ROUND TABLE DISCUSSION
Efficient equity-oriented strategies for health
Göran Dahlgren
Visiting Public Health Professor, Department of Public Health, Whelan Building, The Quadrangle, University of Liverpool, Liverpool L69 3GB, England
Inspired and provoked by Gwatkins interesting article on health inequalities, I am pleased to present the following comments and suggestions.
Define the setting
According to Gwatkin, it is only recently that concern for equality, equity and the health of the poor has begun to creep back into fashion. This may be true for some organizations such as the World Bank where Gwatkin has his office, but is certainly not true for all governments, international organizations and nongovernmental organizations, many of which have had this focus for decades.
Recognize the ideological environment
Gwatkin provides an excellent summary of some recent more sophisticated methods to measure inequities in health and health care services. Within this context, lack of data on social inequities is seen as a major constraint for initiating equity-oriented actions for health. This is only marginally true. The main determinant for action is of course the political will to tackle observed inequities in health. Even the best epidemiological records on social inequities in the world did not put equity in health on the political agenda in the United Kingdom under the former Conservative government. The same database has now, with a Labour government in power, been instrumental in formulating a comprehensive agenda for actions to combat social inequities in health.
Formulate equity-oriented targets
The importance of equity-oriented targets is also well described by Gwatkin. It must however be recalled that these targets have to be gender-specific, as the causes of social inequities in health and health care, as well as the magnitude and effects of those inequities, differ between males and females.
In addition to equity-oriented health targets, it is also of critical importance to formulate targets related to determinants of poor health in general and of social inequities in health in particular. Targets of particular relevance in this perspective could be specific reductions in terms, for instance, of absolute poverty and income differences, and improved access to clean water and proper sanitation as well as to basic education and health services. There should also be a focus on reducing unemployment and creating healthier work conditions.
The advantage of formulating targets related to the determinants of health is that actions aimed at reducing social inequities in health are related directly to these determinants rather than to poor health and premature deaths in themselves. Furthermore, the focus on both determinants and outcomes often reveals that there is a political consensus to reduce social inequities in health but far from any consensus to tackle the causes of these inequities. Thus this dual approach to target-setting is also useful for testing, to see if the equity targets in health are real or more likely to be window-dressing.
Equity-oriented strategies for health
Gwatkin is very vague about how to achieve equity-oriented targets for health. Instead of trying to suggest equity-oriented strategies for health for the coming decades, he dismisses efforts of the past such as the health-for-all movement and recalls that government-led socioeconomic development strategies are increasingly questioned. A more valid approach would have been to call for a real evidence-based assessment of positive and negative experience to date.
It is then of critical importance to distinguish between healthy and unhealthy economic policies. Examples of countries with unhealthy economic policies may be the Russian Federation, where male life expectancy declined from 64 years in 1990 to 58 years in 1994, and the United States, where black Americans as a group have a smaller chance of reaching advanced ages than people born in countries such as Sri Lanka and Costa Rica with a much lower per capita income.
The key indications of a healthy economic strategy are, as also recalled by Amartya Sen in his keynote address at the World Health Assembly in 1999 (1), the extent to which increased economic resources improve the incomes of the poor and are invested in public systems for health services and education. These findings also provide an important starting-point for understanding why, for example, the remarkable health achievements in China have been replaced by stagnation and even higher mortality rates among the rural poor during recent periods of unprecedented economic growth.
In a historical perspective, it thus seems as if the Alma-Ata Declaration and the health-for-all strategy provided not only a positive vision but, to a large extent, evidence-based equity-oriented strategies for health. It thus seems wiser to update and further develop these strategies in the context of the economic and social realities of today as WHOs Regional Office for Europe has recently done (2, 3) than to dismiss them as unrealistic.
Health care reforms benefiting the poor
The market-oriented health sector reforms introduced during the 1990s in high-income as well as low-income countries have often been driven more by ideology than by evidence. They have been seen as tools for cost containment and privatization rather than for improved health and access to health services. Considering the important role played by the World Bank in promoting such reforms, it is regrettable that Gwatkin is so vague about present and future World Bank policies for the provision and financing of health services for economically less privileged groups.
Awaiting clarification on this, I would like to suggest some points for consideration.
Measurements of efficiency should always be related to overall objectives, such as improved economic access to good health care. The key issue is thus not, as suggested by Gwatkin, how to make a trade-off between efficiency and equity, but how to find the most efficient way to achieve the equity-oriented targets. To do the wrong things more efficiently can hardly be considered a positive achievement.
Financial strategies for health must be progressive. Progressive financing can be achieved by direct public funding (with revenue from taxes) to providers of health services or by social health insurance schemes covering the whole population, or by a combination of these two. Direct user fees constitute the most regressive approach to health care financing. Experience indicates that high user fees can be a major poverty trap as people have to sell land or cattle or take a loan to pay their medical bills. In rural China, this is true for 40% of all patients. It means that private costs of medical services are a leading cause of impoverishment.
Access to and use of health care services must be according to need rather than according to purchasing power. This can be gradually achieved by increasing government funding either by direct payments to providers of health services or by subsidizing social health insurance schemes.
High user fees and health insurance schemes which only cover better-off groups usually increase both economic and geographical inequities in access to care. Systems for waiving and reallocating fees may at best only marginally reduce these negative effects. The magnitude of this problem can be illustrated by an example from rural China, where 40% of those reporting seriously ill said that they had not sought medical assistance because it cost too much, and nearly 60% of those for whom hospitalization was recommended did not apply for admission because they said they could not afford it.
China is not unique. The same problems are experienced in most if not all poor countries employing high user fees without securing public or community-based financing for all those who cannot pay.
In view of all this, an international organization such as WHO has an important role to play in promoting evidence-based strategies for efficient equity-oriented health sector reforms. 
1. Sen A. Health in development. Bulletin of the World Health Organization, 1999, 77(8): 619623.
2. Health 21. An introduction to the health for all policy framework for the WHO European Region. Copenhagen, WHO Regional Office for Europe, 1998 (WHO European Health for All Series, No. 5).
3. Health 21. The health for all policy framework for the WHO European Region. Copenhagen, WHO Regional Office for Europe, 1999 (WHO European Health for All Series, No. 6).