SERIE SOBRE EQUIDAD EN SALUD Y DESARROLLO SOSTENIBLE SERIES ON EQUITY IN HEALTH AND SUSTAINABLE DEVELOPMENT
OVERVIEW

 

Health equity: the linchpin of sustainable development

 

 

Francisco Becerra-Posada

Assistant Director, Pan American Health Organization/World Health Organization, Washington D.C., United States of America

 

 

The Region of the Americas, together with the rest of the world, is preparing to face the major challenges presented by the post-2015 sustainable development agenda (SDA), whose 17 objectives include health and wellbeing, the reduction of inequity, and action on a wide range of social and environmental determinants of health (1). In these times of change, the first of many lessons learned on the road toward achieving-or in some cases, not achieving-the Millennium Development Goals (MDGs) is that the principle of equity is an ethical imperative essential to guiding, informing, and defining political priorities for action on health and wellbeing. Rooted in the Health for All movement and in the legacy of AlmaAta, the principle of equity continues to inspire the spirit of universality and social inclusion required to implement the global and Regional post-2015 agenda, eliminate social inequities in health, and achieve the sustainable development goals.

If the mission of public health is to fully satisfy society's interest in ensuring conditions in which people can be healthy (2), then this mission-our mission-should focus primarily on mitigating the profound and ubiquitous social, economic, and environmental inequities that perpetuate a world of arbitrary and unjust inequalities in terms of people's ability to live full, healthy, decent, and gratifying lives. The studies and evidence presented in the Final Report of the World Health Organization (WHO) Commission on Social Determinants of Health (3) make it clear that the reduction and eventual elimination of health inequities can only be achieved through action on the social determinants of health. It has also become clear that action on the social determinants of health basically implies a commitment to the progressive achievement of universality in health (i.e., universal access to health and universal health coverage) and, in accordance with the Rio Declaration (4), the adoption of an integrated approach by government and society: the Health in All Policies approach. The Pan American Health Organization (PAHO) and its Member States have been pioneers in openly and decisively adopting Regional commitments in this regard by recently approving two fundamental documents: the Strategy for Universal Access to Health and Universal Health Coverage, and the Plan of Action on Health in all Policies (5, 6).

A critical part of these Regional strategic efforts to promote health equity within the framework of sustainable development is to overtly and systematically assess health equity. This implies a shift from the axiological toward the operational: committing ourselves to the task of objectively demonstrating progress toward health equity. In this necessary shift, the conceptual, methodological, and instrumental recommendations enabling an assessment of health equity (or a lack thereof) are supported by solid empirical evidence based on systematic observation and unbiased measurement of health inequalities in social groups and gradients (7, 8). A priority for PAHO and its Member States is to build and strengthen institutional capacities for monitoring social inequalities in health: a health intelligence system that reports and evaluates policies and interventions aimed at health equity, enabling us to assess the impact of political action on the social determinants of health and the effects of advocacy for Health in All Policies.

In keeping with the recommendation of the Committee on Social Determinants of Health to gather evidence, this issue of the comprises the first in a series of reports on Health Equity and Sustainable Development, a multidisciplinary technical effort emerging from the PAHO special program by the same name. In this and subsequent issues of the Journal, readers will find a series of original, peerreviewed research articles offering generally applicable knowledge on crucial features of the topic at hand, while helping to consolidate the empirical basis for institutional capacitybuilding aimed at addressing health equity as a key aspect of sustainable development in the Region. The series begins with a study by Restrepo and colleagues from the International Center for Equity in Health (Federal University of Pelotas, Brazil), which presents the current state of inequality in reproductive, maternal, and child health in Latin America and the Caribbean, based on a detailed analysis of microdata from the available standardized surveys (9). This article is very timely, since it perfectly complements the recent WHO global report on the state of inequality (10) and supports the Regional movement, A Promise Renewed for the Americas (11, 12).

This series also pays particular attention to the situation and sociohistorical context of the Region of the Americas and offers locally significant examples from the perspective of health equity and sustainable development. Studies by Castro and colleagues (13) and by Haeberer and colleagues (14) focus, respectively, on the role of ethnicity and of gender in generating inequalities in health access and the health situation in the Region. The study by Munayco and colleagues (15) documents the magnitude and trend in social inequalities related to tuberculosis incidence, indicating the need to address social determinants in TB control strategies. The article by Mujica and colleagues (16) systematically and innovatively illustrates the extent of health inequalities among, and within, the countries of the Region according to population gradients defined by coverage by water and sanitation access, underscoring the role of environmental determinants in public health. Lastly, the study by Ferrelli (17) persuasively highlights the inextricable link between social cohesion and health equity in terms of achieving social change.

