Levelling up: Global examples of reducing health inequalities.

Clare Bambra

doi:10.1177/14034948211022428

Abstract

There are significant inequalities in health by socio-economic status, race/ethnicity, gender, neighbourhood deprivation and other axes of social inequality. Reducing these health inequalities and improving health equity is arguably the ‘holy grail’ of public health. This article engages with this quest by presenting and analysing historical examples of when sizeable population-level reductions in health inequalities have been achieved. Five global examples are presented ranging from the 1950s to the 2000s: the Nordic social democratic welfare states from the 1950s to the 1970s; the Civil Rights Acts and War on Poverty in 1960s USA; democratisation in Brazil in the 1980s; German reunification in the 1990s; and the English health inequalities strategy in the 2000s. Welfare state expansion, improved health care access, and enhanced political incorporation are identified as three commonly held ‘levellers’ whereby health inequalities can be reduced – at scale. The article concludes by arguing that ‘levelling up’ population health through reducing health inequalities requires the long-term enactment of macro-level policies that aggressively target the social determinants of health.

Highlights

There are significant social inequalities in health by income, race, gender, neighbourhood deprivation and other axes of social inequality [1]
In 1985, Brazil started a gradual transition from military dictatorship (1964–1985) to become a stable democracy by the mid-2000s. This increased political participation was accompanied by an expansion of health and welfare programmes, including the introduction of universal health care in 1988; a national women’s health programme and a national programme for child health in 1984; a family health programme in 1994; a national programme for the reduction of infant mortality in 1995; and the Bolsa Família cash transfer programme for low-income women with children in 2003.These led to a significant improvement in maternal and child health care and a reduction in Brazil’s poverty rates as well as a decrease in income inequalities between the rich and poor [28,29,30]
It is possible to identify common levellers across these five examples of when health inequalities were reduced at scale, namely welfare state expansion, improved health care access, and enhanced political incorporation

Summary

Introduction

There are significant social inequalities in health by income, race, gender, neighbourhood deprivation and other axes of social inequality [1]. In 1985, Brazil started a gradual transition from military dictatorship (1964–1985) to become a stable democracy by the mid-2000s This increased political participation was accompanied by an expansion of health and welfare programmes, including the introduction of universal health care in 1988 (the Unified Health System); a national women’s health programme and a national programme for child health in 1984; a family health programme in 1994; a national programme for the reduction of infant mortality in 1995; and the Bolsa Família cash transfer programme for low-income women with children in 2003.These led to a significant improvement in maternal and child health care and a reduction in Brazil’s poverty rates as well as a decrease in income inequalities between the rich and poor [28,29,30]. The strategy may have been even more effective if it had been sustained over a longer time period, but from 2010 the newly elected Conservative–Liberal coalition government pursued a policy of austerity, which has been associated with increasing health inequalities [40]

Findings

Discussion

Conclusion