ROUND TABLE DISCUSSION
Overcoming inequity means finding approaches that work
Former Minister of Health, France; Consultant in Health Strategy, Santé International, 2 rue Cognacq-Jay, 75007 Paris, France
For a long time, international health statistics were crudely equated with the disparities in gross domestic product (GDP), and Gwatkin points out the inadequacies of such an approach. A more insightful one is now being devised, which involves analysing the situation of the vulnerable population on the one hand, and social inequalities in access to health care, on the other.
Two major earlier efforts have not provided the expected results. In spite of its far-reaching targets and global approach, "health for all by the year 2000" has not durably improved the conditions of the most vulnerable. And the structural approach, although it focused on the necessary reform of health care systems, has not reduced the inequalities between the rich and the poor either in industrialized countries or in developing ones, despite the drastic structural readjustment schemes the latter were forced to carry out.
Other approaches deserve consideration. They are perhaps less bold but could just possibly be more efficient in the long run. These would involve identifying a limited number of priority pathologies within a congruent geographic area. The next step would be to reform the organization of health services around the prevention and control of these diseases. In certain areas of the world, the example of acquired immunodeficiency syndrome (AIDS) may serve as a model. In southern countries where programmes for preventing perinatal transmission are being set up, there is a growing realization that the issues at stake call for comprehensive responses whose expected benefits will greatly exceed the AIDS framework. The aim is not to bring back unreplicable microschemes or airtight vertical programmes. It is to learn from the experience and findings of special programmes and use them to spur change throughout the health care system.
These approaches should help overcome the conceptual contradiction between equity and equality in health care. The purpose is to reconcile two priorities: an urgent response to the specific needs of the most vulnerable population (without triggering the perverse effects of excluding people who are not taken into account by these special procedures), and the necessity of working towards more equity in access to health care.
This latter objective must entail empowering people and giving them more freedom of choice. It involves tackling issues that are much broader than health care, such as education and womens status.