Introduction
This article suggests that health economists need to rethink their position on equity and access. Currently we struggle to define these adequately and restrict most of our efforts to equity in health care. Health equity is given less attention than it merits. The paper also suggests a better road for health economists (and perhaps public health professionals more generally) to follow.
Equity is most commonly defined in terms of access, as in for example equal access for equal need. Given, however, the obsession with quantification in economics, in practice in analyses of equity, ‘use’ has frequently been substituted for ‘access’ and the problem of defining ‘access’ has thereby been by-passed, even if not overcome. In turn, this has taken the pressure off researching into access per se. Further what are meant by both equity and access are in part culturally determined. The continued efforts of health economists to treat equity as some universal construct are misplaced.
There is a lack of interest on the part of health economists to look at equity more broadly than simply health care equity. Quite why this is the case is unclear. Certainly, for equity in both health and health care to be pursued in practice, there needs to be a shift in resources towards the poor, disadvantaged, and powerless. This will be opposed by those who hold more power in health care and society more generally. Currently health economists’ analyses say all too little about issues of power and property rights in health care and in society.
Social justice
Most societies and cultures have some concerns for social justice, although the extent of this varies from one society to another and one culture to another. While social justice is a concept that is difficult to pin down with any precision, it involves concerns for the lot of the less well off in society. More specifically Swartz (2004) suggests that ‘social justice ... embraces an equitable distribution of social resources, including nutrition, shelter, health care, and education’. He goes on to propose that it ‘means a political and structural commitment by society to direct the resources of modern civilization to benefit all people’, particularly those ‘who are economically, socially, politically, and/or culturally underresourced’. He argues that ‘an implicit assumption of a social justice perspective is that the integrity of any community suffers when some of its members are systematically deprived of their dignity or equality’. He adds that ‘structural poverty is a major contributor to this condition’ where such poverty is defined as ‘the institutionalized condition in which the social and economic marginalization of hundreds of millions of people throughout the world is the logical and anticipated end of government and intergovernmental policies that maximize tremendous wealth for a privileged few’. Swartz thus emphasizes the need for a shift in political and structural power relations.
In similar vein, Bell (1997) suggests that the goal of social justice is ‘full and equal participation of all groups in a society that is mutually shaped to meet their needs. Social justice includes a vision of society in which the distribution of resources is equitable and all members are physically safe and secure.’ Again Chizhik and Chizhik (2002) (quoted in Russell-Mayhew, Reference Navarro and Navarro2007: 4) propose that at ‘the heart of social justice is an examination of social structure inequality and practices that involve unequal power distributions, determining those with power … and those without power’. Moving closer to considerations of social justice and health, in the specific context of eating disorders, Russell-Mayhew (2007: 9) argues the case for ‘the social, political, cultural and economic aspects … to be pushed to the forefront’ and that ‘research needs to target systemic change to address the inequities as a matter of policy and practice’. She continues (p. 9): ‘A social justice approach pushes the boundaries of problem definition beyond the individual to consider larger systemic influences.’
At present in health care economics these concerns for social justice (and in this article I equate social justice and equity) are handled in a rather narrow way. Neither of the paradigms underlying current health economics, welfarism, and extra welfarism ‘pushes the boundaries of problem definition beyond the individual’. Further, they seldom get beyond the descriptive to analyse why there are inequities in health care and even more importantly what might be done to reduce these. They are also limited in being consequentialist, which is clearly problematical when equity is most often defined in health care policy in terms of access, a form of procedural fairness.
Health economics of equity in health and in health care
This article seeks to set the analysis of equity in health and health care in the wider context of social justice in society as a whole. This is especially important because most of the analyses of equity which have been conducted by health economists have been in health care rather than health more generally. Few have been around the relationships between income inequality and health (but see Gravelle, Reference Gravelle1998); even fewer have dealt with power inequalities. For example, neither of the two major reviews of the literature on income inequalities and health – the one by epidemiologists (Wilkinson and Pickett, 2006) with over 170 references and the other by a mainstream economist (Deaton, Reference Deaton2003) with nearly 200 references cites an article in either of the two leading pure health economics journals, Health Economics and The Journal of Health Economics.
