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Defining equity in health

P Braveman and S Gruskin

J. Epidemiol. Community Health 2003;57;254-258

doi:10.1136/jech.57.4.254

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254

THEORY AND METHODS

Defining equity in health

P Braveman, S Gruskin
.............................................................................................................................

J Epidemiol Community Health 2003;57:254–258

Study objective: To propose a definition of health equity to guide operationalisation and

measurement, and to discuss the practical importance of clarity in defining this concept.
Design: Conceptual discussion.
See end of article for
authors’ affiliations Setting, Patients/Participants, and Main results: not applicable.
....................... Conclusions: For the purposes of measurement and operationalisation, equity in health is the absence
of systematic disparities in health (or in the major social determinants of health) between groups with
Correspondence to:
Dr P Braveman,
different levels of underlying social advantage/disadvantage—that is, wealth, power, or prestige.
Department of Family and Inequities in health systematically put groups of people who are already socially disadvantaged (for
Community Medicine, example, by virtue of being poor, female, and/or members of a disenfranchised racial, ethnic, or reli-
University of California, gious group) at further disadvantage with respect to their health; health is essential to wellbeing and to
San Francisco, 500
Parnassus Avenue, MU-3E,
overcoming other effects of social disadvantage. Equity is an ethical principle; it also is consonant with
San Francisco, California, and closely related to human rights principles. The proposed definition of equity supports operationali-
94143-0900, USA; sation of the right to the highest attainable standard of health as indicated by the health status of the
[email protected] most socially advantaged group. Assessing health equity requires comparing health and its social
Accepted for publication determinants between more and less advantaged social groups. These comparisons are essential to
21 October 2002 assess whether national and international policies are leading toward or away from greater social jus-
....................... tice in health.

I
n a widely cited 1992 paper on The concepts and principles of For the purposes of operationalisation and measurement,
equity in health, Whitehead defined health inequities as equity in health can be defined as the absence of systematic
differences in health that are unnecessary, avoidable, unfair disparities in health (or in the major social determinants of
and unjust.1 That influential, articulate, and well conceived health) between social groups who have different levels of
paper was “...not meant to be a technical document, but underlying social advantage/disadvantage—that is, different
...aimed at raising awareness and stimulating debate in a positions in a social hierarchy. Inequities in health systemati-
wide, general audience...” in Europe.1 The document suc- cally put groups of people who are already socially disadvan-
ceeded in its stated aim and has been useful in many settings taged (for example, by virtue of being poor, female, and/or
on other continents. Valuable contributions also have been members of a disenfranchised racial, ethnic, or religious
made by other discussions of the concept of equity in health or group) at further disadvantage with respect to their health;
in health care, or both.2–13 Accumulated experience now health is essential to wellbeing and to overcoming other
permits a fresh look at the question of how to define equity in effects of social disadvantage.
health in a conceptually rigorous fashion that can guide Health represents both physical and mental wellbeing, not
measurement and hence accountability for actions at the just the absence of disease.43 Key social determinants of health
policy and programmatic levels. This question is of particular include household living conditions, conditions in communi-
relevance given the growing interest in equity among national ties and workplaces, and health care, along with policies and
and international health organisations.6 10 11 14–32 The need for a programmes affecting any of these factors.43–50 Health care is a
more precise definition of equity in health also has arisen in social determinant in so far as it is influenced by social
the context of a recent debate between researchers at the policies; we use the term broadly here to refer not only to the
World Health Organisation33–35 and at a number of academic receipt/utilisation of health services, but also to the allocation
institutions36–38; this debate is discussed below (see Do the defi- of health care resources, the financing of health care, and the
nitions matter?). This paper is primarily addressed to the quality of health care services.
research community, proposing a definition of health equity to Underlying social advantage or disadvantage refers to wealth,
guide measurement and, hence, accountability; we also power, and/or prestige—that is, the attributes that define how
discuss the practical importance of clarity in defining this people are grouped in social hierarchies. Disadvantage also can
concept, in terms of consequences for both policies and be thought of as deprivation,51 52 which can be absolute or
measurement. We are not aware of other literature addressing relative53 54; the concept of human poverty developed by the
this issue. United Nations Development Program reflects severe
disadvantage.55 Thus, more and less advantaged social groups are
groups of people defined by differences that place them at dif-
EQUITY MEANS SOCIAL JUSTICE ferent levels in a social hierarchy. Examples of more and less
Equity means social justice or fairness; it is an ethical concept, advantaged social groups include socioeconomic groups (typi-
grounded in principles of distributive justice.39–42 Equity in cally defined by measures of income, economic assets, occupa-
health can be—and has widely been—defined as the absence tional class, and/or educational level), racial/ethnic or religious
of socially unjust or unfair health disparities.1 6 However, groups, or groups defined by gender, geography, age, disability,
because social justice and fairness can be interpreted sexual orientation, and other characteristics relevant to the
differently by different people in different settings, a definition particular setting. This is not an exhaustive list, but social
is needed that can be operationalised based on measurable advantage is distributed along these lines virtually everywhere
criteria. in the world. A health disparity must be systematically

