Health Equity and Sustainable Development Goals: Role and the Complexity
Over the past few decades, there have been remarkable improvements in heath states or indicators in many countries in terms of infant and maternal mortality rates and other health indicators also. Despite these general and overall improvements, there remain substantial inequalities and disparities between the countries, regions, socioeconomic groups, and also individuals. For example, many African countries are bearing burden of HIV/AIDS, and countries of former Soviet Union are also facing high mortality rates (Leon and Walt 2001). Even in rich countries as the UK, there are evidences that health disparities are widening over the past few decades (Povall et al. 2013). Alongside the intrinsic importance of health as a dimension of welfare, poor health can directly influence an individual’s opportunities – his earning capacity, educational attainments, ability to care for children, participation in community activities, and so on. This important instrumental function of health implies that inequalities in health often translate into inequalities in other dimensions of welfare. And these inequalities are reproduced over time as well as across generations sometime.
Defining health inequity, health disparity, and health equity is very important before moving to the bigger issue of attainment so as to involve the diverse stakeholders in this difficult task, each one with a different task in hand. It means that the definition is important for desired operationalization and measurement. We have three terms herein, health inequity or equity, health disparity, and health inequality, which in common literature are used simultaneously sometime. But these terms are conceptually different, and it is important to define them for a better understanding of social justice and equity-based Sustainable Development Goals. Defining the term is very important as ambiguity regarding the meaning may lead resources to direct away from the intended purposes (Braveman 2014a). Health equity, although, has been in limelight since John Rawlsian work has been extended to include health into Social Justice and Amartya Sen’s theory Justice. The concept has been in wider discussions after the constitution of World Health Organization in 1946 which adopted health equity as an objective in terms as “the highest standards of health should be within reach of all, without distinction of race, religion, political belief, economic or social condition.” Soon after, the United Nations also adopted the UN Declaration of Human Rights mentioning equitable healthcare. The major declaration on health termed as Alma Ata in 1978 also emphasized upon the concept of health equity as “Health for All.” The introduction of Millennium Development Goals brings in new development agenda for the world as a whole with a lot more emphasis on the health outcomes (Wirth et al. 2006).
Hence, health equity is more than justice in terms of access, and the core value of this equity is derived from human rights principle. And as such, equity is a process, and equality is an outcome of it, and it will be achieved by treating everyone equitably or justly according to their circumstances.
The absence of unfair and avoidable or remediable differences in health among populations or groups defined socially, economically, demographically or geographically. (World Health Organisation 2010)
Equity means social justice: health equity can be defined as absence of systematic disparities between social groups. In greater sense, it means absence of social exclusion in healthcare sector. Such social exclusion can be racial, ethnic, religious, caste based, etc. Health equity does not only mean utilization of healthcare but also equitable and fair allocation and financing of healthcare with quality services across all social groups.
Health inequalities are different from health inequities: not all disparities are unfair, i.e., we expect young population to be healthy than old age population, and special policies for aging population are fair.
Health equity as a human right: the concept of health equity is an ethical concept, and it can be related to “right to health” as also mentioned by WHO. Health equity is inevitable part of right to health.
Health inequities are socially produced and are generally avoidable through collective actions by the government and nongovernment sources, but avoidability should not always be the only criteria for defining it as it cannot be measured or determined always (Braveman and Gruskin 2003).
In simpler terms now, health equity involves the fair distribution of resources needed for good health, equitable access to the opportunities to be healthy, and fairness in the support offered. The objective of health equity is to reduce the excess burden of ill health among socially and economically disadvantaged population.
The Determinants of Health Equity
By far we have discussed that health inequities are socially produced, and various social determinants of health are also the determinants of health disparity or health equity. Although, there are other factors which impact health in general, these social factors are always overpowering the. Such social determinants have been researched upon and enumerated by various studies, and to name a few, they are World Health Organization (2010), Marmot et al. (2008), Kawachi et al. (2005), and many others. Regional studies as Heiman and Artiga (2015) also put importance of social determinants of health and health equity. Social determinants of health are “the structural determinants and conditions in which people are born, grow, live, work and age” (Marmot and Bell 2018). They include factors like socioeconomic status, education, the physical environment, employment, and social support networks, as well as access to healthcare. Many definitions recognize that health disparities are rooted in the social, economic, and environmental context in which people live. Achieving health equity as the highest level of health for all people will require addressing these social and environmental determinants through both broad population-based approaches and targeted approaches focused on those communities experiencing the greatest disparities. Some of the social determinants as inferred from the literature review are enumerated in the following table.
