What does equity in health mean?

The author posits some ethical concerns and theories of distribution in order to gain some insight into the meaning of equity in health, as referred to in WHO documents. It is pointed out that the lack of clarity in the WHO positions is evidenced by examining 1) the European strategy document, which focuses on giving equal health to all and equity access to health care, and 2) the Global Strategy for Health, which talks about reducing inequality and health as a human right. The question raised in document 1 is whether more equal sharing of health might mean less health for the available quantity of resources. The question raised in document 2 is whether there is a right to health per se. The question is how does one measure health policy effects. Health effects are different for an 8-year-old girl and an octogenarian. How does one measure the fairness of access to health care in remote mountain villages versus an urban area? Is equal utilization which is more easily measured comparable to equal need as a measure? How does one distribute doctors equitably? The author espouses the determinant of health as Aday's illness and health promotion, which is not biased by class and controversy. The Aday definition embraces both demand and need, although his definition is still open to question. Concepts of health with distinction between need and demand are made. Theories of Veatch which relate to distributive justice and equity in health care are provided as entitlement theory (market forces determine allocation of resources), utilitarianism (greatest good for the greatest number regardless of redistribution issues), maximum theory (maximize the minimum position or giver priority to the least well off), and equality (fairness in distribution). Different organizational and financing structures will influence the approach to equity. The conclusion is that equity is a value laden concept which has no uniquely correct definition. 5 theories of equity in distribution of health resources are discussed: 1) a theory of maximum (Rawl's theory modified to include health care institutions providing opportunity as the social good), 2) altruism as a basis for equity (Titmuss' Kantian view of national responsibility to provide equitable service delivery altruistically or equal access), 3) a fair share theory of distribution (Margolis' process utility theory of doing one's fair share or equality of access for equal need, 4) commitment to equity (Sen's focus on sympathy and commitment to another's ill health status and access), and 5) equity as externality (Culyer's health care consumption where government determines the merit good or extent of consumption). If policy objectives are not clear and the definitions muddy, resources may be badly wasted or misdirected and the pursuit of equity unfulfilled, even though there is agreement in principle.     

New labour and the third way in the British National Health Service.

The British Labour Party claims that its policies are based on a "third way," new and distinct from both the old left and the new right. This article critically examines this claim with respect to health policy. After examining the Conservative legacy in the National Health Service and the evolution of Labour's health policy, the author introduces the concept of the "third way" and discusses the extent to which Labour's health policy can be seen in these terms, using the themes of spending, competition, accountability, and public health. There are many differences between the health policies of New and Old Labour, and some differences between those of New Labour and the Conservatives. Indeed, to a large extent Labour's health policy is built on the legacy of the Conservatives and is characterized by evolution. It is difficult to find any "big idea" or coherent philosophy behind the third way. Rather than being a new and distinctive approach rejecting both the old left and the new right, it seems to be a pragmatic pick and mix, attempting to combine the best from the market approach of the Conservatives and the hierarchical approach of Old Labour.     

The concepts and principles of equity and health

All the 32 member states in the World Health Organization EuropeanRegion adopted a common health policy in 1980), followed byunanimous agreement on 38 regional targets in 1984. The firstof these targets is concerned with equity. Target 1: "By the year 2000, the actual differences in healthstatus between countries and between groups within countriesshould be reduced by at least 25%, by improving the level ofhealth of disadvantaged nations and groups" (WHO, 1985a). In addition, equity is an underlying concept in many of theother targets. At present, the targets are being reassessedand revised, in particular moving away from a focus on physicalhealth status as measured by mortality to encompass, whereverpossible, many other dimensions of health and well-being. Butstill the underlying concept of equity in health has been judgedto be just as important for the 1990s as it was when the programmebegan (WHO, 1985b). However, it has not always been clear what is meant by equityand health and this paper sets out to clarify the concepts andprinciples. This is not meant to be a technical document, butone aimed at raising awareness and stimulating debate in a widegeneral audience, including all those whose policies have aninfluence on health, both within and outside the health sector.     