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Equity in health 255

associated with social advantage, that is, the associations must discrimination.64–66 In such contexts, equality is a crucial refer-
be significant and frequent or persistent, not just occasional or ence point in attempts to achieve greater equity in health.
random.56 Furthermore, the notion of equal opportunities to be
healthy is fundamental to the concept of equity in health and
closely linked with the concept of equal rights to health. The
EQUITY IS NOT THE SAME AS EQUALITY
notion of equal opportunities to be healthy is grounded in the
The concept of equity is inherently normative—that is, value
human rights concept of non-discrimination and the respon-
based 1 37; while equality is not necessarily so.1 6 9 10 57 Often, the
sibility of governments to take the necessary measures to
term health inequalities is used as a synonym for health inequities,
eliminate adverse discrimination—in this case, discrimination
perhaps because inequity can have an accusatory, judgmental,
in opportunities to be healthy in virtue of belonging to certain
or morally charged tone. However, it is important to recognise
social groups. A selective concern for worse off social groups is
that, strictly speaking, these terms are not synonymous. The
not discriminatory; it reflects a concern to reduce discrimina-
concept of health equity focuses attention on the distribution
tion and marginalisation. Equal opportunity to be healthy
of resources and other processes that drive a particular kind of
refers to the attainment by all people of the highest possible
health inequality—that is, a systematic inequality in health
level of physical and mental wellbeing that biological
(or in its social determinants) between more and less advan-
limitations permit, noting that the consequences of many bio-
taged social groups, in other words, a health inequality that is
logical limitations are amenable to modification. For example,
unjust or unfair.
the functional limitations associated with many physical
Not all health disparities are unfair.2 6 For example, we
handicaps can be markedly changed with basic measures
expect young adults to be healthier than the elderly
(such as providing wheelchairs, installing protective railings,
population. Female newborns tend to have lower birth
or providing physical training to increase mobility and
weights on average than male newborns. Men have prostate
strength); similarly, the degree of impairment associated with
problems, while women do not. It would be difficult, however,
many psychological and physical conditions is highly related
to argue that any of these health inequalities is unfair.
to the degree of social stigmatisation or acceptance of people
However, differences in nutritional status or immunisation
with those conditions.67 68
levels between girls and boys, or racial/ethnic differences in
According to human rights principles, all human rights are
the likelihood of receiving appropriate treatment for a heart
considered inter-related and indivisible.69 70 Thus, the right to
attack, would be causes for grave concern from an equity per-
health cannot be separated from other rights, including rights
spective.
to a decent standard of living and education as well as to free-
dom from discrimination and freedom to participate fully in
EQUITY AND HUMAN RIGHTS: EQUAL RIGHTS AND one’s society. Equalising opportunities to be healthy requires
OPPORTUNITIES TO BE HEALTHY addressing the most important social and economic determi-
The concept of equity is an ethical principle; it also is nants of health, including, as stated earlier, not only health
consonant with and closely related to human rights principles. care but also living conditions in households and communi-
The right to health as set forth in the WHO Constitution43 and ties, working conditions, and policies that affect any of these
