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Defining Equity in Health

Defining Equity in Health

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doi:10.1136/jech.57.4.2542003;57;254-258
J. Epidemiol. Community Health 
P Braveman and S Gruskin
Defining equity in health
These include: 
 
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on 19 March 2007 jech.bmj.comDownloaded from 
 
THEORY AND METHODS
Defining equity in health
P Braveman, S Gruskin
.............................................................................................................................
 J Epidemiol Community Health
2003;
57
:254–258
Study objective:
To propose a definition of health equity to guide operationalisation andmeasurement, and to discuss the practical importance of clarity in defining this concept.
Design:
Conceptual discussion.
Setting, Patients/Participants, and Main results:
not applicable.
Conclusions:
For the purposes of measurement and operationalisation, equity in health is the absenceof systematic disparities in health (or in the major social determinants of health) between groups withdifferent levels of underlying social advantage/disadvantage—that is, wealth, power, or prestige.Inequities in health systematically put groups of people who are already socially disadvantaged (forexample, by virtue of being poor, female, and/or members of a disenfranchised racial, ethnic, or reli-gious group) at further disadvantage with respect to their health; health is essential to wellbeing and toovercoming other effects of social disadvantage. Equity is an ethical principle; it also is consonant withand closely related to human rights principles. The proposed definition of equity supports operationali-sation of the right to the highest attainable standard of health as indicated by the health status of themost socially advantaged group. Assessing health equity requires comparing health and its socialdeterminants between more and less advantaged social groups. These comparisons are essential toassess whether national and international policies are leading toward or away from greater social jus-tice in health.
I
n a widely cited 1992 paper on
The concepts and principles of equity in health
, Whitehead defined health inequities asdifferences in health that are unnecessary, avoidable, unfairand unjust.
1
That influential, articulate, and well conceivedpaper was “...not meant to be a technical document, but...aimed at raising awareness and stimulating debate in a wide, general audience...in Europe.
1
The document suc-ceeded in its stated aim and has been useful in many settingson other continents. Valuable contributions also have beenmade byotherdiscussions of the concept of equityin health orin health care, or both.
2–13
 Accumulated experience nowpermits a fresh look at the question of how to define equity inhealth in a conceptually rigorous fashion that can guidemeasurement and hence accountability for actions at thepolicy and programmatic levels. This question is of particularrelevance given the growing interest in equity among nationaland international health organisations.
6 10 11 14–32
The need for amore precise definition of equity in health also has arisen inthe context of a recent debate between researchers at the World Health Organisation
33–35
and at a number of academicinstitutions
36–38
; this debate is discussed below (see
Do the defi-nitions matter? 
). This paper is primarily addressed to theresearch community,proposing a definition of health equity toguide measurement and, hence, accountability; we alsodiscuss the practical importance of clarity in defining thisconcept, in terms of consequences for both policies andmeasurement.We are not aware of other literature addressingthis issue.
EQUITY MEANS SOCIAL JUSTICE
Equity means social justice or fairness;it is an ethical concept,grounded in principles of distributive justice.
39–42
Equity inhealth can be—and has widely been—defined as the absenceof socially unjust or unfair health disparities.
1 6
However,because social justice and fairness can be interpreteddifferentlybydifferentpeopleindifferentsettings,adefinitionis needed that can be operationalised based on measurablecriteria.For the purposes of operationalisation and measurement,equity in health can be defined as the absence of systematicdisparities in health (or in the major social determinants of health) between social groups who have different levels of underlying social advantage/disadvantage—that is, differentpositions in a social hierarchy. Inequities in health systemati-cally put groups of people who are already socially disadvan-taged (for example, by virtue of being poor, female, and/ormembers of a disenfranchised racial, ethnic, or religiousgroup) at further disadvantage with respect to their health;health is essential to wellbeing and to overcoming othereffects of social disadvantage.
 Health
represents both physical and mental wellbeing, not just the absence of disease.
43
Keysocialdeterminants of healthinclude household living conditions, conditions in communi-ties and workplaces, and health care, along with policies andprogrammes affecting any of these factors.
43–50
Health care is asocial determinant in so far as it is influenced by socialpolicies; we use the term broadly here to refer not only to thereceipt/utilisation of health services, but also to the allocationof health care resources, the financing of health care, and thequality of health care services.
Underlying social advantage or disadvantage
refers to wealth,power,and/or prestige—that is,the attributes that define howpeoplearegroupedinsocialhierarchies.Disadvantagealsocanbe thought of as deprivation,
51 52
 which can be absolute orrelative
53 54
; the concept of human poverty developed by theUnited Nations Development Program reflects severedisadvantage.
55
Thus,
more and less advantaged social groups
aregroups of people defined by differences that place them at dif-ferent levels in a social hierarchy. Examples of more and lessadvantaged social groups include socioeconomic groups (typi-cally defined by measures of income,economic assets,occupa-tionalclass,and/oreducationallevel),racial/ethnicorreligiousgroups,or groups defined by gender,geography,age,disability,sexual orientation, and other characteristics relevant to theparticular setting. This is not an exhaustive list, but socialadvantageisdistributedalongtheselinesvirtuallyeverywherein the world. A health disparity must be
systematically
See end of article forauthors’ affiliations
.......................
Correspondence to:Dr P Braveman,Department of Family andCommunity Medicine,University of California,San Francisco, 500Parnassus Avenue, MU-3E,San Francisco, California,94143-0900, USA;pbrave@itsa.ucsf.eduAccepted for publication21 October 2002
.......................254www.jech.com
 on 19 March 2007 jech.bmj.comDownloaded from 
 
