Since the days of Hippocrates, health inequities and the role of social and environmental factors in the determination of marked differences in health status have been well recognized. For some time now, the driving force behind public health has been understanding and intervening in the underlying causes of health inequity. The publication of the Black Report1 in the United Kingdom in 1980 brought a more focused approach to this discourse by identifying specific factors, such as social class, gender, and race/ethnicity, as the social and economic determinants of health inequities. With this evolution came a conceptual and operational distinction between health disparities/inequalities and health inequity/equity.2
These distinctions aside, the issue of health inequity has moved beyond the academic discourse into the arena of policy and action. In the United States, the 2002 Institute of Medicine report Unequal Treatment: Confronting Health Care Disparities marked a turning point.3 It is, however, important to recognize that like the problem of health inequity itself, the struggle to confront it is neither unique to the United States nor simply a local matter. Many nations, both developed and developing, have adopted strategies to reduce health inequities.
Confronting health inequities is increasingly a priority for health policymakers, both nationally and internationally. There are several recent examples of national governments in developed countries undertaking major initiatives to reduce health inequities. For instance, in the United Kingdom one of the first decisions of the incoming Labor government in 1997 was to commission the “Independent Inquiry into Inequalities in Health.” Under the direction of Sir Donald Acheson, the commission’s mandate was to establish the facts and suggest why, despite the increase in prosperity and substantial reductions in mortality evinced in the United Kingdom in the previous 2 decades, the gap in health status between those at the top and bottom of the social scale, as well as between various ethnic groups and between the sexes, had continued to widen.4 On the basis of the commission’s recommendations, the government formulated a comprehensive plan that recognizes the structural determinants of health, such as the social environment and the wider community, with the overarching goal of reducing avoidable health disparities.5,6
In 1998, the EURO Health for All policy (Health 21) was published.7 This policy specifies that by 2020 the health gap between countries and between socioeconomic groups within countries should be reduced by at least one fourth in all member states. Since that time, other European countries have undertaken similar comprehensive reviews and action plans at regional, national, and local levels.8,9 The following EURO Health for All policy recommendations are being implemented, at least partially, in member states of the European Union and various other neighboring countries, providing a useful model for similar action in other regions10:
Establish national health inequity targets by identifying and advocating relevant national and regional health targets and by tackling health determinants to reduce health inequalities. Integrate health determinants into other policy areas at national, regional, and local levels, using cross-sectoral approaches. Work at the local level by supporting community development approaches and the integration of local services, multi-disciplinary approaches, and partnerships. Reduce barriers to ensure access to and use of effective health care and prevention services by socially disadvantaged and vulnerable groups. Develop indicators and systems for monitoring health inequalities, including systems for collecting data on structural factors and determinants of health, such as social class, gender, and ethnicity. Assess health impact by developing and applying procedures, methods, and tools by which policies, programs, and projects may be judged as to their potential effects on the health of a population and the distribution of those effects within the population. Evaluate financial and human resources to ensure sufficiency and to increase knowledge on how to effectively tackle health inequities. Create and support opportunities to disseminate models of good practice and evidence-based approaches to tackle health inequalities, including databases of successful interventions.1. 2. 3. 4. 5. 6. 7. 8.
Other developed countries, such as Australia, New Zealand, and Canada, are also in the process of incorporating health equity and social determinants of health into regional or national public health policies.11–13
In the United States in 1998, the Clinton administration established the Initiative to Eliminate Racial and Ethnic Disparities in Health, which set a national goal of eliminating longstanding racial/ethnic disparities in health status by 2010 and, for the first time, set high national goals for all Americans, ending a practice of separate, lower goals for racial and ethnic minorities.14 There are mounting public and private coalition efforts aimed at “closing the gap” in health and health care that have continued under the Bush administration.15
In contrast to the European approach to health inequities, it is racial and ethnic disparities that are of greater policy relevance in the United States. First, there are obvious historical reasons for the extensive overlap of socioeconomic and racial inequalities in the United States. Second, the predominant use of ethnic and racial group categories in most vital statistics, census, economic, and other population and health related data greatly facilitates monitoring disparities by race instead of by social class.16 In fact, it has been well demonstrated in the United States that socioeconomic differences between races account for much of the racial differences in health, even though race per se—or rather, the results of societal discrimination based on race—may have an independent effect on health status and health care access/utilization.17–19
The emergence of health equity as a public health issue is also occurring in the developing world. Following the Alma-Ata Primary Health Care Summit in 1979, many national governments in Latin America, Asia, and Africa came together to formulate a strategy for achieving the goal of “Health for All.”
The Alma-Ata summit advocated the achievement of greater health equity and the reduction of health disparities as national goals. Prior to the emergence of the HIV/AIDS epidemic in the 1990s, many developing countries achieved noteworthy improvements in national average life expectancy and mortality rates, even though health disparities between socioeconomic and ethnic groups within countries actually increased in most cases. For example, in Latin America and the Caribbean, the region that experienced the highest rate of improvement in health indicators in that period, health disparities were also the greatest. The ratio between the highest and lowest national infant mortality rates in the region of the Americas was 7:1 in 1964 and had risen to 14:1 by 1994. Similarly, within Brazil, even though the national infant mortality rate fell by 40% between 1977 and 1995, the ratio between the rural northeast and the rest of the country actually increased from 1.7:1 to 2.0:1.20
In response to these disparities, from 1996 to 2002 the Pan American Health Organization undertook an ambitious effort to promote health equity in its technical cooperation programs in the Americas by promoting research, benchmarking, strengthening information dissemination, establishing databases, and improving health information analysis for monitoring and reducing health disparities within and between countries in the region.21,22 In fact, some Latin American countries—for example, Costa Rica, Chile, Peru, Bolivia, and Brazil—have incorporated equity goals into their national public health programs.