international human rights treaties is the right to “the highest factors. Concern for equal opportunities to be healthy is the
attainable standard of health.” Although this notion has basis for including within the definition of equity in health the
sometimes been criticised by public health practitioners for absence of systematic social disparities not only in health sta-
being vague and difficult to operationalise, accumulating tus but in its key social determinants.
experience suggests its utility.58–63 We believe that the highest
attainable standard of health can be understood to be reflected EASE OF AVOIDABILITY SHOULD NOT BE A
by the standard of health enjoyed by the most socially advan- CRITERION FOR INEQUITY
taged group within a society. One could argue that, given suf- The 1990 Concepts and principles paper1 defined inequity in
ficient resources, the highest attainable standard could be far health as inequalities in health that are unjust, unfair and
greater than that currently experienced even by the best off avoidable. That definition has been very helpful in giving the
group in a society. The health levels of the most privileged abstract notion of equity meaning in terms that most people
groups in a given society at least reflect levels that clearly are understand and recognise as a widely shared social value.
biologically attainable, and minimum standards for what However, we recommend that avoidability not be used as a cri-
should be possible for everyone in that society within a terion to define equity in health, for two reasons. Firstly,
foreseeable future. The proposed definition of equity in health including this criterion is unnecessary, because unjust and
thus is useful in operationalising the concept of the right to unfair imply avoidability. Secondly, certain health inequities
health. may be extremely challenging to tackle because they require
While it is important, as noted above, to be clear about the fundamental changes in underlying social and economic
distinction between health inequalities and health inequities, structures; one would not want the ease of avoidability to be a
the concepts of equality and equal rights are none the less measure of the degree of inequity. Furthermore, using avoid-
central and indispensable. The concept of equality is indispen- ability as a criterion introduces but begs the question:
sable for the operationalisation and measurement of health avoidable by whom? Is a given health disparity that adversely
equity and is important for accountability under the human affects already disadvantaged groups in a poor country
rights framework. Equality can be assessed with respect to considered to be avoidable by the groups adversely affected, by
specified measurable outcomes, whereas judging whether a their community, by government—and at what level—and/or
process is equitable or not is more open to interpretation. Fur- by the international community?
thermore, in practical terms, it is generally those who are in Thus, in defining equity in health, avoidability should only
positions of power who are likely to be determining at a soci- be invoked in so far as injustice and unfairness imply
etal level what is equitable and what is not, with respect to the avoidability. The degree to which an inequitable health
allocation of resources necessary for health. For example, in disparity is avoidable does, however, have important practical
some countries where women are particularly disenfran- implications for efforts to achieve greater equity, in that it will
chised, those in power have argued that conditions for women generally be easier to mobilise public opinion and policies to
in their countries are not unfair but rather are appropriate address disparities that are more clearly and easily recognis-
given the different capacities and roles of men and women; able as avoidable, particularly those that can be achieved more
similar arguments have been used to justify racial/ethnic quickly, at lower cost and with less challenge to underlying

