COLLEGE OF MEDICINE

DEPARTMENT OF HEALTH SYSTEMS AND POLICY

MASTER OF SCIENCE IN GLOBAL HEALTH IMPLEMENTATION

MODULE: MGH 711 GLOBAL HEALTH ETHICS AND HUMAN RIGHTS

TITLE: DEFINE HEALTH EQUITY AND EQUALITY, EXPLAIN THE DIFFERENCES

BETWEEN THE TWO CONCEPTS

FROM: PATRICK BALUWA

REGISTRATION NUMBER: 201970095449

TO: PROFFESOR NFUTSO BENGO

DUE DATE: MARCH 2020

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ABSTRACT

Policymakers, researchers, and public health practitioners have long sought not
only to improve overall population health but also to reduce or eliminate
differences in health based on geography, race/ethnicity, socioeconomic status, and
other social factors. This is called achieving health equality and equity.

The objective of this paper is to give a detailed description of health equity and
equality and present it as a global issue and if not well achieved affect the health of
the communities and countries. Describing the difference between the two
concepts and how they are related to each other helps policy makers to effectively
plan health systems thus avoiding inequalities and inequities. Equality means equal
distribution of health resources and determinants of health while equity refers to
the absence of avoidable disparities that happen in the health sector.

Health inequalities and inequities are a global problem and are institutionalized
with human rights. Achieving equality and equity ensures that right to equitable
high standard of health to all people globally regardless of social or financial
background is attained. Both developed and developing countries should have a
corrective effort to achieve global equity and equality.

Key words: Health Equality, Health Equity, Health inequalities Social

determinants of health; Social inequity; Global health

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INTRODUCTION

Health equity and inequalities are concepts that are mostly used interchangeably in
the context of health care delivery and outcomes. It is imperative that health equity
and equality are understood comprehensively so that implementation of global
public health is achieved and maintained. It is therefore the objective of this paper
to define and discuss comprehensively the differences between these two concepts
and how they interfere with the outcome of health of different individuals and
communities locally and internationally; furthermore, the paper will relate these
concepts to ethical principles and health human rights.

DEFINITIONS

Health equity and inequities

Equity in health is the absence of systematic disparities in health or in the major

social determinants of health between groups with different levels of underlying
social advantage and disadvantage that is, wealth, power, education levels or
prestige [4]. WHO defines equity as the absence of avoidable or remediable
differences among groups of people, whether those groups are defined socially,
economically, demographically or geographically. Therefore as WHO notes, health
inequities involve more than lack of equal access to needed resources to maintain
or improve health outcomes. The opposite of health equity is health inequities,
which refers to avoidable disparities in health or its key determinants that are
systematically observed between groups of people with different levels of
underlying social privilege i.e. wealth, power or advantage [4].

The focus of equity in healthcare provision is to ensure that all people have access
to a minimum standard of healthcare according to need and not any other criteria,
such as ability to pay. In this case, equity may therefore be defined as equal access
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for equal need, where access refers to the absence of barriers mainly geographical
and financial barriers; and need refers to the capacity to benefit or severity of
illness. Equity in service provision takes two forms horizontal equity and vertical
equity [3]. While horizontal equity implies equal treatment for equal need, vertical
equity implies that individuals with unequal needs should be treated unequally
according to their differential need.

Inequities in health systematically put groups of people who are already socially
disadvantaged for example, by virtue of being poor, female, and/or members of a
disenfranchised racial, ethnic, or religious group at further disadvantage with
respect to their health. Equity is an ethical principle; it also is consonant with and
closely related to human rights principles. The proposed definition of equity
supports operationalization of the right to the highest attainable standard of health
as indicated by the health status of the most socially advantaged group.

Assessing health equity requires comparing health and its social determinants
between more and less advantaged social groups. These comparisons are essential
to assess whether national and international policies are leading toward or away
from greater social justice in health, [4]. Equity is an ethical issue and it is one of
the elements of ethical principles.

Equity entails social justice or fairness; it is an ethical concept, grounded in

principles of distributive justice which concerns the equitable distribution of scarce
resources among all socioeconomic groups and population sectors [2]. Equity in
health can be and has widely been defined as the absence of socially unjust or
unfair health disparities. This is because achieving equity entails respecting human
right to good health and access and providing good health to all people regardless
of their social status [6].

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Health equity ensures that provision of health care resources considers less
privileged uplifted marching the same health status levels that the highly privileged
group of people attains. Inequities in health systematically put groups of people
who are already socially disadvantaged for example, by virtue of being poor,
female, and/or members of a disenfranchised racial, ethnic, or religious group at
further disadvantage with respect to their health that is essential to wellbeing and to
overcoming other effects of social disadvantage.

