Socioeconomic inequalities in health
Social Inequalities in Health
Equity in health is a cardinal expression of social justice, attained when every individual has the opportunity to reach his full health potential and no one is excluded or hindered from reaching that potential because of his social status or other socially determined circumstances. This ethical imperative is accompanied by a political imperative, since today it is recognized that social equity is a prerequisite for good governance. Thus, equity is a political objective that consists of creating equal opportunities for health and well-being. Indeed, without social equity, sustainable human development cannot be guaranteed (). In recognition of this, “Transforming our world: the 2030 Agenda for Sustainable Development,” embraced by every country in the world in 2015, has explicitly promised that no one will be left behind ().
Two inseparable notions: equity in health and the social determinants of health
Aspiring to equity in health, including universal access to health and universal health coverage, implies altering the underlying distribution and role of the social determinants of health—that is, the circumstances in which individuals are born, grow, live, work, and age and the broader array of forces and systems that affect those circumstances, such as the global, national, and local distribution of wealth, power, and resources. Transformational action that addresses the social determinants of health and promotes equity in health requires, on the one hand, abandoning public health practices based on the risk-factor paradigm, in which the individual and behavior are the focus, while, on the other hand, adopting a more comprehensive approach to public policy that empowers individuals and communities to exercise control over their circumstances—a multidisciplinary and essentially intersectoral approach under the principle of Health in All Policies.
The Americas: a vibrant region plagued by persistent inequities
Guaranteeing the universal right to health will remain simply an aspiration if the profound social inequalities behind the health gaps in the Region are not addressed. Empirical studies offer clear proof that the population groups with the worst health outcomes in the countries of our Region also are those that demonstrate the tangible expressions of socioeconomic inequality, including low income and consumption levels, poor housing, job insecurity, limited access to quality health services, fewer educational opportunities, inadequate access to water and sanitation services, marginalization, exclusion, and discrimination, among other adverse social and health situations ().
Evidence of the stubborn persistence of profound social inequalities, exclusion, and discrimination—and, thus, profound inequalities in population health and the burden of disease—is present even in Latin American countries where “post-neoliberal” political, economic and social reforms have been implemented to counteract the neoliberal model that emerged in the 1980s (). One possible explanation for this could be a certain myopia in the policies designed and implemented, even in those consistent with the universal right to health.
According to Garcia-Subirats et al., 20 years after the introduction of reforms to increase equity in access to health care, inequities (defined in terms of unequal use for equal need) are still present in both Brazil and Colombia (). According to these authors, the inequalities in the two countries illustrate the close connection between use of the health services and the design of each health system ().
For example, and delving a bit further into the matter, bridging gender gaps in health implies unmasking and addressing explicit and, especially, implicit, discrimination or bias in their various forms, which make public policies ineffective for women. The combination of gender based discrimination and the material constraints imposed by poverty and the consequences of other social discrimination (such as living in a neglected geographical area or belonging to an ethnic group subject to social discrimination), will lead to significant health service access barriers (even to services in the public sector) for certain women. In other words, the different forms of discrimination, which tend to fuel each other (intersectionality ) and, in practice, affect certain women, become real obstacles to taking advantage of public policies that, in theory, could benefit them. As a result, if the aspiration is to make the health system an effective equalizer that intervenes to improve the health of disadvantaged groups and, consequently, bridge the gaps in health, its design and implementation should be based on a paradigm that involves an analysis of the target populations’ most pertinent problem stemming from the array of inequalities, exclusion, and discrimination to which they are subject.
The causality between socioeconomic and health inequalities runs in both directions: on the one hand, conditions associated with poverty (such as economic insecurity, stress, and malnutrition) and different types of social discrimination directly affect people’s health and at the same time limit their access to health services; and on the other hand, poor health limits the potential for income generation and upward mobility by lowering school and work performance, thus reinforcing the patterns of social exclusion and discrimination.
A regional look at health through the window of the Millennium Development Goals: focusing on equity
Notwithstanding the historical structural impact of harmful colonial legacies, tremendous social injustice, and profound socioeconomic inequities (), the Region of the Americas, and Latin America in particular, enjoyed macroeconomic growth for much of the period 1990–2015, characterized by a reduction in poverty, extreme poverty, and inequality in income distribution—a period that has come to be known as the temporary window of the Millennium Development Goals (MDGs). As documented in this publication and its preceding edition (), the Region consolidated undeniable gains in health, meeting several of the targets set for MDG 4 (child mortality), MDG 6 (incidence of infection with the human immunodeficiency virus [HIV], tuberculosis), and MDG 7 (access to safe drinking water).