Again coverage of topics covered by the papers presented at the most recent International Health Economics Association (iHEA) Congress in Copenhagen in 2007 is revealing in this context. This congress is the ‘world meeting’ of health economists. Out of 840 papers presented, there were at most 12 for which the title could be interpreted as possibly dealing with income inequality and health. The word poverty appears in the title of only three papers.
In making these criticisms of the seeming failure of health economists to grapple with the impact of inequalities in income and in power on health, a defence might be that there is not universal agreement from existing research that such inequalities are bad for health. However, two issues here are important and are often understated or simply not acknowledged in the relevant broader literature. The first is with respect to the level of aggregation at which inequalities are observed; and the second is regarding the explanation for the source of the inequalities.
In an important article on health and inequalities, Wilkinson and Pickett (2006) show that, for the studies conducted on this issue, when these are disaggregated according to levels of geographical area, those at a national level are heavily supportive of the hypothesis that inequalities and health are related. The authors suggest that this is because the links between health and inequalities are driven by class or social stratification and it is at the more aggregated, societal level that these features show up. Their review also suggests that there may or may not be relations between such inequalities at more micro levels. On social stratification or class Wilkinson and Pickett (2006) conclude:
Our interpretation of 168 analyses of the relationship between inequality and health is that income distribution is related to health where it serves as a measure of the scale of social class differences in a society … In small areas, where income inequality is unlikely to reflect the degree of social stratification in the wider society, it is [as the authors show] less likely to be related to health. The overwhelmingly positive evidence for studies of larger areas suggests that this interpretation is correct. The fact that social stratification is such a fundamental feature of social organization explains why there are so many socioeconomic factors correlated with inequality. (p. 1778; emphasis added)
Thus, this important evidence suggests that class is the true explanatory variable rather than inequalities in income.
The review by Wilkinson and Pickett (2006) provides supporting evidence for Navarro’s view (2007a) that it is in class that the explanation of the relationship between inequalities and health lies. For example in his critique of The Health of Nations: Why Inequality is Harmful to Your Health (Kawachi and Kennedy, 2002) he writes (Navarro, Reference Mooney and Wiseman2007a): ‘the emphasis of The Health of Nations on choice and values rather than on power and exploitation makes its message pretty limited. The message is profoundly apolitical.’
Navarro (2007b: 21) argues: ‘We need to look for the roots of the problem in the ways that power (class, race, and gender power) is reproduced in the state, in the media, and in the value-generating systems, and to focus on the need to politicize the response by organizing the disorganized, showing them that what they have in common outweighs whatever separates them.’ Navarro goes on to argue not that income inequalities do not matter but that what is important are the issues of power and in turn class divisions that such inequalities expose. He claims (Navarro, Reference Navarro and Navarro2007b: 21). ‘The real problem ... is not absolute resources but social distance and the different degrees of control over one’s own resources.’
Coburn (2004) provides further support for this class analysis. He presents a ‘class-based model of the relationships between inequalities in health within and between nations … by setting income inequality and health linkages within a broader conceptual framework’. His model ‘places income inequality and social cohesion within a radically different causal sequence to the orthodox income inequality approach and suggests that many other material factors, and their interpretation or imputed meaning, rather than simply income inequality, are central determinants of health inequalities’.
Equity in health economics
The question in health economics of how best to define equity in health care is one that health economists have tended to avoid. In part this is because there is an obsession in health economics generally with quantification which has meant that rather than grapple with ‘access’, the much more quantifiable ‘use’ has been adopted in the definition of equity (see for example Wagstaff and van Doorslaer, Reference Veatch2000). There are many health economics studies that look at equity in terms of equal use for equal need. That is seldom if ever the policy objective.
