Efficient equity-oriented strategies for health

Abstract

Inspired and provoked by Gwatkin's interesting article on health inequalities, I am pleased to present the following comments and suggestions. Define the setting According to Gwatkin, it is only recently that concern for equality, equity and the health of the poor has begun to creep back into fashion. This may be true for some organizations such as the World Bank where Gwatkin has his office, but is certainly not true for all governments, international organizations and nongovernmental organizations, many of which have had this focus for decades. Recognize the ideological environment Gwatkin provides an excellent summary of some recent more sophisticated methods to measure inequities in health and health care services. Within this context, lack of data on social inequities is seen as a major constraint for initiating equity-oriented actions for health. This is only marginally true. The main determinant for action is of course the political will to tackle observed inequities in health. Even the best epidemiological records on social inequities in the world did not put equity in health on the political agenda in the United Kingdom under the former Conservative government. The same database has now, with a Labour government in power, been instrumental in formulating a comprehensive agenda for actions to combat social inequities in health. Formulate equity-oriented targets The importance of equity-oriented targets is also well described by Gwatkin. It must however be recalled that these targets have to be gender-specific, as the causes of social inequities in health and health care, as well as the magnitude and effects of those inequities, differ between males and females. In addition to equity-oriented health targets, it is also of critical importance to formulate targets related to determinants of poor health in general and of social inequities in health in particular. Targets of particular relevance in this perspective could be specific reductions in terms, for instance, of absolute poverty and income differences, and improved access to clean water and proper sanitation as well as to basic education and health services. There should also be a focus on reducing unemployment and creating healthier work conditions. The advantage of formulating targets related to the determinants of health is that actions aimed at reducing social inequities in health are related directly to these determinants rather than to poor health and premature deaths in themselves. Furthermore, the focus on both determinants and outcomes often reveals that there is a political consensus to reduce social inequities in health but far from any consensus to tackle the causes of these inequities. Thus this dual approach to target-setting is also useful for testing, to see if the equity targets in health are real or more likely to be window-dressing. Equity-oriented strategies for health Gwatkin is very vague about how to achieve equity-oriented targets for health. Instead of trying to suggest equity-oriented strategies for health for the coming decades, he dismisses efforts of the past such as the health-for-all movement and recalls that government-led socioeconomic development strategies are increasingly questioned. A more valid approach would have been to call for a real evidence-based assessment of positive and negative experience to date. It is then of critical importance to distinguish between healthy and unhealthy economic policies. Examples of countries with unhealthy economic policies may be the Russian Federation, where male life expectancy declined from 64 years in 1990 to 58 years in 1994, and the United States, where black Americans as a group have a smaller chance of reaching advanced ages than people born in countries such as Sri Lanka and Costa Rica with a much lower per capita income. The key indications of a healthy economic strategy are, as also recalled by Amartya Sen in his keynote address at the World Health Assembly in 1999 (1), the extent to which increased economic resources improve the incomes of the poor and are invested in public systems for health services and education. …