Health equality and inequality

Health equality means treating people in the same way regardless of their social
status, background or level of development [3]. It involves the allocation of
resources in the health sector equally without looking and considering at the other
disparities that specific communities might have within them. For example, a
district council in Malawi might decide to cut the budget for 25 health centers by
reducing the operational hours for all centers by the same amount and at the same
times.

Globally, health equality might involve providing same health opportunities to

different countries regardless of their developmental level hence ensuring that the
health outcomes of all the people in these countries are taken into consideration.
On the other hand, it also constitutes equal distribution of the determinants of
health among different countries. These determinants of health if equally
distributed among countries globally, they entail collective and common health
outcomes that fosters collective efforts and solutions.

The main focus on health equality is to ensure that every person regardless of his
or her social determinant is not deprived the right to access to optimal and
complete health care. In this stance, achieving health equality is an ethical issue

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and it ensures that human rights as regards to access to health care are achieved.
This helps to improve health outcomes of people in the communities, countries and
globally.

The opposite of health equality is health inequalities; this is defined as differences

in health status or in the distribution of health determinants between different
population groups (WHO). Health inequalities can also be described as the unfair
differences in people’s health across social groups and between different
population groups. They are caused by an unequal distribution of income, power
and wealth and can mean that factors that promote good health and well-being are
not equally available, acceptable, appropriate or of good quality For example,
differences in mobility between elderly people and younger populations or
differences in mortality rates between people from different social classes. The
term health inequality generically refers to differences in the health of individuals
or groups (3). Any measurable aspect of health that varies across individuals or
according to socially relevant groupings can be called a health inequality. Absent
from the definition of health inequality is any moral judgment on whether observed
differences are fair or just [6].

There are two main approaches to studying inequalities within and between
populations. Most commonly, examination of differences in health outcomes at the
group level to understand social inequalities in health [7]. For example, we might
ask how mean body mass index (BMI) of the poor compare it to that of the rich
and the outcomes denote the inequalities that exists between the two groups as
regards to nutrition.

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DIFFERENCE BETWEEN HEALTH EQUITY AND EQUALITY

As discussed above on the definitions, the two concepts of health equality and
equity are not the same, however they are always used interchangeably among
global health experts. The concept of equity is inherently normative, that is value
based [8] while equality is not necessarily so often the term health inequalities is
used as a synonym for health inequities, perhaps because inequity can have an
accusatory, judgmental, or morally charged tone. However, it is important to
recognize that these terms are not synonymous.

The concept of health equity focuses attention on the distribution of resources and
other processes that drive a particular kind of health inequality that is a systematic
inequality in health or in its social determinants between more and less advantaged
social groups, in other words, a health inequality that is unjust or unfair.

For example, to achieve equality, a global countries meeting by WHO can be

called where ministers of health from different countries can be invited to attend a
briefing on global response to corona virus and the conference is held in English
though English is not the primary language for most of the countries, In this case,
equity is when WHO hires translators to attend the meeting or offer additional
briefings held in the other languages to ensure that even those that do not
understand and speak English also fully participate to the discussion. This shows
that equality deals with resource distribution in an equal way while equity looks at
allocation of resources with regards disparities that exist between people that are
sharing the resources.

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RELATIONSHIP BETWEEN HEALTH EQUALITY, EQUITY ETHICS
AND HUMAN RIGHTS

The concepts of equity and equality are ethical principles; they also are consonant
with and closely related to human rights principles. The right to health as set forth
in the WHO Constitution 43 and international human rights treaties is the right to
the highest attainable standard of health. Human rights belong to everyone,
everywhere, throughout our lives, from birth until death [6]. They are the basic
rights we all have because we are human, regardless of who we are, where we live
or what we do. They cover many aspects of everyday life, ranging from the rights
to an adequate standard of living (including food and housing), education and
health, freedom of thought, religion and expression [7].

According to human rights principles, all human rights are considered inter-related
and indivisible [8]. Thus, the right to health cannot be separated from other rights,
including rights to a decent standard of living and education as well as to freedom
from discrimination and freedom to participate fully in one’s society. The concepts
of equality and equal rights are none the less central and indispensable. The
concept of equality is indispensable for the operationalization and measurement of
health equity and is important for accountability under the human rights
framework. The right to health is an inclusive right; it includes not only the right to
health services, but to the wide range of factors that help us to achieve the highest
attainable standard of health [3].

Health inequalities and inequities put a serious threat to global health human rights.
Every individual globally has a right to access quality health care and attain the
most standard health life. In this case, the avoidable disparities in health care
infringe the right to good health of the people thus prone to different diseases.

