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Health equity 

Health equity
Chapter:
Health equity
Author(s):

Hideki Hashimoto

, and Norito Kawakami

DOI:
10.1093/med/9780198792994.003.0013
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date: 26 February 2020

Introduction

Achievement of health equity is a pivotal goal of healthcare systems [1]. However, the underlying philosophical definition of health equity is ambiguous, which complicates the formulation of policies and targets, and precludes effective implementation of the concept. This chapter has three objectives. Firstly, it seeks to review the existing literature to demonstrate the heterogeneity of the concept of health equity, and will review what is needed for health equity to be achieved in the context of the ethical basis referred to, such as libertarianism, utilitarianism, Kantian liberalism, and capability theory. Secondly, it will discuss the importance of mental health in the achievement of health equity, with reference to existing reviews of public mental health, and will examine the influence of social stigma and subsequent social exclusion as a barrier to achieving health equity. Finally, it will discuss the policy agenda to achieve health equity in the context of public mental health. The chapter refers to the concept of ‘social determinants of health’ to inform the formulation of a range of policies to achieve health equity.

Equity and equality

The most widely cited definition of ‘health equity’ is that proposed by Margaret Whitehead in her influential 1992 paper, namely that a lack of health equity is a condition where differences in health exist that ‘are not only unnecessary and avoidable but, in addition, are considered unfair and unjust’ [2]. Since then, however, the terms ‘equity’ and ‘equality’ have been used ambiguously and interchangeably too often, and the meaning of ‘equity’ varies across the literature.

For example, the United States Healthy People programme defines health equity as the ‘attainment of the highest level of health for all people’ [3]. In contrast, the World Health Organization (WHO) extends Whitehead’s argument to define health equity as ‘the absence of avoidable or remediable differences among groups of people … therefore involves more than inequality with respect to health determinants, access to the resources needed to improve and maintain health or health outcomes’ [4]. In the latter context, inequity implies the existence of social injustice, and achievement of health equity requires moral discussion, whereas ‘inequality’ is a more value-neutral term and is taken semantically to equate with ‘disparity’.

Equity is the absence of avoidable or remediable differences among groups of people, whether those groups are defined socially, economically, demographically, or geographically. Health inequities therefore involve more than inequality with respect to health determinants, access to the resources needed to improve and maintain health or health outcomes. They also entail a failure to avoid or overcome inequalities that infringe on fairness and human rights norms.

Reducing health inequities is important because health is a fundamental human right and its progressive realization will eliminate inequalities that result from differences in health status (such as disease or disability) in the opportunity to enjoy life and pursue one’s life plans.

A characteristic common to groups that experience health inequities—such as poor or marginalized persons, racial and ethnic minorities, and women—is lack of political, social or economic power. Thus, to be effective and sustainable, interventions that aim to redress inequities must typically go beyond remedying a particular health inequality and also help empower the group in question through systemic changes, such as law reform or changes in economic or social relationships.1

Others argue that inequity is a difference in the opportunities or means to achieve health, whereas inequality is a difference in ends, or health as a final outcome of concerns (e.g. Pan-American Health Organization). Equity therefore requires that all individuals in a population have equal opportunities to achieve health, whereas equality concerns whether consequences are equal. In this context, the differences between equity and equality reflect differences in appropriate targets for policy interventions to close gaps.

Disparities in consequential health outcomes will arise from several sources, including differences in availability of baseline resources and opportunities. Some may be less modifiable and may be distributed randomly, such as genetic properties and subsequent physical or cognitive capacities. Others are more susceptible to non-random selection due to socio-economic, cultural (e.g. caste), demographic (e.g. race or ethnicity), and political factors. Finally, given equal availability of baseline resources and opportunities, outcomes could still differ according to an individual’s commitment to achieving goals, as well as by external influences such as accidents, economic shocks, conflict, and natural disasters.

Some differences in health outcomes can therefore be attributed to random chance, systemic selection by social structures, and individual commitment. There is a wide consensus that differences caused by systemic social selection beyond an individual’s control are ‘unfair’, and should be alleviated by distributional justice [5]. Differences arising solely from individual commitment and voluntary choice are attributed to individual responsibility, and interventions cannot (or should not) be made. However, individual commitment is often shaped by factors other than an individual’s free will, such as the availability of resources, future projection, and sense of control, which are further influenced by social selection and subsequent resource availability. Thus, it may not be possible to attribute health outcome differences separately to social, individual, and chance attributes. This leads to the moral debate on how to achieve ‘fairness’ in equity.

