ROUND TABLE DISCUSSION
Equality, equity: why bother?
George A.O. AlleyneI,1; Juan Antonio CasasII; Carlos Castillo-SalgadoIII
IRegional Director, Pan American Health Organization, Regional Office for the Americas/Pan American Sanitary Bureau, 525 23rd Street NW, Washington, DC, 20037, USA
IIDivision of Health and Human Development, Pan American Health Organization, Washington, USA
IIIHead, Special Program for Health Analysis, Pan American Health Organization, Washington, USA
The excellent papers in this theme section of the Bulletin aim mainly at defining the inequalities in health that occur, and Gwatkin presents some interesting aspects of the problem of how to reduce them. It is usually assumed that inequalities in health are undesirable and should be reduced, but the reasons for this are not always made explicit.
The reason most commonly adduced is that it is morally indefensible not to allow all human beings to enjoy what is often posed by Amartya Sen as one of the essential freedoms and the mechanism through which other freedoms can be enjoyed. There is a cap on the level of health that can be attained if one uses commonly accepted measures such as mortality and morbidity indicators. For material goods, however, there is in theory no limit to the potential gap between those who are best and worst off. The case is made that for an essential requirement such as health the gaps that can be reduced should be.
In addition we concern ourselves with inequalities in health because we believe that they may be a cause of social instability. Inequality in health or in access to measures that ensure it can foment discontent and intergroup enmities that disturb the social order within a country. Likewise the differences between countries contribute significantly to the instability of the world. Unfavourable conditions in human health and the environment in some countries are seen to be threats to the security of the more favoured ones. Men and women do not usually use health as a yardstick of achievement or strive to be healthier than others, but they do regard it almost as a right to be as healthy as others and to have access to the means of being so.
Finally there is the prosaic consideration that health is one of the ingredients of human capital that is so essential to other aspects of development. Unequal access to measures that lead to formation of human capital inhibits the reduction or alleviation of poverty. Improvement of health status and the reduction of health inequalities are more and more recognized as essential ingredients for schemes to reduce poverty.
Our concern is not only instrumental. We wish to ground our comment firmly within the historical background of thinking and practice in the World Health Organization over the last two decades. We place the concern for health differentials squarely within the context of the goal of health for all, which has equity as its underlying value and sees inequalities in terms of the social injustice implied by inequity. This framework is in no way inimical to efforts to identify the inequalities that represent inequities and seek measures to reduce them.
The policy issues that these papers raise include the need to establish with more precision some measure of the inequality that exists with regard to health status or outcome. These inequalities can only be deemed inequities if they are unjust and their determinants lend themselves to being manipulated so as to reduce them. Thus, while we acknowledge the need for a measure of the distribution of health status in order to establish the degree of inequality, this can only be a first step if we believe that these differences can be reduced. The real issue is the relation of these differences or inequalities to the distribution of the social determinants of the state of health or the distribution of that state itself.
Gwatkin makes a powerful argument for the significance of the distribution of health outcomes. National averages hide the differences that need to be tackled in order to reduce inequity. But this welcome focus has very practical implications: most of the countries in the Americas do not have the tools to make these determinations, and in many cases they do not see the need for producing the data in a form that shows the relevant distribution and gaps. Only recently has it been possible to organize health data with the degree of geographical disaggregation that will determine the inequalities that exist between the different areas and population groups concerned. The political drive towards decentralization has assisted by making it necessary to have these kinds of data in order to determine resource allocation.
Apart from the measurement issues, the main concern in public health is whether these inequalities or inequities can be reduced. Some governments are making it national policy to reduce them. Those inequalities in the determinants of health that can be considered unfair, unjust, avoidable and therefore reducible can be divided roughly into three main categories: inadequate access to essential health services, exposure to unfavourable social and living conditions, and health-damaging behaviour that cannot be modified by individual choice alone.
The major thrust of most of the health reform movements in both the industrialized and the developing countries is the equitable provision of services. "Equitable" is assessed in terms of access to and use of services that are no longer segmented in the manner traditional to the Americas. A novel effort of investigation in this area bears some promise. Large segments of our populations are in the informal sector, by definition poor, mainly female and without access to a social security system. The possibility of establishing micro-insurance schemes is being explored, with the thesis that schemes that are grounded in the local environment will be more responsive to the needs of the local population who, partly because they are economically and socially poor, do not or cannot pay the transactional costs involved in obtaining the traditional services.
Another challenge for the services is to ensure the equitable delivery of the health technologies that have been shown to be effective in improving health. Our services have remarkable success with technologies or interventions that are supply-driven, such as immunization, while those that are demand-driven, such as treatment or prophylaxis for chronic diseases, are inequitably delivered, with the distribution favouring the prosperous. We believe that the only feasible approach is to work for a better understanding of the information needs of the different segments of the population, with the clear understanding that special communication techniques have to be developed for the poor. Information will be one of the most powerful tools for ensuring the equitable provision and accessibility of essential health services.
The most important of the social conditions whose distribution makes an impact on health is income. The evidence now clearly shows that not only absolute poverty but also income inequality leads to unequal health outcomes. The solution lies outside the competence of the health sector except insofar as inequality in access to health as a contributor to human capital has an impact on poverty reduction. It has not yet been proved that investment in health affects income distribution. The role of the health sector here is essentially one of advocacy, pointing out that economic measures leading to a more equitable distribution of income and reduction of poverty will result in improved population health. We must also point out that there is evidence that investment in health itself enhances economic growth and therefore reduces poverty.
Changing health-damaging behaviour is doubly difficult when it is not a matter of individual choice. Much of the behaviour of the poor is the result of their social situation and is only to a limited extent within their own volition. Much more attention has to be given to the role of the community and other social groups in the adoption or modification of behaviour. It is of increasing interest whether behaviour such as smoking represents only individual choice when the techniques of advertising are so powerful and so skilfully targeted.
To the extent that most of the health inequalities lie outside the area of individual responsibility, the agent usually held responsible for identifying and rectifying them is the state. In many of the constitutions of our countries and in the international declarations on rights this responsibility is implied or made explicit. However, the nature of political processes is such that the most vocal and privileged groups often influence policy to make equity in the health of population groups a minor issue. We may hope that the currently increasing respectability of welfare economics and awareness of health as a social desideratum will help to make self-evident the need to reduce those inequalities that are unjust and are deemed to represent inequity. 
1 Correspondence should be addressed to this author.