health Act has defined five core principles to ensure equity and solidarity in the delivery of health care. These are public administration, comprehensiveness, universality, portability and accessibility. 10 Universal access to health care services is a key indicator of these principles and critical to ensure the optimal wellbeing of Canadians. Notwithstanding these principles, severe health inequities affecting population groups exist. These inequities are avoidable and unjust since they result from inequalities in the social determinants of health. National data show that those who experience precarious income, housing, and education have worse health outcomes than their Canadian counterparts. 11 In 2012, United Nations Member States including Brazil and Canada, endorsed the Rio Political Declaration on Social Determinants of Health. 12 This declaration calls World Health Organization Member States to take action to improve the working and living conditions of their populations to improve their health and wellbeing. 12 Five priority themes were established in the Rio Declaration to decrease inequalities in health. 12 In 2015, the Canadian Government released a report documenting progress in each of these themes. 12 In addition, building on the findings of a Pan Canadian dialogue held in 2016, 13 the Canadian Institute of Health Information proposed that age, sex, gender, income, education, and geographic location be used as standard population identifiers (equity stratifiers) to measure equity. 14 The adoption of these equity identifiers is a crucial step towards eliminating unfair or unjust health inequalities affecting population groups and will ultimately serve to improve their health status and access to health care services as well as health care quality and outcomes. 14

CHALLENGES FOR A NURSING PR ACTICE WITH EQUITY: BR AZILIAN AND CANADIAN INTERFACES
In the context of Brazilian health care practice, mostly after the recognition of health as a universal right in the 1988 Brazilian Constitution, nurses' work is centred on health care actions directed at individuals and population groups served by SUS. This entails activities related to the organization, maintenance, and coordination of processes to ensure the proper functioning of diverse therapeutic environments, and facilitating the involvement of all health care team members. 15 The daily work of nurses entails activities that range from patients' admission to any of the health care levels within low education, and non-white ethnicity have been linked to late diagnoses and worse prognosis. 18 The Primary Health Care System (PCS) is the main entry point for SUS users. This level of care oversees the coordination of care and the organization of SUS health care networks. Breast cancer control depends on quality primary health care that is well organized and articulated with other levels of care. 20 The majority of early detection breast cancer actions including screening and early diagnosis take place within the PCS. 20 At this level of care, in the context of a family health approach, nurses practice with considerable autonomy and are in turn able to structure and develop their care management actions. This also entails their effective participation in health education processes. 21 As central agents in this process, nurses continue to face daily challenges in the development of these actions. One of the major challenges has to do with the fact that in Brazil breast cancers affecting women of low income status -who depend entirely on the public health care system -are predominantly diagnosed at a late stage due to a reduced number of spaces to serve these women. This emerges from a structural deficit in the health care network that is not well prepared to support these women throghout their cancer trajector from diagnosis to curative and supportive care.
In the context of education, our approach needs a focus on the uniqueness of our work and an ethical and political commitment with an education of professional nurses that is in line with national health policies. International organizations such as the National League for Nursing Research, the Royal College of Nursing, the European Federation of Nurse Educators, Sigma Theta Tau International, and Brazilian entities including the Brazilian Nursing Association have addressed challenges and potential strategies for Nursing education. Common questions raised by these bodies concern the quality of Nursing education, pedagogical conceptualizations, suitable academic environments, and both proper training and sufficient numbers of professionals to respond to professional practice requirements. 22 We need to recognize that the introduction of equity discussions in professional Nursing programs, beyond being a simply curricular concern, is a political demand from Nursing students as well as civil society. It is necessary that we envision a solid Nursing formation in health ethics that is able to relocate the theme of equity from the periphery to the centre of the educational process. 23 Brazilian higher education, regulated by the Law of Lines of Direction and Bases of the Education establishes that higher education program approvals take into account the National Curricular Guidelines for professional programs. 24 The National Council of Education expects of nurses to have a generalist, humanist, critical, and reflexive education that enables them to serve the health needs of the population with an emphasis on the strengthening of SUS, and ensuring the provision of comprehensive, quality, and humane care. While it is important to prepare competent professionals equipped with technical and scientific knowledge, we also need professionals capable of establishing humane, participative, and constructive relationships, who enact autonomy, diversity and responsibility when taking care of social demands. 