Ethical basis for ‘health equity’

What equity means depends on which ethical basis is referred to. As Amartya Sen elegantly stated, equity achieved under one school of ethical theory may be inequity under another [6]. This highlights the importance of understanding the contributions of different schools of ethical theory to the health equity debate.

Utilitarianism

Utilitarianism seeks for the maximization of social utility; an individual’s utility is counted as one and no more than one, and any individual’s welfare is treated equally. Utilitarianism weighs consequences regardless of the nature of interests, original positions, or conditions. Resource allocation is to be determined when the marginal utility gain derived from the obtained consequence of one (or one group) equals the marginal loss of others, so that no additional net gain is achievable in a society. Because it is concerned with consequences and ignores processes, utilitarianism is often criticized as lacking justice. In the health equity context, utilitarianism would seek to maximize the sum of ‘quality adjusted life years’, or a utility-weighted life year in the society [7]. As those with chronic conditions tend to have a lower chance of recovering their health status for a given investment, utilitarianism will assign a lower priority to investment for those with chronic conditions. As such, a utilitarian approach may not well address inequalities in opportunities to achieve health [8].

Libertarianism

Libertarianism takes the most value in self-governance, or an individual’s right to determine her/his own destiny without external interference. If self-governance is equally secured, the outcomes that an individual could achieve are determined by her/his own commitment and responsibility. Differences in initial conditions leading to differences in outcomes do not induce a moral claim in the libertarian context. Those with impaired life chances, for example those with permanent disability and reduced opportunities to participate in the formal workforce, would be left to fend for themselves with or without informal care or support from family or charity. Redistribution through taxation to help those in need is against libertarian ethics, because the government institution coerces individuals into paying for somebody else. Thus, some criticize libertarianism for generating inequality in health outcomes [8].

Kantian liberalism

Kantian liberalism, also known as Rawlsian ethics, claims that differences in outcome caused by factors beyond an individual’s control should be compensated, and further claims the ‘min-max’ rule, namely that the least advantaged should be provided with the greatest possible opportunity. The concept is based on liberalism, in that individuals should be responsible for their own acts and decisions. Kantian liberalism claims that factors such as sex, race, ethnicity, socio-economic position, political minority status, and inherited physical or cognitive capacities are all beyond an individual’s voluntary choice, and the baseline disadvantage due to these factors should be compensated for by‘equal-footing’. The concept thus seeks equal opportunities for individuals with different original positions.

Kantian liberalism is often criticized for presuming that individuals with capacity will fully commit to social activities, and precludes those with permanent physical or psychiatric disability [9]. For example, individual capacity to translate a given resource or opportunity into a health outcome would vary, and those with permanent disability would need larger investment to achieve the same level of health as those without the condition. How to ‘fairly’ compensate for differences in capacity is not explicitly discussed in this ethical claim.

Capability approach

The capability approach has been proposed by Sen as a means of achieving equity beyond utilitarianism-based welfarism and liberalism ethics [6]. Sen argued that utility-based welfarism simply focuses on what is achieved, and does not consider how choices are made. If an individual makes a choice, but only from a limited set of alternatives, it should not be considered to equate to the same choice made from a broader, richer range of alternatives. Sen claims that fairness should be sought not only in realized well-being, but also in the freedom and potential to choose alternative statuses of well-being, or different kinds of living.

Sen further argued that liberalism narrowly focuses on opportunities, and fails to consider what is actually or potentially achieved. He introduced the concept of ‘functionings’, or ‘beings and doings’, as the ultimate ends to constitute a valuable living. For example, ‘being healthy’ is a type of functioning. Then, he claimed that individuals should be free to realize their own goals with the ‘capability’ to achieve valuable functionings. The capability approach requires a set of valuable functionings to be achievable, and freedom of choice to act for one’s own value to be equally distributed for fairness to be achieved. In this approach, health equity means more than equal achievement of health status or equal access to health resources, as Sen commented:

(Health equity) includes concerns about achievement of health and the capability to achieve good health, not just the distribution of health care, but it also includes the fairness of processes and thus must attach importance to non-discrimination in the delivery of healthcare [10].