增强理解力:“将健康融入所有政策”的首要策略

"将健康融入所有政策"是WHO提出的旨在改善人群健康和健康公平的公共政策制定方法,它要求各部门系统地考虑公共政策可能带来的影响,寻求部门之间的合作,避免政策对公众健康造成不良影响。但目前关于如何在我国实现"将健康融入所有政策"仍存在认识不足、理解不清及实施策略不明的问题。鉴于此,本文基于WHO发布的《实施"将健康融入所有政策"的国家行动框架》,结合我国国情、部分国家实施经验及相关理论,详细分析"将健康融入所有政策",以增强各方对其理解力,推进在我国的顺利实施。     

Equity and the Social Determinants of Health in European Cities

Equity in health has been the underlying value of the World Health Organization’s (WHO) Health for All policy for 30 years. This article examines how cities have translated this principle into action. Using information designed to help evaluate phase IV (2003–2008) of the WHO European Healthy Cities Network (WHO-EHCN) plus documentation from city programs and websites, an attempt is made to assess how far the concept of equity in health is understood, the political will to tackle the issue, and types of action taken. Results show that although cities continue to focus considerable support on vulnerable groups, rather than the full social gradient, most are now making the necessary shift towards more upstream policies to tackle determinants of health such as poverty, unemployment, education, housing, and the environment, without neglecting access to care. Although local level data reflecting inequalities in health is improving, there is still a long way to go in some cities. The Healthy Cities Project is becoming an integral part of structures for long-term planning and intersectoral action for health in cities, and Health Impact Assessment is gradually being developed. Participation in the WHO-EHCN appears to allow new members to leap-frog ahead established cities. However, this evaluation also exposes barriers to effective local policies and processes to reduce health inequalities. Armed with locally generated evidence of critical success factors, the WHO-EHCN has embarked on a more rigorous and determined effort to achieve the prerequisites for equity in health. More attention will be given to evaluating the effectiveness of action taken and to dealing not only with the most vulnerable but a greater part of the gradient in socioeconomic health inequalities.     

Revisiting the social determinants of health agenda from the global South

ABSTRACT

In an effort to provide an overview of the conceptual debates shaping the mobilisation around social determinants of health and health inequities and challenge the apparent consensus for equity in health, this essay compares two of the most influential approaches in the field: the WHO Commission on Social Determinants of Health approach (CSDH), strongly influenced by European Social Medicine, and the Latin American Social Medicine and Collective Health (LASM-CH) ‘Social determination of the health-disease process’ approach, hitherto largely invisibilized. It is argued that the debates shaping the equity in health agenda do not merely reflect conceptual differences, but essentially different ethical-political proposals that define the way health inequities are understood and proposed to be transformed. While the health equity agenda probably also gained momentum due to the broad political alliance it managed to consolidate, it is necessary to make differences explicit as this allows for an increase in the breadth and specificity of the debate, facilitating the recognition of contextually relevant proposals towards the reduction of health inequities.     

The Right Kind of Evidence—Integrating, Measuring, and Making It Count in Health Equity Research

As health equity researchers, we need to produce research that is useful, policy-relevant, able to be understood and applied, and uses integrated knowledge translation (KT) approaches. The Manitoba Centre for Health Policy and its history of working with provincial government as well as regional health authorities is used as a case study of integrated KT. Whether or not health equity research “takes the day” around the decision-making table may be out of our realm, but as scientists, we need to ensure that it is around the table, and that it is understood and told in a narrative way. However, our conventional research metrics can sometimes get in the way of practicality and clear understanding. The use of relative rates, relative risks, or odds ratios can actually be detrimental to furthering political action. In the policy realm, showing the rates by socioeconomic group and trends in those rates, as well as incorporating information on absolute differences, may be better understood intuitively when discussing inequity. Health equity research matters, and it particularly matters to policy-makers and planners at the top levels of decision-making. We need to ensure that our messages are based on strong evidence, presented in ways that do not undermine the message itself, and incorporating integrated KT models to ensure rapid uptake and application in the real world.     

Health in All Urban Policy: City Services through the Prism of Health

In April, 2014, the City of Richmond, California, became one of the first and only municipalities in the USA to adopt a Health in All Policies (HiAP) ordinance and strategy. HiAP is increasingly recognized as an important method for ensuring policy making outside the health sector addresses the determinants of health and social equity. A central challenge facing HiAP is how to integrate community knowledge and health equity considerations into the agendas of policymakers who have not previously considered health as their responsibility or view the value of such an approach. In Richmond, the HiAP strategy has an explicit focus on equity and guides city services from budgeting to built and social environment programs. We describe the evolution of Richmond’s HiAP strategy and its content. We highlight how this urban HiAP was the result of the coproduction of science policy. Coproduction includes participatory processes where different public stakeholders, scientific experts, and government sector leaders come together to jointly generate policy goals, health equity metrics, and policy drafting and implementation strategies. We conclude with some insights for how city governments might consider HiAP as an approach to achieve “targeted universalism,” or the idea that general population health goals can be achieved by targeting actions and improvements for specific vulnerable groups and places.     