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When the determinants of health are not shared equally among communities,
societies and countries, health inequalities on the outcomes exists. At the same
time when health resources are shared equally among groups of different levels of
social status of health, health inequities exists, this therefore lead to poor health
outcomes to the disadvantaged groups thus difficult to attain right to health.
Protecting, respecting and fulfilling human rights is therefore necessary if we are to
address health inequalities and inequities globally and realize the right to health for
everyone globally.

HEALTH INEQUITIES AND EQUALITIES GLOBAL OVERVIEW,

MALAWI, AFRICA AND GOBALLY

Health disparities along racial, ethnic, and socioeconomic lines are observed in
both low and high income countries, and may be widening (9).Despite the
commitment of governments to pursue pro poor health policies and interventions
vigorously, in sub-Saharan Africa the level of inequity in health status and access
to basic health care interventions remains high. Benefit incidence studies in a
number of African countries have unequivocally shown that government
expenditures on health tend to benefit the richest of society in absolute terms. On
average the richest 20% receive more than twice the financial benefit than the
poorest 20% of the population from overall government health spending [8].

Monitoring trends in equity in health and access to essential health interventions is

important in order to target scarce public resources to those who have more needs,
for example the poor. Poor countries in sub-Saharan Africa face many constraints
in collecting and processing relevant information for gauging trends in equity.
This, however, should not be a cause for inaction. It is possible, even in the poorest

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countries with the least resources, to do much more with the existing data and
resources than what is being done currently [9].

The cost of health inequalities is staggering. For example, between 2003 and 2006
alone, the direct economic cost of health inequalities based on race or ethnicity in
the United States was estimated at $230 billion. Researchers calculated that
medical costs faced by African Americans, Asian Americans, and Hispanics were
in excess by 30% due to racial and ethnic health inequalities, including premature
death and preventable illnesses which reduced worker productivity. When indirect
costs were factored into the calculations, the economic burden was estimated as
$1.24trillion, [4]. In addition to the costs that could be avoided if socially
disadvantaged groups enjoyed equitable health outcomes, inequality itself may be
harmful to health.

If equity is to prevail, the principle of vertical equity (unequal treatment for

unequal need) demands that those with greater need should receive more of the
treatment. However, what is observed in the current case is that there is equal
treatment for unequal need and clearly violates the requirements of vertical equity.
Hence, there is inequity, as the poor who have a greater need for treatment as
compared to the non-poor are not getting the treatment according to their need. A
study by Ezel etal in Malawi showed that the use of public sector facilities has
become more inequitable the non-poor using the public sector healthcare resources
more than the poor and out of proportion to their need.

Many studies demonstrate the presence of significant inequalities based on urban

rural, education, socioeconomic and regional differences in developing countries,
[4-6]. For example a study by Bobo and Yusuf on Inequities in utilization of
reproductive and maternal health services in Ethiopia found out that Inequity in

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service utilization was exhibited favoring women in developed regions, urban
residents, most educated and the wealthy. Antenatal care by skilled provider was
three times higher among women with post-secondary education than mothers with
no education. Women in the highest wealth quintile had about 12 times higher
skilled birth attendance than those in lowest wealth quintile. The rate of postnatal
care use among urban resident was about 6 times that of women in rural area. Use
of modern contraceptive methods was more equitably utilized service while, birth
at health facility was less equitable across all economic levels, favoring the
wealthy.

Developed countries like the United States, Norway and the UK have done a lot to
achieving health equality and inequity. However there is a lot to be done globally
to achieve the equality and inequity in the health sector for the other developed and
developing countries. Many African countries are still far behind in achieving
these two fundamental rights of health care delivery. It is still a big challenge for
the third world countries to fully achieve the above due to the complexity of health
determinates of the diseases. It is imperative that a collective global step should be
taken to improve equal accessibility to health care thus achieving equality and
inequity.

CONCLUSION

Understanding the difference between equity and equality is the key component in
the effort to reduce health disparities among vulnerable populations. The difference
between health equality and equity is that health equality means treating people in
the same way regardless of the social background and status while health equity is
the absence of systematic avoidable disparities in or in major social determinant of
health. The opposite of these two concepts are inequities and inequalities. Health

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inequalities and inequities are global problems. The understanding that many of
these inequalities are unjust, and therefore inequities, is largely derived from the
inequalities that are identified between the various social groups of a given society.
Inequalities and inequities between countries are related to the differences in
economic and social development achieved by different countries, which are
generated by the position that these countries have occupied during different
phases of history within the global productive system. Achieving equality and
equity helps to reinforce health human rights and improves the health status of
people locally and globally.

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