The concept of capability was recently applied to health by Jennifer Ruger [11], who defined ‘health capabilities’ as ‘the conditions affecting health and one’s ability to make health choices to achieve optimal health under given genetic, social, political, and economical environment’, and provided a list of factors affecting capabilities composed of internal factors (e.g. health literacy, self-efficacy, and health values) and external factors (e.g. social norms, social networks, economic and political power, and access to health care).

The capability approach explicitly incorporates the difference in individual capacity to translate a given investment to well-being (e.g. inherited cognitive capacity, and permanent physical and mental health conditions). The approach argues that instead of realized outcomes and resource investment, equity should be sought in the degree of functioning potentially realized, or the capabilities. This may explain why the concept has high affinity with the conceptual model of what makes ‘disability’.

The International Classification of Functioning, Disability and Health, released by the WHO in 2001, sought to integrate medical and social models of disability, and took into account individual and environmental factors that influence functioning, disability, and quality of life [12, 13]. Some argue that the model has a considerable conceptual overlap with the capability approach, in that it also treats functioning as a realization of valuable social inclusion that is affected by personal and environmental conditions [14].

In summary, different ethical schools view health equity differently. In the context of public mental health, the capability approach seems to be the most promising ethical basis for equity, as mental health is a consequence, as well as a target, of public health policy. However, the capability approach can be criticized for being too broad and being resistant to standardization or operationalization for measurement and evaluation, giving rise to challenges when translating health equity into public mental health policy-making and action. To use the health equity concept based on the capability approach effectively, sharing a working definition and goals to be realized should be carefully and transparently discussed by stakeholders.

Why and how equity matters in public mental health discussion

Good mental health is a resource that enables an individual to fully realize their value in life. Accumulated evidence consistently indicates that those who experience social and economic hardship, including sex and ethnic status, are at higher risk of poor mental well-being and developing mental ill health [15, 16, 17, 18, 19, 20]. Poor mental well-being and mental ill health further preclude fair access to quality health care [21, 22, 23], and a broader range of social, economic, and other resources to achieve full social participation [24, 25]. Consequent social exclusion further leads to higher risks of developing mental ill health [26, 27].

As such, when addressing equity in public mental health, mental health should be regarded not merely as a consequence or a cause of inequity, but as an important medium that reciprocally links social structure and individual well-being. In other words, mental health, as well as physical health, is a key target to break a vicious cycle linking ill health and socio-economic disadvantage (Fig. 13.1) [18].

Fig. 13.1 Vicious cycle of social determinants and mental health.

Fig. 13.1 Vicious cycle of social determinants and mental health.

Source: Reproduced from Patel, V, Lund C, Hatheril, S, et al., Mental disorders: Equity and social determinants. In: E. Blas & A.S. Kurup (Eds.), Equity, Social Determinants and Public Health Programmes, pp. 115–134, Copyright (2010), with permission from the World Health Organization

Socio-economic inequity in mental health within and between countries

There are many known risk factors for the development of mental ill health, ranging from genetic and biological factors to social environments in high-income countries [15, 16] and middle-to-low-income countries [17]. Depression has been most rigorously studied; the results provide convincing evidence that educational attainment of individuals and their parents, and sex-determined status such as marital disadvantage, within-family power imbalance, and related domestic violence are significant risk factors for depression. There is also reasonable evidence that low economic status has a role to play [18].

Low educational attainment may lead to higher chance of being exposed to social stress, and may also be related to low mental health literacy that precludes adequate coping with stress and timely seeking of self-help and professional help [28]. Self-efficacy and lack of control often accompany socio-economic hardship, and all are associated with depression [26, 27]. Some studies also suggest that immigrant populations are more susceptible to mental ill health because of acculturation and perceived discrimination [29], and the association is further intensified by low educational background [30].

The risk factors for depression are not randomly distributed, but are systematically shaped by social structures such as social class, and are over-represented in socio-economically and culturally vulnerable populations reflected in the socio-economic gradients of mental ill health within a society [18].

From the macroscopic point of view, there are some national-level factors that affect population-level trends in mental ill health prevalence. A classic study by Emile Durkheim found differences in suicide rates between countries with different religion-related norms about social control [31], although the methodology and interpretation was criticized. Most recent economic studies have found consistent relationships between the incidence of suicide and economic growth [32, 33]. However, the impact of the 2008 global economic shock was differentially presented in the suicide rate across countries [34, 35], suggesting there are population-level moderators affecting economic impact on the risk of mental ill health and subsequent suicide behaviour, such as national policy regarding workers’ compensation and social security (Fig. 13.2).