Social determinants of health equity
System of healthcare
Hunger and food security
Hygiene and sanitation
Early childhood care
Opportunities to be healthy
Drinking water facilities
Race or ethnicity or caste
Quality of care
Social integration and community engagement
Affordability of care
Parks and playgrounds
Hazardous working conditions
Access to household and modern energy sources
Global warming and climate change
The Role of Health Equity in Realizing the Sustainable Development Goals: Why Health Equity Matters
The Millennium Development Goals talked about health and called for an action to promote gender equality, reduce child mortality, improve maternal health, and combat HIV/AIDS, malaria and other diseases along with gender equality in this sector. The detail of these targets and the achievement and limitations are being discussed in detail by World Health Organization (2015a). The role of Health Equity in Sustainable Development goals whose principle is already “leaving no one behind” is exigent in achieving the social justice principle of the Sustainable Development Goals itself (Marmot and Bell 2018). The targets relating to healthcare has appeared in Goal 3 under “Ensure healthy lives and promote well-being for all at all ages,” and the sentence itself talks about the need of health equity – “for all at all ages.” The reduction of inequalities is also articulated explicitly in SDG 10, to reduce inequality within and among countries, and is also evident in SDG 1, to end poverty; SDG 4, to ensure inclusive and equitable quality education; and SDG 5, to achieve gender equality and others. All of these issues are embraced within an equity framework and interwoven with health considerations (Tangcharoensathien et al. 2015).
Observing closely the 169 targets of the SDGs, health equity is an important part of almost all of the goals in one way or another. Either there is a two-way causal relationship to achieve the goal and the health equity or the goal itself is directly helping equity in health. For relating and understanding the importance of health equity in realizing the SDGs and as a part of it, the concept must be seen holistically and not merely in the form of physical access to healthcare and economic affordability in terms of opportunities to be healthy. As discussed earlier, health equity also includes the environmental, food security, and educational factors along with the social determinants as gender and ethnicity. Health equity is a matter of human rights or social justice under “right to health,” and sustainable development is a concept envisaging the idea of human and planetary rights in itself for better future of both. The goal of right to health needs a consistent and progressive efforts to improve health across countries and population which stand disadvantage because of certain socioeconomic determinants and that are still not a part of efforts to achieve the SDGs. Their exclusion and the unfair treatment of these groups have a two-way casual relationship.
The following table simplifies the interrelationship between SDGs and health equity in a very simple form.
Health equity and the sustainable development goals: The relationship
Linkage with health equity
SDG 1: End poverty in all its forms everywhere
The goal to end poverty is not attainable without equity in healthcare. The causal relationship is two way here. To achieve the targets of this goal, healthy physical environment including working conditions has to be provided, opportunities to be healthy have to be increased, and access to healthcare has to be there. Such determinants are both cause and effect of poverty. More healthy people will have more chances to come out of poverty with better education and employment skills
Moreover, vulnerability of poor people to diseases are greater, and hence policies should aim at health equity of the poor than with the rich
In short, healthy and less vulnerable population will come out of poverty easily
SDG 2: End hunger, achieve food security and improved nutrition, and promote sustainable agriculture
Hunger is a great cause of malnutrition and related health problems. Therefore equity in food production and distribution is a must to end hunger. Also, food security is inevitable part of health equity
SDG 3: Ensure healthy lives and promote well-being for all at all ages
The health goal of SDG is in itself promotes the equity in health by including phrase “for all at all ages.” The goal is achievable only by including the excluded disadvantaged groups by inter-sectoral linkages with other SDGs also. The access to healthcare needs to be increased for universal health coverage for all, men and women, rich and poor, and at all ages – child, young, and old
SDG 4: Ensure inclusive and equitable quality education, and promote lifelong learning opportunities for all
There is also two-way causation between health equity and education. Learning will help socially excluded groups to increase their chances to be healthy, and equity in terms of health will increase their opportunities of getting education
SDG 5: Achieve gender equality and empower all women and girls
The issue of gender is vital in health systems and delivery also. Women need to be included in healthcare access and coverage to realize this goal and gender equality, on the other hand, will provide for gender equity in health
SDG 6: Ensure availability and sustainable management of water and sanitation for all
Access to safe drinking water, hygiene, and sanitation levels is major determinants in deciding vulnerability of a group to unhealthy events, and hence health equity in terms of safe physical and work environment are must to achieve sustainability in terms of water and sanitation. Sustainable management of water resources will ensure long-term health equity in terms of availability of water
SDG 7: Ensure access to affordable, reliable, sustainable, and modern energy for all