The international community also has a role in the global campaign to confront health inequalities. Some international organizations are already in the forefront of this campaign. For example, the Poverty and Health Network of the World Bank23,24 has developed a methodology for the analysis of socioeconomic differences in health, nutrition, and population in developing countries that is based on the World Bank’s demographic and health surveys. This methodology provides a much needed empirical approach for monitoring intracountry trends and intercountry comparisons of health disparities.25,26
In 1996, the Rockefeller Foundation and the Sweden International Development Cooperation Agency established a Global Health Equity Initiative, with a network of more than 100 researchers in more than 15 countries, for the purpose of raising global awareness and building capacity to address health inequities. The most visible product of this effort was the publication in 2001 of a groundbreaking report27 that established a solid conceptual and operational framework, based on a global perspective and country-specific analysis, of health equity in which global and national determinants are closely interrelated (via the economic and social consequences of economic and financial globalization, political stability and governance, poverty and development, ethnic conflicts, migration, etc.). The report emphasized the need to strengthen the capacity of the health sector in all countries and provide it with tools for tackling health disparities, in partnership with all potential partners in government and civil society.
Various current global initiatives have emerged from the Global Health Equity Initiative and other aforementioned efforts. One is the Global Equity Gauge Alliance, also supported by the Rockefeller Foundation and the Sweden International Development Cooperation Agency, which was created to participate in and support an active approach to monitoring health inequalities and promoting equity within and between societies. The Alliance currently includes 11 member-teams, called Equity Gauges, located in 10 countries in the Americas, Africa, and Asia.28 In sub-Saharan Africa, an initiative closely linked to the Global Equity Gauge Alliance is EQUINET, the Regional Network on Equity in Health in Southern Africa. EQUINET involves professionals, civil society members, policymakers, state officials, and academic, government, and civic institutions from Botswana, Malawi, Mozambique, South Africa, Tanzania, Zambia, Zimbabwe, and the South African Development Community who have come together as an equity catalyst to promote shared values of equity and social justice in health.29
The International Society for Health Equity, founded in 2000, has successfully held 3 international conferences with hundreds of participants from all continents; today it constitutes the most authoritative international professional association of health equity researchers, analysts, and advocates.30 The most recent conference, held in Durban, South Africa, in June 2004, dealt with a myriad of emerging issues for effectively reducing health disparities in the developing and developed world. Some of these issues included insurance and finance, resource allocation, access to care, special population groups, analytical methods for time trends and life-course determinants, community action, social empowerment, gender and health, law and human rights, local governance and planning, and the impact of HIV/AIDS.31
The United Nations organizations, such as the World Health Organization (WHO), also have a leadership role to play in the global effort to confront health inequalities. Such action is consistent with the 1998 World Health Assembly resolution, which confirmed that a reduction in socioeconomic inequalities in health was a priority for all countries.32 In 2000, a special issue of the Bulletin of the World Health Organization 33 was devoted to inequalities in health, and the WHO Global Health Survey, initiated in 2001, provides valuable health indicators that can be crossed with socioeconomic data to provide the basis for the monitoring of health disparities.34
Since 2003, under the leadership of Director General Lee Jong-Wook, the issue of health equity has acquired a new place in the priorities of WHO.35 An equity team has been established within the area of evidence and information for policy, with the objective of supporting innovation and strengthening knowledge sharing on a global level. An expressed goal is to develop new forms of collaboration between health experts and decisionmakers to translate current evidence on the social and environmental determinants of health disparities into effective public policy.36 In his speech to the 57th World Health Assembly in May of this year, the WHO director general announced his intention to set up and launch a new global commission formed by expert public health scientists and policymakers to gather evidence on the social and environmental causes of health inequities and ways to overcome them, with the purpose of providing guidance for all WHO programs.37
In summary, there is a global movement for health equity that began in the last decade of the 20th century and continues to grow. The role of information and knowledge sharing is key in linking this global effort to local actions and challenges; international and national health organizations in the developed and developing countries, be they in the public sector or in civil society, must join hands with local communities and governments if health inequities are to be effectively reduced.
The optimists among us believe that the road toward globalization can lead us to a future in which development becomes freedom38 and in which all human beings can enjoy complete citizenship, wherever they may be; exercise the right to gainful employment; and fully share in the benefits of knowledge and information.39 Such a world is one in which avoidable and unfair differences in the opportunity to lead a healthy life—differences between men and women; among Black, White, and brown; among inhabitants of the North and South, East and West—would cease to exist. The road to this world is a long one, one that will take us far beyond the horizon. Although it begins on our very doorstep, it has global dimensions.
