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Improving equity 

Improving equity
Improving equity

Sharon Friel

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date: 12 November 2019


After reading this chapter you will:

  • be familiar with the concept and extent of health inequity in high and middle income countries

  • understand how the health care system can be both a cause of health inequities and a mechanism by which to improve health equity

  • recognized how to address the social determinants of health inequity

  • begin to systematically apply an equity lens to your daily professional practice.

Definitions and key terms

  • Health inequities are avoidable inequalities in health outcomes

  • Health equity is not only about health outcomes, but also about equitable exposure to factors which affect health; and prevention of disadvantage due to ill-health

  • Social determinants

  • Community empowerment

  • Health literacy.

Why improving equity is an important public health issue

Despite the increase in global average life expectancy of more than 20 years since 1950 and improvements in health more generally, some startling differences in health experience exists between and within countries. Improving health equity requires attention to the underlying social causes in addition to more equal access to appropriate levels of quality health care. Health inequities can be best reduced through needs-based universal primary health care and intersectoral action, action which requires leadership by public health professionals.

The extent of health inequities

The World Health Organization Commission on Social Determinants of Health (CSDH) shone a global spotlight on the marked inequities in health conditions between countries and population groups.1 For example, premature death among adults remains a major health issue in countries rich

and poor, but the rates differ enormously, for example, Australia 76 per 1000 compared with Papua New Guinea 380 per 1000.2

If there is no biological reason for the systematic differences in life expectancy or health conditions between different regions and countries then they are not inevitable and need not exist. These avoidable health inequities occur not just between countries, but also within countries. For example, an assessment of socio-economic inequities in mortality and prevalence of health risks among 22 countries in all parts of Europe demonstrates persistent and large inequities in health conditions within developed countries in the region. People with the lowest level of education were found to be consistently at higher risk of poor health compared to those with the highest levels of education (see Box 5.8.1).3

The causes of health inequities

The social determinants of health inequities

Perhaps you are a primary care physician, a tobacco cessation officer or a community health worker? When a person walks through your door, you are aware of at least two things:

  • Many factors have brought the person to this meeting: factors positively and negatively affecting health, experienced in the immediate moment and over the course of a lifetime

  • If in a health care setting: behind the patient are many others who do not make it to your door.

By now you should be asking what it is about society that is causing such unfair differences in health outcomes (see Box 5.8.2). For health in general, people need the basic material resources for a decent life, they need to have control over their lives, and they need voice and participation in decision-making processes. The level of material, psychosocial and political resource among different social groups is influenced by the social determinants of health and health inequities. The social determinants refer to the distribution of power, income, goods, and services, globally and nationally, and immediate circumstances of people’s lives, for example, their access to health care and education, their conditions of work and leisure, their homes, communities, towns, or cities.1

Health care systems: a determinant of and solution to health inequities

International, national, and local health care systems are both a determinant of health inequities and a powerful mechanism to reduce inequities.4 Given the high burden of illness particularly among the socially disadvantaged groups, it is urgent to make health care systems more responsive to population needs.

Inequities in health care are systematic differences in the use or receipt of quality primary, secondary and tertiary health care services, including hospitalizations, diagnostic tests, surgical procedures, physician visits, allied health services, medications, health promotion programmes. Gender, education, occupation, income, ethnicity, disability, and place of residence are all linked to access, experiences of and benefits from health care.

The inverse care law, initially identified by Tudor Hart, in which the poor consistently gain less from health services than the better off, is visible in every country across the globe. Out-of-pocket expenditures for health care contribute to health inequities, tending to deter poorer people from using both essential and non-essential services, leading to untreated morbidity. In OECD countries the cost of most doctor visits are subsidized and there are provisions to limit out-of- pocket costs, for a given level of need. In these countries socio-economically advantaged women are more likely to use specialist medical, allied health, alternative health and dental services than less advantaged women.5 These inequities in access and use of a range of health care services, not just the doctor, are particularly concerning in the context of chronic disease where optimal care includes use of multidisciplinary services.

