Abstract

This study aims to identify how the principle of equity is employed in health studies in Brazil. It features a review of the scientific production of four databases using the Health Sciences Descriptors “equity” and “health” in all of them. Thirty-four articles addressing the topic of health in Brazil were reviewed. Results show that equity is understood in most articles as an essential factor for social justice, considering the context of social inequalities in which the Brazilian Unified Health System operates. There was a prevalence of the concept of equity proposed by the World Health Organization, which emphasizes the moral and ethical dimension of the term. The restriction of the discussion on equity to the level of access suggests a narrow understanding of the term, which can be explained by the difficulty in applying it, since a social principle is an abstract value.

Keywords:
Equity; Health Equity; Brazilian Unified Health System; Health Management

Introduction

The concept of health equity was first debated by the World Health Organization (WHO) in 1986, featuring in the Ottawa Charter - the concluding document of the First International Conference on Health Promotion - as one of eight prerequisites for health (WHO, 1986OMS - ORGANIZAÇÃO MUNDIAL DA SAÚDE. Carta de Ottawa - Primeira Conferência Internacional sobre Promoção da Saúde. Ottawa, 1986. Disponível em: <Disponível em: https://goo.gl/awIW3D >. Acesso em: 15 set. 2015.
https://goo.gl/awIW3D... ). The term gained prominence in subsequent conferences, leading WHO to request the elaboration of a document aimed at refining a definition of health equity. (Whitehead, 1990WHITEHEAD, M. The concepts and principles of equity and health. Copenhagen: WHO Regional Office for Europe, 1990.) states that there is no definition per se, but makes an important contribution by including the moral and ethical dimension as one of the main reference points of the theme. This document was later published in the International Journal of Health Services (Whitehead, 1992WHITEHEAD, M. The concepts and principles of equity and health. International Journal of Health Services, Westport, v. 22, n. 3, p. 429-445, 1992.).

In discussing equity and health, (Whitehead, 1992WHITEHEAD, M. The concepts and principles of equity and health. International Journal of Health Services, Westport, v. 22, n. 3, p. 429-445, 1992.) starts out from two assumptions: less favored groups have lower chances of survival and there are major differences in people’s experiences of illness. Given the differences in health profile between nations and between groups within a same nation, inequity refers to a specific difference: that which is unnecessary, avoidable and unfair. The term is imbued with a moral and ethical perspective as socioeconomic and environmental factors become protagonists in this scenario, although biological factors and the effects of sick people moving down the social ladder are partly responsible for differences in health.

The issue of injustice relates to the degree of choice involved: there are people who have little or no choice regarding their living and working conditions, resulting in disparities in health. For (Whitehead, 1992WHITEHEAD, M. The concepts and principles of equity and health. International Journal of Health Services, Westport, v. 22, n. 3, p. 429-445, 1992.), equity requires, ideally, that people have fair opportunities to attain their full health potential, and that no one be less fortunate in reaching that potential if such a situation can be avoided. Policies should reduce or eliminate differences in health resulting from factors considered avoidable and unfair.

In Brazil, equity is one of the doctrinal principles of the Brazilian Unified Health System (SUS), although the term does not appear in the main legal provisions that govern it: the Federal Constitution of 1988 (Brasil, 1988BRASIL. Presidência da República. Casa Civil. Subchefia para Assuntos Jurídicos. Constituição da República Federativa do Brasil de 1988. Brasília, DF, 1988. Disponível em: <Disponível em: https://goo.gl/HwJ1Q >. Acesso em: 15 set. 2015.
https://goo.gl/HwJ1Q... ) and Law No. 8,080 of 1990 (Brasil, 1990BRASIL. Lei nº 8.080, de 19 de setembro de 1990. Dispõe sobre as condições para a promoção, proteção e recuperação da saúde, a organização e o funcionamento dos serviços correspondentes, e dá outras providências. Diário Oficial da União, Brasília, DF, 20 set. 1990. Disponível em: <Disponível em: https://goo.gl/twYSz >. Acesso em: 15 set. 2015.
https://goo.gl/twYSz... ). When equity appears for the first time after the creation of SUS in a Brazilian Ministry of Health booklet (Brasil, 1990BRASIL. Lei nº 8.080, de 19 de setembro de 1990. Dispõe sobre as condições para a promoção, proteção e recuperação da saúde, a organização e o funcionamento dos serviços correspondentes, e dá outras providências. Diário Oficial da União, Brasília, DF, 20 set. 1990. Disponível em: <Disponível em: https://goo.gl/twYSz >. Acesso em: 15 set. 2015.
https://goo.gl/twYSz... ), its concept is related to the equality of citizens regarding SUS actions and services. The influence of Whitehead’s contributions (¹⁹⁹²WHITEHEAD, M. The concepts and principles of equity and health. International Journal of Health Services, Westport, v. 22, n. 3, p. 429-445, 1992.) appears in the following decade: gradually the focus on citizens’ equality is replaced by an emphasis on reducing existing social and regional disparities in Brazil (Brasil, 2000BRASIL. Ministério da Saúde. Secretaria Executiva. Sistema Único de Saúde (SUS): princípios e conquistas. Brasília, DF, 2000.).

