Ethics of health equity
R. RAMACHANDRAN
|
Collection of essays examining health equity from different perspectives by experts
|
PUBLIC HEALTH, ETHICS AND EQUITY: Sudhir Anand, Fabienne Peter, Amartya Sen — Editors; Oxford University Press, YMCA Library Building, Jai Singh Road, New Delhi-110001. Rs. 595.
What is health? The word is derived from the old English word `h<109,90>àe<109,100>lth', which, according to the Chambers 20th Century Dictionary, means, "sound bodily condition; soundness; condition of wholesomeness; well being; a state with respect to soundness." The World Health Organisation (WHO) defines "health", as formalised in its constitution nearly 60 years ago, "a complete state of physical, mental and social well-being, and not merely the absence of disease or infirmity" (emphasis added). In more recent years, in the 1978 Health for All declaration at Alma Ata, this definition has been qualified to mean the ability to lead a "socially and economically productive life."
Today the world is still far from being anywhere near achieving that goal. Inequalities in health in large parts of the world stare us in the face. While life expectancy in the developed world is around 80 years, in many parts of Africa it is less than 40 years. If the under-five mortality rate in the West is a single digit per thousand, in some of the least developed countries it is in three digits. The maternal mortality rate in many European states is less than 10 per 100,000. In Afghanistan or parts of Africa it is over 1000. Indeed, India is closer to the worst off regions, than otherwise, with 81 and 540 for the last two indicators respectively.
Disparities
But, more significantly, there are large disparities within a country, which national averages do not reveal. Systematic health inequalities exist across different social groups, socio-economic classes, ethnic groups, race and gender.
The social gradient in most countries is similar: that is, economically well off groups enjoy better health because they have access to better health care. While public health care systems do result in the improvement of a nation's average health, quite often the policies and measures benefit the rich more than the poor. This is clearly morally unjust, iniquitous and unethical. How does one address these persistent health inequalities of the world in an equitable, just and ethical way?
Notwithstanding its all-encompassing definition of health, WHO's prescriptions for national health policies have tended to focus on national health care systems to improve national health indicators on the average implying indirectly that a right to health meant only a right to health care. The indices and measures for the health of nations or communities that it has evolved too have been arrived at in this one-dimensional fashion, focussing on the health of the aggregate population and ignoring aspects of distribution from the perspectives of equity and justice.
Health inequalities
The collection of essays in the volume under review is an attempt to bring out in the language of welfare economics — health economics to be more accurate — the fact that the health inequalities arise from several factors that go beyond distributive aspects of health care and prescriptive health care policies a la WHO and depend on, as Amartya Sen in his essay "Why Health Equity?" puts it, "The larger issue of fairness in social arrangements, including economic allocations, paying appropriate attention to the role of health in human life and freedom... The extent of inequality in health cannot give us adequate information to assess health equity."
Only recently, in March 2005, the WHO constituted the Commission on Social Determinants of Health (CSDH) to address social factors that lead to ill health and health inequities. The commissioners include Kiyoshi Kurokawa, Amartya Sen and Michel Marmot. The volume includes the contributions of the last two.
The essays authored by distinguished scholars, formed part of a seminar series at Harvard University in 1998 and 1999 to address issues concerning health equity that has been generally lacking in academic discourses on health inequalities.
The book examines health equity from the different perspectives of economists, sociologists, philosophers, anthropologists and public health specialists which have been broadly classified into five themes: what is health equity?; health equity and its relation to social justice; health inequalities and responsibilities for health; ethical issues in health evaluation and prioritisation; and, anthropological perspectives on health equity. While the contributions are accessible to a multidisciplinary and policy-oriented scholarly audience, not all of them are easy reading. Some of them may, in fact, seem tedious to a general reader.
"What is particularly serious as an injustice," writes Sen, "is the lack of opportunity that some have to achieve good health because of inadequate social arrangements, as opposed to, say, a personal decision not to worry about health in particular... This calls for the further distinction between health achievement and the capability to achieve good health... It is important to distinguish between the achievement and capability, on the one side, and the facilities socially offered for that achievement (such as health care), on the other."
Social gradients
Drawing upon the famous Whitehall studies of British civil servants in the U.K., which showed that health is influenced by socio-economic status, Michel Marmot discusses how social inequalities impinge on health and stresses the importance of social gradients in evolving health policies. While conceding that individual responsibility matters, Daniel Wikler emphasises that health gradients exist independent of behavioural patterns and argues that the society cannot, therefore, absolve itself from an obligation to correct social inequalities in health.
Though many of the papers have been published elsewhere earlier, and in that sense there may not be anything new for those engaged in the field, it is useful to have them together in one volume from the perspective of evolving national policies and interventions to achieve equity in health. But translating the theoretical ideas presented here into policy instruments and practical measures will certainly not be an easy task.
Printer friendly
page
Send this article to Friends by
E-Mail
Book Review