However, inequities in access and utilization of health care are not only financial—inequities play out by race, gender, age, and location. In spite of near universal coverage for antenatal visits in Pelota, Brazil, the quality of care was consistently higher among women of white skin colour and high socio-economic status women than among black and poor women.6

Key messages

  • Health care systems are socially determined and are determinants of health and health equity

  • The health care system, whether publicly or privately supported, should promote health equity and should contribute to wider efforts to reduce health inequities.

What can be done to improve equity

Primary health care systems

Appropriately configured and managed health systems provide a vehicle to improve people’s lives, protect them from the vulnerability of sickness, generate a sense of life security, and build common purpose within society. Health care systems contribute most to improving health equity where the institutions and services are organized around the principle of universal coverage (extending the same scope of quality services to the whole population, according to needs, regardless of ability to pay), and where the system as a whole is organized around Primary Health Care (PHC, including both the model of locally-organized action across the social determinants of health, and the primary level of entry to care with upward referral if necessary).

Levels of care

Within each level of care, there are opportunities to improve health equity. Secondary and tertiary levels of care are concerned, mainly, with the progression from disease to death. How these types of care are set up can make an important contribution to health equity.

There are four main characteristics of primary care practice: first-contact health care, person-focused care over time, comprehensive care, and coordinated care, as well as family and community orientation. In a comparison of the supply and adequacy of primary care characteristics across 13 industrialized countries, Starfield and colleagues found that the stronger a country’s primary care orientation, the lower the rates were of all-cause mortality, all-cause premature mortality, and cause-specific premature mortality from asthma and bronchitis, emphysema and pneumonia, cardiovascular disease, and heart disease.7 In state-level analyses in the USA, there were fewer differences in self-rated health between higher and lower income-inequality areas where good primary care experiences were stronger. Evidence of success of primary level services in reducing health inequities is also available from Africa (Liberia, Niger, Zaire), Asia (China, Kerala in India, Sri Lanka) and Latin America (Brazil, Cuba).7

Key messages

  • Strengthen geographical access to care (particularly for remote rural communities)

  • Reduce/remove financial barriers (both formal and informal user fees increasing direct individual and household costs of health-seeking behaviour and treatment)

  • Poorer, less educated and other categories of socially disadvantaged patients may not be aware of their rights to health care nor advocate for their own health needs as effectively as do patients with higher incomes

  • Ensure health care system working models are sensitive to cultural diversity.

A focus on prevention

As a public health practitioner a large part of your professional remit is to prevent disease onset and promote wellbeing. A number of the inequities in health outcomes in middle and high income countries relate to non-communicable diseases, injuries and accidents. Much of public health’s prevention focus has been on individuals and their behaviours. Eating healthy diets, being physically active, limiting alcohol consumption and not smoking are each socially graded. For example, in high and middle income countries, excess body weight tends to be more prevalent among people further down the social and economic scale. Similarly, the prevalence of tobacco use decreases with increasing socio-economic status.8 However, even if we were able to equalize lifestyle behaviour factors, health inequities are likely to persist between socioeconomic groups.

A number of interventions at the individual and community level, such as screening, healthy eating advice, smoking cessation and statin prescribing have been shown to widen socioeconomic inequities.9 A more upstream systems approach would involve, for example, legislating smoke-free public spaces or banning dietary transfats. Similarly, obesity prevention interventions that focus on behaviour change through personal skill development, information and social marketing campaigns may perpetuate socioeconomic inequities in obesity rates, given that the uptake of message is generally greater in higher social status groups.

Obesity prevention requires approaches that ensure an ecologically sustainable, adequate and nutritious food supply; material security; a built habitat which lends itself towards easy uptake of healthier food options and participation in both organized and unorganized physical activity, and a family, educational and work environment which positively reinforces (see Box 5.8.3) healthy living and empowers all individuals to make healthy choices.10 Very little of this action sits within the capabilities or responsibilities of the health sector. We will return to this point later.

A central component of health promotion and disease prevention is community empowerment. Restricted participation results in deprivation of fundamental human capabilities, setting the context for differentials in, for example, employment, education and health care. Health equity depends vitally on the empowerment of individuals and groups to represent strongly and effectively their needs and interests. Evidence from interventions for youth empowerment, HIV/AIDS prevention and women’s empowerment suggest that the most effective empowerment strategies are those that build on and reinforce authentic participation ensuring autonomy in decision-making, sense of community and local bonding, and psychological empowerment of the community members themselves.