Finally, this series on Health Equity and Sustainable Development also offers a select set of articles with great scientific merit and practical importance, originally published in English in highimpact journals and translated into Spanish with the generous permission of the respective publishers. The first of these, included in this issue, is the substantial article by Hosseinpoor and colleagues at WHO and the Rockefeller Foundation (18) on the need for equityoriented monitoring in the context of universal health coverage. Other articles include one by Andrews and colleagues (19) on the rationale and advantages of focusing tuberculosis control measures on the most economically disadvantaged population groups, and another by Arcaya and colleagues from Harvard University (20) on the definitions, concepts, and theories underlying the notion of health inequality.

This series complements other exceptional scientific articles already published in the Journal (21-24), documenting recent examples of successful implementation of national social inclusion policies and social protection mechanisms in the Americas-powerful models for effective action to reduce social inequities and advance the righttohealth approach. This series substantially supports the conviction that, on our road toward health and sustainable development in the Americas, we must not be indifferent to equity. Outside of this series and faithful to its editorial line, the Journal will, of course, continue to publish highquality, original scientific contributions that highlight health equity and sustainable development, report on best practices and lessons learned in Region and around the world, and help to institutionalize local capacities to address health equity-that linchpin of development sustainable, that essential element needed to fully accomplish the collective mission to ensure the conditions by which people can achieve the full enjoyment of complete physical, mental, and social wellbeing.

 

REFERENCES

1. United Nations. Transforming our world: the 2030 agenda for sustainable development. Finalized text for adoption (1 August 2015). Available from: https://sustainabledevelopment.un.org/content/documents/7891TRANSFORMING%20OUR%20WORLD.pdf Accessed on 7 August 2015.

2. Institute of Medicine of the National Academies of Science. The Future of the Public's Health in the 21st Century. Washington DC: National Academies Press, 2003.

3. Organización Mundial de la Salud. Subsanar las desigualdades en una generación: alcanzar la equidad sanitaria actuando sobre los determinantes sociales de la salud. Informe Final de la Comisión sobre Determinantes Sociales de la Salud. Ginebra: OMS; 2008. Available from: www.who.int/social_determinants/thecommission/finalreport/es Accessed on 7 August 2015.

4. Organización Mundial de la Salud. Declaración Política de Río sobre los Determinantes Sociales de la Salud. World Conference on Social Determinants of Health. Rio de Janeiro, Brasil; 19-21 Octubre, 2011. Available from: www.who.int/sdhconference/declaration/Rio_political_declaration_Spanish.pdf Accessed on 7 August 2015.

5. Organización Panamericana de la Salud. Estrategia para el Acceso Universal a la Salud y la Cobertura Universal de Salud. CD53/5, Rev. 2. Washington DC: OPS; 2014. Available from: www.paho.org Accessed on 7 August 2015.

6. Organización Panamericana de la Salud. Plan de Acción sobre la Salud en Todas las Políticas. CD 53/10, Rev. 1. Washington DC: OPS; 2014. Available from: www.paho.org Accessed on 7 August 2015.

7. World Health Organization. Handbook on Health Inequality Monitoring, with a special focus on lowand middleincome countries. Geneva: WHO; 2013. Available from: www.who.int/gho/health_equity/handbook/en/ Accessed on 7 August 2015.

8. Harper S, Lynch J. Midiendo Desigualdades en Salud: curso autoinstruccional. Washington DC: Universidad de Michigan y Organización Panamericana de la Salud; 2011. Available from: www.paho.org Accessed on 7 August 2015.

9. RestrepoMéndez MC, Barros AJD, Requejo J, Durán P, Serpa LAF, França G, et al. Inequalities in reproductive, maternal, newborn and child health in Latin America and the Caribbean: an unfinished agenda. Rev Panam Salud Publica. 2015;38(1):9-16.

10. World Health Organization. State of Inequality: reproductive, maternal, newborn and child health. Interactive visualization of health data. WHO and ICEH/Pelotas, Geneva: 2015. Available from: www.who.int/gho/health_equity/report_2015/en Accessed on 7 August 2015.

11. Declaración de Panamá. Una Promesa Renovada para las Américas: reduciendo inequidades en la salud reproductiva, materna y del niño. Septiembre 10-12, 2013. Ciudad de Panamá: 2013. Available from: www.apromiserenewedamericas.org Accessed on 7 August 2015.

12. Pan American Health Organization. A Promise Renewed for the Americas: reproductive, maternal, neonatal, and child health indicators and equity mapping: a framework for discussion. Washington DC: PAHO; 2013.

