BULLETIN 2000 FEEDBACK

Response to P. Braveman et al.

C.J.L. Murray^I; E.E. Gakidou^II; J. Frenk^III

^IDirector, Global Programme on Evidence for Health Policy, World Health Organization, 1211 Geneva 27, Switzerland
^IIHealth Policy Analyst, Economics Advisory Service, World Health Organization, Geneva, Switzerland
^IIIExecutive Director, Evidence and Information for Policy, World Health Organization, Geneva, Switzerland

In the above commentary, Braveman et al. criticize our papers (1, 2) for taking health inequalities across individuals as the starting point for efforts to standardize and promote the comparable measurement of inequality in health across populations. They interpret our approach as an attempt to “discredit research on social inequalities in health” and a “rejection of research on social inequalities”. It is neither. Nor is it “univariate”, as Braveman et al. suggest. What we have attempted is to construct a better dependent variable than the literature has provided so far: the distribution of health expectancy. With this dependent variable one can then analyse in a more rigorous fashion its social determinants. Far from “discrediting” or “rejecting” the scientific quality of research on social inequalities in health, our approach aims at improving it.

Braveman et al. seem to imply that the only valid way of carrying out social analysis is by constructing an a priori categorization of the population through a social attribute such as occupation or education. In contrast, we maintain that social research is introduced as part of the theoretical framework from which social variables are derived in order to explain the distribution of health. Using the distribution of health expectancy across individuals as the dependent variable is perfectly compatible with a theoretical framework where social variables such as income, education and occupation are used to explain that distribution.

Furthermore, we explicitly recognize the usefulness of the study of social group differences in health in developing estimates of the underlying distribution of health expectancy across individuals in a population (1) .

Below we respond to some of the more specific concerns raised by Braveman et al.

1. Geographical groups are social groups

Braveman et al. argue that “geographical comparisons are similar to social group comparisons in that both involve a priori selection of a categorizing variable based on knowledge indicating its likely relevance”. We agree with this statement, and have pointed out that “small area analyses may hold out the greatest promise for studying the extent to which social group health differences vary across countries” (2) and that “one particular approach to defining social groups, namely community location, has been much underutilized” (2). We also proposed that despite the limitations that small area analyses face, they do “hold out the promise of being one of the most refined methods for revealing the underlying distribution of health expectancy in a population” (1).

2. Health inequalities in the policy agenda

Braveman et al. argue that promoting the measurement of health inequality across individuals rather than the “social group” approach, “could be used ... to prevent social inequalities in health from occupying an important place on the global research and policy agenda”. This claim is very hard to understand. We believe that our efforts will place the critical problem of health inequalities prominently on the global agenda. The absence of comparable measures of health inequality across countries, such as those our approach is designed to achieve, is a major obstacle to placing health inequality more prominently on the global agenda. Thus WHO’s efforts to develop such a standard, comparable measure that can be used to make meaningful comparisons across countries is likely to bring more rather than less attention to the issue.

3. Determinants of health inequalities

Braveman et al. have misunderstood our statement that “defining health inequality as the difference in health status between social groups ... does not allow for scientific inquiry into other key determinants of health inequality across individuals” (2). If health inequality is measured only through social group differences, such as differences in education, health inequality that is not correlated to the social variable chosen will simply not be measured. If it is not measured then determinants of that population’s inequality cannot be investigated.

Braveman et al. claim that looking at differences in health status across individuals does not provide “even a general direction to look towards for an explanation of those inequalities”. We believe that the study of the determinants of health inequality across individuals in different countries will be a very interesting research question, which we hope that WHO and other researchers and institutions will be deeply involved in. Explaining why some countries do better in reducing health inequality is the logical step that will follow our current agenda of measuring health inequality across individuals.

4. Ethical basis for the study of health inequality

Braveman et al. criticize our approach in that it does not put more emphasis on caring for the poor than for the rich. They present the empirical, and most certainly true, claim that disadvantaged groups have on average worse health than advantaged groups. This fact will emerge and be fully captured in our efforts to measure and explain differences in health inequality across populations.

5. WHO and health inequality

In contrast to what Braveman et al. imply, WHO is placing renewed emphasis on the description and explanation of health inequality as a basis for developing more effective policies to reduce it. As an example of such emphasis, health inequality occupies a central place in the WHO framework for assessing health system performance. Through this instrument, WHO is promoting the routine measurement and reporting of health inequality across countries. The resulting evidence base will bring the important problem of health inequality clearly into the centre of the policy debate.

References

1. Gakidou EE, Murray CJL, Frenk J. Defining and measuring health inequality: an approach based on the distribution of health expectancy. Bulletin of the World Health Organization, 2000, 78: 42–54.         

2. Murray CJL, Gakidou EE, Frenk J. Health inequalities and social group differences: what should we measure? Bulletin of the World Health Organization, 1999, 77: 537–543.