Fig. 13.2 Body economics by Stuckler.
Fig. 13.2 Body economics by Stuckler.

Fig. 13.2 Body economics by Stuckler.

Reproduced from Lancet, 374(9686), Supplement to: Stuckler D, Basu S, Suhrcke M, et al., The public health effect of economic crises and alternative policy responses in Europe: an empirical analysis, pp. 315-323, Copyright (2009), with permission from Elsevier.

Examples of population-level determinants of mental health can also be found from international studies of aged populations. The Survey of Health, Ageing and Retirement in Europe (SHARE) is a transnational panel study of middle-aged and older populations following the US Health and Retirement Study [36, 37]. Depression was measured using the Euro-D scale to translate the results of different measurement batteries used between countries into a comparable score. The survey found commonality, as well as differences, across countries in risk factors for depression. Not being married and living alone were consistently found to correlate with depression status across countries. The report also confirmed that female sex was related to higher odds of being depressed, although there was a significant country–sex interaction; the correlation was stronger in Southern European countries. Equivalent household income was not consistently related to depression prevalence across countries, although an association between low income and depression was observed in Northern European countries, which reflected the findings of a sister study in Japan [38]. Although European panel data found that older age is associated with depression prevalence, the Japanese counterpart study did not find a clear correlation with age. A possible explanation is that elderly Japanese people face fewer financial risks for healthcare co-payment thanks to a reduced co-payment rate for those aged over 75 years under public universal coverage, which exhibited a protective effect for mental health status [39]. These transnational variations strongly suggest that important structural mediators work to influence associations between depression and individual socio-economic status.

Life course perspective in public mental health

Exposure to risk factors for mental ill health are accumulative over an individual’s life, starting in the very early developmental stage, including the prenatal period. Childhood adversity, ranging from maltreatment of any type (e.g. physical, emotional, and sexual), neglect by carers, parental maladjustment (e.g. parental mental ill health conditions, including substance abuse), and the experience of domestic violence, all damage emotional, behavioural, and psychological development, and lead to higher risks of mental ill health in adulthood [40, 41, 42, 43]. Again, these conditions are disproportionally distributed in socio-economically vulnerable populations.

Some studies have reported that the early onset of mental disorders is associated with significantly reduced household income in later life [44, 45]. However, the impact was found only in high- and upper-middle-income countries and not in low- or lower-middle-income countries [24]. In addition, mental disorders further trigger job discrimination, and there is increasing awareness of the economic costs incurred by mental disorders and subsequent lost productivity [25].

Mental ill health, discrimination, and socio-economic disadvantages are intertwined to reproduce disadvantage and inequity in mental health, which can be transferred inter-generationally [20]. Thus, the life course perspective indicates that earlier intervention in the life course is most important, and that interventions at different stages of the life course through different institutions are required. It further indicates that interventional activities in different stages should be integrated in consistent health policy.

Stigma and healthcare access

Discrimination and subsequent social exclusion are critical themes in the discussion of public mental health. Discrimination evokes the perception of stigma to those with mental ill health conditions. Perceived stigma forces people with mental illness to react ‘to avoid the label of mental illness’ [22]. Perceived stigma damages self-esteem and is itself a risk factor for depression. More seriously, perceived stigma discourages people with mental illness to seek timely and appropriate healthcare attention [22, 23]. Discouraging access to quality care further widens disparities in mental health, especially among those with lower education and who are socially isolated [21].

Social determinants of health and health equity in public mental health

It is not sufficient to provide equal access to quality mental health care to achieve equity in public mental health. Health equity is not only about the equal distribution of health status, but also about the equal distribution of functionings and freedom to choose alternative functionings, as the capability approach stipulates. As this review has so far confirmed, public mental health is strongly determined by social, economic, cultural, and even political factors (e.g. in the cases of humanitarian crisis during wartime and political turmoil). Thus, it is logical to argue that equal distribution of social determinants of mental health to prevent, treat, and compensate for the burden of mental ill health is required to achieve public mental health equity [5]. For this purpose, health policy and a range of social, economic, and welfare policies should be implemented in a coordinated fashion [18, 20, 46].

