13 How Do We Address Health Equity in a Globalising World Flashcards

Question

1.3 Social determinants of health

Answer 1

By rejecting endogenous causes as sole causes for poor health, Marmot paved the way for broader policy action addressing more factors than just health per se, namely what he describes as the causes of the causes. Put differently, what his work showed was that to understand why there may be a high incidence of cancer, or a particular type of infectious disease or mental ill health amongst a population group or in a particular region, we need to understand and most importantly address the wider causes in society, the environment and economy, the political system and so on. Important here is that this broke with the orthodoxy that to improve health you need concentrate solely on medicines and health facilities, rather work on the social determinants shows that addressing power imbalances or discrimination is just as important for health as a new hospital ward, for example.

Answer 2

Now that we have an overview of the terms necessary to understand health equity, we need to concentrate on how to actually measure good or poor health equity. As we noted previously, better health outcomes are helpful and always good news but not necessarily a good way of measuring progress towards health equity. Addressing health inequities requires an understanding of both a) differences in health between different sections of the population e.g. based on ethnicity, gender and other identity or legal status, and b) of their possible causes such as income, education, housing and employment and so forth. Only measurement of health status (mortality and morbidity) disaggregated by different determinants and social identifiers allows understanding on whether health inequities are growing or diminishing.

Answer 3

To understand health difference, process indicators are also important. The difference between outcome-related evaluation and process-related evaluation has been underlined by scholars such as Amartya Sen. Sen stresses the importance of procedural considerations when looking at health equity. By that he means, for instance, non-discriminatory measures such as health centres adapted to welcome people with physical disabilities.

Answer 4

What may seem obvious is not a given: if health facilities are not equipped for providing health care to patients with reduced mobility for example, they will not be in a position to access health services and health inequity will worsen. In brief, the ‘how to’ measure health equity is intrinsically linked to the definitions seen above and is a major contributor to research on health inequalities and health equity, as Margaret Whitehead points out. She stated that “the measurement of health disparities without respect to how the disparities are distributed socially is not a measure of equity and does not reflect fairness or justice with respect to health”.

Answer 5

Globally, evidence can be difficult to collect and compare due to substandard health information systems and a lack of available and quality data. Health indicators such as the infant mortality rate (IMR) or and the maternal mortality ratio serve as a gauge for population health and are collected by the UN system, many through the WHO.

Answer 6

Another type of measure, the disability-adjusted life year (DALY) are increasingly used to understand difference in health status. The burden of disease globally is calculated through the Institute of Health Metrics and published through its Global Burden of Disease report and website. DALYs for a disease or health condition are calculated as the sum of the Years of Life Lost (YLL) due to premature mortality in the population and the Years Lost due to Disability (YLD) for incident cases of the health condition: the higher the DALY, the poorer the health outcomes. Another metric used for assessing the cost-effectiveness of policies is the quality-adjusted life year (QALY) that takes into account the quality of the years lived. The idea of the QALY was to measure cost-effectiveness of interventions by comparing countries’ outcomes.

Answer 7

Figure 1 represents a map of the world, showing each country by DALYS. On the map, you can see countries with a higher DALY marked from dark blue (the lowest DALYS to RED the highest rate). Rates are of the age-standardised disability-adjusted life years (DALY) per 100,000 inhabitants. Countries in sub-Saharan Africa rate highest according to the 2017 data. However, these indicators have also in turn been criticised from an equity perspective as they hide much stratification or difference for example by socio-economic status that may occur in one geographic region.

Answer 8

Unfair differences: 1. Women are denied access to health services because they‘re not accompanied 2. Children from a certain ethnic group are denied immunization 3. Indigenous people are not treated for a disease that may be specific to their region. Not unfair differences per se: 1. Men have prostate problems, women don’t 2. Young adults are healthier than elder adults 3. Female newborns are lighter at birth than boys

Answer 9

Equity has received greater attention in debates on global health over the past decade. This has been largely driven by the growing inequalities in the current era of globalisation, not only in health but also in the distribution of income and other determinants. As we have already seen inequities in health are a direct result of wider social and economic factors and processes governing these. Processes of globalisation and the greater integration of the world economy with concomitant changes in our cultures, ways of life and levels of consumption have had far reaching consequences for health, and for the determinants of health. We have gained greater understanding of these consequences and thus on the relationship between globalisation and inequalities in health.