24 The National Curricular Guidelines of undergraduate Nursing education acknowledge that nurses' formation requires the development of competencies to deal with individuals from diverse social groups at both individual and collective levels, taking into account the uniqueness of each social group. 25 Yet these Guidelines do not specifically deal with aspects of professional education that concern conditions such as ethnicity and race, socioeconomic status, gender, extreme age, and sexual orientation, among others. For example, in the case of adding courses to develop competencies for nurses to provide quality Nursing care for older adults, it is a concern to realize that few Nursing programs in Brazil have in their curriculum mandatory courses with this content, even though the need for curricular adjustments were mentioned by the 2006 National Public Policy of the Older Adult. 26 This example points to the need for vulnerable populations to be considered in the guidelines that direct nurses' education in Brazil. This takes us back to the words of Paulo Freire who states that inclusion happens when one learns from differences and not equal to others. 27 There is no denying that nurse educators have multiple opportunities to advance health equity knowledge. Several educational initiatives to promote equity values and integrate learning experiences in the Nursing curriculum in general have been reported (18). A focus on social justice, advocacy, cultural competence, and cultural safety, among others, as well as on populations with an increased susceptibility to experience health inequities was present in these initiatives. 28 Strategies to advance equity in the curriculum included teaching and learning experiences, recruitment of students from minority groups, international experiences in low resource areas, collaborative partnerships, and research projects to support the needs of populations experiencing social and health inequities. These developments together with local, provincial, state, or national initiatives and policies to ensure access to education for groups who experience inequities as well as increase awareness of these inequities among students and educators provide the basis to advance equity in Nursing education.
In Canada, a significant equity development in recent years has been the response of Canadian Nursing schools There is an urgent need to advance knowledge of the underlying roots of inequities. The impact of the social determinants of health on the health status of populations is well known. 4 Yet the mechanisms by which these determinants interact with one another to generate or perpetuate inequities are not well understood. 32 Studies to examine these interactions and investigate equity pathways to improve the health of affected populations should be part of national research agendas both in Brazil and Canada where significant health disparities exist.
Another important step is the identification of the population groups with an increased likelihood to experience of health inequities because of their multiple social vulnerabilities. Women are prone to experience higher rates of poverty than males, a history of social inequities, low wages, unemployment, and subordination. They are also likely to lead single-parent households. Members of gender minorities are also prone to experience severe health inequities due to barriers in access to health care, higher rates of poverty, and experiences of discrimination and marginalization. These facts are a call to incorporate gender in research led by nurses and allied health professionals.
Another vulnerable group are older adults who represent one of the fastest growing population segments in both countries. While demographic transition characteristics are different in Brazil and Canada, in both countries the increasing participation of older adults in society requires rapid state and government responses with regards to the implementation of specific public policies for this population group. 33 Such policies must have equity as a principle that grants the ability to address questions related to low quality access as well as issues of inaccessibility experienced by older adults within the health care system. In this regard, the undertaking of studies to delineate pathways to operationalize equity principles at all levels of health care programs may contribute to the development of strategies to minimize inequities suffered by this population group. 34 Migrant populations are another group who experience health inequities due to their vulnerable living and working conditions. The rapid growth of these populations in the Americas pose the need to generate knowledge of their health situation and the challenges on our health care systems to prevent and correct potential inequities. The health of Indigenous populations is a major global health issue and a significant challenge for both Brazilian and Canadian Nursing researchers. Indigenous peoples worldwide embody a to the recommendations of the Truth and Reconciliation Commission (TRC). 28 The TRC investigated the historical and abhorrent abuses suffered by Canadian Indigenous peoples as a consequence of the residential school system implemented in Canada for over a century. Residential schools enacted an insidious political agenda to assimilate Indigenous peoples through the elimination of their Indigenous systems including family and social relations, culture, language, and traditions. The TRC issued key calls to action to remedy the historical trauma, severe inequities, and precarious status of Indigenous peoples in Canada as a result of residential schools, colonization, and systemic oppression. 29 In the context of health care, the TRC recommended action to increase the number of Indigenous health care professionals; take action to keep Indigenous health care professionals working in Indigenous communities, and the provision of cultural training for health care professionals.
