AFRO-NETS> How many lives is Equity worth?

[Claudio Schuftan <aviva@netnam.vn>]

How many lives is Equity worth?
-------------------------------

Excerpted and paraphrased from:
Intl. J. for Equity in Health 2002, 1:1, 22 April 2002.
http://www.equityhealthj.com/content/1/1/1

Macinko J.A. and Starfield B., 'Annotated bibliography on Equity in 
Health'

HOW MANY LIVES IS EQUITY WORTH? (borrowed from Lindholm et al., 1998)

1. Inequality is reflected in differences in health between popula-
tion groups in any given society.

2. Equity is defined as the absence of potentially remediable, sys-
tematic, differences in one or more aspects of health across so-
cially, economically, demographically or geographically defined popu-
lation groups or sub-groups. (IJEH)

3. WHO defines inequity as differences in health status which are not 
only unnecessary and avoidable but, in addition, are considered un-
fair and unjust. [This because not all health differences (inequali-
ties) are considered unfair or unjust... But beware: Despite the fact 
that members of society have legitimate claims to fairness in health, 
there is no way to assess fairness without imposing some value judge-
ment].

4. Two types of equity have to be considered: -Vertical equity, i.e., 
preferential treatment for those with greater health needs --or 'the 
unequal, but fair treatment of unequals', and -Horizontal equity, 
i.e., equal treatment for equivalent needs --or 'the equal treatment 
of equals'.

5. In other words, equity implies no differences in health services 
where health needs are equal (horizontal equity) or enhanced health 
services being provided where greater health needs are present (ver-
tical equity). Therefore, from a vertical equity perspective, groups 
in society that have the lowest starting points require preferential 
treatment and investments.

6. Overall, the dilemma we are often faced with is whether to provide 
the greatest good for the greatest number of beneficiaries or rather 
to improve the health of the most disadvantaged in society.

7. There are three types of responses to health inequities: a) In-
creasing or improving the provision of health services to those in 
greatest need; b) Restructuring health care financing mechanisms to 
aid the disadvantaged; and c) Altering broader social, economic and 
political structures intended to influence more distal determinants 
of health inequities. [Note that this influence (the one of politics 
on inequities in health) has been grossly under-
researched....certainly not a coincidence...].

8. Success of these responses is to be measured by the size of the 
reduction in the gap between the better off and worse off group --or 
by the improvements attained by the worst off group relative to where 
it started from before the intervention.

9. Note that 'individual-based measures of (and responses to) health 
inequality' do not address differences across population sub-groups 
and are thus of limited use in policy making since they do not inform 
us about comparisons between the more and the less disadvantaged 
groups in society. Individual measures: a) ignore the important so-
cial determinants of health inequalities, b) prevent them from being 
placed in the policy agenda, and c) ignore guiding resources to those 
with both poorer health and lower socio-economic position. Increased 
individualization also explains the fact that only rarely are struc-
tural policy measures being taken to more frontally tackle health 
inequalities worldwide: the driving force in individualization is 
mainly utilitarian.

10. An equitable health care system, therefore, is one that assures 
probabilities of access will be equal across population groups for a 
given set of health needs and problems.

11. 'Distributive justice' focuses on the distribution of health out-
comes across groups in society. 'Procedural justice' --needed as 
much-- emphasizes fairness in the processes followed rather than 
fairness only in the actual outcomes.

12. 'Benchmarks of fairness' can be set to judge these two types of 
justice in health. Examples are: the existence of financial and non-
financial barriers to access, levels of accountability of providers 
and empowerment of beneficiaries, comparisons of each income group's 
share of need for medical care with the share of medical care they 
actually obtain (equity of health benefits).

13. To reiterate, then, equity in health is ultimately concerned with 
creating equal opportunities for receiving quality health care, and 
with bringing unfair health differentials down to the lowest levels 
possible.

14. Six principles of action flow from this, namely: improving peo-
ple's living and working conditions, decentralizing decision-
making/encouraging true participation, enabling healthier lifestyles, 
assessing health impacts of all major development actions, keeping 
equity on the agenda, and providing quality services accessible to 
all.

15. Inequalities in health status attributable to the distribution of 
income are inequitable, basically because they are systematic and re-
mediable; moreover, income inequality is associated with individual 
morbidity and mortality risks.

