Human rights: Food for a missing fair thought  ‘inequality in health’

Human Rights Reader 505

[Excerpted and paraphrased from: Intl. J. for Equity in Health, 1:1, 22 April 2002.  (www.equityhealthj.com/content/1/1/1 ) Macinko J.A. and Starfield B., ‘Annotated bibliography on Equity in Health’. I have added what I found there to my list of iron laws and present them here as such: Use them!].

1. Equality in health is here defined as the absence of potentially remediable, systematic, differences in one or more aspects of health across socially, economically, demographically or geographically defined population groups or sub-groups. (IJEH)

2. WHO defines inequality as differences in health status that are not only unnecessary and avoidable but, in addition, are considered unfair and unjust. [This because not all health differences (inequalities) are necessarily considered unfair or unjust... But beware: Despite the fact that members of society have legitimate claims to fairness in health, there is no way to assess fairness without imposing some value judgment].

Inequality is clearly reflected in differences in health between population groups in any given society

3. Two types of equality have to be considered:

-Vertical equality, i.e., preferential treatment for those with greater health needs  --or ‘the unequal, but fair treatment of unequals’, and

-Horizontal equality, i.e., equal treatment for equivalent needs --or ‘the equal treatment of equals’.

4. In other words, equality implies no differences in health services where health needs are equal (horizontal equality) or enhanced health services being provided where greater health needs are present (vertical equality). Therefore, from a vertical equality and human rights (HR) perspective, groups in society that have the lowest starting points require preferential/priority treatment and investments.

5. Overall, the dilemma we are often faced with is whether to provide the greatest good for the greatest number of claim holders or rather to improve the health of the most disadvantaged in society. [But is this really a dilemma from the HR perspective…?].

6. There are three types of responses to health inequalities:

a) Increasing and/or improving the provision of health services to those in greatest need;

b) Restructuring health care financing mechanisms to aid those rendered disadvantaged; and

c) Altering broader social, economic and political structures intended to influence the more distal determinants of health inequalities. [Note that this influence (the one of politics on inequalities in health) has been grossly under-researched ...certainly not a coincidence...].

7. Success of these responses is to be measured by the size of the reduction in the gap between the better off groups and the groups rendered worse off --or by the measurable improvements attained by the worst off group relative to where it started from before the intervention.

8. Note that ‘individual-based measures of (and responses to) health inequality’ do not address differences across population sub-groups and are thus of limited use in policy making since they do not inform us about comparisons between the more and the less disadvantaged groups in society. Individual measures of health inequalities: a) ignore the important social determinants of health inequalities, b) prevent the latter from being placed in the policy agenda, and c) ignore guiding resources to those with both poorer health and lower socio-economic position. Increased individualization also explains the fact that only rarely are structural policy measures being taken to more frontally tackle health inequalities worldwide: the driving force in individualization is mainly utilitarian (!).

9. An equitable health care system, therefore, is one that assures probabilities of access will be equal across population groups for a given set of health needs and problems.

10. ‘Distributive justice’ focuses on the distribution of health outcomes across groups in society. ‘Procedural justice’ --needed as much-- emphasizes fairness in the processes followed rather than fairness only in the actual outcomes.

11. ‘Benchmarks of fairness’ can be set to judge these two types of justice in health. Examples are: the existence of financial and non-financial barriers to access to care; levels of accountability of providers and degree of empowerment of claim holders; and comparisons of each income group’s share of need for medical care with the share of medical care they actually get (i.e., equality of health benefits).

To reiterate, then, equality in health is ultimately concerned with creating equal opportunities for receiving quality health care […and with bringing unfair health differentials down to the lowest levels possible]

12. Six principles of action flow from this, namely: improving people’s living and working conditions; decentralizing decision-making/encouraging true participation; enabling healthier lifestyles; assessing health impacts of all major development actions; keeping equality on the agenda; and providing quality services accessible to all.

13. Inequalities in health status attributable to the distribution of income are inequitable, basically because they are systematic and remediable; moreover, income inequality is associated with individual morbidity and mortality risks.