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256 Braveman, Gruskin

social and economic structures. This is a pragmatic considera-

Key points
tion and should not be considered a fundamental component
of the definition of equity. • A definition of equity in health is needed that can guide
measurement and hence accountability for the effects of
actions.
CAUSAL ASSUMPTIONS • Health equity is the absence of systematic disparities in
According to the definition of equity proposed here, a health health (or its social determinants) between more and less
disparity is inequitable if it is systematically associated with advantaged social groups.
social disadvantage in a way that puts an already disadvan- • Social advantage means wealth, power, and/or prestige—
taged social group at further disadvantage. In addition, it must the attributes defining how people are grouped in social
be reasonable based on current scientific knowledge to believe hierarchies.
• Health inequities put disadvantaged groups at further
that social determinants could play an important part in that
disadvantage with respect to health, diminishing opportuni-
disparity at one or more points along the causal pathways ties to be healthy.
leading to it; that is, that at least one factor associated with • Health equity, an ethical concept based on the principle of
social disadvantage is causally connected with at least one distributive justice, is also linked to human rights.
factor associated (directly or indirectly) with the specified
health condition or determinant. This does not, however,
require definitive understanding of the most proximate—that The World Health Organisation’s (WHO) World Health Report
is, immediate cause(s), the causes most amenable to interven- for the year 200071 made a welcome argument for the import-
tion, or the entire causal pathway(s) explaining a health dis- ance of assessing health not only by average levels but also by
parity between social groups. The causes of health disparities examining its distribution. However, the report examines the
between more and less advantaged groups are likely to be distribution of health by measuring what it refers to as “pure
complex and multifactorial, and may not be clearly or imme- health inequalities,” disparities in health between ungrouped
diately linked to underlying differences in social advantage. A individuals, in contrast with examining differences between
health disparity between more and less advantaged popula- social groups.33–35 The total magnitude of health differences
tion groups constitutes an inequity not because we know the among all individuals is assessed, but there are no compari-
proximate causes of that disparity and judge them to be sons of health among different social groups. Thus, the WHO
unjust, but rather because the disparity is strongly associated measure compares the health of healthier people with the
with unjust social structures; those structures systematically health of sicker people within a country, but does not, for
put disadvantaged groups at generally increased risk of ill example, compare the health of wealthier people with the
health and also generally compound the social and economic health of poorer ones, the health of different ethnic groups
consequences of ill health. with each other, or health care for men and women with simi-
Given the complex and multifactorial nature of the causal lar health conditions. Nevertheless, most audiences naturally
pathways leading from underlying social determinants to assume that work on health inequalities is work on health
most health disparities, causal assumptions should not be equity.
made based on observed associations between particular The measurement of health disparities without respect to
measures of social advantage and any given health outcome. how the disparities are distributed socially is not a measure of
For example, when a particular health disparity in a society is equity and does not reflect fairness or justice with respect to
systematically seen across income groups, the underlying health.2 36 37 72 73 If countries or organisations use this WHO
causal differences could be in factors associated with income measure rather than established measures of health equity
rather than in income itself; thus, it would be a mistake to (reviewed comprehensively in Mackenbach and Kunst74 and
assume that efforts focused only on equalising income would Wagstaff et al75), they will be unable to monitor differences in
necessarily be effective in reducing that particular inequity. health and health care between the rich and the poor or
between more and less privileged racial/ethnic groups or to
make appropriate comparisons with respect to gender.
DO THE DEFINITIONS REALLY MATTER? Without such comparisons between identifiable social groups,
In practice, different social, political, economic and cultural it will not be known who is benefiting most or least from poli-
contexts, will undoubtedly suggest the need for different ways cies affecting health and therefore how best to target
of defining and explaining equity. However, clarity is required interventions or redistribute resources to achieve greater
to determine when different definitions represent substan- health equity.36 37 Thus, the choice of definition for equity in health
tially different paradigms, and the implications of adopting matters because of the implications for the utility of measurement.
these different paradigms in particular contexts. As noted ear-
lier, people often use the term health inequalities in what may be CONCLUSION
an effort to avoid the judgmental or moral connotations that Equity in health is an ethical value, inherently normative,
may be associated with health inequities. Health inequalities is less grounded in the ethical principle of distributive justice and
cumbersome than social inequalities in health, the latter term consonant with human rights principles. Like most concepts,
also often used as a more succinct way of referring to equity in health cannot be directly measured, but we have
inequalities in health between more and less advantaged proposed a definition of equity in health that can be
social groups. We believe that using these more concise terms operationalised based on meaningful and measurable criteria.
will not be problematic so long as there is clarity as to how In operational terms, and for the purposes of measurement,
they are being used—that is, that both health inequalities and equity in health can be defined as the absence of disparities in
social inequalities in health mean inequalities in health or its health (and in its key social determinants) that are systemati-
social determinants, between more and less advantaged social cally associated with social advantage/disadvantage. Health
groups, favouring the already more advantaged groups. When inequities systematically put populations who are already
using the more abbreviated expressions, one must be clear socially disadvantaged (for example, by virtue of being poor,
that equity, at least as understood here and in the vast major- female, or members of a disenfranchised racial, ethnic, or reli-
ity of the literature, cannot be assessed without comparing gious group) at further disadvantage with respect to their
how better off and worse off social groups are faring in health.
relation to each other. The importance of clarity regarding While equity and equality are distinct, the concept of equal-
these concepts is illustrated by a recent debate. ity is indispensable in operationalising and measuring health

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Equity in health 257

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P Braveman, Department of Family and Community Medicine, University 36 Braveman P, Krieger N, Lynch J. Health inequalities and social
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S Gruskin, International Health and Human Rights Program, Francois 37 Braveman P, Starfield B, Geiger HJ. The World Health Report 2000’s
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