The emphasis on using ‘use’ is further heightened by health economists’ efforts to compare equity across different countries (see for example Wagstaff and van Doorslaer, 2000 and van Doorslaer et al., Reference Thiede, Akweongo, McIntyre, McIntyre and Mooney2006). Yet the construct of equity will vary across different countries and cultures and the relative weight attached to it as a policy objective, as compared say to efficiency, may also vary. This drive to conduct comparability studies again pushes us to try to measure some common construct of equity, which in turn means seeking something that is measurable on a comparable basis across different systems or across different cultures within the same system – hence the use of ‘use’.
There is a problem here, partly philosophical, partly cultural, partly Western arrogance. Why would or should Iranians perceive of equity as the same construct as Indians? Why would they be expected to acknowledge the same barriers in getting to health services? With respect to any barrier that they both do acknowledge to be present, why would these be expected to be perceived as the same height? And since equity is but one possible goal of any health service, why might we assume that the relative weight attached to it would be the same for all nationalities and all cultures?
A related but different equity issue is raised by Adams (1999). She writes (p. 3) about the ‘inequity of epistemology’ (which might be translated as Western arrogance) and the fact that the language and culture of international exchange of ideas around health and equity are so dominated by Western thinking. This means, for example, that ‘Tibetan medical theories and practices both resist description and quantifiability in a manner acceptable to secularist discourse but may nevertheless remain essential to health’ in Tibet.
Given these issues, there is reason to wonder what value such comparative analyses might have. Even if equity in health care were to be defined as being the same in all countries and weighted the same, if Afghanistan is ‘doing better’ on equity than is Argentina or Azerbaijan, what relevance is this to the citizens of these three countries or their health services?
Secondly and more importantly for this article, there has been a slowness to recognize that what is meant by equity is in part culturally determined. With respect to trying to define equity, Braveman and Gruskin (2003: 181) suggest, for example, that ‘because social justice and fairness can be interpreted differently by different people in different settings, a definition is needed that can be operationalized based on measurable criteria’.
Note the reasoning here. It is claimed that it is ‘because (emphasis added) social justice and fairness can be interpreted differently by different people in different settings’ that there is a need to have it ‘based on measurable criteria’. The goal of measurement dictates the definition. Yet if social justice is interpreted by one nation in a different way from another or one culture has a different interpretation than another, do such differences matter in any meaningful sense to the people of these different nations or of these different cultures? If researchers make such comparisons by converting Italian apples into Italian oranges, so that these oranges can now be directly compared with Iranian oranges, how valid is such research? (It is to be noted that to pose this question does not rule out the possibility that some practices can be observed to be unjust from every ethical and religious perspective. However, this is not the issue for debate here but simply the question of measurability.)
In this regard the World Health Report (WHO, Reference Wagstaff, van Doorslaer, Culyer and Newhouse2000) did much damage in its assumptions that the same criteria, including equity, and with the same weights attached to them, could be used to judge the goodness of all health care systems. There is an added problem at the global level since so much of health and health care policy, and not just policy on equity, is influenced by global institutions such as the WHO, the World Bank, and the IMF. As Homedes and Ugalde (2005: 94) write in summarizing their assessment of reforms in Latin America: ‘The formidable concentration of power in the hands of a few IMF’s and [World Bank’s] policy makers and bureaucrats weakens national policy making and the finding of correct answers to each country’s health problems based on local political, cultural, and historical realities more than on generic formulation based on ideology.’
In many cases, the situation is worse in that the neo liberal ideology of the World Bank can have an inhibiting effect on countries seeking to pursue equity goals. Homedes and Ugalde (2005: 94) indicate that the Costa Ricans have been put under pressure by the World Bank ‘to dismantle one of the most equitable and efficient health systems in [Latin America]’. These authors tell a similar story regarding Chile (Homedes and Ugalde, Reference Homedes and Ugalde2005: 89).