Occasionally, as in Whitehead’s discourse (¹⁹⁹²WHITEHEAD, M. The concepts and principles of equity and health. International Journal of Health Services, Westport, v. 22, n. 3, p. 429-445, 1992.), the concept of equity is linked to the discussion on social justice. Two authors deserve attention in this debate for presenting views with different assumptions: John Rawls and Amartya Sen.

(Rawls, 1997RAWLS, J. Uma teoria da justiça. São Paulo: Martins Fontes, 1997.) proposes a theory of justice based on equity, starting out from a hypothetical situation in which there is a position of equality among all individuals, ignoring knowledge on contingencies that result in disparities between men, such as social status, class position and natural attributes and abilities. (Rawls, 2003RAWLS, J. Justiça como equidade: uma reformulação. São Paulo: Martins Fontes, 2003.) calls this state of affairs “veil of ignorance” and ensures that all participants are in the same situation, preventing individuals from being guided by their prejudices and establishing principles that benefit their private situation. To this end, institutions (specified by the author as political constitution and main economic and social agreements) play a fundamental role, since they constitute the basic structure of society and can cause profound inequalities by favoring certain circumstances (such as different social positions) that are not justified by merit or value. In Rawls’s theory (²⁰⁰³RAWLS, J. Justiça como equidade: uma reformulação. São Paulo: Martins Fontes, 2003., p. 14), the basic structure is the primary subject of justice, because its effects on the goals, aspirations and opportunities of citizens “are profound and present from the start.” Once the situation of equality has been established, a set of principles would be consensually accepted. The author proposes two principles that could be admitted under this hypothetical situation: that certain rules that define the basic liberties allow each person the most extensive liberties compatible with similar liberties for all; and that economic and social inequalities be distributed in a way that they are both to the greatest benefit of the least advantaged persons and attached to offices and positions open to all under conditions of equality of opportunities.

The principles are sequential, so that the basic liberties (of the first principle) cannot be justified or compensated for by economic and social issues (of the second principle). In the first principle, liberties can only be limited when they conflict with other liberties, being adjusted to form a single system. The second principle is known as the principle of difference and defines that if there is no distribution that improves the situation of the least advantaged and the most advantaged persons, an equal distribution is preferable. This ensures that changes in the expectations of those who are better off will only be a fair situation if they also increase the perspectives of those who are in a lower situation.

(Sen, 2011SEN, A. A ideia de justiça. São Paulo: Companhia das Letras, 2011.) starts out from the criticism of Rawls’s work to present an approach whose principles of justice are not solely defined with regards to institutions (which are the primary subject of Rawls’s theory of justice), but centers on the life and liberty of the people involved. Sen’s (2011, p. 48) main criticism of Rawls focuses on the understanding that justice should not be limited to the choice of institutions and the definition of ideal social arrangements, but also depends on human achievements and “includes the lives that people are able - or not - to live.” Given that institutions are neither manifestations of justice nor inviolable, the influence of the behavior patterns of people associated with the search for institutions that promote justice must be jointly analyzed in pursuing justice. Sen presents the theory of social choice as a counterpoint to Rawls’s proposal, concentrating on the rational basis of social judgments and on public decisions to choose between social alternatives.

In Sen’s (²⁰⁰¹SEN, A. Desigualdade reexaminada. Rio de Janeiro: Record, 2001.) view of promotion of justice, individuals play a key role as they have different capabilities to pursue their goals. Reducing inequalities means acknowledging the diversity of internal (age, gender, propensity to disease, etc.) and external (available assets, social environments, etc.) characteristics that interfere with individuals’ capability to perform functions (states and actions) which, in turn, constitute their liberty to achieve goals that they consider valuable.

In this sense, health plays a role in social justice in several different ways, since it is a fundamental component of human possibilities. Health equity, therefore, should focus on how health relates to other characteristics through the distribution of resources and social arrangements. As a multidimensional concept, health equity includes: aspects that relate to achieving good health and the possibility of achieving good health (and not merely the distribution of health care); promotion of justice in processes by giving attention to the absence of discrimination in the provision of health care; integration between health considerations and the broader issues of social justice and global equity (Sen, 2002SEN, A. ¿Por qué la equidad en salud? Revista Panamericana de Salud Pública, Washington, DC, v. 11, n. 5/6, p. 302-309, 2002.).

