ROUND TABLE DISCUSSION
Understanding and setting up the process for health equity
Senior Research Associate, Department of Health Policy and Management, Harvard School of Public Health, Fourth Floor South, 124 Mount Auburn Street, Cambridge, MA 02138, USA. E-mail: firstname.lastname@example.org; tel. +1 617 496 8841, fax: +1 617 496 8833
Simply put, one of the central questions raised by Gwatkins lead article is: why do we keep on "talking the talk" but not "walking the walk", when it comes to achieving health equity goals? Recent years have seen a renewed interest in health equity, as reflected in part by a significant increase in the number of international initiatives and published studies (1, 2). While different views have been expressed regarding how to define and measure health equity, a conviction shared by many is that expressed by Gwatkin, that "what matters are not societal averages with respect to health, but rather the health conditions that prevail among different groups within society, particularly among disadvantaged groups". But why has this conviction not been translated into policies in any noticeable way? There might be two basic reasons for lack of action on the health equity front. First, societies may not be highly motivated to take action. Second, they may want to take action but not know what exactly that action should be. I would argue that to help move from analysis to action, we need to fill two important knowledge gaps: an understanding of the political process for setting health equity goals, and empirical evidence on how practically to achieve those goals.
Understanding the process
There usually seems to be an implicit assumption embedded in health equity studies that epidemiological evidence on determinants of health and health equity will inevitably lead to the development of more equitable policies. That may help to explain why the majority of these studies tend to focus on finding a clinical explanation for the link between low social status and ill-health. As pointed out by Rich & Goldsmith, however, epidemiological information is but one input into the political decision-making process, and often a minimal one at that (3). Social, economic, and political forces that produce and sustain inequities in the first place might be more important (4). Compared to the abundant measurement studies and prescriptive policy analyses that come out, there is a serious lack of positive enquiry into the political process of generating health equity goals in different societies. At present we do not know why health equity is defined differently in different societies, or what makes policy-makers care about health equity, or why specific health equity goals have been put on the political agenda in some countries but not in others.
As any equity-oriented health policy changes seek to expand benefits for relatively powerless population groups and promise to impose new costs on relatively powerful groups, the resulting political challenges are significant. The demise of the Clinton health reform in 1994 vividly illustrated for the world the importance of politics: politics affects the definition and explanation of a policy problem, the way it is formulated, its recognition or denial, and the implementation of public policy aimed at solving it (5, 6). For industrialized as well as developing countries, therefore, the success of health reforms aimed at increasing health equity requires in-depth political analysis and astute political management. Would-be reformers have to find out who the movers and shakers are in formulating health equity policies. Then they need support in assessing the political feasibility of a policy, managing the process of policy design and acceptance, and thinking up strategies that improve the prospects of implementation. For this, applied political analysis provides a relevant assessment procedure to probe the political dimensions of policy-making in ways that increase effective interaction and enhance the quality of the reform process. Some tools such as PolicyMaker, a computer software program for political mapping, can be readily applied for this purpose (7).
Setting up the process
Whenever and wherever political will is in place, the next question naturally arises: what are the most feasible and effective strategies for reducing inequities in health and health care? The basic source of information for policy-makers in their search for viable options is domestic and international experience of what has worked and what has failed. Intervention studies aimed at achieving specific equity goals represent a cost-effective way of providing policy-makers with the most relevant information. Some policy changes may work on paper but not in practice. Before applying a new policy nationwide, a country might want to try it out in some representative local communities. In this way even failed pilot projects can provide valuable lessons and yield the benefit of avoiding high costs associated with setting up an unproven scheme on a national scale. To illustrate this point, I shall draw on experience from an on-going project in China, in which I had the privilege to be closely involved (8).
In 1993, UNICEF launched the Basic Health Care for Chinas Rural Poor project. Initially, this project focused on building up a thorough understanding of the health and poverty problems of 114 poor counties in China, especially among minority ethnic groups. Drawing heavily on the research findings of the first phase of this project, the Chinese government decided at the first National Conference on Health Policy in December 1996 that a viable system for financing and delivering basic health care to Chinas rural poor was a top priority. In the light of the large variations in socioeconomic and cultural backgrounds across rural China, operational field research was needed for the successful implementation of this policy.
The second phase of the project has been under way since 1997 to field test an entirely new system for financing and organizing health care in 10 pilot counties. Key elements of the pilot project include:
provision of basic medical equipment and essential drugs to needy villages;
creation of a revolving fund to make sure clinics can afford to replenish drug supplies;
establishment of a two-tiered health protection system.
The first tier of this system is a community-level Cooperative Medical Fund to pay for basic preventive and curative services. Each of these funds is financed by the farmers and rural industries and managed by local people. The second tier is a Hospital Insurance Fund to cover catastrophic medical expenses for the poor. The fund is organized at the county level, with seed money from donors and matching funds from government sources. Encouraging results from the pilot interventions have prompted the Chinese Ministry of Health to work with the World Bank (the World Bank Health Loan VIII to China) to expand these models to other poor regions in China. At the international level, governments and health planners in countries such as Viet Nam and Bangladesh are keeping a close eye on the projects progress. It is viewed as one of the viable models for combining external assistance with local community participation to enhance health equity.
Needless to say, the limited experience of some local communities cannot and should not be seen as a recipe for a whole nation, and one countrys successful models cannot and should not be blindly transplanted into another country. Nonetheless, such evidence does raise a question: do we learn more powerful lessons from "talking" or from "walking"?
1. Van Doorslaer E, Wagstaff A, Rutten F. Equity in the finance and delivery of health care. Oxford and New York, Oxford University Press, 1993.
2. Equity in health and health care: a WHO/SIDA initiative. Geneva, World Health Organization, 1996 (unpublished document WHO/ARA/96.1).
3. Rich RF, Goldsmith NM. The utilization of policy research. In: Nagel S, ed. Encyclopedia of policy studies. New York, Marcel Dekker, 1983.
4. Navarro V. The political economy of the welfare state in developed capitalist countries. International Journal of Health Services, 1999, 29(1): 150.
5. Rochefort DA, Cobb RW, eds. The politics of problem definition: shaping the policy agenda. Lawrence, KS, Kansas University Press, 1994.
6. Sabatier PA. Public policy: toward better theories of the policy process. In: Crotty E, ed. Political science: looking to the future, volume two: comparative politics, policy, and international relations. Evanstan, Northwestern University Press, 1991.
7. Reich MR, Cooper DM. PolicyMaker: computer-assisted political analysis (Software and manual). Newton Center, MA, PoliMap, 1996.
8. Liu Y et al. Is community financing necessary and feasible for rural China? Health Policy, 1996, 38(3): 155171.