Sustainable energy and urban planning will ensure safe and healthy environment for mankind, and disadvantage groups like displaced population, tribal, etc. will be ensured equity in terms of safe healthy environment. Such good pattern of development will have good bearing on health. On the other hand, healthy equity also includes the concept of access to household energy to mitigate the vulnerability of disadvantaged groups
SDG 8: Promote sustained, inclusive and sustainable economic growth, full and productive employment, and decent work for all
Decent work and economic growth will ensure health for all by improving the economic determinants, and equitable health services will generate a better workforce in terms of education and skills by reducing their health risks
SDG 9: Build resilient infrastructure, promote inclusive and sustainable industrialization, and foster innovation
This goal will improve the access to health and healthcare facilities and will also consolidate the economic determinants of heath equity
SDG 10: Reduce inequality within and among countries
Local and international inequalities in terms of income and opportunities will also help to mitigate health inequities
On the other hand, bringing in health equity will help overall economic equality also by increasing opportunities. This also includes the LGBT rights
SDG 11: Make cities and human settlements inclusive, safe, resilient, and sustainable
This goal is closely related to health equity target of safe and non-vulnerable physical environment with sustainable and inclusive urban planning that will increase the opportunities to be healthy
SDG 12: Ensure sustainable consumption and production patterns
Sustainable agriculture and soil and water management will help the local communities or groups by bringing in conducive and safe environment around them. The concept of health equity included the equity in terms of protecting the local and tribal communities by making their physical environment safer
SDG 13: Take urgent action to combat climate change and its impacts
The targets of health equity are only attainable if the environment around us is kept safe for the mankind, and the lop-sided development must not deprive certain sections of their health rights. Hence the health equity includes the safety of our climate in terms of climate change
SDH 14: Conserve and sustainably use the oceans, seas, and marine resources for sustainable development
Conserving life under the ocean will ensure good health for local communities and will also mitigate the negative health impacts on mankind
SDG 15: Protect, restore, and promote sustainable use of terrestrial ecosystems, sustainably manage forests, combat desertification, halt and reverse land degradation, and halt biodiversity loss
Conserving life on earth will ensure food security and environment sustainability for health equity goals
SDG 16: Promote peaceful and inclusive societies for sustainable development, provide access to justice for all, and build effective, accountable and inclusive institutions at all levels
Peace and justice are important components to ensure social integration. Violence has a negative impact on equity in health, and the victim groups are generally the excluded groups. String world institutions will help in ensuring the peace and hence equity worldwide
SDG 17: Strengthen the means of implementation and revitalize the global partnership for sustainable development
Global partnership is very important for health equity to mobilize financial and technological resources globally to achieve a parity
Hence we can say that health and health equity are multi-sectoral concepts, and the objective can also be found in other SDG goals as given in “Health in All Policies” framework by Nunes et al. (2016).
Closing the Health Equity Gap: The Complexities in the System
Above discussion puts a light on the determinants of health equity and the interlinkages as well as importance of health equity with relation the Sustainable Development Goals. Looking at the multidisciplinary definitions of the equity which relate the concept to social justice, human rights, and economic justice, it is obvious that this concept of health equity is base for many further goals as quality life, sustainable environment, prosperity, etc.; for effective implementation of Agenda 2030, we need to understand the issues that were left behind in implementation of MDGs that also included goal of health equity, which stands as barrier to equity in health. Even explicitly laid down as global goal, the targets of equity in health as access to all, safe working conditions, child and maternal health, etc. are still not achieved specially in the developing world. The question is not only the global inequities but also the inequities within the countries.
Such within-countries inequities are not merely income inequalities but a more harmful form of inequities of opportunities. As per the World Development Report 2006, “these inequities are usually associated with differences in an individual’s ‘agency’ i.e. the socioeconomically, culturally, and politically determined ability to shape the world around oneself. Such differences create biases in the institutions and rules in favor of more powerful and privileged groups” (The World Bank Staff 2005). These include race, religion, region of the birth, gender, caste, etc. in most developing world. Inequalities of opportunity are also transmitted across generations, and such intergenerational immobility is also observed in rich countries as the USA (The World Bank Staff 2005).
To achieve equity in health, the issues under social determinants of health or SDH are a great barrier to it. As per Commission on Social Determinants of Health, “Social injustice is killing people on a grand scale” (World Health Organization 2008). The problem in terms of social determinants is lack of community level efforts or NGO at ground level to bring social linkages as well as lack of governmental policies on strengthening of these policies mainly because of fiscal incapacity or political conditions. Overall low level of economic development, lack of physical as well as human capital, social stratification and unequal distribution of power, and resources and wealth are important barriers in equitable health within nations.
