Equity on both the scientific and the policy agendasBMJ 1998; 316 doi: https://doi.org/10.1136/bmj.316.7137.1035 (Published 04 April 1998) Cite this as: BMJ 1998;316:1035
WHO report reminds us of the essentials
- Louise J Gunning-Schepers, Professor
It is time to admit that we need a two pronged approach to equity in health: a scientific and a policy effort. These may not be synchronised and each has to be allowed to run its own course, but they need to happen simultaneously.
On the one hand we are confronted with a teasing scientific problem. Why are social inequalities in health so universal? They show a clear gradient for almost any health indicator by any measure of social position—be it education, income, professional class, or social class—in every country where data have been collected, irrespective of the country's position on income distribution, access to education, regulations on working conditions, social benefits, or social housing policies. Why do health inequalities appear to affect almost all diseases, both the diseases of poverty and the lifestyle related diseases of more affluent societies?
Through which more proximal risk factors do socioeconomic factors affect the occurrence and pathophysiology of individual diseases? And what do we know about the lag times between exposure and outcomes? We do not accept mere correlations of time series as sufficient evidence of causation in other areas of epidemiology, so why here? When we see the strength of the relation diminish with old age, is that an artefact of selective mortality or of misclassification of social position in older people, or is it part of the explanation? And, finally, with the limited evidence we have on interventions that seem to improve the health of deprived groups can we confidently recommend policies to governments eager to reduce inequities in health?
These and many other questions need to be answered by careful scientific research, teasing apart the elements that play a part in causing inequalities and trying to measure the potential for reducing them through interventions. This is a necessary and intellectually stimulating venture, but not one likely to yield substantial results in the near future.
That is why a second—policy—approach is also necessary. The World Health Organisation has known that all along, and its most recent publication gives all the ingredients necessary for a sound approach to governments wanting to reduce the social inequalities in health in their own societies.1 For the first time this publication raises the question of equity in health policies in developing countries, using much of the experience gained in recent decades in Europe.
Reading the familiar concepts in a third world context is refreshing because it presents the basic policy proposals uncluttered by the more detailed scientific debates that are becoming more important in a European context. The basic preconditions for health are well known, and their equitable distribution an objective many societies are willing to consider. After all few societies are actively trying to achieve inequalities in health. It is only when measures that help ensure equality in health interfere with other policy goals that equality in health may be sacrificed—for instance, for economic growth. In choosing between policy options that concern such known preconditions for health as education, income, environmental safety, housing, and working conditions, policymakers should consider distributions as well as general average outcomes. But for that to happen equity in health needs to remain on the political agenda.
An important measure to prevent health inequalities—but even more so to redress them—is an equitable health service. Equitable here means that it guarantees equal access, priority of care in relation to medical need instead of ability to pay, equal quality of care (both effectiveness and patient satisfaction), and an equitable distribution of the financial burden. The generation of those who remember what it was like before we had universal healthcare systems has almost disappeared and with them the memories of the arguments used in those early policy debates. That is why it is useful for the WHO to re-emphasise these arguments. We should use them when western governments propose reforms to cope with aging populations and new technologies. It might well be that equity is the most powerful concept to help not only developing countries in their growth towards health for all but also western countries in trying to adapt health policies for the 21st century.
One important opportunity to achieve as much equity in health as possible, given our limited understanding, may be in the daily practice of health care itself. Institutions and individual practitioners need carefully and continuously to ask themselves if their efforts produce equal benefits for those entrusted to their care. Such smallscale efforts are unlikely to resolve the inequalities in health we measure at population level, but a continuing effort at least not to add to these inequalities may well be the best way to preserve equity as a central value in our healthcare services.