Integrated health care

The public health practitioner is a key person within a primary health care system, playing an important role in helping to ensure fair access and use of quality health care services, from health promotion through to tertiary care. Take child, adolescent, and maternal health, for example. Lawn and colleagues demonstrated that linking communities and facilities in a continuum of care is more effective in reducing maternal and newborn deaths than is focusing on either community or facility alone.11 In the case of child and maternal health, this lifecycle integrative approach to health requires primary- and community health care workers to engage in various levels of care including

  • health promotion and community mobilization (e.g. infant and young child feeding; school health; special programme areas such as HIV)

  • outpatient services (e.g. family planning; malaria prevention such as bed nets)

  • case management and care (e.g. childbirth; malnutrition care and rehabilitation)

  • health system tasks (e.g. essential drugs supply and logistics; data monitoring; financing such as issuing vouchers for health care).

A social determinants approach through intersectoral action

A critical starting point for health equity is within the health sector itself. However, to make a fundamental improvement in health equity requires not only technical and medical solutions, but also action in the immediate and structural conditions in which people are born, grow, live, work, and age. As a social determinants lens on health equity illuminates, good health for all is not only a matter for the health sector, but must also involve sectors such as agriculture, urban planning, employment, and education.

Effective action on health equity therefore depends vitally on cross- sectoral co-ordination. This is manifested in a dynamic inter-relation between the health system and the wider system of governance through which inequity in health outcomes are produced. Through your role as a public health practitioner you can bring together the benefits of primary health care and action in the social determinants of health. This will promote health equity through attention to the needs of socially disadvantaged groups and help provide leadership in promoting coherent policies and practices in different sectors.

Let’s take mental health as an illustrative case study. Promoting equitable mental wellbeing and reducing inequities in the causes and treatment of mental illness requires an intersectoral approach as outlined in Table 5.8.1 below.12

Table 5.8.1 Intersectoral action in relation to equity in mental health




Violence/crime prevention programmes

Substance abuse

Alcohol and drugs policies

Social fragmentation

Promoting programmes building family and wider social cohesion


Mental health promotion programmes

Natural disasters

Trauma and stress support programmes

Inadequate housing

Housing improvement interventions

Work stress

Protective labour policies (e.g. restrictions on excessive shift work): workplace health promotion programmes


Employment programmes, skills training

Financial insecurity

Welfare policies that provide a financial safety net

Social protection

Economic policies to promote financial security, and adequate funding for a range of public sector services (education, health, housing)

Lack of available health services

Improving availability of mental health services through integration into primary health care

Unacceptable health services

e.g. ensuring that mental health staff are culturally and linguistically acceptable

Economic barriers to health care

Providing financially accessibly services

Mental health policy and legislation

Strengthening mental health policy; legislation and service infrastructure

Differential vulnerability


Early developmental risks

Promote early childhood development programmes

Early developmental risks, maternal mental illness, weak mother-child bonding

Mother-infant interventions, including breastfeeding

Developmental risks for adolescence

Depression prevention programmes targeting adolescents

Development risks for older adults

Education and stress management programmes; peer support mechanisms

Inaccessibility to credit and savings facilities

Improve access to credit and savings facilities for poor

Financial consequences of impact of depression on productivity

Support to caregivers to protect households from financial consequences of depression; rehabilitation programmes

Social consequences of depression

Anti-stigma campaigns; promotion of supportive family and social networks

Financial consequences of depression treatment

Reduce cost

Lifestyle consequences of depression

Mental health promotion, including avoidance of substance abuse

Amended WHO 2010.

Improving equity: implications for public health practitioners

There are three key areas in which public health practitioners can helpfully focus their attention in such a way that will improve health equity. What follows is not an exhaustive list, but rather an illustration of different types of action that can be taken by public health practitioners

Evidence informed practice

As a public health practitioner, using sound evidence to inform your daily practice offers the best hope of tackling health inequities. Evidence informed practice requires good data on the extent of the problem and up-to-date evidence on the causes and on what works to reduce health inequities. It also requires an understanding of the evidence such that the causes of health inequities are acted on. Routine data collection and monitoring systems that collect socially stratified health information are essential for knowing the magnitude of the problem, understanding who is most affected, and whether health equity is improving or deteriorating over time, and for assessing entry-points for intervention and evaluating the impact of practice.