Despite the impressive overall improvements, a regional look at health through the window of the MDGs paints a different and more troubling picture when examined through the lens of equity. Achievement of––or progress toward––the health-related MDGs has not generally been accompanied by a systematic reduction in social inequalities in health, especially relative inequality, which tends to be the most sensitive indicator for determining the impact of policies targeting population segments at greatest social disadvantage to ensure that no one is left behind. An eloquent—and dramatic—example is illustrated for MDG 5 (maternal mortality) in Figure 1, which looks at the maternal mortality situation through the lens of equity.
Figure 1. Inequalities in maternal mortality in the Americas, by human development quartiles in the MDG period (1990–2015)
On average, the Region succeeded in halving the maternal mortality ratio between 1990 (101.8 per 100,000 live births) and 2015 (51.7 per 100,000 live births)—information that, in principle, is necessary and sufficient to determine whether or not MDG 5 (which established a 75% reduction) has been achieved. However, the histograms of human development quartiles among countries (Figure 1, left side) show that while the absolute gaps in maternal survival have been reduced—especially at the expense of a reduction in maternal mortality in the countries in the quartile with the lowest human development levels—gradients of inequality in maternal mortality persist. Both the regression curves (lower left-hand corner) and the concentration curves (lower right-hand corner) of social inequality (i.e., according to human development) for maternal mortality among countries in the Americas, which yield more sophisticated and detailed metrics of the inequality gradient (i.e., the slope index of inequality and the health concentration index, respectively), confirm this undesirable effect. In fact, 50% of maternal deaths in the Region continue to be concentrated in the 20% of countries with lower human development levels—a situation that did not change in the period 1990–2015. These women represent the people we have left behind.
There is documented evidence of health inequalities between countries—analogous to those illustrated here with maternal mortality—involving other health outcome indicators and other stages of the life course (). For example, a regional study of the burden of tuberculosis incidence in the Americas between 2000 and 2013 found that the absolute inequality gradient (measured as the slope index of inequality) was virtually constant throughout the period: around 54 excess new cases per 100,000 population in the countries with the lowest human development versus those with the highest human development; the relative inequality gradient (measured as the health inequality concentration index) grew even more steeply (shifting from –0.20 to –0.24 between 2000 and 2013): 40% of the regional tuberculosis incidence burden in 2013 was concentrated in the quintile of countries with the lowest human development (). Similarly, recent studies using double stratification have documented the presence of profound educational and gender inequalities in the risk of death () and the burden of blindness () in the countries of the Region.
More eloquent still is the available evidence on health inequalities within countries, based on microdata from population surveys. The distinguished International Center for Equity in Health of the Federal University of Pelotas in Brazil—a new PAHO/WHO Collaborating Center on Equity in Health—has produced a detailed study that, using data from demographic and health surveys (DHS) and multiple indicator cluster surveys (MICS), systematically documents the magnitude and extent of social inequalities in reproductive, maternal, newborn, infant, child, and adolescent health in many of the countries in the Region that have these surveys for the MDG window. These unjust inequalities in health outcomes, health coverage, and access to health services and programs, are reproduced in inequality gradients in income and wealth, access to education, and the urban-rural, male-female, and geographic dichotomies (). On a more positive note, this study also notes the gradual progress toward universal maternal and child health care observed in some countries, which have managed to reduce extreme absolute inequalities among social groups. Another study, conducted in 14 Latin American countries, documented the presence of profound sociogeographic inequalities in the distribution of ophthalmologists and underscored the critical implications of redistributing human resources for the gradual achievement of universal health ().
The persistence of inequities and inequalities in the Region
The Region of the Americas—and Latin America and the Caribbean in particular—continues to have the dubious distinction of being one of the regions of the world with the greatest social and health inequities (), especially in terms of inequality in income distribution (the starting point for the construction of the imaginary group on regional inequality). The social, economic, and health inequalities observed and felt in the streets and among the peoples of our Region tend to be the product of something more deeply rooted and, therefore, less evident: policies, laws, and regulations whose design and implementation reflect the persistent inequality of access to power in our countries.
In an article published in 2006, Navarro et al. () noted the scarcity of scientific research on the connection between political power, health policy, and people’s health. In order to bridge this knowledge gap to some extent, these authors developed and tested a model that linked political and power resources with two types of public policies (labor market policies and government welfare policies) and their effects on income inequality and mortality levels in the majority of the Organisation for Economic Co-operation and Development (OECD) countries from 1950 to 1998. The countries studied were grouped by the political tradition that had governed them for the longest time during the period in question.
Some of the conclusions of this study reinforce the idea of the connection between political contexts and certain health outcomes: the duration of governments headed by pro redistribution parties in the period 1950–1998 played an important role in reducing income inequality and infant mortality in the OECD countries analyzed ().
