Putting health equity at heart of universal coverage—the need for national programmes of action

Uneven progress on health inequalities

The millennium development goals (MDGs), which set targets to be achieved by 2015, saw accelerated health progress in target areas, saving millions of lives.8 The international community created innovative institutions such as the Global Fund to Fight AIDS, Tuberculosis, and Malaria, and a goal that would have once seemed fanciful—treating 15 million people with HIV/AIDS by 2015—was achieved.9

The MDGs, however, failed to articulate and implement targets through an explicit equity lens (box 1). Consequently, evaluations have used measurements of overall progress, masking inequitable distribution.13 Reductions in HIV prevalence, for example, were relatively rapid for the wealthiest 60%, while the poorest 40% made little gains.14 In one study, the poorest 40% were doing worse on MDG health outcomes in about a quarter of 64 countries analysed later in the MDG period, based on national surveys conducted between 1990 and 2011.14 Relative inequality grew in MDG health outcomes in nearly half these countries.15

We analysed data on key MDG targets relating to reproductive, maternal, newborn, and child health (table 1).16 Although child and maternal mortality nearly halved under the MDGs, progress towards narrowing gaps between wealthier and poorer populations has remained far too slow. Without substantial reforms, many countries will not close core health equity gaps this century, much less achieve the commitment to leave no one behind by 2030.

One reason for this is the failure to focus on equity. The aggregate nature of MDG targets and indicators limits our understanding of health inequities. A second reason is the complexity of health inequities, requiring action across numerous social determinants.1718 Siloed, medically focused approaches to health have become common since an initial push for comprehensive primary healthcare was quickly seen as too expensive.6162 Intersectoral collaboration and action require a change in mindset. This is made harder by the deeply rooted, structural nature of the injustices underlying health inequities, from power and wealth imbalances to centuries of discrimination against populations who experience poorer health. In addition, income inequality, a major determinant of health, is growing in nearly all the world’s regions.19 Without taking explicit account of these structural factors, little progress will be made.

Despite these problems some countries have made substantial progress. Costa Rica achieved near equality in skilled birth attendant coverage between women in the poorest and wealthiest quintiles. The government built an extensive primary care network and increased girls’ access to education.202122 The participatory slum upgrading programme improved the lives of 22 million people living in slums across 35 countries, reducing their negative effects on health.2324 Bolivia significantly reduced income inequality thanks to targeted social welfare programmes paired with macroeconomic strategies that raised income in the informal economy through strong currency, cheap imports, and increased minimum wages.2526 These approaches indicate not only that progress is possible but also that health equity requires comprehensive approaches.

Measuring what we value

An effective strategy starts with making health inequalities more visible. If we measure what we value, and act on what we measure, then it seems that the international community does not value health equity very much. For example, although the SDG indicator for universal health coverage (UHC) encompasses interventions for both the general and most disadvantaged populations, the monitoring report omits data for disadvantaged groups.27 A failure to collect more granular data prevents UHC being compared “across different dimensions of inequality.”28

Data that breaks down health indicators by population group, collected across sectors and monitored over time, is foundational to understanding, targeting, and establishing accountability for advancing health equity. Does the rate of improvement in health for disadvantaged populations exceed the national rate of improvement? Which populations are furthest behind in health outcomes and why? As well as numerical data we need qualitative data to understand the causes of health inequality and why policies are succeeding or failing.

Disaggregated data can help target interventions—such as in Rwanda, which is focusing on the most disadvantaged 25% of the population29—and shift “success” measures within the health system to include improved equity. But current surveillance data already provide governments with enough information to begin to identify common markers of discrimination and disadvantage without waiting for new data systems.

A new approach to equity will require increasing the quantity and quality of disaggregated data, including expanding the dimensions of inequality that survey instruments cover to include, for example, disabilities, indigenous communities, and gender, ethnic, and racial identity. It is important to link demographic survey data to health indicators, using sampling methods to fill data gaps.30 SDG 17 includes a target of enhancing capacity for “high quality, timely and reliable” disaggregated data, yet these data remain sorely lacking. There are multiple reasons for this, including insufficient funding, failure to include relevant dimensions in survey and health instruments, and lack of training for public health authorities.3132 Greater development assistance and domestic investment to build statistical skills could substantially improve measurements of health inequities.3334

The continued lack of attention to granular data on health inequalities cannot be justified. Supporting countries should be a priority for WHO, the World Bank, and national assistance programmes. Beyond country specific data, global reporting on SDG goals and targets should be disaggregated to enable fuller insights into the distribution of inequalities.

Health equity programmes of action

Understanding the problem is a start, but it is not enough. The persistence of health inequalities, their gravity, and the injustices they reflect demand action. To dramatically reduce health equity gaps, governments must explicitly plan to do so—dedicating time, political attention, and resources to setting priorities and crafting solutions expressly aimed at ending health inequities.

