How would you relate equality, equity and justice in Healthcare?

"Fairness does not mean everyone gets the same. Fairness means everyone gets what they need." -Rick Riordan, The Red Pyramid

Equality, Equity and Justice
You have probably come across a popular cartoon illustrating the difference between "equity" and "equality".1 It shows three people trying to watch a baseball game over the top of a fence. The people are of different heights, so the shorter ones have a harder time seeing. In the first of two images, all three people are standing on a single crate of equal sizes. While this confers an unfair advantage to the tallest person, a single crate is not enough for the shortest person. This is "equality" because everyone has an access to similar resources. In contrast, in the second image, everyone gets a reasonable number of crates required to watch the game. The shorter person getting the maximum number of crates while the taller person not requiring the crates at all. This is "equity" because each person has the rational number of crates needed to enjoy the game.2 Another reference to help better understand the difference between "equity" and "equality" is Olympic runners on a racetrack. On a racing track, the outer lanes are longer than the inner lanes. So, understandably, we start runners from a different place on each lane, in turn bestowing equal opportunity to all sprinters.

In contrast to "equity" and "equality", "justice" is focused on ensuring that each person has the access and opportunity to the resources. It is about making appropriations towards fairness even in the light of past inequality and unfairness. It is about making things accessible for all by giving equal opportunities.
Healthcare equity
In the context of medicine, "equity" and "equality" is associated with distribution of resources and its access by all sections of society. "Equality" is giving everyone the access to healthcare, assuming that everyone is same. While it aims to bring fairness, it can only work if everyone starts at the same level and has the same needs. "Equity" "levels this playing field "by distributing resources according to the current needs and requirements. While this may seem "unfair" to few people, it actually brings the society closer to "fairness".
Opportunity gap
The distinction between "equality" and "equity" may still seem quite ambiguous to some. In case of public health funding, advocating for "equality" would mean that all communities have equal amount of resources. That means, equal funds, equal healthcare workers and equal infrastructure to all regions of country irrespective of demographic dividends or past unfairness. On the other hand, advocating for "equity" would mean that some communities – like those in remote, densely populated or minority communities – will actually need more resources, if we wish to make any dent in the current "opportunity gap". "Opportunity gap" is the disparity in access to quality healthcare and resources for disadvantaged communities. This in turn could be attributed to deficit thinking - present day metaphor of oppression and colonization. This ideology blames victims of oppression for their own situation. That means, "deficit thinkers" believe that slum-dwellers have poor access to healthcare because they live in slums. Doesn’t make any sense, right? By closing the "opportunity gap" and weeding out "deficit thinking", is the only way we are going to make any advances in Universal Health Coverage.
Universal Health Coverage
Universal Health Coverage (UHC) is defined by WHO as "access to promotive, preventive, curative, rehabilitative and palliative health services, of sufficient quality, while also ensuring that the use of these services does not expose the user to financial hardship, by all people and communities".3 It has become a flagship program of WHO for ensuring "equity" in access to health services while ensuring the quality and protected against financial-risk. However, vulnerable population continues to receive inadequate or inferior healthcare due to complex situations. Most notable of that is the "inverse equity hypothesis"4, one of the many scenarios against which UHC was created to tackle with. Here, interventions reach the most privileged groups first and then "trickle down" to the poor and marginalized communities. This could not only widen the current disparities and widen the "opportunity gap", but also undermines the true meaning and intent of UHC. If extended for a long period, UHC could fall short of realizing its own goals. This can only be tackled by implementing what many call "progressive universalism"5. This advocates for strategically targeting program towards most disadvantaged first, by increasing coverage and decreasing economic barriers to access. The success of this plan was effectively reflected in Brazil’s Family Health Programme and Mexico’s Popular Insurance initiative.5 In Brazil, poor people from deprived municipalities were reached first and then program was expanded to other parts of the country. Mexico government offered fully subsidized premium-free coverage to people previously determined to be poor by existing social security mechanisms. Both of these programs strategically focused on the most disadvantaged group first and then extending access to those from higher strata.
Social determinants of equity