Answer 10

A key criticism of the Millennium Development Goals, which guided actions by the international community between 2000-2015 was that these failed to take equity or rather the distribution of health into account. While the MDGs had a strong focus on health, including amongst other things HIV, TB and maternal and child health, it focused on achieving specific targets overall rather than looking at where progress was made. While overall much was achieved the progress on the different health goals was uneven. This lead early on to discussions that whatever would replace or follow the MDGs needed to have an explicit focus on equity. This signals the realisation that equity including health equity has become one of the key challenges for people and planet.

Answer 11

As a result of these developments, the SDGs agreed by the UN General Assembly in September 2015 recognise not only health and wellbeing for all, and the specific target of Universal Health Coverage (see also below), they also include a specific goal (Goal 10) on addressing inequality within and between countries.

Answer 12

Since the 1990s there has been a scientific consensus that we live in the era of globalisation, which is driven by the increase in trade and the greater integration of the global economy. However, globalisation has affected all spheres of life and to some extent has led to greater homogeneity in global culture, especially in terms of patterns of consumption. As already described, a key feature of globalisation has not just been economic growth but the growth in inequalities. In 2019, a British NGO – Oxfam – estimated that the richest 26 people owned the same amount as the poorest 3.8 billion people who make up the poorest half of humanity (Oxfam, 2019).

Answer 13

Globalisation is of course directly associated with: The global economy, trade and markets: multinational companies becoming more powerful actors and the high circulation of goods and money. The ever faster advance of new technologies and internet communication in particular created new, instant flows of information and knowledge sharing, creating new virtual communities of interest and social identities. Travel also experienced a shift with cheaper prices and an increase in the number of flights allowing the de facto shrinking of geographical distance. Finally, globalisation also has meant far-reaching changes in the governance between states and non-state actors (Hanefeld, 2014).

Answer 14

In addition, globalisation had a rather negative impact on the environment, arguably climate change has been exacerbated by the same economic processes that have driven globalisation. However, it has also allowed accelerated pace for example of scientific discovery and the exchange of ideas. What about health equity?

Answer 15

Does globalisation have a positive or negative impact on health? Research has dedicated a lot of attention to the links between globalisation and human health and health equity in a globalising world. Some scholars (for example, Chen and Berlinguer, 2009), argue that globalisation is generating epidemiological diversity and complexity in terms of emerging infections, environmental threats, and socio-behavioural pathologies. Firstly, emerging infections have changed, including their potential to cross borders more rapidly through intensified trade and travel but also urbanisation and its accompanying phenomena such as extreme poverty. There have also been changes in vectors through environmental processes such as deforestation. Secondly, environmental threats including challenges such as sanitation or water provision on the one hand, on the other, globalisation also means new forms of environmental hazards through pollution and contamination. Global warming also has an impact on the spread of diseases itself. Thirdly, socio-behavioural pathologies reach from substance abuse to non-communicable diseases like diabetes due to changes in diets.

Answer 16

A key feature of the current era of globalisation has been the rise of global corporations which operate across a series of states and which have in many instances been successful in avoiding strict regulation of their activities in relation to health. Their activities and the extent to which these have shaped for example the pattern of consumption of unhealthy commodities have led to the rise of the term commercial determinants of health. These have been defined by Kickbusch et al (2016) as “strategies and approaches used by the private sector to promote products and choices that are detrimental to health”. The current rise of the epidemic of non-communicable diseases, including in low- and middle- income countries, is largely seen as a manifestation of the impact of the commercial determinants on health, which exacerbate health inequities.

Answer 17

Globalisation including of trade has undoubtedly acted as a pathway that has enabled the commercial determinants of health, changes in diet, tobacco and alcohol consumption for example are linked to patterns of trade liberalisation and concomitant lower price and greater availability of processed goods, making this in many instances more affordable than say fresh produce, which in turn means that it becomes harder for poorer people to afford a healthy diet. However, these processes have not been unidirectional, the same processes also have led to greater availability of fresh produce for example all year round including at lower prices

Answer 18

Thinking about planetary health also helps highlight inequities in the health effects of globalisation. For example, in many instances it is low-income countries in the Global South, who have historically contributed least to C02 emissions, which suffer from drought and the destruction of livelihoods with concomitant health effects as a result of global warming.

