Equity in health: From concept to application in healthcare system

Equity is the prime virtue of social institutions, and its role is as truth is for human thought system [1]. Equity has been studied in various areas such as economics, politics, and judicial system. One of the areas of social equity that has recently been considered by experts is health. Health is defined as complete physical, mental, and social well-being. Health refers not only to the physical well-being, but also focuses on social, emotional, spiritual, and cultural well-being of the whole society [2]. Equity in health could be defined as absence ofunfair disparities in health. Since social equity and fairness can be interpreted differently by different people, its definition requires measurable functional criteria. For the purpose of functionality and measurement, equity in health can be defined as absence of disparities or systematic prejudices (or in the most important social determinants of health) among social groups with varying levels of social entitlementor deprivation in the social hierarchy. Health inequities systematically expose socially deprived groups to problems associated to their future health. Social entitlement or deprivation, based upon wealth, power, and prestige, determines how people are grouped in the social hierarchy. Deprivation may also be understood as being deprived that can be absolute or relative [3]. Not all health inequities are unjust, only those specific health inequalities systematically created between more and less entitled social groups are unjust. For instance, we expect young people to be healthier than older people. It is expected that baby boys weigh more than girls at birth. Men have prostate cancer problem and women do not. It is hard to judge all these inequalities unfair. Even though differences in nutrition or immunization between boys and girls, or differences in ethnicity or race could be a major concern to equitable approach in likelihood of receiving proper treatment for heart attack [3]. On the other hand, it could be argued that not all equalities are just, either. A clear example of this is a deprived group with severe health needs receiving similar level of services as an entitled and rich group [4]. The World Health Organization has considered three fundamental goals for health systems, which include health promotion of the population under cover, response to people’s non-medical needs,and equitable participation in provision of funds. It seems equity is an important factor in achieving these goals [5]. Health promotion is the first and undoubtedly the most important goal of health systems. However, the global health report of 2000 emphasizes that health promotion alone is not enough, and reducing health inequalities among groups must also be considered. Accordingly, there are two aspects to the goal of a desirable health the best attainable average level (being good), and the least difference between people and groups (being fair). The second goal of health system is responsivenessto people’s lawful expectations. Of course, responsiveness explicitly ignores expectations for improving population health, since these expectations are already reflected in the first goal (of health). Responsiveness has two components of respect for the individual and customer-orientation. The distinction between general level of health and its distribution among population also has an application in responsiveness. Being good, in health system responsiveness terms means that the health system can on average respond well to what people expect of it. Being fair in responsiveness means that the systems response to every person is equally good, and there is no distinction or prejudice in treating people. Fairness in responsiveness, just like distribution of health is important [6]. The third goal of health systems is fairness of financial contributions. The important issue is how fairly health systems can share their financial burden. To be fair in funding health systems, two main indicators must be considered first, households must not be impoverished or pay great portions of their income for providing healthcare. In other words, fairness in financial contribution requires application of advanced payment systems such as insurance systems based on people’s ability to pay and significant degree of risk accumulation. A healthcare system in which some individuals or households are forced further into poverty through having to purchase their needed healthcare, or else do not receive it, since they cannot afford the costs, is an unjust system. Second, payment for healthcare services rendered must not be such that less well-off people pay comparatively more than affluent people. The first problem can be solved by minimizing direct contribution from the pocket to the system, such that, predictable advanced payments that are unrelated to disease or provision of services, are as much as possible relied upon. The second problem can be solved by ensuring that, any form of payment has a rising trend, or at least is neutral in relation to income, and it is linked to capacity to pay rather than to health risk [5]. What was briefly described here was an examination of equity in health within the health system boundaries with especial attention to its main goals. Nevertheless, it must be admitted that the strongest determinants of equity in health are structural factors such as national wealth, income inequality, and access to education and employment. These are often referred to as social determinants of health [7]. These factors can accentuate the role of national governments and states in reducing health inequities. Successful governments can reduce health inequities in at least three ways. First, they can ensure that basic services are fairly distributed, and improve and protect human rights (including issues like healthcare and education), provide proper living standards, and ensure fair distribution of resources. Second, they can provide legal regulatory frameworks that could influence and monitor their own actions as well as other sectors’. Third, they can monitor health status of different groups of population, health consequences of social inequalities, and progress of actions to reduce in equities, and use this information to enforce sustainable interventions [8].