13. Castro A, Savage V, Kaufman H. Assessing equitable care for indigenous and Afrodescendant women in Latin America. Rev Panam Salud Publica. 2015;38(2). [Upcoming].

14. Haeberer M, Noguer I, Mújica OJ. Desigualdades educacionales en mortalidad y supervivencia de mujeres y hombres de las Américas, 1990-2010. Rev Panam Salud Publica. 2015;38(2). [Upcoming].

15. Munayco CV, Mújica OJ, León FX, del Granado M, Espinal MA. Social determinants and inequalities in tuberculosis incidence in Latin American and Caribbean countries. Rev Panam Salud Publica. 2015;38(3). [Upcoming].

16. Mújica OJ, Tegue J, Haeberer M, SantosBurgoa C, Galvão LA. Gradients of access to water and sanitation and inequalities in health between countries of the Americas, 19902010. Rev Panam Salud Publica. [Unpublished].

17. Ferrelli RM. Cohesión social como base para políticas públicas orientadas a la equidad en salud: reflexiones desde el Proyecto EUROsociAL. Rev Panam Salud Publica. [Unpublished].

18. Hosseinpoor AR, Bergen N, Koller T, Prasad A, Schlotheuber A, Valentine N, et al. El monitoreo orientado a la equidad en el contexto de la cobertura universal de salud. Rev Panam Salud Publica. 2015;38(1):17-28.

19. Andrews JR, Basu S, Dowdy DW, Murray MB. Ventaja epidemiológica de orientar las iniciativas de control de la tuberculosis con preferencia a las personas de escasos ingresos. Rev Panam Salud Publica. 2015;38(3). [Upcoming].

20. Arcaya MC, Arcaya AL, Subramanian V. Desigualdades en la salud: definiciones, conceptos y teorías. Rev Panam Salud Publica 2015;38(4). [Upcoming].

21. Harper S, King NB, Meersman SC et al. Juicios de valor implícitos en la medición de las desigualdades en salud. Rev Panam Salud Publica. 2014;35(4):293-304.

22. Almeida G, Sarti FM. Measuring evolution of incomerelated inequalities in health care utilization in selected Latin American and Caribbean countries. Rev Panam Salud Publica. 2013;33(2):83-9.

23. Welch V, Petticrew M, Tugwell P, Moher D, O'Neill J, Waters E et al. Extensión PRISMA-Equidad 2012: guías para la escritura y la publicación de revisiones sistemáticas enfocadas en la equidad en salud. Rev Panam Salud Publica. 2013;34(1):60-7.

24. Guanais FC. Efectos combinados de la ampliación de la atención primaria de salud y las transferencias condicionadas de dinero en efectivo sobre la mortalidad infantil en Brasil, 1998-2010. Rev Panam Salud Publica. 2014;36(1):65-72.

1. United Nations. Transforming our world: the 2030 agenda for sustainable development. Finalized text for adoption (1 August 2015). Disponible en: https://sustainabledevelopment.un.org/content/documents/7891TRANSFORMING%20OUR%20WORLD.pdf Acceso el 7 de agosto de 2015.         

2. Institute of Medicine of the National Academies of Science. The Future of the Public's Health in the 21st Century. Washington DC: National Academies Press, 2003.         

3. Organización Mundial de la Salud. Subsanar las desigualdades en una generación: alcanzar la equidad sanitaria actuando sobre los determinantes sociales de la salud. Informe Final de la Comisión sobre Determinantes Sociales de la Salud. Ginebra: OMS; 2008. Disponible en: www.who.int/social_determinants/thecommission/finalreport/es Acceso el 7 de agosto de 2015.         

4. Organización Mundial de la Salud. Declaración Política de Río sobre los Determinantes Sociales de la Salud. World Conference on Social Determinants of Health. Rio de Janeiro, Brasil; 19-21 Octubre, 2011. Disponible en: www.who.int/sdhconference/declaration/Rio_political_declaration_Spanish.pdf Acceso el 7 de agosto de 2015.         

5. Organización Panamericana de la Salud. Estrategia para el Acceso Universal a la Salud y la Cobertura Universal de Salud. CD53/5, Rev. 2. Washington DC: OPS; 2014. Disponible en: www.paho.org Acceso el 7 de agosto de 2015.         

6. Organización Panamericana de la Salud. Plan de Acción sobre la Salud en Todas las Políticas. CD 53/10, Rev. 1. Washington DC: OPS; 2014. Disponible en: www.paho.org Acceso el 7 de agosto de 2015.         