Practical action

  • develop a national/local health equity action plan which is fully supported by an effective health equity monitoring system

  • build-up, and systematically use, an information system that collects health outcome data stratified by different social groups (including sex, income, education, occupation, age, ethnic group)

  • incorporate measures on the determinants of health inequities into the health monitoring system.

Action on the determinants of health inequities requires a rich and diverse evidence base, not just a quantitative monitoring system. Collaborative knowledge production between researchers and public health professionals is needed to elucidate what works to reduce health inequities in what circumstances, and how best to implement interventions, such that they contribute to a reduction of these inequities.

Practical action

Commit appropriate amounts of public health research funding into understanding how to improve health equity through action in the social determinants and health care systems, and proactively engage with relevant researchers.

People-centred practice

All members of society, including those most disadvantaged and marginalized, are entitled to participate in the identification of priorities and targets that guide deliberations underlying public health practice. That focus is stimulated by, and feeds into, local conditions of inclusion and fair representation.

Practical action

  • public health practitioners should promote the inclusion of all groups and communities in decision-making that affects health, and in subsequent programme and services delivery and evaluation

  • develop a statutory local health equity action plan that is regularly monitored and reviewed, and provide statutory funding to support community engagement and participation in the processes

  • ensure annual monitoring and reporting against a set of specific health equity focused outcomes.

Health literacy is a critical empowerment strategy to increase people’s control over their health and their ability to seek out information. The understanding of health inequity and its causes needs to be improved as a new part of health literacy. Health literacy is not just about the individual’s ability to read, understand and act on health information, but also the ability of public health professionals to communicate health related information in relevant and easy to understand ways.

Practical action

  • raise awareness among the public about health inequity and its causes

  • improve knowledge among socially disadvantaged groups about health and health care rights

  • improve awareness and knowledge among health professionals of health equity literacy.

Prevention focused practice

Action within the health sector

If public health practitioners are to improve health equity through the health care system this means a refocusing of activities towards the removal of barriers to access and use of quality primary health care, and on the conditions in which people grow, live, work, and age.

Practical action

  • Expand programmes in health promotion, disease prevention and primary health care to include a social determinant of health approach. This means prioritizing services that prevent or ameliorate the health damage caused by living and growing up in disadvantaged circumstances rather than on behaviour-change and social marketing

  • Focus on developing and improving good-quality, integrated local services coproduced with the public to achieve needs driven outcomes.

Intersectoral action

Bureaucratic structures, statutory requirements, limited funding and traditional disciplinary boundaries can act to impede intersectoral action. However, it is imperative that you act as a champion and facilitator to influence other sectors to take action to reduce health inequities.

Practical action

  • Make the argument for intersectoral action to reduce health inequity using regularly updated evidence and increasing the visibility of social determinants of health issues

  • Map all public sector mechanisms, for example, internal and external committees, that have relevance for health equity, thereby identifying points of potential overlap and collaboration

  • Sensitize colleagues in non-health sectors to the relationship between what they do and the effect on health equity, through, for example, knowledge sharing, seminars, one to one briefings

  • The health equity implications of actions by other sectors need to be routinely considered. Health equity impact assessment is one tool that can be used to systematically assess the potential impact of policies, programmes, projects or proposals on health equity in a given population.

Competencies needed to achieve these tasks

A competent health workforce with the necessary specialized knowledge, skills and abilities to translate policy and current research into effective action is vital for health equity. Public health professionals need to understand how the health care sector—depending on its structure, operations, and financing—can exacerbate or ameliorate health inequities. The health care sector has an important stewardship role in intersectoral action for health equity. This requires an understanding among professionals in the health care sector of how social determinants influence health equity.

Practical action

  • Commit time and financial resources to the development of relevant skills and capacity among the health workforce, and provide reward structures for intersectoral working

  • Explicit integration of equity values into public health workforce competencies.


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