The concepts of health equity imply certain pragmatic principles of action when striving to reduce social inequities in health status. These are set out below as 10 principles for general guidance. A framework for analysing causes of social inequities in health, and for highlighting policy options and strategies for reducing them, is contained in the companion paper (Dahlgren & Whitehead, 2007).
1. Policy should strive to level up, not level down
Nobody would seriously suggest trying to close the health gap by bringing healthier people down to the level of the least healthy. A worsening in the infant mortality rate of the babies of rich parents, for example, with no change in the mortality rate of poor babies, would not be seen as a success, but would rather be seen as a tragedy – even if it led to a narrowing of the differences between the two groups, purely in terms of measurement. Yet, opponents of an equity policy have warned of this danger. Therefore, to make it absolutely clear, the principle set out in this paper emphasizes that the only way to narrow the health gap in an equitable way is to bring up the level of health of the groups of people who are worse off to that of the groups who are better off. Levelling-down is not an option.
2. The three main approaches to reducing social inequities in health are interdependent and should build on one another
The relative merits of different ways of addressing social inequities in health have been debated recently (Mackenbach et al., 2002; Graham, 2004a). Essentially, the three main approaches being applied to measure and tackle social inequities in health are: focusing on people in poverty only, narrowing the health divide and reducing social inequities throughout the whole population.
- Focusing on people in poverty only. This is a so-called targeting approach, which measures progress in terms of an improvement in health for the targeted group only, without any reference to improvements in health taking place in the population as a whole or among the most privileged group. From this perspective, any improvement in the health status of disadvantaged groups can be considered a success, even if the health divide between rich and poor is increasing.
- Narrowing the health divide. This approach takes as its starting point the health of disadvantaged groups relative to the rest of the population. The focus of action in this category is to reduce the gap between the worst off in society and the best off – the disparity in health status between the extremes of the social scale.
- Reducing social inequities throughout the whole population. This approach recognizes that morbidity and premature mortality tend to increase with declining socioeconomic status and that they are not just an issue of a gap in health between rich and poor. This approach, therefore, takes in the whole population, including middle-income groups, and seeks to reduce the differences in health between high-, middle- and low-income groups, by equalizing health opportunities across the socioeconomic spectrum.
The definition of equity in health adopted in this paper encourages seeing these three approaches as not only complementary to one another, but also seeing them as interdependent. They must build on one another. The logical sequence is, therefore, to make sure that the health of disadvantaged groups is improving, as an essential fi rst step. We are not, however, recommending an isolated targeted approach here, but a general approach which may include specific actions aimed at improving the health of disadvantaged groups at a rate that reduces existing social inequities in health. The second step, narrowing the health divide, has the more ambitious aim of improving the health of people in poverty at a faster rate than that among the rich. The third step is to reduce health inequities between all groups, not just between the extremes of the social scale. The third approach, however, cannot be isolated from the other two, as reduced differences can technically be achieved by reducing the health divide between middle and higher socioeconomic groups while neglecting people in poverty and leaving their health even further behind. The only valid indicator of reduced social inequities throughout the whole population is when the health of the most disadvantaged groups has improved faster than that of the middle- and high-income groups, as explained in Principle 1 above.
3. Population health policies should have the dual purpose of promoting health gains in the population as a whole and reducing health inequities
Some portray these twin goals as confl icting, presenting a trade-off between improved health for the population as a whole and even faster improvement in health among the worse off in society – that is, between overall gains in population health and reducing social inequities in health. This is a false tradeoff. The objective of reducing health inequities constitutes an integral part of a comprehensive strategy for heath development, not an alternative option. In reality, no national strategy in Europe, or elsewhere, abandons attempts to improve the health of the population as a whole in favour of concentrating solely on reducing health inequities. Also, it is increasingly recognized that national heath targets for the population as a whole stand little chance of being met without attention to the health of the worst off in society. The two goals typically go hand in hand.
4. Actions should be concerned with tackling the social determinants of health inequities
This principle focuses not only on the social determinants of health in general (the social conditions that can affect people’s health) but also focuses on the main determinants of the systematic differences in opportunities, living standards and lifestyles associated with different positions in society (Graham, 2004b). Working conditions are a good illustration of this point. In post-industrial Europe, exposure to poor working conditions has ceased to be a major determinant of Population health policies should have the dual purpose of promoting health gains in the population as a whole and reducing health inequities ill health in the population overall. However, a study in Sweden found that differences in exposure to poor working conditions across the social spectrum explained a considerable proportion of the observed inequities in health between socioeconomic groups in the country (Lundberg, 1991). Tackling such social determinants, therefore requires a greater understanding of the processes that generate and maintain social inequities and then intervening in these processes at the most effective points (see companion paper: Dahlgren & Whitehead, 2007).
5. Stated policy intentions are not enough: the possibility of actions doing harm must be monitored
This principle requires an assessment of differential impacts, not just average effects. The classic example in the fi eld of health equity is that of the adverse effects of some health sector reforms of recent decades, which have created a medical poverty trap (Whitehead, Dahlgren & Evans, 2001), where the increasing necessity to pay for care when sick pushes more people into poverty. In this case, the welfare system, which originally intended to support the sick, is turned into a poverty-generating system. This trap developed at a pace that required vigilance to catch it in time. Similarly, interventions designed to help people in poverty may be implemented in such a way as to stigmatize the very people the programme was designed to help and, in so doing, push them to avoid the help on offer. This principle of carrying out health inequity impact assessments applies to a variety of policies outside and inside the health sector. Indeed, the greatest danger may lie in wider macro-policies that hide the negative health impacts, because they are not seen as health related (see companion paper: Dahlgren & Whitehead, 2007).
