Equity in health in unequal societies: meeting health needs in contexts of social change

Abstract

The paper explores the implications for health policy of the segmentation of society into social groups with very different levels of income and wealth. Discourses on equity in health are presently dominated by a debate between ‘European’ and ‘American’ models of health delivery. This has led to a focus on ideal outcomes rather than practical options for organising and financing health services in poor countries undergoing rapid change. The paper argues for a more explicit acknowledgement of the dynamic character of health development and the political nature of the negotiations regarding the use of government powers. Unregulated markets for health care are neither equitable nor efficient. Government must play a role in supporting the organisation of health services used by different social groups. Countries with low levels of inequality may be able to provide universal access to relatively sophisticated health services. Otherwise, governments need to operate within a segmented system. This means the negotiation of strategies to reduce the burden of sickness and premature death, whilst meeting the needs of different social groups. The discussion is organised in terms of the powers of government to require individuals and institutions to transfer resources for social uses, enforce regulations and generate and disseminate information. The paper concludes that governments committed to equity-enhancing health development need to increase their capacity to facilitate coalition building and manage change. It proposes an international public health legal framework that might include a definition of minimum standards for certain health services, to be underwritten by national and international financial commitments.

Introduction

Fifty years ago Babasaheb Ambedkar [1] wrote about the contradiction policy-makers faced in managing India's post-colonial transition,

…we are going to enter into a life of contradictions. In politics we will have equality and in social and economic life we will have inequality…. We must remove this contradiction at the earliest possible moment or else those who suffer from inequality will blow up the structure of political democracy which this Assembly has so laboriously built up

This is a stark expression of the reality in much of Africa, Asia and Latin America in the years following the Second World War. That was a period of great social optimism, following a global war, which had been understood as a confrontation between opposing ideologies [2]. The victors proclaimed themselves the representatives of democracy and social justice. The post-war decades were dominated by major projects for social change such as the rehabilitation of Western Europe through the Marshall Plan, post-revolutionary construction of command economies and the ending of the political structures of colonialism. There was a great deal of optimism about the possibilities for restructuring societies. In practice, however, international social policy debates were dominated by the conflict between the different visions of opposing political and military blocs.

The international community's expression in the health sector of this vision of social reconstruction was the primary health care concept, which viewed health in the context of an agenda for social development. The ideas underlying this concept emerged from the experience of the post-revolutionary command economies and some of the more equitable Latin American and post-colonial societies. International institutions accepted them as the cornerstone of their health strategies in the late 1970s [3].

Half a century later, the projects for radical social reconstruction are only partly successful. The hopes for a rapid removal of socio-economic inequalities have not been fulfilled. One of the most striking characteristics of the global social structure is the existence of substantial inequalities in wealth and income associated with major differences in health between countries and between social groups [4], [5]. Many regions have experienced reductions in absolute poverty and excess mortality. However, the targets set in the late 1970s have not been attained and Sub-Saharan Africa and the former Soviet Union, are experiencing a reversal of earlier health gains [6].

The persistence of these inequalities attests to the ambition of the attempt to implement major structural changes nationally and internationally. It is largely due to the difficulties involved in overcoming deeply rooted inequalities in the face of resistance by political elite groups. It also reflects weaknesses in government strategies for negotiating and managing change.

There is an international debate about strategies for social sector development between advocates of what Deacon [7] calls ‘European universalistic social expenditure’ and ‘USA residualism’. This characterisation of the debate points to its focus on social arrangements in advanced market economies (or idealised versions of them). The reference to these economies diverts attention from the real issues and options elsewhere [8]. Low and middle-income countries with substantial structural inequalities are probably unable to provide equal social benefits to all, even if their governments aspire to do so. The real debate in these countries concerns how governments can use their limited powers to influence sectoral development and alter the balance of benefits between social groups.

Toye [9] calls for a shift of attention from debates about ideal arrangements in the social sector to a ‘nationalisation of the anti-poverty agenda’. This would involve the identification of strategies for overcoming structural inequalities and political constraints. He suggests three common conditions for catalysing state action to reduce poverty, a belief in the social interdependence of rich and poor; the existence of a credible threat from the poor and the belief that state action can make a significant difference to the situation. He emphasises the need to convince national elite groups that the needs of the poor can be met at an acceptable cost to themselves.

This paper explores what nationalising the reform agenda means for the health sector. It rejects universalising models that set simple targets or aim at the transfer of organisational structures between different societies. It calls for strategies that begin with a country's reality and explicitly recognise the political nature of the management of health sector change.