Answer 19

Other consequences of globalisation include trade in counterfeit drugs; a global intellectual property system that many would argue reinforces existing inequalities; the migration of people displaced through conflict or for economic reasons; the brain drain of health workers towards richer regions; as well as in some countries the segmentation of health systems and diminished access in poorer communities due to increasing privatisations. Health inequity is deeply rooted within the unequal distribution of science and technology in that the development of pharmaceutical capabilities tends to concentrate on commercially profitable products rather than on products focused on the burden of disease.

Answer 20

However, globalisation has also intensified the diffusion of knowledge and information. For example, more and more e-health initiatives are being carried out via internet-based technology such as Skype or Zoom, and there is some potential for telemedicine for example to redress the shortages of skills in countries with small populations. The more rapid spread of disease is arguably also balanced by the opportunities offered by new technologies. For example, zoonoses are being monitored more effectively thanks to text message technology, allowing instant reporting from the most remote places. At the same time the outbreak of Ebola Virus Disease in West Africa 2014-2016 highlighted, however, that despite new technology the world is sometimes slow to act. In affected countries in West Africa at the time there was definitely the sense that the pandemic was taken more seriously once citizens from high income countries were affected.

Answer 21

To summarise, positive impacts of globalisation on health equity are: the increasingly rapid diffusion of knowledge and technologies due to the information revolution; some overall improvements due to economic development, although it has proven insufficient to flatten health inequalities so far; global governance efforts have been strengthened with greater awareness of our shared humanity; global trade offering some improvement in the access to health goods and healthy goods.

Answer 22

Overall, the progress of humanity has not been shared equally and inequities have grown, and there have been negative impacts for health of people and planet. Economic growth has led to serious consequences for our climate, the impact of which is again inequitable, including for health e.g. the impact of drought and on livelihoods. Some examples of this include: asymmetries in the global market along with intellectual property laws which place the majority of the world at a disadvantage in accessing health products and services; the migration of health workers from low- to middle- and high- income countries has, in many instances, further weakened health systems; globalisation has also intensified the spread of the commercial determinants of health and as a result the epidemics of non-communicable diseases; global environmental change is responsible for the re-emergence of certain vector-borne diseases and changing environmental health impacts often affecting the poor.

Answer 23

It is clear that the challenges of inequity lie within and between countries are too complex and intertwined for countries to address on their own. Therefore, global initiatives such as the SDGs are important in bringing humanity together.

Answer 24

a) No correct answer b) Maps such as these can mask other inequities that may not be due to a persons’ location. For example, the map on HIV prevalence, shows clearly the differences in HIV prevalence. However, it does not tell you where HIV prevalence may be extremely high in a small sub-set of the population such as people who use drugs, young women and girls or men who have sex with men and where these may represent great inequities. In other words, even if HIV prevalence may be low in a specific country such as Russia when compared with countries in Southern Africa, it may be very high in a specific sub-group of the population – in this instance people who use drugs. This in turn is indicative of the lack of services and a social injustice. What this specific example shows is i) the complexity of equity, and correspondent the need of policy to be sensitive to these, ii) as the need for data and analysis. It also demonstrates the trade-offs you have to think about when wanting to address inequities, do you want to benefit the most or do you want to benefit the most marginalised? Do you have enough budget to do both at the same time, or is there a temporal dimension? The important thing to stress here is that often this does not mean there is ‘one’ right answer or policy, but it is important to have data and analysis that makes the trade-offs clear and allows informed decision-making.

Answer 25

Health equity is, as we have seen, an ideal linked to social justice. It is as such linked to the broader political economy and isolated measures or interventions targeted at a specific disease alone, for example, are not enough to reach a better distribution of health and of the capabilities to be healthy. This makes addressing health inequities so complex and in many cases challenging, as it requires action across all sectors not only health, and changing policies in areas such as trade and the economy where there are powerful vested interests at play. Specific challenges are discussed below.

Answer 26

One area which is important to address to addressing health inequities is the health system. Unequal access to quality, appropriate and acceptable health care remains a key challenge to health equity and this is why health systems and access to health services are so fundamental to addressing inequities in health. Health systems are understood are intended to provide the services necessary to “promote, restore or maintain health” as well as to convey societal norms and values- but they have often failed to ensure health equity. Indeed, health systems can only exist within social contexts, which exert a powerful influence on the individual’s health status and can prevent those in need from fully using them to their benefit. Often discrimination in one form or another may affect people’s access to health systems and medical treatment.

Answer 27

Not all people have equal access to treatment. This is an obvious challenge for achieving health equity: without access to health care and products, health equity cannot be reached. Access issues are linked to many determinants, amongst these are direct and indirect discrimination in providing treatment; remoteness; price inequities and price discrimination; and education.