Social strata is a crucial factor in widening gap and inequalities in delivery and access of healthcare. This was substantiated by Marmot Review into health inequalities in England.6 The report, titled 'Fair Society, Healthy Lives', highlighted the social gradient of health inequalities and reaffirmed the popular perception that health improves as social status goes up. Health inequalities arise from a complex interaction of many factors- social determinants of health- all of which are strongly affected by economic and social status. Any action targeting these social determinants of health will bring about a more fair and sustainable distribution of health resources.
Ubiquitous inequality
There is hardly any field, other than healthcare, where "equality", "equity" and "justice" comes with such uncertainties and perplexing issues. While some of us can easily afford expensive cosmetic surgeries, 5 billion people7 still lack access to safe and affordable surgical and anesthetic care. While pharmaceutical companies continue to dole out enormous profits and generating huge revenues, many families from low income countries have to go without basic care because of unaffordable medicines. Medical research is creating new cancer drugs and gene therapy but the drugs and therapies are so expensive that majority of cancer patients cannot afford it. Inequality is present just as much on the physician’s side as the patient’s side. Some doctors performing enhancement procedures on rich patients make millions of dollars a year while other doctors performing life-saving surgery have to leave the profession because they cannot make a living with the salaries that they get.
Broken spectrum of care
Modern scientific medicine today, with all its sophisticated investigations; procedures and techniques, is better than ever equipped to cure and to prevent disease, but most individuals and communities cannot afford the cost. Patients may experience the euphoria of recovery from highly advanced cancer, only to be burdened later with financial liability. A corporate, profit-maximizing culture that may foster unnecessary healthcare – healthcare costs higher than appropriate – may have played a significant role in driving up costs. When richer people from developed countries with fatal diseases have access to quality diagnostic and treatment facilities and survive but poorer people from developing or under-developed countries, with the same disease, die even before the diagnosis, we know that "equity" is violated. In turn, "justice" is violated.
Paradigm of ambiguity
Any proposed solution to bring "equity" to healthcare is skewed with ambiguities and uncertainties. While governments may focus on bolstering up their nuclear arsenals or building walls around countries or talk-at-length about nationalism and patriotism, we can’t look away from the fact that our public health infrastructure is in shambles. If you think that building up new AIIMSs while ignoring the impecunious infrastructure of district hospitals will bring any "justice" to healthcare, then you, my friend, are woefully naïve. For society too, there are uncomfortable difficulties. We may not be ready to accept -or pay for- health coverage of people who belong to outside or opposite of our ideology or community. And the existence of a truly uniform health care -paid for by those who can afford and served to all- requires an acknowledgement that most of us are not yet ready to confront.
Medicine and healthcare, in a way, has been smothered by its own success. Our ideas of "equality", "equity" and "justice" has been distorted with commercialization and marketing of healthcare. Healthcare, in most parts, has been turned into a business with integration of terms such as net profit, revenue and dividends. Agreed, that cancer medications cannot be developed without putting in huge funding and those who fund will have an interest in its revenue. But can’t we also agree that affordable and quality healthcare is a fundamental right and it also requires our immediate and ample attention? We should realize that "equity" in healthcare becomes more realistic when it is restricted to primary and preventive care. By bringing affordable and quality healthcare through scaling up of innovations and integrating public private partnership in delivering primary health care, we can bring a lot of change. Ideals cannot translate into action unless we pledge to practice them. We need to engage in equitable practices in order to be truly fair.
  • 1. "Illustrating Equality VS Equity." Interaction Institute for Social Change. N.p., 2017.
  • 2. Kuttner, Paul. "The Problem With That Equity Vs. Equality Graphic You’Re Using." Cultural Organizing. N.p., 2017.
  • 3. "What Is Universal Coverage?." World Health Organization. N.p., 2017.
  • 4. Rodney, Anna, and Peter Hill. "Achieving Equity Within Universal Health Coverage: A Narrative Review Of Progress And Resources For Measuring Success." International Journal for Equity in Health. N.p., 2017.
  • 5. Gwatkin, Davidson R, and Alex Ergo. "Universal Health Coverage: Friend Or Foe Of Health Equity?." The Lancet 377.9784 (2011): 2160-2161.
  • 6. "Marmot Review Report − 'Fair Society, Healthy Lives." N.p., 2017.
  • 7. "Emergency And Essential Surgical Care." World Health Organization. N.p., 2017.

Ankit Raj
Final MBBS,
Kasturba Medical College, Manipal 1 mei 20184188GM IFMSA-NLGlobal Medicine