6. Select appropriate tools to measure the extent of inequities and the progress towards goals
This principle may seem obvious, but as principles 1–5 illustrate, interventions intended to reduce inequities can be focused on one of several distinct goals or targets, and each one may require a separate indicator. Measures that only monitor changes in the health of the poor, for example, will not be able to contribute anything about how poorer groups are faring relative to more advantaged groups. This requires measuring progress at both the top and bottom of the social scale and then comparing these two measurements. This comparison between the extremes of the social scale will not be able to assess the impact across the whole of society. This may require indicators of the so-called shortfall – that is, the cumulative difference between the most advantaged group and each successive social group for each specific factor. It is important to monitor both relative and absolute changes in social inequities in health because they give different information about the magnitude and direction of change. An example of a relative measure is the ratio of the mortality rate of the most disadvantaged group to the mortality rate of the most privileged group. An absolute measure, in this case, would be the difference between mortality rates of the disadvantaged and privileged groups. Table 1 in the Appendix gives a numerical example, using English data on trends in circulatory diseases by deprivation category. Using the absolute measure in this example, inequities in mortality show a decrease, while using the relative measure they show an increase.
7. Make concerted efforts to give a voice to the voiceless
This principle entails, for example, seeking the views of marginalized groups and increasing their genuine participation (as opposed to token consultation). The more articulate members of the population and those with the most powerful representation tend to have more infl uence than those in a weaker position. To address this, administrators and professionals need to make a determined effort to provide administrative systems and information to make it easier for lay people to participate in decisions that affect their health. Make concerted efforts to give a voice to the voiceless Select appropriate tools to measure the extent of inequities and the progress towards goals
8. Wherever possible, social inequities in health should be described and analysed separately for men and women
This separate description and analysis are needed because both the magnitude and the causes of observed social inequities in health are sometimes different for the two sexes. It is therefore of critical importance that these differences are known and taken into consideration when developing strategies to combat inequities in health. The value of combining gender-specific and socioeconomic analyses has been clearly illustrated recently by the Swedish accident prevention programme. Data on accidents for the population as a whole indicated relatively good progress on injury prevention. When the data were separated by sex and social status, however, very different rates and types of accidents were observed for girls compared with boys, men compared with women, and low-income groups compared with highincome groups. The combined gender and socioeconomic analysis also revealed that working class women, in particular, had very high levels of risk in the home and in the workplace. Once these differences were recognized, the need to tailor prevention strategies by gender and socioeconomic condition became clear (La Flamme, 1998). The same is increasingly true for tobacco control policies (Kunst, Giskes & Mackenbach, 2004). Another reason for ensuring that systematic differences in health by gender are analysed by socioeconomic background is that the causes may differ by social position. Poor women, for example, may be discriminated against both for being women and for being poor. Tackling the differences in health generated by this so-called double burden may need different strategies from those designed to tackle the gender effects on health experienced by more affl uent women. The present trend to neglect gender in analyses of social inequities in health and, conversely, to neglect social position in gender-specifi c analyses should therefore be replaced by a combined approach that considers both social position and gender.
9. Relate differences in health by ethnic background or geography to socioeconomic background
Analyses of systematic differences in health by ethnic background should, whenever possible, be related to socioeconomic background, as the magnitude and causes of the ethnic differences observed tend to differ by social position. Likewise, ethnic background needs to be included in analyses of social inequities in health in countries with marked ethnic discrimination. Differences in health between geographical areas should also be analysed, with due consideration to differences in the social structure. Age-adjusted health status in areas with a fairly homogenous population from a socioeconomic perspective can then be used as a proxy for assessing socioeconomic inequities in health, when measures of individual socioeconomic status, such as a person’s occupation or income, are not available routinely.
10. Health systems should be built on equity principles
Equity principles include the following.
- Public health services should not be driven by profi t, and patients should never be exploited for profit.
- Services should be provided according to need, not ability to pay. This requires a system of health care fi nancing that pools risks across the population, so that those at high risk are subsidized by those at low risk at any given time.
- The same high standard of care should be offered to everyone, without discrimination with respect to social, ethnic, gender or age profile.
- The underlying values and equity objectives of a health system should be explicitly identifi ed, and the monitoring carried out to ensure these objectives are approached in the most efficient way possible.
Summary
Social inequities in health are systematic differences in health status between different socioeconomic groups. These inequities are socially produced (and therefore modifi able) and unfair. In practice, all systematic differences in health between socioeconomic groups in European countries could be regarded as unfair and avoidable, and therefore regarded as inequities. This judgement about unfairness is based on universal human rights principles.
The evidence points to the existence of extensive (and widening) social inequities in health in Europe today, at least in relative terms. The need to take action to reduce these inequities and their root causes is becoming ever more pressing as a major public health challenge. This calls for a new way of thinking about the direction of policy and also calls for renewed vigilance in monitoring impacts, to make sure that no segment of the population is excluded or loses out.
Increasing numbers of countries across Europe have been striving to face the challenge of social inequities in health and are working out what practical action can be taken in their own country to improve the situation. The aim of this paper is to help promote a common understanding of the concepts and principles on which actions for tackling health inequities can be based.
Strategies for reducing social inequities in health are presented in a companion paper “European strategies for tackling social inequities in health: Levelling up Part 2” by Dahlgren and Whitehead (2007).
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Source :- Concepts and principles for tackling social inequities in health: Levelling up Part 1
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