Health equity: we need political action not performative promisesBMJ 2023; 383 doi: https://doi.org/10.1136/bmj.p2735 (Published 21 November 2023) Cite this as: BMJ 2023;383:p2735
The Alma Ata Declaration of 1978 called for health for all.1 Most declarations since reiterate this commitment to health equity, including the 2023 UN political declaration on universal health coverage recently adopted in New York.2 But the meetings and processes producing these declarations differ markedly. The 1978 meeting intended to “exert moral pressure” and was deliberately international and multisectoral, involving political movements. The 2023 universal health coverage process aimed at inclusion, but was criticised for “recycling ancient promises.”3
Declaring commitment alone is meaningless without political action to improve the social and commercial determinants of health. Health equity will not be achieved through technical fixes alone; technical inputs have a role to play, but there is no getting around the fact that making health for all a reality is a political project. On this path, we must disrupt prevailing paradigms and galvanise fresh commitments to tangible action.
The Sustainable Development Goals adopted in 2015 were remarkable for their, now clichéd, slogan of “leaving no one behind,” and for target 17.18 which committed countries to strengthen reporting of data disaggregated by gender, race or ethnicity, socioeconomic status, and seven additional variables. Governments can use disaggregated data to identify groups most at risk and design reform measures that reach them.
Sadly, we can’t learn enough from most reported data about who is affected by these failures in health equity. Take, for example, the covid-19 pandemic. Though it was clear early on that there were distinct socioeconomic patterns, and despite efforts to undertake reporting by many ministries of health and the World Health Organization, a review on reported data found only half of countries were publicly reporting sex disaggregated data, only five reported on race or ethnicity or disability, with even fewer on place of residence or socioeconomic status. No low or middle income country reported on these variables.4 These data could be disaggregated to reveal who is being left behind and to guide action on the upstream determinants of health inequities.
These operational challenges notwithstanding, there is also emerging pessimism around the “abuses”3 of health equity as a performative clarion call without action to support it. But the problem is deeper than rhetoric and we must question whether power structures are distracting from and distorting our view of equity. In many countries, policy attention is deliberately diverted away from the upstream social determinants and the inequality of opportunity. Health policy and systems are segmented such that separate processes and entitlements exist for the elite. Emphasis is placed on disease, serving the interests of the “illness industry” including private hospitals, insurers, or big pharmaceutical companies, who profit from sickness.
We must challenge the prevailing growth focused, acquisitive economic model for health that mostly considers health a personal, illness related phenomenon managed by professionals. Power and autonomy—over our bodies and over health priority setting and reform—need to be claimed by people and communities. We can look to existing examples of community action shaping services, reform, and enhancing trust in health and other systems for guidance.56 This requires strengthening government capacity to support social participation in policymaking, establishing mechanisms, and legislating for inclusion and accountability across all stages of the health policy cycle.7
To achieve health equity, taming the commercial determinants of ill health must become a priority. For most governments, that involves limiting and requiring transparency around commercial participation in politics and policymaking, anti-trust legislation to prevent monopolies, and progressive taxation on corporations.8 Progress on health equity needs to be tied to advocacy for social justice more broadly. This requires advocating for laws and policies that promote distributive justice for fairer allocation of resources and opportunity. This represents a movement away from individualising the causes of ill health and ensuring properly funded and functioning public institutions to ensure implementation and accountability for redistributive policies.
As the Alma Ata Declaration made clear, we need to shift our collective organising to the inequalities of daily living—of the privileged and the disadvantaged—which beget and perpetuate health inequity. Critically, more efforts need to be made to hold governments to account for engaging with, and meeting the needs of, people who have been structurally excluded. Anything less political will not be enough.
DN is conjoint associate professor, Faculty of Medicine, University of New South Wales, Australia, and conjoint professor, Prasanna School of Public Health, Manipal Academy of Higher Education, India.