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—from Epidemiological Bulletin , Vol. 25 No. 4, December 2004—
Health Inequalities
The two core values on which the work of the Pan American Health Organization (PAHO) revolves are equity and Pan Americanism. These values form the basis for cooperation with countries, and measuring and monitoring inequalities are therefore fundamental activities for decision-making. Technical cooperation with countries should focus on the identification of inequities and on the formulation of effective strategies for reducing and, ultimately, eliminating them.
Although important gains have been made in the overall health situation in the Region, the Americas remains the region with the greatest inequity in income distribution in the world. There are still large disparities in health status between different countries and social groups. It is known that groups with lower socioeconomic status not only suffer a greater burden of disease, but, in addition, they tend to develop chronic diseases and disabilities at earlier ages; they have less access to health services, and the services they do receive are of poor quality.
The measurement of health inequalities is an indispensable condition for moving forward in the effort to improve the health situation in the Region, where the analysis of average values is no longer sufficient. This type of analysis is a key tool for action aimed at achieving greater equity in health. In general, health information systems and health situation analyses do not include evaluation of inequalities. Measuring inequalities in health and living conditions constitutes the first step toward the identification of inequity in the field of health. According to Whitehead (1991) and Schneider (2002), inequality is not synonymous with inequity. Inequity is an unfair and avoidable inequality, and therein lies its importance for decision-makers. Classifying an inequality as inequity implies knowing its causes and being able to substantiate a judgment as to the unfairness of those causes.
In light of the importance of the matter, this issue of the Epidemiological Bulletin presents a summary of the special issue on measuring health inequalities published by the Pan American Journal of Public Health in December 2002 (Vol. 12, No. 6). In addition, it revisits one of the articles, Methods for Measuring Inequalities in Health, by Schneider et al., which presents a simple explanation of the various methodologies for examining health inequalities. The article by Schneider et al. provides a guide for calculating indicators and discusses the advantages and disadvantages of each of them. This issue of the Epidemiological Bulletin includes a summary of the introduction and the type of indicators and their characteristics; subsequent issues will present the methodology for calculating the indicators most frequently used to measure inequalities in the field of health, including rate ratio and rate difference, effect index, population attributable risk, index of dissimilarity, slope index of inequality and relative index of inequality, Gini coefficient, and concentration index.
Outline of the Inequality Journal of Health
Inequities in health are the differences in
the levels of health among distinct socioeconomics groups that are considered
unfair, on the basis of a detailed judgment of their causes.1 Similarly, Kawachi,
Subramanian & Almeida-Filho2 define inequities in health as the inequalities in health that are considered
unfair or stemming from some form of injustice. Common to the different published
definitions of inequities in health, is the underlying assumption of injustice.3 Then, to evaluate inequities in health, there is the need for making possible
the measurement of fairness in a given society. Although some methodologies
have been proposed, all are based in a necessary judgment of value and are
dependent of the adopted theory of justice and the accepted explanations
for the etiology of the observed inequalities, involving therefore a political
conception.2,3 Consequently, the International Society for Equity in Health
adopts, as operational definition, that inequities are “systematic
[and potentially remediable] differences in one or more aspects of health
status across socially, economically, demographically or geographically defined
populations or population sub-groups”.4 A readily measurable dimension
of this concept, that has allowed an approach of the iniquities in health
in a society, is that of inequalities in health. These are understood as
a generic term that involves population differences, variations and disparities
in the health achievements of individuals and groups that need not imply
moral judgment of these differentials, nor strict considerations on their
remediation.2
Recently, a great interest in the subject of inequities and inequalities in
health has been noticed. Several studies have pointed out the important magnitude
of health inequalities in countries with varying degrees of development. In
addition, and more disturbing, is that regardless of a general improvement
of the average population health conditions, an increasing trend of health
inequalities occurred in recent years in many regions. The importance of health
policies as instruments to correct and decrease those inequalities in highlighted
each time more frequently; however, when existing inequalities are ignored,
policies may influence the health sector in such a way that the sector could
actually constitute another determinant of the amplification of health inequalities
in a society. In this regard, the concept of equity in health services must
also be mentioned, which implies that there should be no differences in health
services where health needs are equal (horizontal equity) or that improved
health services be provided where greater health needs are present (vertical
equity).5 Obviously, the issue of inequalities in health and their marked socio-economic
determination is not a subject that only concerns the health sector, both with
respect to its conceptual frame, as well as from the perspective of the identification
and development of effective interventions for their solution. Due to the variety
of determinant factors involved in the causal net of health inequalities, a
muti-sectoral approach, with policies, programs and interventions leading to
reduce or limit the negatives effects on health, are required.
