INEQUALITY VS. INEQUITY
Most proposals pretending to measure Health equity really define statistical analysis of
dispersions1.The statistical approach does not allow correlation with the underlying causes of
Health inequalities. Identifying fair limits of inequality through the distribution of the most
influencing variable of Health distribution, adds an ethical component. In 2003 Whitehead and
Gruskin aimed at an operational definition of health equity as the absence of systematic
disparities in health (between groups with different levels of underlying social
advantage/disadvantage—that is, wealth, power, or prestige. In 2006 Paula Braveman proposed
an updated definition: “Systematic Health differences between socially advantaged and
disadvantaged groups”2. If we combine the features of Whitehead3 and Braveman’s definitions, we
would point at a threshold of Health equity based on social differences which are unfair and
avoidable. The following table describes the key differences and consequences of measuring
inequality vs. inequity:
TABLE 1: DIFFERENCES BETWEEN MEASURING INEQUALITY AND INEQUITY.
Inequality
Inequity
Concept
Differences
Unfair differences
Measurement
Differences or ratios between
Gap from best feasible and sustainable
subpopulations.
level: burden of inequity.
Arbitrary conclusions
Measurable objective, inter and intra-
Conclusions
national, intra and inter-generational.
Strategy
Approach
to
disadvantaged
groups : poverty alleviation
Approach
social
to
minimum
cohesion
extremes),
levels
thresholds:
(address
of
dignity
both
and
universal rights.
Effect
Mitigation
Transformation
Equity is the fair distribution of inequality.
1
PÉREZ, G.J.G; LÓPEZ, M.G.V.; PIVARAL, C.E.C (ORGS).Desigualdad social y equidad en salud: perspectivas
internacionales. Páginas 25 a 45. Universidad de Guadalajara. Centro Universitario de Ciencias de la Salud,
México. Primera Edición, 2010. Disponible en:
http://www.cucs.udg.mx/revistas/libros/DESIGUALDAD_SOCIAL_Y_EQUIDAD_EN_SALUD.pdf
2
3
http://www.ncbi.nlm.nih.gov/pubmed/16533114
http://jech.bmj.com/content/57/4/254.short
THE RELEVANCE OF ESTIMATING THE BURDEN OF HEALTH INEQUITY The setting of minimum and progressive thresholds has been considered by others as critical to enable the recognition and exercise of economic, social and cultural rights4. However, this approach never resulted in standardized thresholds5. The burden of ill Health has been assessed for all diseases when comparing the effects of one disease event due to disability (by much debated arbitrary grading of disability and even different values to age periods) and live years lost due to premature death, with best national average level of Healthy live years´ expectancy: Japan6. That method defined the unit of Disability Adjusted Life Year –DALY-­‐. The methodology of burden of ill Health by specific diseases has meant the basis of Health economics by estimating the cost-­‐utility (cost related to its impact on burden of ill Health prevented/recovered) and opportunity-­‐cost (the difference between options according to their cost-­‐utility) of Health preventive or therapeutic interventions. Such methodology – led by the World Bank-­‐ guided the prioritizations of Health interventions based on their efficiency. This Health econometrics fed the World Bank-­‐led strategy of structural adjustments: reducing public spending to address the national budget deficits and reducing the tax revenues considered as barriers to global flow of capital. It followed faithfully the conceptual framework of the Washington consensus7. The power of the conditions of World Bank loans influenced Health policies and strategies aimed at reducing public spending and increasing its impact through specific cost-­‐effective interventions. In the early 90s the threshold of efficiency for low income countries´ interventions with public budget (or loans) was at 30 US $/ DALY8. In parallel, the growing evidence of HIV/AIDS triple therapy/life-­‐saving treatments diluted that threshold. But the emphasis on specific cost-­‐
effective (including consideration of externalities) interventions, started the still ongoing fragmentation of Health services, their financing, organization and even Health politics, activists, academics and organizations, during the last two decades. The selected views of diseases have led to today´s fragmentation which rather than advancing on the goal of the universal right to health, introduces yet another dimension of inequity across diseases. In that context, it is essential to estimate, as committed by all countries in the World 4
CEPAL. La hora de la igualdad: brechas por cerrar, caminos por abrir. 2010. Capítulo 4. Disponible
en:http://www.cepal.org/publicaciones/xml/0/39710/100604_2010-114-SES.33-
3_La_hora_de_la_igualdad_doc_completo.pdf
5
ASADA, Yukiko. A framework for measuring health inequity. Journal Epidemiol Community Health; 59:700–
705. 2005. http://jech.bmj.com/content/59/8/700.full.pdf+html
6
http://www.who.int/healthinfo/statistics/GlobalDALYmethods_2000_2011.pdf?ua=1
7
http://www.who.int/trade/glossary/story094/en/
8
Investing in health. The World Bank report of 1993.
Health Assembly´s resolution on social determinants of Health, the overall burden of Health inequity, across and within countries9. 9
See WHO 62.14 in http://apps.who.int/gb/ebwha/pdf_files/WHA62-REC1/WHA62_REC1-en-P2.pdf