PHA-Exchange> How many lives is Equity worth?

[Aviva]

Excerpted and paraphrased from:
Intl. J. for Equity in Health 2002, 1:1, 22 April 2002.
(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 population groups
in any given society.

2.Equity is defined as the absence of potentially remediable, systematic,
differences in one or more aspects of health across socially, economically,
demographically or geographically defined population 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 unfair and
unjust.
[This because not all health differences (inequalities) 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 judgement].

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 (vertical 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) Increasing 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 social 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 structural 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 outcomes
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 people'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 remediable;
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 inequality 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 highest 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 vulnerability (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 general
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 independent
effect on life expectancy, distinct from the well known association between
absolute per capita income levels and a population's health. The greater the
income inequality, the greater likelihood 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 household'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 inequality-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 expected 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 societies are the most important
force that determines the level of well-being and health of their
populations. In short: the growth of inequalities 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 redistributive
effects (...and user fees only raise an insignificant fraction 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 redistributive 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 increased financial barriers
to access in rural areas and, more worrisome yet, diminished rural
publicly-financed public health services and programs.

25.As a way out, we basically need to promote greater direct
community-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. Furthermore, some have
suggested that international agencies should condition their aid on the
surveillance of equity; therefore, each country should decide on a stepped
approach towards achieving health equity targets.

Claudio Schuftan, Hanoi
aviva at netnam.vn