Health promotion in South Africa

Health promotion first entered the South African health system in 1990. Today, Health Promotion is a Directorate located within the Social Sector Cluster (SSC) within Primary Health Care (PHC), District and Development operations which falls under the Deputy Director General for Health Service Delivery in the National Department of Health (DoH). The first significant piece of new policy for health promotion in South Africa appeared in the African National Congress (ANC) health policy document, health care services including reproductive health care. At the moment, health promotion service delivery is the responsibility of the national, provincial and local governments with provincial and local governments mainly implementing and the National Health Promotion Directorate offering support. Funding for health promotion activities comes from the Department of Health budget allocation by the National Treasury. One major problem for Health Promotion development is infrastructure. There is significant community participation in South Africa including health promotion policy and strategy document development. Health Promotion research and evaluation is limited. The National Department of Health considers the settings approach to be crucial in driving the progress of health promotion. There are very few trained health promotion specialists either capable or in the position to inform politicians and opinion leaders about the relationship between health and social determinants, and the evidence of effectiveness of health promotion action. Mechanisms for demonstrating evidence of health promotion effectiveness in terms of health, social, economic and political impact are lacking and occupational standards for health promotion education and training are needed.     

Realities of Health For All by the year 2000.

The European Region of the World Health Organisation (WHO) took the global lead on Health For All when the Regional Committee in 1980 approved a European Health For All Strategy. This was an important breakthrough for WHO as it was the first time Member States in a Region endorsed a common health policy and agreed to be monitored on their progress towards attainment of the strategy. The paper reviews the progress of Member States to date towards the Regional Health For All goal. Progress is discussed within the context of the six fundamental principles which underpin the Health For All concept, vis: equity; health promotion; community involvement; multisectoral participation; primary (local) health care; and, international cooperation. The paper argues that the commitment of Member States to the Health For All Strategy has been patchy with only moderate success towards meeting the 38 Regional Targets. Poor progress is attributed to changing national and international political and economic circumstances and limited resources but perhaps most importantly to a lack of political will to take the strategy seriously.     

Civil Society, Health, and Social Exclusion in Bangladesh

Civil society has the potential to have a positive impact on social exclusion and health equity through active monitoring and increased accountability. This paper examines the role of civil society in Bangladesh to understand why this potential has not been realized. Looking at two models of civil society action—participation in decentralized public-sector service provision and academic think-tank data analysis—this analysis examines the barriers to positive civil society input into public policy decision-making. The role of non-governmental organizations, political, cultural and economic factors, and the influence of foreign bilateral and multilateral donors are considered. The paper concludes that, with a few exceptions, civil society in Bangladesh replicates the structural inequalities of society at large.Key words: Civil society, Health equity, Health systems, Participation, Social exclusion, Bangladesh     

City Leadership for Health and Well-being: Back to the Future

The new European Health Policy Framework and Strategy: Health 2020 of the World Health Organization, draws upon the experience and insights of five phases, spanning 25 years, of the WHO European Healthy Cities Network (WHO-EHCN). Applying the 2020 health lens to Healthy Cities, equity in health and human-centered sustainable development are core values and cities have a profound influence on the wider determinants of health in the European population. “Making it Happen” relies on four action elements applied and tested by municipalities and their formal and informal partners: political commitment, vision and strategy, institutional change, and networking. In turn, the renewed commitment by member states of the WHO Regional Committee to work with all spheres and tiers of government is a new dawn for city governance, encouraging cities to redouble their investment in health and health equity in all policies, even in a period of austerity. For phase VI, the WHO-EHCN is being positioned as a strategic vehicle for implementing Health 2020 at the local level. Healthy Cities' leadership is more relevant than ever.     

A proposal of policies and interventions to reduce social inequalities in health in Spain.Commission to Reduce Social Inequalities in Health in Spain

In November 2008, at the request of the Directorate General of Public Health of the Ministry of Health and Social Policy, the Commission to Reduce Social Inequalities in Health in Spain was established with a mandate to develop a proposal for interventions to reduce health inequalities. This article aims to present the work carried out and the documents prepared by the Commission. The Commission, consisting of 18 members, conducted a situational analysis of health inequalities and of the policies to reduce them, reviewed international documents and consulted 56 experts from distinct fields to develop a proposal for recommendations to reduce health inequalities. In May 2010, the Commission presented the document "Moving toward equity: a proposal for policies and interventions to reduce social inequalities in health in Spain". The document listed a total of 166 recommendations, divided into 14 areas and ordered by priority. These recommendations highlight that health inequalities cannot be reduced without a commitment to promote health and equity in all policies and to move toward a fairer society.     