The subject of the inequalities in health has been an important object of
attention of the Pan American Health Organization (PAHO) at a right time, integrating
the concept in its mission for strengthening the use and analysis of information
on inequalities for public health management in the Americas. In addition,
several initiatives to stimulate the theoretical-conceptual debate on this
subject have been adopted and a great effort devoted to promote the institutionalization
of evidence-based practices that aim equity in health among population groups
of our societies. Among these practices, the need for monitoring and surveillance
of health inequalities and the assessment of their etiology, which frequently
show important local specificities, are highlighted. Accordingly, PAHO has
made available technical information, methodologies and other materials to
facilitate the approach of health inequalities within the practice of the health
services, and for the sensitization of the health professionals, in particular
decision makers, regarding this theme.
One of PAHO’s recent specific initiatives in this direction has been
the publication of a special issue of the Pan American Journal of Public Health
on “Measuring Health Inequalities” that was distributed in December
of 2002. This issue included six original articles and three current topics.
Moreover, it contained a special guideline on “Methodologies for measurement
of health inequalities”. The following section presents a brief commented
summary of these articles.
The articles by Barbosa, J. & Barros, M.B. [“Epidemiologia e desigualdades:
notas sobre a teoria e a história” – article in portuguese] and by Starfield, B. [“Equity in health: perspective on non-random distribution
of health in the population” - current topic in english] present a conceptual
historical framework on the subject. Barbosa & Barros introduce the history
of the precursory thoughts that lead to the current conceptualization of the
health inequities that is amply discussed on the basis of a relevant bibliographic
review. The article includes historical explanations of disease causation in
human populations and its inherent health inequalities, as well as the development
of the role of Epidemiology in this context. The article by Starfield, starts
indicating that heath inequalities do not occur randomly, and discusses the
determinations of clustering of health-related problems identified in human
populations. The author proposes a complex net of causality of health states
and determinant risk factors that serves as the basis for understanding that
health events aggregate in a systematic way (and not at random). She also points
out that it is very unlikely that this complex causal net acts in the same
way in all areas/regions and calls the attention on the need for further studies
on the genesis of health inequalities. She concludes suggesting that the information
and knowledge originated from such studies be translated into effective actions
for problem solving.
Another article adds a reflection on the situation of inequalities in health
in the Americas, including examples of different methodological approaches
used for their measurement, presented by Alleyne, G.A.O,
et al. [“Overview
of social health inequalities in the region of the americas using different
methodological approaches” - article in english]. In this work the authors
carry out a descriptive analysis of the health situation in the region of the
Americas, followed by an exploratory approach of the social inequalities in
health among countries in this Region. Highlighting the great disparities in
health status and in some of their determinants, the authors indicate that
the search for equity in health is not only a theoretical matter, but a concrete
reference for technical cooperation among countries, once that equity is recognized
as an imperative assumption required to achieve an integral human development
in the Region.
As examples of analyses of health inequalities in countries of the Americas,
the journal includes the articles by Duarte, E.C., Et
al. [“Expectativa
de vida ao nascer e mortalidade no brasil em 1999: uma análise exploratória
dos diferenciais regionais” – article in portuguese] and Gattini,
C; Sanderson, C. & Castillo-salgado, C. [“Variaciones de indicadores
de mortalidad evitable como aproximación a desigualdades en salud en
comunas chilenas” – article in spanish]. In the work carried out
in Brazil (Duarte et al), the inequalities in health among the Brazilian regions
and states were studied, with emphasis on life expectancy at birth, infant
mortality and child mortality (children less than 5 years of age) according
to specific causes (diarrheal and acute respiratory diseases), and mortality
rates due to external causes (homicides and traffic accidents). Ecological
associations between the selected health indicators and socio-economic and
demographic indicators were analyzed. The study results indicated a pattern
of health inequalities in Brazil with a marked intra-national and intra-regional
polarization, as well as juxtaposition of diseases related to both underdevelopment
and development. This complex situation demands more specific actions from
the health sector aiming to minimize these inequalities. The article by Gattini,
Sanderson and Castillo-Salgado analyzes the variation of preventable mortality
indicators, as an approach to assess the magnitude of health inequalities,
among distinct geographical areas. They used for this methodological approach,
health data from small geographic areas in Chile. The authors observed significant
inverse (negative) associations between preventable mortality indicators (potential
years of life lost, preventable mortality rates and infant mortality rates)
with those of socio-economic development and discussed the implications of
their findings for policies on prioritization to those areas with the worst
situation and on increased coverage to prevent the highest number of deaths.