Answer 28

However, it is important to point out that access alone does not ensure better health outcomes, let alone fewer health inequities. We have already learnt about the social determinants of health and that in places where people do not have access to clean water and sanitation, safe housing or secure employment, even the best health services and medicines will not prevent many of the causes of their ill health.

Answer 29

Health has always been embedded in, and protected by, rituals, sometimes religious, sometimes more broadly cultural. It seems evident that different cultures provide different types of health services; this can lead to clashes between advice given by traditional medicine and that advocated by biomedicine.

Answer 30

Beyond this, political constraints can endanger health equity further if they prevent some groups from accessing their traditional practitioners without assuring the use of regular medical services. This might act in a discriminatory fashion towards some groups. Culturally appropriate programmes are essential for reducing health inequities. For example, the treatment of women especially of indigenous women is often a concern. In Ecuador for example maternal mortality overall has been decreasing, but detailed research revealed that rates of maternal mortality are still very high amongst indigenous women who may not feel comfortable for cultural reasons to give birth in a formal health care setting. (Backman et al., 2008; Sanhueza et al., 2017).

Answer 31

Health workers are key to delivering health services. How can they also be part of the challenge to achieving health equity? One of the greater concerns for global health is the migration of health workers from low- and middle- income countries, where shortages of skilled staff exist, to middle- and high- income countries that have a greater number of skilled personnel. The availability and quality of care are a great concern for entire regions and communities. This asymmetry of health workers is a great challenge for already stretched health systems, especially in sub-Saharan Africa.

Answer 32

Health systems are in the short term a good entry point for equity-oriented policies and interventions, especially through targeted services at unserved communities. However, it is important to understand that health expenditure has in many instances increased inequities further. Reforms affecting health systems are often market based and result in public expenditure cuts as well as increasingly segmented financing. User fees have also been increasingly part of successive privatisation moves in many countries with the belief that they will stop the abuse of public health services by giving them a monetary value. These fees were initially justified by policy makers who promised they would flow into health systems and ensure quality services, which we now know in many instances did not happen.

Answer 33

Second, private medical practises and private pharmacies have been booming, leading to exponential out-of-pocket expenditures. This can be particularly the case in low- and middle-income countries where public health systems may be weak or not available in many areas. Where barriers to accessing essential medicines and care exist, it is the poorest - and poor women in particular - who are often most negatively affected. Families facing increasing out-of-pocket expenditure for health care or catastrophic health expenditures have fallen into what has been labelled the ‘medical poverty trap’.

Answer 34

To redress the impoverishing effects of health expenditure the concept of Universal Health Coverage, which is now followed by the international community and enshrined in the SDGs, acknowledges health equity and the health systems effects on equity as one its three core objectives. In fact, the definition by the WHO explicitly states:

Answer 35

‘People should be protected against financial-risk, ensuring that the cost of using services does not put people at risk of financial harm (WHO, 2010)’. This statement explicitly recognises the role of health expenditure in poverty and the need to redress this. There are many health financing initiatives underway that seek to redress inequities through pooling of resources, and in some cases specifically addressing health gaps i.e. seeking to improve the health of those facing the greatest vulnerability. Key is that the availability and accessibility of some form of safe i.e. quality health care is essential to achieving health equity and the SDG 3 health for all.

Answer 36

It is important to note that to work towards achieving health equity, we need universal policies and we need those that target the gap between groups, such as health gaps between rich and poor or urban and rural areas. Only through universal policies together with targeted policies can the gap be closed. This is a concept often termed “progressive universalism” in the policy language on health equity. We have also already seen from these examples and the preceding chapters that you need action in the health system and on the determinants of health to achieve health equity.

Answer 37

In a paper published by Whitehead in 2007 (see in recommended readings), the author lists four categories of policy actions to reduce health inequities based on the theory of interventions we’ve just discussed. 1. The first category focuses on individuals and addresses personal characteristics (such as an individual’s education, culture or skills in general) and discusses measures to tackle the feeling of powerlessness of the worst-off. Here, anti-smoking campaigns are typical examples, such as ads encouraging the individual to quit smoking, by use of shocking pictures or health advice. 2. The second category encompasses measures meant to strengthen communities such as enhancing mutual support. Interventions in this category can be both vertical and horizontal, meaning they can both work within a group or in between groups.