Comments on the Portuguese translation of the International Classification of Functioning, Disability and Health

An analysis of the World Health Organization terminology for disability indicates the influence of the social model of disability in the International Classification of Functioning, Disability, and Health. This theoretical framework should guide any translations of the document. In Brazil, the document was translated as Classifica??o Internacional de Funcionalidade, Incapacidade e Saúde. We argue that more appropriate than translating disability as "incapacidade" and impairments as "deficiências" would be to use the term "deficiência" for disability and "les?o" for impairment. Considering the normative impact of a WHO document for social policy and international research, the translation should accurately reflect the concepts and their theoretical basis.     

论卫生资源分配与医疗公平中的政府责任

在卫生资源分配与医疗服务中，要求政府能够围绕起点和过程实行公平的政策，从而达到结果公平的目的。中国现阶段的卫生资源和医疗服务，应该按公共方式、市场方式和混合方式分类提供，合理分配，同时要发挥卫生政策对医疗公政问题的强有力的调整作用，实行严格而有效的监管。这是政府责任的基本定位。     

WHO draft policy on "Health for All in the 21st Century" - some reflections

World Health Organization (WHO) member states have been charged in the WHO's draft document on health for all in the 21st century with making health central to human development and establishing sustainable systems to meet the needs of their people. The document is, however, flawed. For example, WHO has assumed certain roles for itself which go against its advocacy of sustainable health systems, such as planning to take the lead in eradicating and controlling certain diseases. Another flaw of the draft document is its failure to take WHO resolution 50.27 into account, which outlines a more people-oriented agenda for WHO action. The draft also omits some of the key elements introduced at Alma Ata. The essay highlights areas of concern which deserve attention at the World Health Assembly, concerns related to the interaction between globalization trends, the encouragement of the market-oriented private provision of medicine, and marked advances in medical technology.     

努力开创我国初级卫生保健工作的新局面

20世纪90年代，在WHO的指导下，我国开展了波澜壮阔的初级卫生保健工作，对强化我国政府的卫生工作职责，提高卫生组织服务能力，促进卫生服务的公平性，提高群众的健康水平发挥了重要作用。随着我国社会经济的发展和群众对健康需求的不断增加，我国初级卫生保健既要传承，又要面对新形势，解决新问题。我们已经有了很好的进一步开展初级卫生保健的政治基础和政策基础，我们也必须要有新的工作思路，做到与时俱进，掀起新一轮我国初级卫生保健工作的高潮。     

Health Policy,Ethics, and the Kansas Legislative Health Academy

We describe a unique program, the Kansas Legislative Health Academy, that brings together state legislators from across the political spectrum to build their capacity in advancing policies that can improve the health of Kansans.To that end, the academy helps legislators develop new skills to deliberate the ethics of health policy, use systems thinking to understand the long- and short-term effects of policy action and inaction, and engage in acts of civic leadership. The academy also seeks to foster an environment of respectful open dialogue and to build new cross-chamber and cross-party relationships.Among the most important outcomes cited by program participants is the value of sustained, personal interaction and problem solving with individuals holding differing political views.Health policy often elicits controversy. Recent examples include the uproar over recommendations for mammography screening for women 40 to 49 years old and human papillomavirus vaccination for adolescent girls and boys. Perhaps the most dramatic controversy relates to the passage of the Patient Protection and Affordable Care Act (Pub L No. 111-148); despite being signed into law in 2010 and found substantially constitutional by the US Supreme Court in 2012 (Medicaid expansion was made optional for states), this legislation remains subject to vigorous dissent. Such controversies, although no doubt a function of interest-driven politics, also reflect deep differences in ethical values.Ethical values and premises underpin all public policy.1,2 Ideas about individual liberty, personal responsibility, solidarity, justice, and the role of the government are just a few of the moral constructs that often clash in the making of policy. Policy analysis often ignores these dimensions of policy-making, although that is beginning to change.3–5Here we describe a project based in part on the premise that training policymakers to recognize and talk openly about the ethical values entailed in health policy might improve its content and process. This project, the Kansas Legislative Health Academy (hereafter Health Academy), brought together state legislators from across the political spectrum to build their capacity to respond to complex health policy challenges in Kansas. To that end, the curriculum sought to help legislators develop new skills in 3 areas: health policy ethics, systems thinking, and civic leadership. The Health Academy also sought to foster an environment of open, respectful dialogue and to build new cross-chamber and cross-party relationships.To our knowledge, the Health Academy is a unique program. Many educational programs exist for legislators to focus on leadership development or specific health policy issues, but none we are aware of are specifically designed to cover a broad range of health policy issues while also addressing underlying barriers to effective policy-making within legislative bodies. In what follows, we describe the Health Academy’s origins, structure, substance, and lessons learned.