Given the different meanings that can be attributed to the term equity, this review aims to identify how the principle of equity is employed in health studies in Brazil.

Material e methods

The data were collected in the months of June and July 2015, in the following reference databases: Latin American and Caribbean Health Sciences Literature (Lilacs), Spanish Bibliographical Index on Health Sciences (Ibecs), International Literature on Health Sciences (Medline), Cochrane Library and Scientific Electronic Library Online (SciELO).

The guiding question of the survey was: “How is the principle of equity employed in health studies in Brazil?” As a research strategy, the Health Sciences Descriptors (DeCS) “equity” and “health” were used in all databases (title, author and subject). There were no time period restrictions and the following inclusion criterion was defined: addressing the topic of health in Brazil. Thus, 788 records were found (1985-2015). The following were excluded: repeated records (n=260), occurrences that were not original articles, but comments, editorial material and reviews (n =10), articles that did not relate to Brazil (n=86) and those that did not address the topic of health (n=10). This step resulted in 422 records.

Alongside the reading of titles, abstracts and keywords of the articles, a text search of the term “equity” was performed. Occurrences were classified in relation to the term equity: merely cite the term (n=336), dedicate a paragraph to the term, but do not discuss it (n=2), and discuss the term (n=34). During the full reading of the articles that discuss the term equity, a summary table was prepared with the following information: year of publication, authors, title, objective and concepts on equity. In the end, 34 studies were reviewed. In order not to extend the discussion, the articles were numbered and are shown in Table 1.

It should be noted that there was no need to refer the research project to the ethics and research committee on human beings, since the articles reviewed are available in public access databases.

Results and discussion

Of the 34 studies reviewed, 25 were published between 2000 and 2009, 10 were published between 2010 and 2015, and only one was published previously, in 1993 (Table 1). No prevalence of specific authors was observed in these time periods.

Whitehead’s concept was the most mentioned, featuring in eighteen studies (articles 6, 9, 11-15, 18-20, 22, 23, 25-28, 32, 33). The importance of this work is comprehensible, since it was the first and persists as the main document of the World Health Organization to discuss health equity, making a fundamental contribution: in considering that differences in health are, in addition to unnecessary and avoidable, incorrect and unjust, the author adds a moral and ethical dimension of the term.

Rawls was the second most cited author, his theory relating equity to social justice featuring in eight studies (articles 1, 7, 8, 12, 14, 15, 24, 27). While most authors refer to Rawls’s theory emphasizing the compensatory benefits that should be given to the underprivileged (articles 1, 12, 14, 15, 24 and 27), two articles stress the importance of the state in this process through the redistribution of resources. (Coelho, 2010COELHO, I. B. Democracia sem equidade: um balanço da reforma sanitária e dos dezenove anos de implantação do Sistema Único de Saúde no Brasil. Ciência & Saúde Coletiva, Rio de Janeiro, v. 15, n. 1, p. 171-183, 2010.) resorts to Rawls’s work to suggest that the state should be more incisive when intervening in social problems or the distribution of income. (Fortes, 2010FORTES, P. A. C. A equidade no sistema de saúde na visão de bioeticistas brasileiros. Revista da Associação Médica Brasileira, São Paulo, v. 56, n. 1, p. 47-50, 2010.), in turn, identifies Rawls’s proposal in the discourse of Brazilian bioethicists regarding the importance of the state in distributive justice:

Although the author’s contribution is decisive for the inclusion of equity as a benchmark in promoting social justice, only one article states that Rawls proposes, as a pillar of his theory, a hypothetical situation in which all individuals occupy a position of equality, preventing them from establishing principles that might benefit their private situation (Fortes, 2015FORTES, P. A. C. Refletindo sobre valores éticos da saúde global. Saúde e Sociedade, São Paulo, v. 24, p. 152-161, 2015. Suplemento 1.). In applying this theory to reality without such a proviso, one ignores the influence of people’s individual liberties and standards, assigning the responsibility for the promotion of justice solely to institutions. This is one of Sen’s main criticisms of Rawls, and only (Lucchese, 2003LUCCHESE, P. T. R. Equidade na gestão descentralizada do SUS: desafios para a redução de desigualdades em saúde. Ciência & Saúde Coletiva, Rio de Janeiro, v. 8, n. 2, p. 439-448, 2003.) explores Sen’s “capability approach” to identify priority tasks for reducing health inequalities in Brazil.

