Equity in health [CMAJ - February 8, 2000]

Equity in health

Barbara Starfield

CMAJ 2000;162:346

Equity, the absence of systematic inequality across population groups, has become a politically legitimate and worldwide concern. It is now difficult to ignore the impact of disparities in income distribution, which have been increasing in most countries such that the rich are becoming relatively richer and the poor relatively poorer. The share of global income of the poorest 20% of the world's population dropped from 2.3% to 1.4% in the most recent 30 years, whereas the share of the richest 20% increased from 70% to 85%, thus doubling the ratio of the share of the richest to the share of the poorest from 30:1 to 61:1.¹ Concomitantly, there is mounting evidence that health is directly, and almost linearly, related to wealth across the social position gradient within most countries. Thus, poverty itself is not the only determinant of differences in health status within or across industrialized nations. Countries of equivalent overall wealth, as measured by gross national product per capita, achieve very different levels of health, however measured, according to the equity of their income distributions.² The same phenomenon occurs within countries, and even within highly industrialized countries. For example, in the United States, the populations of states and counties with more equitable distribution of income have better health as measured by a variety of indicators, including but not limited to total adjusted death rates, life expectancy at birth and infant mortality.³

While it is clear that material deprivation of families and communities alone cannot explain compromise in health (the poorest individuals in some wealthy countries have more material resources available to them than the poorest individuals in some poor countries, yet their health is no better), the precise mechanisms by which social inequity produces health inequities are unclear. Theories abound, with factors ranging from political context to characteristics of communities, to psychological impacts of perceptions of inequality, to a variety of types of material deprivation, and even to the role of various modes of organization of health services, but scientific study is in its infancy. Most studies of the pathways through which income inequity operates focus on only one of these classes of determinants. There is, as yet, no framework that could inform the design and conduct of systematic study of their effect on health.

Whereas health and social policy are unlikely ever to be based solely on scientific evidence, evidence can serve the role of raising questions about extant health policy and suggest the need for its reevaluation. That is, evidence can draw attention; when scientific findings are made available and used to develop political constituencies, they can influence policy.

To provide impetus to the development of the type of knowledge that might inform policy, the International Society for Equity in Health (ISEqH) is being formed and will hold its inaugural meeting on June 2930 in Havana, Cuba. A call for papers has been issued (deadline for abstract submission Feb. 15).

The following is taken from the Principles Declaration for the Society.

The purpose of the Society is to encourage advances in knowledge about the importance of equity in the improvement of health of all people, and to promote the application of knowledge to activities directed at this goal. Its primary but not exclusive focus is on the contributions made by health services as a critical social endeavor. Its purposes are to promote equity in health and health services internationally, to facilitate scientific interchange of conceptual and methodological knowledge on issues of equity, to advance research related to equity in health, to foster leadership networking for equity in health and to maintain corresponding relationships with other relevant international and regional organizations.

An equitable society is the foundation for achieving equity in health, including social justice in a participatory process, economic development as one means to attain the goal of social justice, and policy decisions and actions towards equal opportunities. Accordingly, the level of health achievable by individuals requires a process by which health knowledge, health sciences, and health systems and services play an important role, together with other social and economic forces, and in close association with community forces.

The Society assumes that there is a need for a scientific nongovernmental organization with the major purpose to discuss, analyze, and propose health actions to achieve equity in health.

We encourage interested readers to submit papers and attend the inaugural meeting.

Competing interests: None declared.

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Dr. Starfield is University Distinguished Professor, School of Public Health, Johns Hopkins University, Baltimore, Md.

Correspondence to: Dr. Barbara Starfield, School of Public Health, Johns Hopkins University, 624 N Broadway, Rm. 452, Baltimore MD 21205; fax 410 614-9046; bstarfie@jhsph.edu

References

Kawachi I, Kennedy B, Wilkinson R. Income inequality and health. vol 1 of The society and population health reader. New York: The New Press; 1999. p. xi.
Wilkinson R. Unhealthy societies: the afflictions of inequality. London: Routledge; 1996.
Starfield B. Primary care: balancing health needs, services, and technology. New York: Oxford University Press; 1998. p. 8, 403-4.