associatedwithsocialadvantage,thatis,theassociationsmustbe significant and frequent or persistent,not just occasional orrandom.
56
EQUITY IS NOT THE SAME AS EQUALITY 
The concept of equity is inherently normative—that is, valuebased
1 37
;while equality is not necessarily so.
1 6 9 10 57
Often,theterm
health inequalities
isusedasasynonymfor
health inequities
,perhaps because
inequity
can have an accusatory, judgmental,or morally charged tone. However, it is important to recognisethat, strictly speaking, these terms are not synonymous. Theconcept of health equity focuses attention on the distributionof resources and other processes that drive a particular kind of health inequality—that is, a systematic inequality in health(or in its social determinants) between more and less advan-taged social groups, in other words, a health inequality that isunjust or unfair.Not all health disparities are unfair.
2 6
For example, weexpect young adults to be healthier than the elderlypopulation. Female newborns tend to have lower birth weights on average than male newborns. Men have prostateproblems,while women do not.It would be difficult,however,to argue that any of these health inequalities is unfair.However, differences in nutritional status or immunisationlevels between girls and boys, or racial/ethnic differences inthe likelihood of receiving appropriate treatment for a heartattack, would be causes for grave concern from an equity per-spective.
EQUITY AND HUMAN RIGHTS: EQUAL RIGHTS ANDOPPORTUNITIES TO BE HEALTHY 
The concept of equity is an ethical principle; it also isconsonantwithandcloselyrelatedtohumanrightsprinciples.The
right to health
as set forth in the WHO Constitution
43
andinternational human rights treaties is the right to “the highestattainable standard of health.Although this notion hassometimes been criticised by public health practitioners forbeing vague and difficult to operationalise, accumulatingexperience suggests its utility.
58–63
 We believe that the highestattainablestandardofhealthcanbeunderstoodtobereflectedby the standard of health enjoyed by the most socially advan-taged group within a society. One could argue that, given suf-ficient resources, the highest attainable standard could be fargreater than that currently experienced even by the best off group in a society. The health levels of the most privilegedgroups in a given society at least reflect levels that clearly arebiologically attainable, and minimum standards for whatshould be possible for everyone in that society within aforeseeable future.The proposed definition of equity in healththus is useful in operationalising the concept of the right tohealth. While it is important, as noted above, to be clear about thedistinction between health inequalities and health inequities,the concepts of equality and equal rights are none the lesscentral and indispensable.The concept of equality is indispen-sable for the operationalisation and measurement of healthequity and is important for accountability under the humanrights framework. Equality can be assessed with respect tospecified measurable outcomes, whereas judging whether aprocess is equitable or not is more open to interpretation.Fur-thermore, in practical terms, it is generally those who are inpositions of power who are likely to be determining at a soci-etal level what is equitable and what is not,with respect to theallocation of resources necessary for health. For example, insome countries where women are particularly disenfran-chised,those in power have argued that conditions for womenin their countries are not unfair but rather are appropriategiven the different capacities and roles of men and women;similar arguments have been used to justify racial/ethnicdiscrimination.
64–66