16. Socioeconomic position is the major contributor to differences in 
death rates. The mortality burden attributable to socioeconomic ine-
quality is large and has profound and far-reaching implications. 
There is thus a 'social patterning in the causes of morbidity and 
mortality'. This is as true for differences seen between black and 
white men in the US as it is for the fact that death rates are high-
est in the most disadvantaged areas; they also differ by gender, 
i.e., higher mortality rates are found among lower educated women. 
[Since gender is a significant marker of social and economic vulner-
ability (as, for example, manifested in inequalities of access to 
health care), gender inequality and limited economic opportunities 
may be two of the pathways through which the unequal distribution of 
income adversely affects a population's health].

17. Another typical example of inequality in rich countries is seen 
in the fact that lower income groups are more intensive users of gen-
eral practitioners and hospitals; the rich have higher rates of use 
of specialist services. A pro-rich inequity also exits for the total 
number of physician contacts.

18. Additionally, income inequality within a given society has an in-
dependent effect on life expectancy, distinct from the well known as-
sociation between absolute per capita income levels and a popula-
tion's health. The greater the income inequality, the greater likeli-
hood that poor individuals will report poorer health.

19. Class at birth and educational attainment seem to be good proxy 
measures of social position when studying equity. [Nevertheless, how 
social class is specified makes a difference in drawing conclusions 
about the magnitude of inequalities]. Occupation, indexes of material 
living standards, and health expenditures as a proportion of a house-
hold's total budget have also been used as proxies. But equity is too 
complex a concept to be reduced to a single or a couple indicators.

20. The reduction of systematic inequalities in health care is thus 
seen as an overall strategy for the improvement of a population's 
health. But the use of generic categories, such as "the poor" or "the 
very poor" leads to insufficient disaggregation of the impact of 
changes in financing mechanisms and of regressive user fees.

21. Ultimately, what really matters and counts is the equity aspects 
of the actual resource-allocation decisions being made. For instance, 
policy-makers have done or are doing little to reduce current ine-
quality-perpetuating government subsidies to the private sector --
which serves a minority of the population. Further, many questions 
have been raised as to whether public/private partnerships can be ex-
pected to explicitly address the health needs of the poor.

22. Despite the above, the most significant reasons for increased 
inequalities in health today stems: a) from public policies that 
benefit globalization, and b) from technocratic, humanitarian and 
apolitical approaches being used by international aid agencies and 
governments; these approaches disregard the growing inequalities and 
unequal power relations among and within countries. This, despite the 
well accepted fact that different power relations in different socie-
ties are the most important force that determines the level of well-
being and health of their populations. In short: the growth of ine-
qualities is rooted in power relations that are skewed against the 
poor. For example, as the world moves towards globalizing free market 
solutions, equity in health has (ideologically) come to be seen as 
conflicting with the market system's efficiency goals.

23. Private insurance and out-of-pocket payments have negative redis-
tributive effects (...and user fees only raise an insignificant frac-
tion of revenue for the health sector ...and exemption systems for 
the poor seldom work). Taxes used to finance health services, on the 
other hand, are generally pro-poor in their overall redistributive 
effects. Moreover, it is proven that one gets more health per dollar 
by aiming at the health of the poor. Tax progressivity (those who 
earn more paying more) is key though in determining the redistribu-
tive effect of public health care investments.

24. Finally, as part of inequality, we see a widening gap in health 
status between urban and rural residents correlated with increasing 
gaps in income and health care utilization rates. We also see in-
creased financial barriers to access in rural areas and, more worri-
some yet, diminished rural publicly-financed public health services 
and programs.

25. As a way out, we basically need to promote greater direct commu-
nity-surveillance of equity issues; the latter can mobilize political 
forces and strengthen community empowerment. The focus should be on 
the health status of the most vulnerable -- with an eye on acting 
promptly if equity targets are not being met. Local authorities are 
to be held responsible/accountable for meeting equity targets. Fur-
thermore, some have suggested that international agencies should con-
dition their aid on the surveillance of equity; therefore, each coun-
try should decide on a stepped approach towards achieving health eq-
uity targets.

Claudio Schuftan
Hanoi, Vietnam
mailto:aviva@netnam.vn

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