Equity in Health

The report delivers both promising and disappointing messages about the situation in low- and middle-income countries with respect to reproductive, maternal, newborn and child health indicators. Within-country inequalities have narrowed, with a tendency for national improvements driven by faster improvements in disadvantaged subgroups. 

However, inequalities still persist in most reproductive, maternal, newborn and child health indicators. The extent of within-country inequality differed by dimension of inequality and by country, country income group and geographical region. The patterns of change in inequality over time varied by health indicator, and according to country and dimension of inequality. The report observes that while national averages and improvements over time are important indications of progress on a global level, reporting inequalities within countries shows how any progress in national averages is realized by population subgroups. Establishing goals and targets that specify a reduction in inequality encourages the orientation of policies, programmes and practices to promote health in disadvantaged subgroups. Without a dedicated focus on equity, efforts to improve health can risk perpetuating or intensifying within-country inequality, even as increases in national coverage are achieved.

This conference reports on work on the integration of social determinants of health – socioeconomic and structural factors – into immigrant health research and policy. A cross-national framework was used to consider issues of place, migration and health. In addition to public health, it drew upon the fields of economics, sociology of immigration, and social epidemiology, and incorporated three theoretical frameworks: the life-course framework from social epidemiology, the ‘push-pull’ factor theories from geography and economics, and transnational theory from sociology. It built upon recent academic literature, including a Social Sciences and Medicine (SSM) supplement on immigration and health, to formulate areas where more research is needed and to recommend potentially fruitful program interventions and policy changes. It integrated work with North American Latino immigrants, Asian and South Asian immigrants, African and Afro-Caribbean immigrants, and Arab immigrants, and research linking the migration to Europe of Arab, Turks and other populations, and to the Middle East of immigrants from Africa.

A focus on social determinants of health provides a welcome alternative to the bio-medical illness paradigm. However, the tendency to concentrate on the influence of risk factors related to living and working conditions of individuals, rather than to more broadly examine dynamics of the social processes that affect population health, has triggered critical reaction not only from the Global North but especially from voices the Global South where there is a long history of addressing questions of health equity. In this article, the authors elaborate on how focusing instead on the language of “social determination of health” has led to application of more equity-sensitive approaches to research and related policy and praxis. The authors briefly explore the epistemological and historical roots of epidemiological approaches to health and health equity that have emerged in Latin America to consider its relevance to global discourse. In this region marked by pronounced inequity, context-sensitive concepts such as “collective health” and “critical epidemiology” have been prominent, albeit with limited acknowledgement by the Global North. The authors illustrate attempts to apply a social determination approach (and the “4 S” elements of bio-Security, Sovereignty, Solidarity and Sustainability) in five projects within their research collaboration linking researchers and knowledge users in Ecuador and Canada, in diverse settings (health of healthcare workers; food systems; antibiotic resistance; vector borne disease [dengue]; and social circus with street youth). The authors argue that the language of social determinants lends itself to research that is more reductionist and beckons the development of different skills than would be applied when adopting the language of social determination. They conclude that this language leads to more direct analysis of the systemic factors that drive, promote and reinforce disparities, while at the same time directly considering the emancipatory forces capable of countering negative health impacts. It follows that “reverse innovation” must not only recognise practical solutions being developed in low and middle income countries, but must also build on the strengths of the theoretical-methodological reasoning that has emerged in the South.

Access to health care is a particular concern given the important role of poor access in perpetuating poverty and inequality. South Africa has large racial disparities in access despite post-apartheid health policy to increase the number of health facilities, even in remote rural areas. However, even when health services are provided free of charge, monetary and time costs of travel to a local clinic may pose a significant barrier for vulnerable segments of the population, leading to overall poorer health. Using newly available health care utilization data from the first nationally representative panel survey in South Africa, together with administrative geographic data from the Department of Health, the authors use graphical and multivariate regression analysis to investigate the role of distance to the nearest facility on the likelihood of having a health consultation or an attended birth. Ninety percent of South Africans live within 7 km of the nearest public clinic, and two-thirds live less than 2 km away. However, 14% of Black African adults live more than 5 km from the nearest facility, compared to only 4% of Whites, and they are 16 percentage points less likely to report a recent health consultation and 47 percentage points less likely to use private facilities. Racial differentials in the likelihood of having a health consultation or an attended birth persist even after controlling for confounders. The results have two policy implications: minimizing the distance that poor South Africans must travel to obtain health care and improving the quality of care provided in poorer areas will reduce inequality.