The Navarro et al. findings serve as a frame of reference for the Region’s experience in from 2000 to 2010 and the fight against poverty and its relation to the political context at that time. Contrary to the situation in the 1990s, the 2000s were characterized by economic growth, coupled with a reduction in poverty and inequality in the vast majority of countries in the Region (). While the causes of the decline in poverty and inequality in the 2000s following their increase in the 1990s are still a matter of debate, the majority of these causes can be linked to high levels of economic growth, accompanied by the growth of employment and job earnings, or with a change in the political paradigm (expressed in a greater proclivity for public policies with a redistributive impact) or both. (). In any case, there is recognition of the significant role of public interventions in social and labor policy, which need further strengthening, and the reversal of certain pro-market reforms in some countries of the Region. The recent experience in Brazil exemplifies this: some estimates indicate that around 17% of the direct decline in income inequality in that country between 2001 and 2011 was due to conditional transfer programs— specifically the Bolsa Familia and Beneficio da Prestação Continuada programs; 19% to contribution- and non-contribution-based pensions; and 58% to the growth of job earnings ().
In fact, “politics are important in designing, creating, and guaranteeing the sustainability of legitimate institutions and adopting public policies that work to the benefit of all citizens” (). However, the extreme inequality that characterizes the Region can alter the policy-making process, even in democratic contexts in countries where pro-redistribution parties are in power, for it often translates into in imbalances in the way in which the power to influence the political process is distributed in a society. As a result, the real potential of those who lack that power to overcome poverty and exclusion and thus enjoy decent and satisfactory living conditions, including robust health, will be diminished. A study that explores access to justice and the right to health in Brazil from the standpoint of equity in health is useful for exemplifying how the aforementioned asymmetry works in practice. At the time of publication (2009), the author of this study warned about the potentially negative impact of Brazil’s litigation model on equity in health:
The model is characterized by the prevalence of individual lawsuits requesting curative care (often medicines) and a high success rate for litigants. These two elements are largely the consequence of the way in which Brazilian judges have interpreted the enjoyment of the right to health recognized in Articles 6 and 196 of Brazil’s Constitution—that is, as the right of individuals to meet all their health needs with the most advanced treatments available, regardless of cost. Since resources are always scarce in relation to the health needs of the population as a whole, this interpretation can only be sustained at the expense of universality (…). Individuals and (less often) groups that can resort to the courts and exercise this right are therefore privileged over the rest of the population. This is potentially prejudicial to equity in health, because privileging litigants over the rest of the population is not based on any concept of need or justice, but rather, on their ability to resort to the courts, which only a minority of citizens can do ().
Policy-making involves the discussion, approval, and implementation of public policies. It can be understood as a negotiating or transactional process among stakeholders that unfolds in both formal and informal settings. When this process occurs in contexts of profound inequalities, the circumstances, realities, and agendas of the elites—the privileged stakeholders who hold all the power to influence the political process—tend to be reflected in the resulting policies that govern our societies, which reinforces the culture of privilege that prevails in our Region (). As the Economic Commission for Latin America and the Caribbean (ECLAC) points out, reducing the entrenched social inequalities in the Region urgently requires a “shift from a culture of privilege to a culture of equality” ().
The elites use various means to influence the political process in their favor. These range from practices that are not illegal but are a topic of growing concern and debate, such as the lack of transparency in lobbying, the private funding of electoral campaigns or political advertising, to mechanisms that are undesirable, such as “revolving doors” and the concentration of media ownership (which facilitates the dissemination of certain ideas or beliefs and stifles others that oppose the agendas of the elites), or are frankly illegal, such as threats and assaults against journalists, patronage (where public employment and the delivery of public services are considered an exchange of favors), political cronyism, or corruption ().
In any case, the Gordian knot of the issue lies in the fact that the elites and their networks, with their ideas and resources, can be synonymous with forces having great potential to shape the conditions for generating and appropriating the economic surplus in their favor and slanting the workings of government institutions against the public interest. In extreme cases, the elites can come to have a permanent influence on the different branches of government, even when there is a change in the head of the executive branch and political party represented. For example, the elites can exacerbate or take advantage of imbalances in the customary systems of checks and balances among branches of government, which exist to maintain the health of democracy, or of regulatory deficiencies or omissions in key areas. In this regard, Schneider () states that while judicial systems in the Region have become more independent and powerful with democratization, the elites have also been quick to exploit for their own benefit the prerogatives granted to these systems ().
Thus, the influence of the elites and their consequent co-opting of policies (for example, progressive taxation or policies that apply the principles of social justice to health policies) are not simply structural obstacles to combatting inequities but a violation of the basic precepts of democracy, debilitating its institutions and corrupting policy-making in general.
