Why health equity?

Text of Keynote Address to Third Conference of the International Health Economics Association on ‘The Economics of Health: Within and Beyond Health Care,’ York, 23 July 2001. ‘The world ... is not an inn, but a hospital,’ said Sir Thomas Browne more than three and half centuries ago, in 1643. That is a discouraging, if not entirely surprising, interpretation of the world from the distinguished author of Religio Medici and Pseudodoxia Epidemica. But Browne may not be entirely wrong: even today (not just in Browne’s 17th century England), illness of one kind or another is an important presence in the lives of a great many people. Indeed, Browne may have been somewhat optimistic in his invoking of a hospital: many of the people who are most ill in the world today get no treatment for their ailments, nor the use of effective means of prevention. In any discussion of social equity and justice, illness and health must figure as a major concern. I take that as my point of departure – the ubiquity of health as a social consideration – and begin by noting that health equity cannot but be a central feature of the justice of social arrangements in general. The reach of health equity is immense. But there is a converse feature of this connection to which we must also pay attention. Health equity cannot be concerned only with health, seen in isolation. Rather it must come to grips with the larger issue of fairness and justice in social arrangements, including economic allocations, paying appropriate attention to the role of health in human life and freedom. Health equity is most certainly not just about the distribution of health, not to mention the even narrower focus on the distribution of health care. Indeed, health equity as a consideration has an enormously wide reach and relevance. I shall consider three sets of issues. First, I shall begin by discussing the nature and relevance of health equity. Second, I shall go on to identify and scrutinize the distinct grounds on which it has been claimed that health equity is the wrong policy issue on which to concentrate. I hope to be able to argue that these grounds of scepticism do not survive close scrutiny. Finally, in the section dealing with general considerations and particular proposals, I shall consider some difficult issues that have to be faced for an adequate understanding of the demands of health equity. It is particularly important in this context to see health equity as a very broad discipline which has to accommodate quite diverse and disparate considerations.