Combining Forces against Inequity and Poverty Rather Than Splitting Hairs

Davidson Gwatkin's excellent lead article raises many points with important policy implications. I shall comment on just two: equity targets, and health "equity" versus "poverty" approaches. Equity targets focus attention and increase accountability Gwatkin aptly points out the need to move from the standard practice of setting population health goals in terms of averages to specifying goals systematically and explicitly in distributional terms. He demonstrates concretely how sizeable improvements can be manifest in an indicator's average level but be concentrated in the better-off groups. In the present global circumstances there is a particular risk of this occurring, since knowledge of preventive practices and ability to apply them, as well as access to expensive medical technologies, are likely to become increasingly concentrated in the better-off groups in the absence of concerted public policy action. What stands in the way of countries adopting equity targets? From a research perspective, a lack of reliable data on health indicators disaggregated by social group immediately comes to mind, as does lack of consensus about indicators. Progress towards targets must be measurable in terms of specified indicators; otherwise there is no accountability or way to assess whether policies are likely to be generally on or off track in leading to greater equity. Governments routinely report on scores of health indicators. Should there be an equity target for all of them or only for selected ones, and if the latter, which ones? The literature suggests that disparities in health status associated with socioeconomic differences narrow during adolescence, rise again in young adulthood, then fall again among the elderly (1-3). Should all periods in the life-course be reflected? All health conditions? The literature also indicates that associations between socioeconomic status and health vary with both the health indicator and the socioeconomic measure considered. Should we select the indicators likely to reveal the widest gaps or use other criteria, such as the modifiability of disparities, or the total burden of ill-health (considering both prevalence and severity of health consequences)? These are difficult questions, but a far more difficult one lies in the political realm: how to build a broad societal consensus. Societies may generally be less tolerant of social inequalities in health than in wealth but they are likely to vary both in the levels of health inequality they will tolerate, and in what the better-off are willing to pay to reduce inequality. Society as a whole -- including the better-off, who have greater political power -- must feel invested in improving the health of all its members, including those previously left out. Towards that end, equity targets should supplement rather than replace average targets. And there must be adequate public discussion and consensus-building to provide the basis both for setting targets and for formulating actions to achieve them. Health equity targets may indeed provide a useful mechanism to help build and maintain societal consensus. Both the initial target-setting process and periodic reviews of progress towards achieving targets could provide a focus for public discussion of societal views and policy options; clearly, all social groups -- including advocates for the disadvantaged -- and all relevant sectors must be included. Gwatkin has rightly noted that effective response to social inequalities in health will often require action outside the health sector. One of the key functions of the health sector should be to provide information on an ongoing basis to reflect the health consequences (overall and for more and less advantaged groups) of actions in all sectors. This role should not depend on whether health services themselves are likely to be of major importance in an effective response to observed health inequalities. "Equity" and "poverty" approaches I also would like to comment on the "poverty" versus "equity" distinction, and to second Gwatkin's conclusion that the practical differences between these approaches are far smaller than the commonalities. …