Inequity in health: let's not live with it.

Abstract

Variations in population health between nations and among various social and economic groups within a nation beyond a certain limit is unjust. Such variations hinder the population from attaining its maximum health and life potential and have far-reaching implications in terms of human development, health and social consequences. There is a growing realization among policy-makers and implementers of development programmes that the extent of variation in health among social groups and nations should be minimized as much as possible not only for the benefit of the most disadvantaged but for all. This realization itself is a step forward towards the reduction of unnecessary disparity. However, the challenge remains as to how to tackle this undesired phenomenon. Social inequity in health vs health inequity The first step towards dealing with unacceptable disparity is to define what is unacceptable. Due to the inherent nature of human variation, no two individuals or group of individuals can possibly be equal. Then how is the line drawn between an acceptable and an unacceptable level of inequality? Should the yardstick be dependent on the level of development of the society in which the individuals live? Or should there be universal criteria for defining inequity in health? If so what could be those criteria? While ideal answers for the above are hard to get, people still use various techniques to map the situation (1,2). Inequality, in its simplest form, can be viewed as a sum of 'unavoidable inequality' and 'potentially-avoidable inequality' (3). A part of the 'potentially avoidable' inequality can be unacceptable and unfair, and can also be termed as inequity. Efforts to reduce inequity should then be directed towards 'potentially avoidable' and unfair inequalities. Now the challenge is to decide whether the health status of individuals alone be used in classifying individuals in inequitable conditions, meaning that anybody in poor health is in an inequitable condition irrespective of their socioeconomic or other discriminatory conditions, or whether the health status of individuals be examined by their socioeconomic or other discriminatory social factors to see whether the variation among various socioeconomic groups is equitable. Arguments in favour of studying socioeconomic inequality in health has been made by many (4,5), and correspondingly, examination of the health status of individuals by social or similar other grouping is the popular strategy. Conceptualization What follows next is the conceptualization of the link between societal and individual factors and the health status of individuals. This implies an understanding of society on the one hand and human biology and clinical issues on the other. Diderichsen and Hallqvist proposed one such framework elucidating the pathways from the social context to health outcomes identifying the policy intervention points (6,7). Such a line of conceptualization is helpful in understanding the determinants of health inequity with a clear identification of proximate determinants operating at the societal and health fronts, which can be pinned down for policy formulation to reduce health inequity. Remedial actions After the identification of action points to remedy inequity comes the formulation and implementation of actions. Although quite often health is a biomedical outcome, its determinants may well lie outside the scope of the biomedical paradigm. Social inequity in health has its roots in societal factors, and almost certainly, the reduction of social inequities in health would require affirmative action in the social and health sectors. In addition, a preventive or curative response to a health problem can only be effective in reducing social inequity in health if the disadvantaged in the society make equal (if not more) use of the opportunity when they need it. If the available services are primarily used by those with least need and more effectively than those with greatest need, then such services, in fact, increase health inequity. …