Health inequities: causes and potential solutions

Health inequity refers to systematic disparities in health or their social determinants based on defining human characteristics such as wealth, ethnicity or social standing.¹

Significant inequities in health exist in all nations and are a direct consequence of poverty, indifference (political and societal) and the inability to implement or impose global declarations addressing the right to health on individual nation states. There is a strong correlation between socioeconomic and health disparities.² For instance, preterm birth and intrauterine growth restriction have been consistently associated with lower socioeconomic status in Canada, and infant mortality rates are significantly higher in the lowest income neighbourhoods in British Columbia.

Health inequities largely stem from greater exposure to social determinants of health, leading to wide disparities in infectious, non-infectious and injury (intentional and unintentional) disease burdens.³ These inequities remain resistant to change as a result of weak health systems unable to cope within environments overwhelmed by poverty, neglect and discrimination (Figure 1). Health systems are made up of a constellation of actors and organisations whose primary purpose is to promote, maintain or restore the health of the populations they serve, and are tightly interconnected to rules and policies that define roles, responsibilities and accountability.⁴ Pro-equity programs thus must take into account the strengthening of health systems, but reach beyond the health sector to resolve the dominant social determinants that inhibit the effectiveness of health systems and the services they provide. Access to health care means little without access to adequate food and safe working conditions.

Figure 1. Health system elements, subject to multiple social determinants, drive health outcomes.

Ideally, solutions to health care inequities would be holistic and entail addressing international and government policies that have a direct impact on social determinants and health systems. It is important to see this proposed framework as part of a larger social justice movement, committed to identifying and addressing persistent inequities and their elimination. This is a complex challenge and one that requires human resource capacities that can effectively and efficiently implement pro-equity policies. Capacity building and the removal of barriers creating the ‘know-do gap’⁵ must be given highest priority (Figure 2).

Figure 2. The ‘know-dO' gap between what health professionals are trained and skilled in as opposed to what they actually practice.

As an initial step, it will be important to continue with efforts to strengthen health information systems and their capacity to guide decision making as well as monitor health outcomes and their determinants. This should include clearly articulated targets and acceptable thresholds determined by governments and those directly affected. Case histories of low-income countries that have demonstrated reductions in health disparities as a result of policy reforms and strengthened health systems should be identified and disseminated. Western, high-income country models, which also endure significant inequities, should not serve as templates for change.

Health inequities, of necessity, must be dealt with at the national level, but there exists an international role as well. This implies obligations and accountability on the part of higher-income countries to support bilateral and multilateral efforts to reduce health disparities.

Not to be lost in this is the private sector and the influence transnational corporations have on social determinants of health. Public-private partnerships that directly address global development targets, such as the Millennium Development Goals, are to be encouraged.

Pro-equity policies should be promoted by governments, businesses, and non-governmental organisations alike.⁶ This links health disparities to larger societal problems, as many problems of inequity are beyond the control of government or public sector institutions. Nonetheless, public policies and programs that promote sanitary living conditions, free and universal access to primary and secondary education, and human rights all work to combat the ignorance and neglect that allow poor health to remain deeply entrenched in communities.