Inequities

by

Elizabeth Harris, Jane Lloyd

• LAST REVIEWED: 14 October 2016
• LAST MODIFIED: 28 October 2014
• DOI: 10.1093/obo/9780199756797-0139

Introduction

The term “health inequity” can be confusing to those entering the field, as it is often used interchangeably with “health inequality,” “health variation” or “disparities,” and more recently with “social determinants of health.” In the past fifteen years greater clarity has developed around the core concepts relating to health inequity. Collectively a number of major themes can be seen in the definition of health inequity: the concern is with health status, not simply the use of services, and with health differences that are considered to be unfair or unjust; it is about the pursuit of social justice and a belief that differences in health are socially created and therefore amenable to change. Whether or not a particular outcome is considered a health inequity is based on a value judgment. This means that health inequities are not only open to debate but also change over time. Because of the difficulties in making explicit value judgments when describing socially constructed differences as unfair or unjust, in many countries differences in health outcomes are referred to as health disparities or health differentials. Referring to health outcomes in this way allows for the measurement and monitoring of changes in patterns of health inequity without having to make a value judgment as to whether a particular outcome is unfair or amenable to change. This paper provides an introductory overview of published literature and resources on socioeconomic health inequities from the perspective of population health with a specific focus on Western industrialized countries since the late 20th century. It relies on material published in English. It is recognized that other social constructs such as gender, race, and religion are also related to health inequity but are not the focus of this paper nor are the important perspectives of other disciplines such as political science, sociology, or economics More data on health inequity is gradually becoming available in relation to middle- and low-income countries. (The authors wish to acknowledge Ms. Sarah Simpson for assistance with the development of this article.)

General Overviews

The works in this section provide an overview of the different ways in which health inequity has been defined and used. Whitehead 1990 provides one of the first definitions of health inequity, defined as the differences in health status that are not only unnecessary or avoidable, but that are also unfair or unjust. Sen 2002 also stresses that achieving health equity requires much more than providing access to health care, but that it requires fairness and justice in social arrangements. In terms of monitoring and measuring equity in health, Starfield 2006 introduces the concept of monitoring systematic differences in health. Braveman 2003 also argues that equity in health is the absence of systematic differences in health or in the major determinants of health between the most and least advantaged populations in society. In its glossary of health inequalities, Kawachi, et al. 2002 expands on the differences between health equity and inequality. Health inequality is defined as a descriptive difference in an outcome; for example, mortality rates are higher in older than younger people. By contrast, health inequity is defined as a systematic difference in health outcomes for a group where the difference was judged to be unfair or unjust and was possible to change. However in a review of Whitehead and Dahlgren’s earlier work, Whitehead and Dahlgren 2007 recognizes that many countries today use “health inequity” and “health inequality” interchangeably. In this paper we will also use the terms interchangeably as reflected in the literature being reviewed. Marmot 2006 outlines the concept of the social gradient in health; that is, the higher one’s social position, the better his or her health. The impact of the social gradient on health is not confined to those in poverty: there is a lower level of health at every step in the social hierarchy. The strength of the social gradient has been demonstrated in the Whitehall studies that have followed civil servants, at all levels, over a long period of time and found significant differences in health that are related to job status. Equity in access to health services is also a concern. Whitehead and Dahlgren 2007 defines equity in health care as requiring equal access to available care for equal need, equal utilization for equal need, and equal quality of care for all. However, there is growing agreement that health equity is primarily concerned with health outcomes and not just access to health services.

• Braveman, P. 2003. Defining health equity. Journal of Epidemiology and Community Health 57:254–258.

  DOI: 10.1136/jech.57.4.254

  NNNBraveman sets out to develop a definition of equity to guide operationalization and measurement. Focuses on systematic differences between more and less advantaged population groups or subgroups, and moves beyond social determinants of health to see wealth, power, and privilege as the drivers of social position and creating more or less advantaged groups.

• Kawachi, I., N. Subramanian, and N. Almeida-Filho. 2002. A glossary for health inequalities. Journal of Epidemiology and Community Health 56:647–652.

  DOI: 10.1136/jech.56.9.647

  NNNAmong other things, Kawachi, et al. explore the difference between health equity and health inequality by highlighting the differing views held by those who see the origin of inequity in the distribution of resources and those who see these inequities as the result of personal choices. They question the dominant focus of health inequity on socioeconomic groups and suggest expanding this to other factors such as gender, race, political power, and cultural and social assets.

• Marmot, M. 2006. Introduction. In Social determinants of health. 2d ed. Edited by M. Marmot and R. Wilkinson, 1–5. Oxford: Oxford Univ. Press.

  NNNIn his introduction to this book on social determinants of health, Marmot outlines the social gradient in health; that is, the higher one’s social position the better his or her health. The strength of the social gradient has been demonstrated in the Whitehall studies that have followed civil servants at all levels over a long period of time and found significant differences in health related to job status that cannot be accounted for by the usual risk factors.

• Sen, A. 2002. Why health equity? Health Economics 11:659–666.

  DOI: 10.1002/hec.762

  NNNThis article looks at health equity within the broader context of social and economic justice, arguing that health equity is a key component to achieving social justice and that it must include access to economic and social resources. Distinguishes between health achievement and health capability: poor health becomes a serious injustice when it reflects lack of opportunity to achieve good health because of social arrangements as opposed to personal choice.

• Starfield, B. 2006. State of the art in research in equity in health. Journal of Health Politics, Policy and Law 31.1.

  DOI: 10.1215/03616878-31-1-11

  NNNDefines equity in health in order to facilitate its recognition and monitoring. Argues that examining systemic differences in health across socially, demographically, or geographically defined populations or population subgroups is consistent with social justice and imports social dimensions of health related to social, economic, and demographic differences. Moves beyond seeing equity as only concerned with access to or provision of health services.

• Whitehead, M. 1990. The concept and principles of equity and health. WHO Regional Office for Europe, Copenhagen (EUR/ICP/RPd 414, 7734r). International Journal of Health Services 22.3: 429–445.

  DOI: 10.2190/986L-LHQ6-2VTE-YRRN

  NNNThis seminal discussion paper proposes working definitions of health equity and equity in health care. It also provides practical guidance on how to judge if differences in health are not only unnecessary and avoidable, but also unfair and unjust. It lists seven main determinants that can be used to identify whether a difference in health is inevitable or unacceptable and sets out principles to guide health equity policies.

• Whitehead, M., and G. Dahlgren. 2007. Concepts and principles for tackling social inequities in health: Levelling up Part 1. Studies on Social and Economic Determinants of Population Health 2. Copenhagen: WHO Regional Office for Europe.

  NNNIn this updated report the authors identify three key features that create variations in social health inequity. The concept of leveling up is introduced, which emphasizes that health policy needs to be concerned with improving the health of all people and not just disadvantaged groups.