Ritu Sadana, Lead Specialist, Ageing and Life Course, discusses various definitions of equity embraced by the World Health Organization and the relationship of ‘health equity’ to the provision of health services. As a goal, health equity is based on the pursuit of distribute justice defined in the World Health Organization’s (WHO) mission statement as it is one of the basic ways that can illustrate how individuals enjoy the basic right to health. Ritu Sadana elaborates on intersectoral approaches to equity promoted by WHO that are essential towards improving health equity since about half of health inequalities occur outside the health sector.
Interview conducted in May 2013 || New York, NY
Q: How does WHO define equity?
A: I’m unaware of a single definition that has been formally endorsed by Member States. Yet, the Final Report of the WHO Commission on Social Determinants of Health had a rather eloquent statement something like “Where systematic differences in health are judged to be avoidable by reasonable action, they are quite simply, unfair.” It is this that we label health inequity. The definition WHO often uses in its publications is that health equity is the “absence of unfair and avoidable or remediable differences in health services and outcomes among groups of people.” This can be unfair differences in health that affect populations or groups defined socially, economically, demographically, or geographically.
As a goal, health equity is grounded to the pursuit of distributive justice and that goal is actually defined in our constitution. It sets out as a fundamental right that every person without discrimination should have the right to health, and that’s also part of our mission statement. Looking at health equity is one of the basic ways we can show whether each individual enjoys the right to health. That is why we can’t just be concerned about national averages that mask differences within countries.
Q: How do you see the relationship between universal health coverage and equity?
A: Eliminating unfair, avoidable and preventable differences in health is an important step towards realizing universal coverage and the right to health. Global evidence suggests that at least 25% of health inequalities, let’s say differences found within a country’s population, are due to a lack of access to effective health services. When I say effective health services I mean really essential health services spanning prevention, treatment and palliative care, as well as medicines and other technologies. If you add basic public health interventions, like the differences in access to safe water, then these also contribute another 25% to health inequalities. The other half are generated outside of the health sector.
The WHO Global Health Observatory’s Health Equity Monitor notes that 37 out of 42 countries would be at least 25% closer to universal coverage in reproductive, maternal and child health services by eliminating within-country inequality. Across WHO, we describe and measure progress towards universal health coverage by asking about who are the people covered, which effective services are available, and who pays for these services, in particular is there a financial burden on households because of large out of pocket payments. One could look at each dimension from an equity perspective, if you have disaggregated data. Good data by different groups is very useful to track progress on health goals, and can reveal differences between sub-groups that overall averages may hide. This is part of health inequality monitoring, and based on this information, people can determine what is unfair, pick priorities for action and see what can be done in the health sector and possibly other sectors such as in taxation, labor or finance. Being systematic and thinking across different sectors provides an evidence based approach for equity-oriented interventions, and is a key component of the movement toward equitable universal health coverage.
Q: How would an equity perspective on those data look like?
A: When we measure and describe who is covered by health services, we would ask for example, if there is discrimination given who is, and not, covered. Are children in indigenous populations covered or not? Do people in the formal work force have coverage, or all people even if they work in the informal labor market? Or do the poor use health services less than the rich, particularly preventive services or those that give life long benefits?
Another perspective on equity when we look at services offered, would be to check if the services are equity enhancing, efficient and effective. Are the basic, essential services offered with sufficient quality, in an acceptable way to diverse populations? What are implications for gender equity? Is there age-based discrimination, whether leaving out children or older adults? What does it mean in terms of the progressive realization of the right to health? And when one analyzes the financial burden of health costs for people, we would ask for example if the distribution of total government spending on health is pro-rich or pro-poor. Meaning, do the poor subsidize the rich, or vice versa? We see for example that even in high income countries, the poor could be paying more than what they benefit, and sometimes children are left out completely. In fact, my colleagues in health statistics and information have just released a new handbook on ways to measure health inequalities and identify health inequities. The data of course needs to be complemented with information on what policies are being pursed to narrow the gap between those covered and not covered by effective services, reflecting the priorities of each country.
Q: What are the reasons for growing health inequities?