Today, given the sustainable development scenario promoted in the 2030 Agenda, PAHO has identified a key role in rendering policy-making more equitable in furtherance of the universal right to health at all stages of life. First, it must continue producing and disseminating specific analyses and evidence related to the social determinants of health—that is, on the close correlation between certain characteristics of the broader political, economic, and social context (structural determinants) and the social conditions of various population groups (intermediate determinants), the interaction between these groups and their physical and mental health status, and the distributive inequality imposed by the social determinants on the rest of society. These studies should reflect the magnitude of the changes in the paradigms of analysis and practical intervention, which are key to reducing health inequities.
It will also be essential to ensure that that evidence is reflected in the recommendations on public health policies (including those related to health service access, which is one of the channels for translating socioeconomic conditions into health conditions) and on social and economic policies, broadly speaking. Moreover, guaranteeing that health is not just the privilege of the few in the Region also implies the need to facilitate technical cooperation for generating political advocacy to further social equity in health and the search for the common good.
No one left behind…? How to make good on our promise
Notwithstanding its undeniable and timely emphasis on equity, the 2030 Agenda and its Sustainable Development Goals (SDGs) do not have explicit targets or specific indicators for the reduction of social inequities in health or progress toward equity in health, beyond recommending greater availability of data disaggregated by the variables that produce social stratification. We must build institutional capacity to measure, analyze, monitor, and communicate social inequalities in health; to manage statistics, data, and evidence honestly and responsibly; to inform policy-making; and to engender political advocacy to further equity in health throughout the life course. All of this is essential for creating and strengthening national capacity to make good on the promise that no one will be left behind on the road to sustainable development by the year 2030.
A recent and still unresolved debate on target setting for maternal mortality in the SDGs, published in The Lancet (), offers an eloquent example of the need for serious reflection on how to report on the impact of the 2030 Agenda on equity in health. SDG target 3.1 calls for reducing the global maternal mortality ratio to less than 70 per 100,000 live births by 2030. Although it has yet to be determined how this target can be incorporated at the national level, one proposal (Jolivet et al.) is to convert the global target to a relative national target equivalent to a two-thirds reduction in maternal mortality between 2015 and 2030. The other proposal (Kassebaum et al.) is to convert the global target to an analogous absolute national target—that is, to reduce maternal mortality to less than 70 per 100,000 live births by 2030. Figure 2 illustrates the potential distributive impact of maternal mortality between 2015 and 2030 on the social gradient, defined by income per capita quintiles among all the countries in the world, under these two proposals.
Figure 2. Maternal mortality worldwide by 2015 and 2030 income quintiles, according to two types of SDG target
At the conclusion of the MDG period (2015), the risk of maternal death was distributed very unequally among the countries of the world, according to the distribution of their income per capita (deflated and adjusted by purchasing power): there were 610 excess maternal deaths (slope index of inequality) along the length of the income gradient among the countries and an absolute gap of 436 excess maternal deaths in the poorest quintile of countries with respect to the wealthiest quintile (in other words, the maternal mortality ratio in the poorest quintile was 46 times higher than that of the wealthiest quintile: the relative gap). And this was in 2015 (top histogram). Again, these women are the people we have left behind. Under the figure is the distribution of maternal deaths established for the year 2030 at the end of the SDG period, according to the two types of target 3.1 proposals: Jolivet’s relative target (middle histogram) and the Kassebaum’s absolute target (bottom histogram), as well as the magnitude of the reduction in absolute and relative inequality, the gap, and the gradient associated with each scenario—that is, the intensity of potential fulfillment of the promise that no one will be left behind.
This exploratory prospective analysis yields a message of the greatest importance for the success of the 2030 Agenda: only through a systematic analysis of unjust and avoidable social inequalities in health will it be possible to visualize who we are leaving behind; this implies building institutional capacity to study the distributive equity of health gains (in terms of access and outcomes) in socially determined population groups, as well as quantifying the magnitude of social inequality in health through standardized composite metrics over time and throughout the life course. Moreover, only by monitoring inequalities will it be possible to verify the impact of pro equity policies and progress toward keeping the promise that no one will be left behind. This requirement of reporting on the progress toward equity in health was clearly anticipated in 2008 in the final report of the WHO Commission on the Social Determinants of Health, whose third general recommendation invokes the need for evidence: without it, the call for equity and social justice will be reduced to mere rhetoric. Despite the complexity of a regional scenario historically marked by profound inequities, the peoples of the Americas have been taking firm and determined steps toward reducing poverty and social exclusion at the dawn of the new millennium; the primacy of the principle of equity, expressed in the commitment to ensuring that no one is left behind on the road to sustainable development by 2030, should provide reasons to build, with optimism and determination, the fairer, more inclusive, equitable, and cohesive societies that the Region needs for sustainability and health.
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