The special issue of the journal includes, in addition, some useful methodological
experiences for the study of health inequalities that are described as follows.
In the article on ‘methodologies for the measurement of health inequalities’ [Schneider,
MC et al. “Metodologias para la medición de desigualdades en salud”– report
in spanish] the authors discuss appropriate indicators of health situation,
health services and socio-economic status for studies on health inequalities.
In addition, they describe selected basic methodologies for measuring health
inequalities, which may be useful for the health services settings at their
various levels. The circumstances and levels of application as well as advantages
and limitations of the different measurement methods are also discussed.
Using a theoretical and practical approach, Bacallao,
J. Et al [“Indicadores
basados en la noción de entropía para la medición de las
desigualdades sociales en salud” – current topic in spanish], describe
the advantages for measuring inequalities based on the notion of entropy. This
concept has its origin in the Physics, the Statistics and the Information Theory.
In this article, the authors started with a review of the classic indicators
used for measurement of health inequalities, and then describe the indices
based on the notion of entropy. Regarding this last aspect, the definitions
and the properties of such indices are discussed and examples of their use
for measuring health inequalities included. The authors’ conclusions
are in favor of the usefulness of these indices in the field of inequalities,
considering that some of their properties are unique to this end.
The article by Metzger, X [“Agregación de datos en la medición
de desigualdades e inequidades en la salud de las poblaciones” – article
in spanish] had as its objective to determine the consequences and adequacy
of using different levels of data aggregation for measuring of inequalities
in the health situation of populations. The author exemplified the calculation
of the most frequently used measures, having the infant mortality rate from
Costa Rica as health indicator. Metzger discusses the need for considering
the benefit vs. loss trade-off when opting between a higher or a lower level
of aggregation of geographical units used in health inequality studies. With
the Costa Rica example, the effects on the consistency of results obtained
from studies that use larger aggregates are described. The author concludes
that some measures generate important result discrepancies according to the
different levels of aggregation utilized and recommends considering the study
objectives to guide an adequate selection of methodologies to be used.
In another article, Loyola-Elizondo E., Et al. [“Los sistemas de información
geográfica (sig) como herramienta para el monitoreo de las desigualdades
en salud” – article in spanish], discuss the usefulness of Geographic
Information Systems (GIS) for monitoring health inequalities, highlighting
their capability for data and information integration from different sources
and types and their subsequent processing. This allows simplifying, improving
speed and automation of epidemiological analyses at diverse levels of aggregation.
To illustrate the properties of GIS, the authors used as example the inequalities
on the infant mortality rates (because it is one of the indicators with broadest
coverage) in the countries of the region of the Americas, according to socio-economic
indicators, analyzed in three different levels of aggregation (regional, national
and local). They conclude that, based on the definition of the magnitude and
distribution of health events and their determinants, the adequate use of GIS
in the study of health inequalities contributes to facilitate public health
management. In addition, GIS enables focalizing and planning of interventions
in the high priority areas and groups, among other applications.
The compilation of these articles in the special issue of the Pan American
Journal of Public Health constitutes a useful instrument to initiate the debate
on the need to include the subject of health inequalities in the agenda of
decision makers in the health sector.
The articles may be reviewed in full in their electronic version at the following
Internet address:
http://www.scielosp.org/scielo.php?script=sci_issuetoc&pid=1020-498920020012&lng=en&nrm=iso
References:
(1) Kunst AE & Mackenbach JP. Measuring socioeconomic
inequalities in health. Copenhagen: WHO Regional Office for Europe, 1994. 115
p.
(2) Kawachi I, Subramanian SV & Almeida-Filho N. A glossary for health
inequalities. J. Epidemiol Community Health. 2002; 56:647-652.
(3) Macinko J & Starfield B. Annotated Bibliography on Equity in Health,
1980-2001. International Journal for Equity in Health. 2002; 1(1).
(4) International Society for Equity in Health. The Toronto Declaration on
Equity in Heath. Conference Statement: 2nd International Conference. Toronto,
June 2002.
(5) Starfield B. Improving equity in health: A research agenda. International
Journal of Health Services. 2001; 31(3):545-566.
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Epidemiological
Bulletin , Vol. 25 No. 4, December 2004
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