Social justice is linked to equity in 21 studies, since it is understood that inequalities must be overcome with the equity benchmark in the quest for social justice (articles 1, 2, 5-8, 11-13, 15, 16, 18-20, 22-24, 28, 29, 32, 33). The logic of the allocation of public resources in health gains prominence in this discussion, with the purpose of eliminating inequities. In this context, two studies refer to the discussion of targeting versus universalization, highlighting the challenge of promoting equity with scarce resources without neglecting to prioritize groups that suffer unjust and avoidable inequalities (articles 23 and 24). Two other studies cite targeting as a way to promote positive discrimination or inclusiveness (articles 15 and 32). As Senna concludes (²⁰⁰²SENNA, M. C. M. Equidade e política de saúde: algumas reflexões sobre o Programa Saúde da Família. Cadernos de Saúde Pública, Rio de Janeiro, v. 18, p. 203-211, 2002. Suplemento.):

As a value, equity is related to the principles of justice and democracy in two studies in different ways (articles 7 and 16). (Coelho, 2010COELHO, I. B. Democracia sem equidade: um balanço da reforma sanitária e dos dezenove anos de implantação do Sistema Único de Saúde no Brasil. Ciência & Saúde Coletiva, Rio de Janeiro, v. 15, n. 1, p. 171-183, 2010.) affirms that democratization does not necessarily lead to health equity, since, for example, scarce resources may lead to an overlapping of the principles of universality and integrality (article 7). (Costa and Lionço, 2006COSTA, A. M.; LIONÇO, T. Democracia e gestão participativa: uma estratégia para a equidade em saúde? Saúde e Sociedade, São Paulo, v. 15, n. 2, p. 47-55, 2006.), in turn, understand that equity can only be promoted in a democratic environment where subjects have the power and autonomy to state their desires and needs (article 16): “Health equity, understood as the provision of services for the specific needs of groups or individuals, requires subjects and collectivities with power and autonomy to state their desires and needs” (Costa, Lionço, 2006COSTA, A. M.; LIONÇO, T. Democracia e gestão participativa: uma estratégia para a equidade em saúde? Saúde e Sociedade, São Paulo, v. 15, n. 2, p. 47-55, 2006., 47).

The distinction between vertical and horizontal equity features in eight articles, considering the similar demands among similar individuals (horizontal equity) and unequal treatment for unequal individuals (articles: 3, 5, 6, 12, 13, 23, 27, 34). These concepts were used by the authors of three articles to refer to access to health services and actions (3, 5, 6). In this sense, (Sanchez and Ciconelli, 2012SANCHEZ, R. M.; CICONELLI, R. M. Conceitos de acesso à saúde. Revista Panamericana de Salud Pública, Washington, DC, v. 31, n. 3, p. 260-268, 2012.) describe the four dimensions of access to health and conclude that the issue of equity is inseparable: “The definition of access, based on four main elements, called availability, acceptability, capacity to pay and information, each increasingly mixed up with the concept of health equity” (Sanchez; Ciconelli, 2012SANCHEZ, R. M.; CICONELLI, R. M. Conceitos de acesso à saúde. Revista Panamericana de Salud Pública, Washington, DC, v. 31, n. 3, p. 260-268, 2012., p. 267).

Final remarks

It is seen that most articles view equity as an essential factor for social justice, considering the context of social inequalities in which the Brazilian Unified Health System operates. Although few studies relate equity to democracy, it can be understood that the search for health equity is a way of guaranteeing a social right - health - thus strengthening individuals as protagonists in a democratic system.

The concepts of equity identified are strongly influenced by Whitehead’s assumptions and Rawls’s theory, insofar as they relate different health situations to the issue of justice, equity being a means to diminish or eliminate such disparities. On the other hand, when compared to Sen’s multidimensional concept, their understanding seems restricted, referring only to access to the health system of individuals subject to unjust and avoidable inequalities. The limitation of the concept of equity is comprehensible given the difficulty to apply it, since a social principle is an abstract value, linked to ethical and moral aspects.

The discussion on equity should be intensified in the Brazilian context, considering that the Brazilian Unified Health System deals with a limited budget and great demand, which sometimes ends up overriding the principles of universality, integrality and equity. The debate should not be restricted to access to health actions and services, but also address equity in the process, which should be based on the perspective of inclusion, lest individuals have access but feel excluded from participation in the health system. The challenge is to discuss a way to apply equity addressing the scarcity of resources, and doing so on a continuous basis so that the principle is not lost throughout the process, making individuals feel they are being discriminated against in health care.

As a limitation of the study, it should be emphasized that this is a research that, through a sample of articles, aimed to identify the concept of equity and its main uses in Brazilian studies on health, reason why in-depth reformulations of the term were not deemed necessary.

References

Publication Dates

History