14. Socioeconomic position is the major contributor to differences in death rates. The mortality burden attributable to socioeconomic inequality is large and has profound and far-reaching implications. There is thus a ‘social patterning in the causes of morbidity and mortality’. This is as true for differences seen between black and white men in the US as it is for the fact that death rates are highest in the most disadvantaged areas in the world; they also differ by gender, i.e., higher mortality rates are found among lower educated women.  [Since gender is a significant marker of social and economic vulnerability (as, for example, manifested in inequalities of access to health care), gender inequality and limited economic opportunities may be two of the pathways through which the unequal distribution of income adversely affects a population’s health].

15. Another typical example of inequality in countries rendered rich is seen in the fact that lower income groups are more intensive users of general practitioners and hospitals; those rendered rich have higher rates of use of specialist services. A pro-rich inequality also exits for the total number of physician contacts.

16. Additionally, income inequality within a given society has an independent effect on life expectancy, distinct from the well known association between absolute per capita income levels and a population’s health. The greater the income inequality, the greater likelihood that poor individuals will report poorer health.

17. Class at birth and educational attainment seem to be good proxy measures of social position when studying equality in health. [Nevertheless, how social class is specified makes a difference in drawing conclusions about the magnitude of inequalities]. Occupation, indexes of material living standards, and health expenditures as a proportion of a household’s total budget have also been used as proxies. But equality is too complex a concept to be reduced to a single or a couple indicators.

18. The reduction of systematic inequalities in health care is thus seen as an overall strategy for the improvement of a population’s health. But the use of generic categories, such as “the poor” or “the very poor” leads to insufficient disaggregation* of the impact of changes in financing mechanisms and in the use of regressive user fees. Disparity reduction is the key goal!

*: Non-disaggregators are HR violators.

19. Ultimately, what really matters and counts is the equality aspects of the actual resource-allocation decisions being made. For instance, policy-makers have done or are doing little to reduce current inequality-perpetuating government subsidies to the private sector --that serves a minority of the population. Furthermore, many questions have been raised as to whether public/private partnerships (PPPs) can explicitly address the health needs of those rendered poor.

20. Despite the above, the most significant reasons for increased inequalities in health today stems from: a) public policies that benefit globalization, and b) technocratic, humanitarian and apolitical approaches being used by international aid agencies and governments. These approaches disregard the growing inequalities and unequal power relations among and within countries. This, despite the well accepted fact that different power relations in different societies are the most important force that determines the level of well-being and health of their populations. In short: the growth of inequalities is rooted in power relations that are skewed against those rendered poor. For example, as the world moves towards globalizing free market solutions, equality in health has (ideologically) come to be seen as conflicting with the market system’s efficiency goals.

21. Private insurance and out-of-pocket payments have negative redistributive effects (...and user fees only raise an insignificant fraction of revenue for the health sector ...and exemption systems for those rendered poor seldom work). Taxes used to finance health services, on the other hand, have an overall redistributive effect. Moreover, it is proven that one gets more health per dollar by aiming at the health of those rendered poor. Tax progressivity (those who earn more paying more) is key though in determining the redistributive effect of public health care investments.

22. Finally, as part of inequality, we see a widening gap in health status between urban and rural residents correlated with increasing gaps in income and health care utilization rates. We also see increased financial barriers to access in rural areas and, more worrisome yet, diminished rural publicly-financed public health services and programs.

23. As a way out, we basically need to promote greater direct community/claim holder-surveillance of equality issues; the latter is to mobilize political forces and strengthen community empowerment. The focus ought to be on the health status of the most vulnerable --with an eye on acting promptly if equality targets are not being met. Local authorities are to be held responsible/accountable for meeting equality targets. Furthermore, some have suggested that international agencies ought to condition their aid on the surveillance of equality; therefore, each country is to decide on a stepped approach towards achieving health equality targets.

Claudio Schuftan, Ho Chi Minh City

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