Equality, equity: why bother?

Abstract

The excellent papers in this theme section of the Bulletin aim mainly at defining the inequalities in health that occur, and Gwatkin presents some interesting aspects of the problem of how to reduce them. It is usually assumed that inequalities in health are undesirable and should be reduced, but the reasons for this are not always made explicit. The reason most commonly adduced is that it is morally indefensible not to allow all human beings to enjoy what is often posed by Amartya Sen as one of the essential freedoms and the mechanism through which other freedoms can be enjoyed. There is a cap on the level of health that can be attained if one uses commonly accepted measures such as mortality and morbidity indicators. For material goods, however, there is in theory no limit to the potential gap between those who are best and worst off. The case is made that for an essential requirement such as health the gaps that can be reduced should be. In addition we concern ourselves with inequalities in health because we believe that they may be a cause of social instability. Inequality in health or in access to measures that ensure it can foment discontent and intergroup enmities that disturb the social order within a country. Likewise the differences between countries contribute significantly to the instability of the world. Unfavourable conditions in human health and the environment in some countries are seen to be threats to the security of the more favoured ones. Men and women do not usually use health as a yardstick of achievement or strive to be healthier than others, but they do regard it almost as a right to be as healthy as others and to have access to the means of being so. Finally there is the prosaic consideration that health is one of the ingredients of human capital that is so essential to other aspects of development. Unequal access to measures that lead to formation of human capital inhibits the reduction or alleviation of poverty. Improvement of health status and the reduction of health inequalities are more and more recognized as essential ingredients for schemes to reduce poverty. Our concern is not only instrumental. We wish to ground our comment firmly within the historical background of thinking and practice in the World Health Organization over the last two decades. We place the concern for health differentials squarely within the context of the goal of health for all, which has equity as its underlying value and sees inequalities in terms of the social injustice implied by inequity. This framework is in no way inimical to efforts to identify the inequalities that represent inequities and seek measures to reduce them. The policy issues that these papers raise include the need to establish with more precision some measure of the inequality that exists with regard to health status or outcome. These inequalities can only be deemed inequities if they are unjust and their determinants lend themselves to being manipulated so as to reduce them. Thus, while we acknowledge the need for a measure of the distribution of health status in order to establish the degree of inequality, this can only be a first step if we believe that these differences can be reduced. The real issue is the relation of these differences or inequalities to the distribution of the social determinants of the state of health or the distribution of that state itself. Gwatkin makes a powerful argument for the significance of the distribution of health outcomes. National averages hide the differences that need to be tackled in order to reduce inequity. But this welcome focus has very, practical implications: most of the countries in the Americas do not have the tools to make these determinations, and in many cases they do not see the need for producing the data in a form that shows the relevant distribution and gaps. Only recently has it been possible to organize health data with the degree of geographical disaggregation that will determine the inequalities that exist between the different areas and population groups concerned. …