Allen et al. [20] have extended the discussion initiated by the WHO’s Commission on Social Determinants of Health into the public mental health context to propose four principles for the ‘social determinants of health’ approach. The first is ‘proportionate universalism’, meaning that a policy should target the whole population, with a calibrated focus on those with greater needs and vulnerabilities. The second is the trans-sector approach to realize effective coordination of social, economic, and health policies that can be accountable for health impact. The third is the importance of early intervention. Finally, the review also highlighted the interdependency of mental and physical health and emphasized that public mental health policy should be given higher priority with intensified allocation of financial, medical, and human resources, with a long-term vision and effective combination of global and local actions.

The Faculty of Public Health and the Mental Health Foundation in the UK recently issued a comprehensive policy advocacy report to achieve public mental health equity [46]. The report called for the reform of current biomedical models of mental health to take into account the social context of mental ill health and the cumulative impacts of discrimination, poverty, and exclusion. It also argued that ‘a fairer society with a better distribution of opportunities’ should be realized through increasing mental health literacy in the community to reduce stigma and discrimination.

A comprehensive review and policy proposal by the WHO also listed a table of policy targets ranging from economic development, education, labour, housing, welfare, and drug and alcohol policies (Table 13.1) [18], with special emphasis on targeting early adolescence and social intervention to reduce stigma.

Table 13.1 Interventions for mental disorders targeting socio-economic context and differential vulnerability with indicators

Interventions targeting:

Indicators

Socio-economic context and position

Mental health policy, legislation and service infrastructure coordinate service provision

Presence, date, development, and content of policies, legislation and plans

Alcohol and drug policies to reduce substance-related disorders

Economic policies promoting financial security of populations, funding for key services

Labour policies promoting employment and protection against stress

Welfare policies protecting the disabled, sick and unemployed

Education poilcies that provide quality basic education and cater for special needs

Differential exposure

Providing safe home and community environments for children

Child abuse rates, conviction of child abusers

Prevention of injury, violence and crime

Statistics on injury, violence and crime, improved community safety

Provision of adequate housing

Housing backlog, % of population homeless

Relocation of people with mental disorders to less adverse neighbourhood

Access to employment and economic opportunities

Improved antenatal and obstetric care

Infant and maternal mortality rates

Employment creation and skills development

Employment rate, skill levels, available training programmes

Differential vulnerability

Early childhood development programmes targeting impoverished populations, mother–infant interventions, parent training

Number of parents/children in receipt of programme, longitudinal indicators of child health and development

Depression prevention programmes

Number of target population receiving programmes, mental health outoomes

Targeted screening programmes, e.g. following head injury

Detection and treatment rates

Provision of adequate nutrition

Rates of malnutrition and micronutrient deficiency

Antidiscrimination programmes targeting racism, gender discrimination, stereotyping

Social attitudes to and service utilization by age, gender, ethnicity

Access to financial facilities for poor

Households receiving microcredit and savings schemes

Source: Reproduced from Patel V, Lund C, Hatheril S, et al., Mental disorders: equity and social determinants. In: E. Blas & A.S. Kurup (Eds.), Equity, Social Determinants and Public Health Programmes, pp. 115–134, Copyright (2010), with permission from the World Health Organization.

Despite enthusiasm for the ‘social determinants of health’ approach to achieve public mental health equity, currently available evidence mainly supports the effectiveness of provision of quality mental health care and income support to those with mental ill health, whereas there is limited support for the effectiveness of policies to tackle social determinants of mental health [18]. The relative lack of supportive evidence for this approach may not be because of a lack of effectiveness of such policies in practice, but rather because of limited implementation of the policy so far. Indeed, there are several challenges to implement the approach into real-world practice. The most important challenge is the current lack of political awareness of the approach that has reduced the priority given to public mental health policy [47]. It is also methodologically challenging to evaluate the effectiveness of ‘social determinants of health’ policy in an experiment to evaluate its impact precisely and accurately.

It requires political, academic, and civic commitment to achieve health equity in public mental health. It will be a substantial challenge to reach a social consensus on how to achieve a fairer society on the basis of a shared ethical basis in the society.

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Notes:

1 Reproduced from Health Systems Topics: Equity, with permission from the World Health Organization. Available at http://www.who.int/healthsystems/topics/equity/en/