Understanding and setting up the process for health equity

Simply put, one of the central questions raised by Gwatkin's lead article is: why do we keep on "talking the talk" but not "walking the walk", when it comes to achieving health equity goals? Recent years have seen a renewed interest in health equity, as reflected in part by a significant increase in the number of international initiatives and published studies (1, 2). While different views have been expressed regarding how to define and measure health equity, a conviction shared by many is that expressed by Gwatkin, that "what matters are not societal averages with respect to health, but rather the health conditions that prevail among different groups within society, particularly among disadvantaged groups". But why has this conviction not been translated into policies in any noticeable way? There might be two basic reasons for lack of action on the health equity front. First, societies may not be highly motivated to take action. Second, they may want to take action but not know what exactly that action should be. I would argue that to help move from analysis to action, we need to fill two important knowledge gaps: an understanding of the political process for setting health equity goals, and empirical evidence on how practically to achieve those goals. Understanding the process There usually seems to be an implicit assumption embedded in health equity studies that epidemiological evidence on determinants of health and health equity will inevitably lead to the development of more equitable policies. That may help to explain why the majority of these .studies tend to focus on finding a clinical explanation for the link between low social status and ill-health. As pointed out by Rich & Goldsmith, however, epidemiological information is but one input into the political decision-making process, and often a minimal one at that (3). Social, economic, and political forces that produce and sustain inequities in the first place might be more important (4). Compared to the abundant measurement studies and prescriptive policy analyses that come out, there is a serious lack of positive enquiry into the political process of generating health equity goals in different societies. At present we do not know why health equity is defined differently in different societies, or what makes policy-makers care about health equity, or why specific health equity goals have been put on the political agenda in some countries but not in others. As any equity-oriented health policy changes seek to expand benefits for relatively powerless population groups and promise to impose new costs on relatively powerful groups, the resulting political challenges are significant. The demise of the Clinton health reform in 1994 vividly illustrated for the world the importance of politics: politics affects the definition and explanation of a policy problem, the way it is formulated, its recognition or denial, and the implementation of public policy aimed at solving it (5, 6). For industrialized as well as developing countries, therefore, the success of health reforms aimed at increasing health equity requires in-depth political analysis and astute political management. Would-be reformers have to find out who the movers and shakers are in formulating health equity policies. Then they need support in assessing the political feasibility of a policy, managing the process of policy design and acceptance, and thinking up strategies that improve the prospects of implementation. For this, applied political analysis provides a relevant assessment procedure to probe the political dimensions of policy-making in ways that increase effective interaction and enhance the quality of the reform process. Some tools such as PolicyMaker, a computer software program for political mapping, can be readily applied for this purpose (7). Setting up the process Whenever and wherever political will is in place, the next question naturally arises: what are the most feasible and effective strategies for reducing inequities in health and health care? …