In such contexts,equality is a crucial refer-ence point in attempts to achieve greater equity in health.Furthermore, the notion of equal opportunities to behealthy is fundamental to the concept of equity in health andclosely linked with the concept of equal rights to health. Thenotion of equal opportunities to be healthy is grounded in thehuman rights concept of non-discrimination and the respon-sibility of governments to take the necessary measures toeliminate adverse discrimination—in this case,discriminationin opportunities to be healthy in virtue of belonging to certainsocial groups.A selective concern for worse off social groups isnot discriminatory; it reflects a concern to reduce discrimina-tion and marginalisation. Equal opportunity to be healthyrefers to the attainment by all people of the highest possiblelevel of physical and mental wellbeing that biologicallimitations permit,noting that the consequences of many bio-logical limitations are amenable to modification.For example,the functional limitations associated with many physicalhandicaps can be markedly changed with basic measures(such as providing wheelchairs, installing protective railings,or providing physical training to increase mobility andstrength);similarly,the degree of impairment associated withmany psychological and physical conditions is highly relatedto the degree of social stigmatisation or acceptance of people with those conditions.
67 68
 According to human rights principles, all human rights areconsidered inter-related and indivisible.
69 70
Thus, the right tohealth cannot be separated from other rights,including rightsto a decent standard of living and education as well as to free-dom from discrimination and freedom to participate fully inone’s society. Equalising opportunities to be healthy requiresaddressing the most important social and economic determi-nants of health, including, as stated earlier, not only healthcare but also living conditions in households and communi-ties, working conditions, and policies that affect any of thesefactors. Concern for equal opportunities to be healthy is thebasisforincludingwithinthedefinitionofequityinhealththeabsence of systematic social disparities not only in health sta-tus but in its key social determinants.
EASE OF AVOIDABILITY SHOULD NOT BE A CRITERION FOR INEQUITY 
The 1990
Concepts and principles
paper
1
defined inequity inhealth as inequalities in health that are unjust, unfair andavoidable. That definition has been very helpful in giving theabstract notion of equity meaning in terms that most peopleunderstand and recognise as a widely shared social value.However,we recommend that avoidability
not
be used as a cri-terion to define equity in health, for two reasons. Firstly,including this criterion is unnecessary, because unjust andunfair imply avoidability. Secondly, certain health inequitiesmay be extremely challenging to tackle because they requirefundamental changes in underlying social and economicstructures;one would not want the ease of avoidability to be ameasure of the degree of inequity. Furthermore, using avoid-ability as a criterion introduces but begs the question:avoidable by whom? Is a given health disparity that adverselyaffects already disadvantaged groups in a poor countryconsidered to be avoidable by the groups adversely affected,bytheir community, by government—and at what level—and/orby the international community?Thus, in defining equity in health, avoidability should onlybe invoked in so far as injustice and unfairness implyavoidability. The degree to which an inequitable healthdisparity is avoidable does, however, have important practicalimplications for efforts to achieve greater equity,in that it willgenerally be easier to mobilise public opinion and policies toaddress disparities that are more clearly and easily recognis-able as avoidable,particularly those that can be achieved morequickly, at lower cost and with less challenge to underlying
Equity in health 255www.jech.com
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