World Health Report 2000: how it removes equity from the agenda for public health monitoring and policyCommentary: comprehensive approaches are needed for full understanding

BMJ 2001; 323 doi: http://dx.doi.org/10.1136/bmj.323.7314.678 (Published 22 September 2001)
Cite this as: BMJ 2001;323:678

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World Health Report 2000: how it removes equity from the agenda for public health monitoring and policy

  1. Paula Braveman, professor of family and community medicinea (pbrave@itsa.ucsf.edu),
  2. Barbara Starfield, university distinguished professorb,
  3. H Jack Geiger, Logan professor of community medicine, emeritusc
  1. a University of California, San Francisco Box 0900, 500 Parnassus Avenue, MU3E San Francisco, CA 94143-0900, USA
  2. b Johns Hopkins Medical Institutions, 644 North Broadway, Baltimore, MA 21205, USA
  3. c City University of New York Medical School, Department of Community Health and Social Medicine, 138th Street and Convent Avenue, A-109 New York, NY 10031, USA
  4. Evidence and Information for Policy, World Health Organization, 1211 Geneva 27, Switzerland
  1. Correspondence to: P Braveman
  • Accepted 3 May 2001

The World Health Report 2000 recommends that national health systems be assessed not only by the average health status of a country's population but also by the extent to which health varies within the population.1 Although we applaud this recommendation, we are concerned that the report's approach to measuring health inequalities undermines efforts to achieve greater equity in health within nations. We argue that the report's measure of health inequalities is not useful for guiding national policy because it provides no information to guide resource allocation or to target policies. In addition, it does not measure socioeconomic or other social disparities in health within countries. When used as a substitute for monitoring social inequalities in health, as its authors implicitly1 and explicitly2 recommend, it removes equity and human rights considerations from the routine measurement and reporting of health disparities within nations.

Summary points

The World Health Report 2000 measure of health inequality is not useful for guiding national policies

It does not measure socioeconomic or other social inequalities in health within countries

It removes equity and human rights considerations from the routine measurement and reporting of health disparities within countries

The report's measure correlates poorly with other well established indices of social inequality in health

Health and social inequalities

Without studying the report's technical references,24 most readers will assume that health inequalities refer to social inequalities in health. Social inequalities in health are health disparities between population groups defined by social characteristics such as wealth, education, occupation, racial or ethnic group, sex, rural or urban residence, and social conditions of the places where people live and work. These social characteristics are selected for defining population groups and comparing how health and health care vary across the different groups because of their strong and ubiquitous associations with both underlying social advantage …

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