There are at least two main components or aspects to take into account when we want to fit the principle of equity when dealing with health policy. In other words, health inequality has two main components. On the one hand, there is the access to the health system (or coverage of the health system) [aspect 1], and on the other hand there is the social health determinants [aspect 2]. Policy makers mustn’t ignore the second one, as they have been doing a long time ago and in many places.
Besides, at least in Spain, there is an assistive prevalence in health policies instead of preventive policies. The emphasis often is put on the health care (assistance) and on the coverage of the system that provides that health care, instead of on the disease’s prevention and on the health determinants. As it says Rosa Urbanos in Social inequalities in health: bad times for poetry:
“There is a prevalence of the biomedical paradigm of health and disease […] the assistive (care) inertia that tinges the health policy is favored by the existence of influential lobbies (industry, experts, professionals…), interested that the focus of the discussion remain not in how to prevent the contingency of the disease (through primary prevention), but in how to design, finance and organize the health care once the disease, or his simple suspicion, has been appeared. […]
One of key factors that creates inequalities in both aspects of health inequality is the social class, but also the gender, the nationality, ethnicity and territoriality. The stratification of the society by social classes causes an unequal distribution of social health determinants, and this produces an unequal exposure to diseases depending on the social class you belong to. Also, people from different social classes have different degree of access to the health system. And the unequal access to the health care is exacerbated by the organization, the institutional structure and the basic principle in which is based the system. We can find some empirical evidence of both causal associations (social class-unequal distribution of health determinants and social class-unequal access to health care) put in the same single indicator “poor or very poor general health”, for the EU 25 Member States [see figure 3.15, took from Health Inequalities, Final Report of a Consortium]. As we can see, the lower level of education and income, and the more material deprivation, the poorer and very poorer general health is reported. So, depending on the socioeconomic group, people have higher or lower level of general health and also there is a gap in social health determinants.
“In 2008, the World Health Organization (WHO) Commission on Social Determinants of Health (CSDH) concluded that social inequalities in health arise because of inequalities in the conditions of daily life and the fundamental drivers that give rise to them: inequalities in power, money and resources. They argued that social and economic inequalities underpin the determinants of health: the range of interacting factors that shape health and well-being.”
Moreover, the more weight the private sector has, the more polarized will be the health system by social class. Or in other words, the higher is the private expenditure of the overall health expenditure, the more polarized will be the health system. Polarized means that there is a big gap in one dependent variable (in this case the level of health) between different social groups, and the most common social groups that generate polarization are social classes. This gap on the level of health is caused primarily by the fact that private health care attends basically to the sectors with more resources of the society and the public health system attends the popular and most deprived classes. Furthermore, Spain is the country of the EU-15 with the higher private health expenditure, with almost the 30% of the overall health expenditure being private (Navarro, 2012).
Thus, it is clear that austerity policies can’t resolve the very important problem of health inequalities, but they do nothing but worsen the situation. Austerity policies go in a completely opposed direction to that of the goal of reducing health injustices and promoting equity.
“The cuts in public expenditure will accelerate the growth of private health care, process of acceleration facilitated by deductions on private insurance […], reducing the public sector to an assistive sector of minimum for popular classes. This dichotomy will further negatively affect the equity and efficiency of the system.”
Finally, I write down some of the possible and desirable health policies and forms of organization of the system: for the aspect 1, the goal of guaranteeing equal access to health care, a national health system with universal coverage would be an essential requisite, the minimum. For the goal of reducing previous health injustices as the unequal distribution of health determinants by social class (aspect 2), the policies needed must be much more structural, deeper and intended to change socioeconomic variables and reduce the incidence of social class. Some desirable public interventions would be related with education, labor market, health prevention and all kinds of strong public services, among others.
References
Navarro, Vicenç (2012). El error de las políticas de austeridad, recortes incluidos, en la sanidad pública. Debate, Gaceta Sanitaria 2012; 26 (2); 174-175. http://www.scielosp.org/pdf/gs/v26n2/debate1.pdf
Urbanos, Rosa (2012). Desigualdades sociales en salud: malos tiempos para la lírica. Editorial, Gaceta Sanitaria 2012; 26(2); 101-102 http://www.scielosp.org/pdf/gs/v26n2/editorial.pdf
European Comission. Consortium lead: Sir Michael Marmot. Health inequalities in the UE. Final Report of a consortium. http://ec.europa.eu/health/social_determinants/docs/healthinequalitiesineu_2013_en.pdf
Social Policy UPF 