The TRC called Nursing and medical schools to include a mandatory course on Indigenous health that considered the impact of residential schools on the health of Indigenous peoples. 29 Canadian Nursing schools have taken action in response to this call by incorporating such a course in the Nursing curriculum. Nursing educators have also begun to explore ways of indigenizing the curriculum, that is, transforming Nursing curricula in ways that integrate Indigenous knowledge and decolonize Nursing education. 30 Nursing educators face a major task and responsibility to tackle health inequities and improve the health of Indigenous peoples in Canada. As nurse educators, we need to respond to the need to equip nurses with the knowledge and skills to provide equitable and culturally safe care for Indigenous peoples.
In the context of research, Nursing researchers have a unique opportunity to make a difference in the lives of those who bear severe social and health inequities. Nursing researchers can advocate before government levels for the development of funding initiatives to study and address inequities. Researchers can include steps to integrate equity, diversity, and inclusion in the design of their research studies. In Canada, the three major federal research agencies for health, the natural sciences and engineering, and the social sciences issued in 2019 a statement to advance equity, diversity, and inclusion in Canadian research to increase accessibility to research funding for all researchers and trainees, promote equitable, diverse, and inclusive research practices and participation in the research system, and collect data concerning equity, diversity and inclusion to inform decision making. and administered health care system. The global economic challenges are a serious call for nurses throughout the world to be wary of policies directed at transforming health into a profitable commodity that in turn produce extreme health inequities among population groups.

FINAL CONSIDER ATIONS
The exercise of a practice with equity, justice and inclusion requires the simultaneous strengthening of both the singular and collective identities of Nursing. In this sense, it is nurses themselves who need to make a commitment to deepen and advance in their reflection concerning Nursing challenges to enact equity in practice.
Even though there are differences between Brazilian and Canadian nurses, it is noteworthy that nurses in both countries, based on their ongoing reflection on their actions and in their search to tackle challenges to enact equity in practice, need to be professionally prepared to deliver quality Nursing practice. Nurses need to be politically committed to social, political and economic changes, developing actions that promote the transformation of social reality and improvements in the quality of life of all peoples. disproportionately high burden of disease and severe social and health inequities as a result of a long history of colonization. The development of reciprocal partnerships with Indigenous leaders and communities to ensure the conduct of research that is ethical, relevant, and culturally safe is an integral consideration to achieve research outcomes that respond to their priorities. The vulnerability of these population groups also calls for the adoption, adaptation, and development of methodological approaches designed to study these populations that are thus likely to generate knowledge that is close to their health experiences and needs.
In the administration domain, we highlight the challenge of a practice based on shared decision making as well as the need to establish work processes that are democratic and inclusive in both countries. Certainly, examples that show the absence of equity principles in the administration of health care services are seen in long waiting times, difficulties in access to health care, and delayed care, among others. 35 This is a reality that affects both Brazil and Canada. In Brazil, in the context of federal administration of the health care system, policies have been developed to promote equity with vulnerable populations such as women, black populations, rural and forest populations, persons living on the streets, and persons of Romani heritage, among others. 23 However, these policies do not always reach the required level to be implemented at in local areas where the uniqueness of each of these vulnerable groups should be considered.
Lastly, with regards to the political engagement domain, we recognize the need to broaden the political engagement of Nursing professionals in their dialogue with society, government leaders, and regulatory and professional bodies. There is a need to develop a proactive agenda within the profession as well as society for both-profession and society -need to have clarity concerning what Nursing wants to achieve in the coming years and decades. 15 While recognizing difficulties imposed on Nursing professionals to create reflective practice spaces in the face of the complexities of their daily practice, the active engagement of diverse Nursing organizations as formal agents of these spaces can be a way for the profession to consolidate itself as competent, autonomous, and valued for their social contribution. In addition, together with allied health professionals and civil society, Nursing professionals need to engage to the best of their ability in the struggle to unconditionally defend SUS as an essential public policy for Brazilians. This struggle is not only for the maintenance of SUS but for SUS' own survival before the grave economic and political context currently affecting Brazil. 15 In the same line, Canadians more than ever need to be cautious of potential measures that seek to dismantle its universal publicly funded