Countries will have different concerns for equity in health care and in society more generally. For example, the Scandinavian countries are renowned culturally for their ‘Scandinavian solidarity,’ which in turn affects not only their health care systems but social justice more generally. Different religions will have different value bases for health and health care with for example an Islamic perspective having ‘individual health and welfare … closely related to the health and welfare of the whole community’. The Islam perspective on equity is thus seen in community terms (Aroua, no date).
In the case of China, Adams (1999:18) argues that ‘it would seem that calls for basic cultural liberties would be fundamental to policy discussions on health equity’. She asks: ‘what does it mean to ensure cultural freedom and to bring cultural concerns into the policy arena at the same time?’. She worries that this can lead to health care being ‘politicized’ where this means ‘privileging one set of political and cultural ideas that are forged through contestation into the position of being (usually temporarily) dominant, whether or not there is consensus. Government policies are in this sense seldom universally consensual, and one could ask whether international agendas can ever be as well.’
This last point – the lack of universal consensus – is critical. This is partly because of the lack of a consensus per se. It is, however, also a problem that there can be the appearance of a consensus, such an appearance being imposed by the West through Adams ‘inequity of epistemology’. There is a need in the broader context of pursuing equity in health and health care for health economists (especially Western health economists) to acknowledge the cultural differences that clearly do exist across different societies. Analyses that ignore or deny these differences are likely to be misleading.
Within a multicultural society, the constructs of health, access, and equity are also likely to vary culturally. Yet it is clear that defining equity as equal access for equal (health) need is difficult to operationalize when there is neither a common construct of health nor one of access. It is of note, however, that the idea of a cultural basis for equity is accepted within other disciplines. For example the ethicist Veatch (2000: 189) writes: ‘Understanding equitable access to health care to mean that everyone should be able to secure an adequate level of care has several strengths’ and he adds that ‘the concept of adequacy … is society relative’. He goes on: ‘The content of adequate care will depend upon the overall resources available in a given society, and can take into account a consensus of expectations about what is adequate in a particular society at a particular time in its historical development.’
While the above discussion opens up a very wide range of issues regarding social justice across different cultures and hence different countries, this paper now considers the issue only within a single society.
What to do?
This section looks at how we might formalize equity to overcome some of the narrowness of its conceptualization in health economics. To do so requires that we can somehow allow cultural and possibly class differences in the way in which access is conceived and especially equality of access. That means inter alia moving away from the individualism and consequentialism that both welfarism and extra welfarism currently bring to health economists’ analyses of equity in health care. It also means that we cannot assume that all access barriers that are objectively the same are perceived to be the same by all. Since we also have to cope with the issue of two or more cultures within the same society having different constructs of equity, a different approach has to be able to deal with this ‘apples and oranges’ concern.
The proposed way forward is to adopt a combination of Anderson’s expressive theory and ‘communitarian claims’. Anderson (2003) identifies two different evaluative perspectives: one which (p. 239) ‘regards local evaluative perspectives as sources of bias, error, or intolerable conflict’. This she states (p. 240) ‘strives to reduce evaluative perspectives to a small number – typically only to the individual (self-interested) and moral (universal) points of view’. The other (p. 240) ‘regards the plurality of evaluative perspectives in a more epistemological vein … It focuses on the irreducibly numerous, intersecting ways people’s social positions – of wider scope than the individual, but narrower than all of humanity (as of gender, race, ethnicity, class, and so forth) – affect their points of view.’ She argues that ‘instead of seeking one point of view that has authority over all the rest, it views the authority of different points of view in pragmatic terms’ (p. 240).
I propose that health economists adopt Anderson’s second perspective where ‘gender, race, ethnicity, class, and so forth’ can be encompassed. She suggests that some value judgments can be seen as more objective than others. She states (p. 241): ‘A judgment about an object is positionally objective if anyone in that position would accept the same judgment.’ Deciding how to operationalize this is tricky as it requires some articulation of what is meant by ‘in that position’. Anderson appears not to address that. Fortunately, communitarian claims can.