Answer 38

Measures belonging to the second category address the community rather than the individual by encouraging mutual support. This type of intervention is less common but can be used when addressing health burdens shared by many individuals of one group generally isolated from the rest of society, such as in the case of immunization campaigns that may be rejected by some faith-based communities. 1. The third category targets living and working conditions and therefore addresses the main cause of health inequities, namely exposure to hazardous environments, either at work or at home. The measures in category three are the more classical public health interventions with their impact on access to health and social care. Examples here are regulation of working hours and/or the working environment, such as health and safety measures. 2. Finally, the fourth category groups actions based on the belief that the causes of health inequities are global economic, cultural and environmental conditions and the overall standard of living of individuals. Targets set under this category therefore aim to reduce global poverty and wider causes of inequalities.

Answer 39

In doing so, these interventions will address human rights and labour market policies. The interventions have manifold targets, of which health inequalities are only one facet. One example is the WHO Framework Convention on Tobacco Control that can be said to be a macroeconomic policy, regulating supply and demand by legal and/or fiscal measures. It is interesting to note that interventions that Whitehead would classify as typically addressing working and living conditions or macro-level policies have inherently differential impacts. Since their goal is to remove barriers to access to health care services or welfare provision in general, they are bound, if the measures are successful, to make a bigger difference to some groups than to others, namely to those subject to the worst conditions to start with. In this, they are inherently working on reducing health inequities and seek to address issues proportionate to need.

Answer 40

Upstream preventive programmes address the causes of the causes before they have a full impact on health. For example, improving education of women and girls is equally going to have a beneficial effect on their health. Conversely, a curative measure treats a problem likely already after a differential impact on health has occurred. For example, where a community sees a high incidence of cancer in men over fifty due to diet, limited exercise, high tobacco and alcohol consumption, which in turn may be a result of an interplay of factors such as limited or insecure employment, no investment, advertising by the private sector and so forth, providing equitable access to cancer services is important but it addresses the symptom of an underlying inequity within a society rather than its cause. A more sustainable approach here may be to work with the community to understand the causes for high rates of risk factors (such as for example tobacco consumption and diet) and empower members of the community to address these together with macro-level policies that enable them to make positive choices. For example, regulation of private provider advertising etc. This is the type of integration of different dimensions of health that is required to address inequities that Whitehead recommends.

Answer 41

No matter where you are from looking at the different environments within and between countries that people live in you can see straight away that these factors are going to affect their health. Interestingly not all of these mean more income equals better health.

Answer 42

Why has globalisation had negative effects on health equity, think about factors that influence health status and in terms of access to health services? In your answer think about how these factors have negatively contributed to health equity and explain your answer further. Post your answer on the discussion forum and take a look at the answers posted by your colleagues.

Answer 43

This session has covered several topics related to the issue of health equity, including its theoretical origins and practical applications. This has included: The different understandings of the definition and measurements of health equity, its distinction from health inequality, and the concepts of justice inherent in each definition; The causes of health inequalities (the socioeconomic determinants of health), particularly within the context of globalisation, looking at how the processes of globalisation may impact health equity in both positive and negative ways; A range of different policy approaches to improving health equity in a global context; and The broader prospects for improving health equity within the global health policy landscape.

Answer 44

Over the past ten years, research has shown that inequities and in particular health inequities are a burden to societies as a whole, not only to societies’ poorest. Social justice aside, where inequities are great, even the health of those at the top of the pyramid is affected. Moreover, the SDGs with their ethos of leaving no one behind have put equity at the very centre of humanities’ endeavours over the coming decades. We have seen that the notion of health equity rests upon the understanding of social justice and fairness. It encompasses the ideal of achieving good health but essentially focuses on the capacities to do so, therefore health equity is central to achieving all SDGs.

Answer 45

In order to achieve a better distribution of health outcomes, globalisation is an important factor to take into account. At the same time, the causes of the causes, that is, the social, political and commercial determinants responsible for much health inequities ill health in the first place, need to be addressed in holistic approaches at the global level, the SDGs provide a mandate for this agenda for action. Health equity is not only relevant for health issues but is also linked to social determinants and the broader political economy. If global policy makers such as the Group of 7, or even the G20 were to prioritise global health equity, the results could be impressive. At the same time, the research community still needs to provide evidence to back up policy with irrefutable facts. Therefore, the priorities for both the scientific and the policy community ought to be to concentrate on non-biased, empirical and evidence-based research.