Another important determinant under SDH of health is “access to healthcare” in terms of coverage, also called universal health coverage (UHC). The path to UHC differs significantly country to country based on their socioeconomic and political conditions. It ranges from mandatory social health insurance for salaried class to tax-financed mechanisms for poor depending on governments fiscal space. To achieve a favorable UHC outcome, strengthening physical access by improving geographical coverage of health services and financial access by extension of financial risk protection mechanisms are two essential parallel synergistic interventions (Tangcharoensathien et al. 2015). As per Tangcharoensathien et al. (2015), two factors involving UHC for health equity are fiscal space and physical as well as human infrastructure. There are plenty of literature available suggesting that although little progress since MDGs have been made but significant gaps are still there in terms of regional inequities in access to healthcare, chronic lack of primary healthcare, and also inequity in health workforce. Some of them to quote are Tangcharoensathien et al. (2015), Balarajan et al. (2011), World Health Organization – Regional Office for South-East Asia (2017), and many others. Some of the suggestions as also given by the WHO includes giving more importance and funding to the frontline services as health and education; developing integrated health service delivery model from diagnose to advance care; improving quality of care; strengthening health workforce across regions, private, and NGO partnerships; and also a shifting toward evidence-based policy regarding inequity in health with better databases.
Another area to focus for achieving health equity is special focus on women and children as the importance of early childhood care as well as maternal health is fundamental to a healthy nation (Irwin et al. 2007). Reproductive, maternal, and newborn health show a wider inequality across countries. Gender equality, care of all at all ages, and maternal health are integral parts of SDGs. The problem is grave in low- and middle-income counties (World Health Organization 2015b). Some of the reasons as quoted by WHO for high maternal mortality rates are poverty, information asymmetry, lack of coverage of remote areas, inadequate and low-quality services, and cultural practices (Say et al. 2014). Evidences show that within-country inequalities have narrowed with national improvements driven by faster improvements in disadvantaged subgroups, but inequalities still persist in most reproductive, maternal, newborn, and child health indicators. Such indicators as used by WHO include birth attended by skilled health personnel, antenatal care coverage, use of modern contraceptive, immunization coverage, under five mortality rates, etc. Gap exists in funding and awareness regarding the same. Health workforce plays an important role here also. Equity will prevail only if local governments will provide these groups with ample support.
Social exclusion is also a major determinant of health equity as it provides the “opportunity to be healthy.” As per WHO’s report on Social Exclusion Knowledge Network, “Exclusion consists of dynamic, multi-dimensional processes driven by unequal power relationships. These operate along and interact across four dimensions – cultural, economic, political and social – and at different levels including individuals, groups, households, communities, countries and global regions. Exclusionary processes contribute to health inequalities by creating a continuum of inclusion/exclusion” (Popay et al. 2008). Literature as Popay et al. (2008) suggests state-led policies, NGO- or community-led policies, private sector policies, and also multilateral agency policies tackle the problem of social exclusion. State-led policies include universal access policies, targeted transfer policies, market-based policies as promoting private insurance and private primary health centers, etc. Community-led policies include autonomous action by communities and community level participation in policymaking for inclusion.
Other approaches include the role of international institutions as World Bank, IMF, WHO, and also the UN for promoting social inclusion by funding or persuasion because the major cause of these inequities is unequal distribution of power, resources, and money, and to achieve the desired results and to bring equity, institutions and governments have to be provided with financial space to tackle the social and economic equities. WHO’s Social Exclusion Knowledge Network report puts a light on little progression in this area since MDGs and the still-standing grave problem (Popay et al. 2008).
Holistic and integrated policy is required to address issues as peace, migration, and health inequities as highlighted by Mullany et al. (2007), importance of urban planning in sustainable health and hence equity as mentioned by Northridge and Freeman (2011), and role of economic and social infrastructure as access to energy in achieving equity in health, which has been analyzed by Markandya and Wilkinson (2007). Moreover the role of education is also important to realize the values of SDGs in terms of inclusion and benefit of all.
“Leaving no one behind” requires identifying, understanding, and addressing the health inequities within and across countries. Hence the role of monitoring the inequities time to time is also vital (Hosseinpoor et al. 2015). The issue of global health and humanitarian emergency is also a vital part of health equity concern, and research and development for avoiding health disaster must also be committed by multilateral organizations as well as country level governments (Pottie 2015). For achieving the targets of SDGs in general and healthy equity in particular, evidence-based regional and global policies must be focused as discussed by WHO also (World Health Organisation 2010).
The concept and aims of equity are at the heart of SDGs, and besides talking explicitly about health for all in SDG3, health equity is easily relatable to other SDGs also and thus ensuring health lives for all. The lessons learnt from previous phases as MDGs must be taken forward to provide the world with an integrated policy and efforts to improve the health indicators. Adoption of SDGs has now opened a new era of refreshing the institutional integration to provide right to health for all. Political commitments are being made in member nations to check maternal and infant mortality rates and improving child care. The Agenda 2030 offers an opportunity to integrate the micro and individual goals with the macro global picture of sustainable development through proper monitoring, implementation, and reporting mechanisms. Country level studies must be promoted to highlight the key focus areas, and global accountability must follow it. Institutes like WHO are working in close collaboration with area-specific strategies and collaborations with institutes and governments to bring in the equitable distribution of power, resources, and money and hence equity in health.
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