Promising approaches and interventions to reduce inequity do exist. UHC may be central to achieving health equity, but only if it focuses explicitly on progressively eliminating geographical, economic, sociocultural, and gender barriers.35 Numerous interventions in the health, education, and economic sectors have been identified for action on social determinants of health.25 Pairing data with approaches based on human rights has been shown to facilitate effective deployment of resources to advance equity. For example, as part of its effort to increase vaccination coverage for indigenous children, Brazil’s health ministry used factors such as low vaccination coverage, difficult to access geographical areas, and poor immunisation information systems to identify priority areas for health teams to visit during a “vaccination of indigenous peoples” month, resulting in a 30-40% increase in vaccination coverage.36

The SDGs have failed to highlight mechanisms to translate promising approaches into action and there is, so far, little indication that governments have shifted towards active, comprehensive health equity planning.37 Voluntary national reviews, presented every few years, continue to focus on overall health goals and pay little attention to equity. A recent UN report contained only one example of planning towards leaving no one behind in health—Canada’s plans to improve health services for indigenous peoples—which is not new and focuses on a single disadvantaged population. The UN also highlighted Bhutan’s vulnerability baseline assessment,38 which identified opportunities to reduce inequities (not specific to health) but had no plan for resolving them.39 A handful of high income countries have health equity strategies, pre-dating the SDGs, that cut across sectors to improve equity, with some population specific measures (box 2). For example, Norway’s 2007 strategy encompassed income, childhood development, work and the workplace environment, and services and behaviour, with some targeted focus on several specific groups (box 2).46 However, even these neglect important determinants contributing to health inequities or cover only certain populations, and they largely lack specific actions.40

Governments need to develop and implement health equity programmes of action to ensure progress on effective strategies.41 Programmes of action could be standalone or, better still, integrated within health and development planning both nationally and regionally as required. Action programmes should establish explicit targets, a costed set of actions, and a timebound accountability framework for improving health equity, moving beyond the outdated assumption that improving health overall will improve equity. To be effective, they must begin with a clear understanding of the complexity of health inequities, identify systemic approaches designed to be effective for specific populations, and include both biomedical and social determinants.

The programmes will need to be adequately and sustainably funded, buttressed by high level political support from national governments as well as a supportive global environment. This should include funding from higher income countries, WHO, and other multilateral institutions to promote this approach and facilitate knowledge sharing. If national governments are unwilling or unable to take the initiative, or simply unaccountable to their populations, localities could still develop local or regional programmes of action; a health minister could take the lead if a broader governmental initiative is not forthcoming or civil society could develop its own programme of action as a basis for advocacy.

We propose seven key principles to underpin the programmes of action (box 2).55 In developing these plans it is vital for governments to fully engage diverse communities experiencing disadvantage and ensure that marginalised populations have a central role in decision making—including holding leadership positions. Actions should build capacities for meaningful participation and be based in the realities of populations living in situations of vulnerability.56

The programmes of action should have the express goal of maximising health equity and include times for achieving targets towards this goal. This will require actions on structural determinants, including discrimination, political exclusion, and skewed distribution of and control over resources.1857 To be effective, the programmes of action must also be systematic. They should encompass the full range of social, environmental, economic, commercial, and political determinants of health, with genuine collaboration across sectors.58 They need to identify all populations experiencing health inequities, analyse underlying factors, and propose policies to narrow inequities, with additional research as needed. Actions would address causes shared across populations (eg, unaffordable or inaccessible healthcare) and those specific to particular populations (eg, migrants’ exclusion from equal rights to health services, education, and other benefits and challenges of providing services to remote rural communities).

To ensure that the programmes of action are implemented they need to contain specific targets and timelines that are integrated into each sector’s strategies. They should include measures to ensure accountability. Official and independent reporting on progress, fully transparent and bolstered by joint external evaluations, should be supported by disaggregated data. Accountability mechanisms could be as diverse as village health committees, parliamentary hearings, access to courts, and health impact assessments. Finally, programmes of action need sustained high level political commitment to succeed. A supra-ministerial committee could oversee intersectoral action, with leadership from heads of government.

Call to action

Progress in health equity can serve as an organising principle, a bellwether of global action and a powerful response to today’s most pronounced political currents. This requires moving health equity to the centre of health and development agendas. But several years into the SDG era, transformational health equity action planning remains absent.

Health equity programmes of action could be a powerful tool for organising and planning a strong path forward. These require empowering participation, precision, and accountability, with robust political and financial backing. International coordination is necessary because trans-national factors (eg, climate change, migration, and trade) contribute to inequities. Programmes of action could drive multisectoral action for better health for the many people who are yet to benefit from improved overall health outcomes. Governments should make firm commitments, backed where needed by wealthier nations and international financing and action, while the UN builds reporting on these commitments into SDG processes.59

Inequities are at the root of millions of preventable deaths every year. It would be a grave injustice to see 2030 approaching, and yet again, find the world has failed to turn lofty promises into tangible action.