Equity In Health Care
| Autor | Virginia La Rosa-Salas; Sandra Tricas-Sauras |
| Cargo | Departamento de Enfermería Comunitaria y Materno Infantil. Escuela Universitaria de Enfermería, Universidad de Navarra, Pamplona. (España). vlarsal@alumni.unav.es |
| Páginas | 356-368 |
Page 356
It has long been known that a segment of the population enjoys distinctly better health status and a higher quality of health care than the others. These disparities have been documented and have persisted for many years, most notably among those with limited income or education1, the uninsured2, those with limited access to care3, those with language barriers4 and members of certain racial and ethnic groups5. Page 357
However, what is less clear, it is whether society at large appreciates the scope of the problem. For instance, in a 1999 survey of the public conducted by the Kaiser Family Foundation, 43% of respondents thought that the health care system rarely or never treats people unfairly based on race or ethnicity6. An even larger proportion of physicians, 69%, gave this answer in a 2001 survey, suggesting that the medical community is even less attuned to the problem7. Whereas 47% of the public believed that the health care system at least «somewhat often» treats people unfairly, based on race or ethnicity, only 29% of physicians thought so.
In order to improve the situation, many options are being considered to make the health care system better, but the need to choose among them is unavoidable. Not every problem is correctable at once, and resources for improvement-time, human energy, and money-are limited8. Prioritization is thus inescapable, and the larger question is how priorities are set. This raises policy questions about what makes some people more deserving of health care than others.
Rational priority setting would seek the ideal balance between what the World Health Organisation terms the 'goodness' and 'fairness' of health systems9. The first is the extent to which a system improves health, on average, for the population. The second addresses equity, the extent to which people receive equal care for equal need.
It is the aim of this paper to address together both human dignity and efficiency through the context of equity to reconciliate them in a middle ground.
This paper is arranged as follows. In section 1, this document will focus on defining equity and illustrating key concepts of equity in health. This section is of particular relevance, given the growing interest in equity among national and international health organizations10, 11, 12, 13. In section 2, it will explain why there should be a concern Page 358 about equity in health care. Section 3 will describe some of the assumptions and implications that are embedded in equity-efficiency trade-off. It will be particularly interesting to identify some circumstances under which equity and efficiency may not trade-off against each other. Finally, it is worth pointing out some ideas about the relationship between equity and human dignity. This section will also address the concern to inequalities between age groups. A brief discussion and thoughts arising from this essay will be carried out at the end.
Equity in health has been conceptualized and defined in several ways, as its principles derive from the fields of philosophy, ethics, economics, medicine, public health, and others. Common to most definitions of health equity is the idea that certain health differences (most often called inequalities in health) are unfair and unjust. Equity in health means equal opportunities to be healthy, for all populations groups14,15. Equity in health thus implies that resources are distributed and processes are designed in ways most likely to move towards equalising the health outcomes of disadvantaged social groups with the outcomes of their more advantaged counterparts.
Moreover, it is important to distinguish between equity and equality. The concept of equity is inherently normative-that is, value based16,17 while equality is not necessarily so18, 19, 20, 21. Often, the term health inequalities is used as a synonym for health inequities, perhaps because inequity can also have an accusatory, judgemental, or morally charged tone22. However, it is important to recognise that, strictly speaking, these terms are not synonymous. Equity means justice, giving everyone what belongs to them, and recognizing the specific conditions or characteristics of each person or human group/sex, gender, class, religion or age. It is recognition of diversity, without this providing a reason for discrimination. Page 359 On the other hand, equality refers to the similarity of one thing to another in terms of quality and quantity. The achievement of the object of equality is more than the absolute prohibition or elimination of discrimination. To provide equality it is necessary to make a constant and dynamic effort.
In addition, the WHO23 defined inequity as differences (in health status), which are unnecessary and avoidable, but in addition are considered unfair and unjust. Some disparities result from genetic variation and other nonmodifiable factors24. In others words, of the determinants of health differentials between populations groups or individuals, those related to biological variation and freely chosen health- damaging behaviour are not likely to be considered inequitable because they are either unavoidable or «fair». However, differentials due to health damaging behaviours not based on informed choices, exposure to unhealthy living and working conditions, or inadequate access to health and social services are more likely to be judged avoidable and unfair and thus constitute health inequality25.
But at the same time, inequality with respect to something else might be a prerequisite of equity. Moreover, the achievement of equity through equality of something among individuals or groups might require inequality in something else among the same individuals or group individuals or group26. For example, one equity principle in a system of taxation might be to impose equal rates of taxation of all individuals. But where income differs among individuals this equity principle would imply unequal burdens of taxation among individuals.
Considerations such as these have lead to the separate but related concepts in the research literature of 'horizontal' and 'vertical equity'. Horizontal equity requires the like treatment of like individuals and vertical equity requires the unlike treatment of unlike individuals, in proportion to the differences between them27. The former of these is concerned with ensuring that two individuals, who are alike in all respects, including their health status, are treated equally. The latter is concerned with the extent to which individuals who are unequal should be treated differently. In health care it can be reflected by the aim of unequal treatment for unequal need28, i.e. more treatment for those with serious conditions than for those with trivial complaints. Page 360
In order to explain the global preponderance of health inequities, many authors have attempted to elucidate the pathways by which inequities in health come to be and are perpetuated. One of the most prevalent theories concerns the role of socio-economic status, measured by education29, occupation30, and/or income31. Other explanations involve social discrimination based on gender32, 33, 34 or race/ethnicity35,36. Proposed pathways include the environment in which people live, such are their living conditions and the distribution of income in their country or state37, 38, 39. Still other hypothesized pathways involve the political and policy context, including the extent of primary care40, the geographic distribution and mix of health services41, 42, 43, 44, the fairness Page 361 of health finance45 and political, social and economics relationship46, 47.
As a consequence, it is not appropriate to determine for instance, access to care by willingness and ability to pay nor merits of individuals based on judgements about their contribution to society. However this can be replaced by a rationing mechanism based on 'need'48, 49, 50. Unfortunately, as numerous authors have noted, the concept of 'need for health care' is far from unambiguous51. However, it can be concluded that need refers to some circumstances requiring some course of action, particularly in health, some care or treatment52, 53.
A more final distinction has to be made among 'need' for medical care, 'demand' for care and form of use of services or 'utilisation'. Maynard54 stated that a need for medical care exists when there is an effective and acceptable treatment or cure. However, a demand for care exists when an individual considers he has the need and wishes to receive care. Utilisation is understood when an individual receives the care needed. Need is not necessarily expressed as a demand, and demand is not necessarily followed by utilisation, while, on the other hand there can be a demand and utilisation without a real underlying need for the particular services used. In Spain, for example, the utilisation of health system without a real necessity can often be seen in the case of older people when visiting GPs, where the 'need' could be many times questionable55.
Given the above distinctions, it is time to reflect on some foundational questions. Why be concerned with equity in health care? Should we be more concerned about inequalities in health care than about inequalities in other dimensions such as income?
Part of the first answer is that health care serves a significant mean to recover or maintain individuals' health56. In Page 362 general, through the ages, health has been considered a precondition for happiness. Descartes57 asserted that health is the highest good. In «Discours de la Méthode» Descartes writes: «...the preservation of health is ...without doubt the first good and the foundation of all the...
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