A: The WHO’s Commission on Social Determinants looked at this issue in depth and they really focused on why inequities are persistent and what can be done. It tried to understand what are the root causes of inequities. It really focused on root causes— political, economic, social or environmental and called these the causes of causes, that have a fundamental influence on socially patterned health differences. What do I mean by socially patterned? Meaning they are not related to someone’s genetics but rather to their social position, and that’s why it is unfair and especially unfair early in life as inequities can shape one’s life course.
The distribution of these broader determinants lead to more or less social and economic stratification within a society. Significant social stratification then also translates into different opportunities, vulnerabilities and exposures, or even so-called lifestyle choices. I mean some people may consider it an individual’s choice but actually most people have been shaped to some extent by things around them. This plays a very important role in stratifying health outcomes. Some countries have policies that worsen social determinants which can increase inequities, whereas others mitigate these. Increasingly when countries or cities have good policies in place, they show that health inequities can be narrowed. The health system can improve unfair differences in health or can actually make it worse.
Q: What advice would you give Governments to ensure that the families most deprived and children in general have access to health services?
A: Based on evidence, the message is that you must level-up across society and not only narrow the gap between the best off and the worst off. Depending on the country, the “middle group” may also be facing deprivations, or not. Experience shows that it’s better to understand the pattern in every country or location before choosing or refining strategies, but it’s very important that the aim is not leveling down, as then the whole population of course will not be interested to support change. Actually, the Commission made clear, in its Final Report, that a policy maker would know that health inequities are getting better over time if there is documented evidence of a “progressive flattening” of the health gradient, meaning that the health of all social groups are improving toward a level closer to that of the best off group. Of course, this includes children, who also should be covered by universal systems without financial burden to their families. Services, whether public or private, should meet quality standards and the guidelines to care that each country sets.
Data should be disaggregated including by age and sex as well as other social and demographic characteristics, linked and analyzed from across different sectors, such as health, social services, transport, etc. There are many cities and communities around the world that are putting in practice cross sectoral analysis and policy dialogues in order to address health inequities. We see that putting data in the public domain and having good policies make a difference. Demographic and health surveys over time in Africa for example show that if you do something, you are likely to have success. Some countries have made progress in narrowing the equity gap in vaccination coverage for DPT3 over the past decades. This includes not only narrowing the gap and leveling up, but also improving the national average in countries like Burkina Faso, Côte d’Ivoire, Kenya, Malawi, and Niger.
Q: WHO promotes an inter-sectoral approach to equity. Can you provide a concrete example how this looks like in practice?
A: As I mentioned, about half of the health inequalities are generated outside of the health sector so an intersectoral approach is therefore essential towards improving health equity. Health programs generally do not implement interventions that address structural or broader determinants or root causes. Now our global synthesis conducted for the Commission shows some ways forward. The health sector can play a central role in initiating intersectoral actions even though it does not directly control many of the interventions that tackle social determinants of health.
Early child development programs are a good example. They are usually led by the health sector and that is where the first point of contact is for most children. The health sector can also put in place policies and processes that promote inclusion, meaning that early child development interventions can reach a higher proportion of children from all social and geographic strata. The health sector can also play an important role in supporting the delivery of key intersectoral actions for early child development such as parenting and caregiver support, child care, nutrition, education and social protection. And we know economists have provided evidence that together these yield benefits throughout the life course that are worth many times the original investment whether in low, middle or high income countries. In fact, within WHO, colleagues in maternal and child health have recently renewed efforts to strengthen early child development programs.
Ritu Sadana has worked in the public and private sector, including at the World Health Organization’s headquarters in Geneva, Switzerland since 1998, and at its Regional Office for Europe in Copenhagen, Denmark, between 1988-1993. In 2013 she took up a senior position as Lead Specialist within the Department of Ageing and Health, WHO Geneva, where she will continue to strengthen collaborations across WHO and channel worldwide expertise to produce global analysis, evidence synthesis, and policy options. She holds a MSc focusing on health systems and policies research methods, from the University of California Los Angeles (UCLA), and earned her doctorate (ScD) focusing on international health policy, epidemiology and economics from Harvard University, School of Public Health.