The fundamentals of the communitarian approach in this context have been spelt out previously (Mooney, 1998). Here I want to restrict the focus to access and equity. First, it is assumed that it is the community's preferences which should determine the principles underlying any concept of access and the way in which the principle of equity should be operationalized. Second, such community preferences may not be the same as the aggregation of individuals' preferences. Third, since different individuals, and more importantly, different groupings within society (poor people, people of colour) may have different abilities to manage to mount the barriers (which is an idea taken from Sen (1992) regarding people having an inability to manage to desire), even if we wanted to have a common operational definition of access, we cannot legitimately do so.
Communitarianism is a thick form of democracy which involves a shift in the current power structure to give more power to ‘the people’. The issue of equity in health needs to be seen in the wider context of a socially just society. Setting equity in health care in some ‘technical’ arena within health care itself has been in large part the reason why efforts by health economists to promote equity in health care have failed. This requires what I have previously called a constitution (Mooney and Wiseman, Reference Mooney, Russell, Scott, Maynard and Elliott2000), which is a set of principles on which policy and actions regarding equity might be based; for example, what the definition of equity might be and the weight attached to it vis-à-vis other policy prescriptions. Thus, one important issue in the constitution would be to allow different constructs of access in any concerns for equity across different groupings.
The concept of ‘communitarian claims’ is helpful in deciding how best to allocate society’s scarce resources in the specific context of health and health care. How resources are allocated is determined by the community as a whole first deciding what is relevant in identifying and weighting claims in terms of the characteristics of the different potential recipient groups; and second judging the strengths of claims of various different groups for the resources involved. Thus, it is the community's preferences for the various groups' claims that determine how the resources are allocated. (For more detail, see Mooney and Russell, 2003.)
The fact that different social groupings within the same society may have different constructs of benefits or weight the same constructs differently would be problematic if attempts were to be made within the current health economics paradigm to deal with this issue. This is because equity in health economics is most often construed in terms of equal access for equal need or equal use for equal need, where equal need is defined as equal health need. If that definition were replaced by one which allowed different social groupings to define health (and hence health need) differently and to have different preferences for what they mean by benefits (and hence need more generally), then the equity construct of equal use or access for equal need would not be sustainable. There is then no need that can be equalized.
The proposed approach, using Anderson’s theory and communitarian claims, gets over the problem in current health economics of requiring two common numeraire – access and need. Access is to be determined according to the nature and extent of barriers as perceived by different groups. Racism may be a barrier for Aboriginal people for example. Need is replaced by ‘capacity to benefit’ (Mooney and Houston, Reference Mooney and Blackwell2004) which is accepted as being a subjective construct which may vary from one social grouping to another. The community as a whole has to weigh up the claims of one group as compared to another’s, even when one group’s potential for claims is set in different terms to the other’s. Thus, for example, in Australia the claims of Aboriginal people would be set in terms of their more holistic, communitarian construct of health; non-Aboriginal people in terms of primarily a western, more individualistic construct of health. Aboriginal people might place more weight on involvement in decision-making regarding the nature of the health system. Non-Aboriginal people might weight this lower or even as zero. Again, Aboriginal people might argue that the impact of land dispossession is a basis for a claim on health care resources. It is then required that the whole society – in this case the Australian community – would decide which of these various factors – racism (for access), Aboriginal health, non-Aboriginal health, involvement in decision making and the impact of land dispossession (for need) – constitute the basis of a claim and what strength (or weight) to attach to each claim for each group.
Thus, in a society concerned not to be seen to be racist, wishing to right the wrongs from a colonial past and seeking to protect and support minority cultures, the strength of claims of, for example, Aboriginal people will be high and allocating resources to make health services more culturally secure will be a priority. Where the emphasis in a society is on assimilation by the dominant culture, where egalitarianism takes the form of equality and universal values are promoted as the basis of good citizenship, the strengths of claims of Aboriginal people will be lower and the resources allocated to make services to Aboriginal people more accessible will be fewer.