7. World Health Organization. Handbook on Health Inequality Monitoring, with a special focus on lowand middleincome countries. Geneva: WHO; 2013. Disponible en: www.who.int/gho/health_equity/handbook/en/ Acceso el 7 de agosto de 2015.         

8. Harper S, Lynch J. Midiendo desigualdades en salud: curso autoinstruccional. Washington DC: Universidad de Michigan y Organización Panamericana de la Salud; 2011. Disponible en: www.paho.org Acceso el 7 de agosto de 2015.         

9. Restrepo-Méndez MC, Barros AJD, Requejo J, Durán P, Serpa LAF, França GVA, et al. Progress in reducing inequalities in reproductive, maternal, newborn, and child health in Latin America and The Caribbean: an unfinished agenda. Rev Panam Salud Publica. 2015;38(1):9-16.         

10. World Health Organization. State of Inequality: reproductive, maternal, newborn and child health. Interactive visualization of health data. WHO and ICEH/Pelotas, Geneva: 2015. Disponible en: www.who.int/gho/health_equity/report_2015/en Acceso el 7 de agosto de 2015.         

11. Declaración de Panamá. Una Promesa Renovada para las Américas: reduciendo inequidades en la salud reproductiva, materna y del niño. Septiembre 10-12, 2013. Ciudad de Panamá: 2013. Disponible en: www.apromiserenewedamericas.org Acceso el 7 de agosto de 2015.         

12. Pan American Health Organization. A Promise Renewed for the Americas: reproductive, maternal, neonatal, and child health indicators and equity mapping: a framework for discussion. Washington DC: PAHO; 2013.         

13. Castro A, Savage V, Kaufman H. Assessing equitable care for indigenous and Afrodescendant women in Latin America. Rev Panam Salud Publica. 2015;38(2). [De próxima publicación]          .

14. Haeberer M, Noguer I, Mújica OJ. Desigualdades educacionales en mortalidad y supervivencia de mujeres y hombres de las Américas, 1990-2010. Rev Panam Salud Publica. 2015;38(2). [De próxima publicación]          .

15. Munayco CV, Mújica OJ, León FX, del Granado M, Espinal MA. Social determinants and inequalities in tuberculosis incidence in Latin American and Caribbean countries. Rev Panam Salud Publica. 2015;38(3). [De próxima publicación]          .

16. Mújica OJ, Tegue J, Haeberer M, Santos-Burgoa C, Galvão LA. Gradients of access to water and sanitation and inequalities in health between countries of the Americas, 1990-2010. Rev Panam Salud Publica. [inédito]          .

17. Ferrelli RM. Cohesión social como base para políticas públicas orientadas a la equidad en salud: reflexiones desde el Proyecto EUROsociAL. Rev Panam Salud Publica [inédito]          .

18. Hosseinpoor AR, Bergen N, Koller T, Prasad A, Schlotheuber A, Valentine N, et al. El monitoreo orientado a la equidad en el contexto de la cobertura universal de salud. Rev Panam Salud Publica. 2015;38(1):17-28.         

19. Andrews JR, Basu S, Dowdy DW, Murray MB. Ventaja epidemiológica de orientar las iniciativas de control de la tuberculosis con preferencia a las personas de escasos ingresos. Rev Panam Salud Publica. 2015;38(3). [De próxima publicación]          .

20. Arcaya MC, Arcaya AL, Subramanian V. Desigualdades en la salud: definiciones, conceptos y teorías. Rev Panam Salud Publica 2015;38(4). [De próxima publicación]          .

21. Harper S, King NB, Meersman SC et al. Juicios de valor implícitos en la medición de las desigualdades en salud. Rev Panam Salud Publica. 2014;35(4):293-304.         

22. Almeida G, Sarti FM. Measuring evolution of incomerelated inequalities in health care utilization in selected Latin American and Caribbean countries. Rev Panam Salud Publica. 2013;33(2):83-9.         

23. Welch V, Petticrew M, Tugwell P, Moher D, O'Neill J, Waters E et al. Extensión PRISMA-Equidad 2012: guías para la escritura y la publicación de revisiones sistemáticas enfocadas en la equidad en salud. Rev Panam Salud Publica. 2013;34(1):60-7.         

24. Guanais FC. Efectos combinados de la ampliación de la atención primaria de salud y las transferencias condicionadas de dinero en efectivo sobre la mortalidad infantil en Brasil, 1998-2010. Rev Panam Salud Publica. 2014;36(1):65-72.         

Organización Panamericana de la Salud Washington - Washington - United States
E-mail: contacto_rpsp@paho.org