Citizens’ constructs of access and equity
In some senses, the health economics literature has come a long way on access, given that for some time access was seen almost exclusively in terms of only two factors: money fees at the point of consumption, and distance. Recently in something of a break through, Thiede et al. (Reference Swartz2007: 105) have considered access in terms of three variables: availability, affordability, and acceptability, all under the important umbrella of access being interpreted as ‘the freedom to use health services’ (for more detail, see also McIntyre et al., Reference McIntyre, Thiede and Birch2009, this issue).
Most often access is today seen in principle by health economists as the opportunity to use health services and that does inter alia distinguish it neatly from use per se. The notion of freedom from Thiede and his colleagues (Reference Swartz2007: 104) goes beyond opportunity, suggesting that the definition of access ‘should also incorporate the notion of empowerment to make well informed decisions about health service use’.
This notion of freedom is one with which it seems people as citizens can associate. Recently the author facilitated a citizens’ jury in Adelaide in Australia. The members of such juries are randomly selected from the community at large, brought together, presented with relevant information from experts, allowed to quiz the experts, and then asked to indicate what principles they want to underpin their health services and what their priorities are for the services involved. This jury was asked to judge what principles and priorities they had for what is known as ‘GP Plus’, a planned new service which is about enhancing primary health care (Government of South Australia, 2007). They were asked to say what they wanted when this new PHC service opened. Their focus was very much on improving equity, especially for disadvantaged groups, and they endorsed a form of vertical equity. In this context and with regard to access, they saw a major barrier to access being simply lack of information about what services were available, what were appropriate services for people to use who had certain specific problems, and how to make best use of these services. While this GP Plus service was being funded by the local health authority, the citizens took a wide view and wanted the service to help improve information about primary care, including for example housing and social security, and not just primary health care. While they did not use the word freedom in their deliberations, implicitly their conception of access involved something very much akin to the concept of freedom from Thiede and his colleagues.
The question of whose values are to count in assessments and concepts of equity and access is central to questions of definition and objectives. To date most definitions have come from health policy makers or health economists. The stance taken in this article is that equity is better seen through the eyes of the potential users, i.e. the citizens. Once we endorse opportunity to use and especially if we accept the notion of freedom to use, we are bound to look to the community for the values that are to underpin constructs of equity and access. It is they who must form judgments about which features represent barriers to use and about the extent of the hindrances or disincentives that exist to deter them from using services.
An example of doing just that is the definition of equity which was elicited from the preferences of Australian citizens in a citizens’ jury in Perth (Mooney and Blackwell, Reference Mooney and Blackwell2004). This is a particularly interesting definition in the context of allowing access to vary across different cultural groupings.
The definition is as follows:
Equal access for equal need, where equality of access means that two or more groups face barriers of the same height and where the judgment of the heights is made by each group for their own group; where need is defined as capacity to benefit; and where nominally equal benefits may be weighted according to social preferences such that the benefits to more disadvantaged groups may have a higher weight attached to them than those to the better off.
The idea of the barriers and the heights of the barriers being based on the perceptions of the citizens is important. If we are taking access to mean opportunity to use or freedom to use, it is immediately apparent that it is the potential users’ perspectives on what constitutes a barrier and its height that must be used in assessing differential access. Two population groups, each facing a fee of $50, a white, male gynaecologist, and a travel distance of 100 kilometres, will not perceive barriers as having the same height if one group is Aboriginal, largely car-less, poor, and culturally averse to a gynaecologist being male, and the other group is white, mostly car-owning, rich, and has no problem with the fact that the gynaecologist is male.
If health economists are genuine in their desire to grapple with equity, they need to recognize more readily that these issues have to be seen through the eyes of potential users and let citizens first include whatever barriers they perceive and second attribute heights to different barriers. To continue the obsession with the quantifiable ill serves the sub-discipline. It serves the disadvantaged even worse.
