For an account of the workshop upon which this entry is based, see the blogpost at https://torch.ox.ac.uk/article/bolg-post-what-do-we-mean-by-equity-in-global-health
Equity is a central concept, if not the central concept, in global health. Most definitions of ‘global health’ include a reference to equity in health action worldwide. While everyone agrees that equity matters, there typically is disagreement about what it means in theory and, therefore, what kind of global health intervention counts as equitable. Different understandings of equity can lead to different decisions about which interventions are prioritised and who ultimately benefits.
One problem is that there are many possible dimensions to equity. Those discussing equity in global health often focus on different such dimension, so that when we talk about equity we don’t necessarily talk about the same thing. Equity can refer to the outcome of a certain process or to the process itself. It can be based on different criteria or combination thereof, such as the consideration of the needs of those affected or how the benefits and burdens are distributed. Equity can be primarily retrospective or primarily prospective, depending on the extent to which it focuses on redressing past injustices or on creating a future situation that meets some relevant criterion. Equity might require prioritizing immediate interventions to address emergencies or prioritizing long-term interventions aimed at structural problems.
A second problem is that it is impossible to define equity in terms of one or the other term of each of these pairs without presupposing what needs to be defined.
Instead of providing a definition based on a choice that can never be ethically neutral, this entry will focus on the key factors that an understanding of equity would need to consider, especially as the concept is applied to discussion in global health.
It will do so by providing examples of how such factors have been discussed in an interdisciplinary context and by abstracting from this discussion to provide a more theoretical framework for equity. The fact that there are different factors that could be given different weights, rather than an monolithic definition of global health, helps explain why people working in global health may reach different conclusions about what equitable action looks like.
Equity: examples from interdisciplinary discussion
In our interdisciplinary workshop, equity as pertaining to global health discussion was applied to 2 problems.
Problem 1: Tackling malaria: Bed nets or addressing underlying vulnerability?
Anthropologist Ann Kelly discussed malaria prevention strategies and explained that lasting insecticide treated bed nets for malaria prevention are typically favoured as humanitarian good also because they are low cost. But whether that is equitable depends on whether equity requires prioritizing the immediate problem, and therefore access to nets for those who need them the most; or focusing primarily on the structural interventions aimed at the underlying conditions that produce vulnerability. If the latter, then the question of equity becomes the question of whether other types of interventions (in addition or instead of nets) are required, and who should bear the higher costs and be the main beneficiary. It is worth mentioning that structural approaches are often more difficult, slower and more resource-intensive than emergency interventions. That’s another reason why equity can be difficult to achieve in practice.
In a similar fashion, philosopher Caesar Atuire used the example of bed nets against malaria to emphasize the risk that equity becomes a band aid rather than a solution. You can only use bed nets if you have beds in the first place, which not everyone does. How do we ensure we are paying attention to the deeper, structural issues that generate these unfair conditions in the first place?
Discussion of this problem emphasized equity as pertaining to the dimension emergency vs structural interventions, but also to the dimension of reparative vs transformative problem. Bed nets might address some claims individuals have and ground some duty to assist on the basis of responsibilities of the global North for the underlying vulnerabilities in the global South. But on some other view of equity, this is an individualistic and myopic approach which doesn’t give due consideration to addressing structural problems within a transformative view of equity.
Problem 2: Costs and benefits of global public goods.
Anti-malaria bed nets are private goods, in the sense that they only benefit those who use them. Since malaria is not transmissible between humans, preventing one person from getting malaria via bed nets would not reduce the risk for other. But many health goods in global health are public goods, in the sense that to the extent that some benefit from them, all of us do. One example is herd immunity against human-to-human transmissible infectious diseases (or indeed, ideally but less feasibly, eradication of such diseases). Philosopher Lovro Savic discussed equity as related to the concepts of (global) “public goods”. Apart from benefits, public goods involve certain burdens to be sustained, such as distributing vaccines and, for some, getting vaccinated. One question is whether equity requires thinking of the burdens and benefits of public goods as applying to groups or to individuals. Ultimately, equity raises a question about what counts as relevant burden and benefit and for who, and who gets to decide that.
But answering this question depends, among other things, on whether we locate equity in the outcome, that is, a certain distribution of burdens and benefits (according to whatever criterion for equity we choose, to whether we want equity to be mainly reparative or transformative, and so on); or in the process, for instance by making sure that all relevant voices are adequately heard. Or, of course, both.
Different answers lead to different decisions in policy, programme design and implementation, ultimately shaping whose interests are prioritised, how burdens are shared and who benefits from global health interventions.
Having seen how the factors contributing to equity came up in an interdisciplinary context about various global health issues, let’s try to abstract from this conversation and provide a theoretical framework for equity in global health.
According to this framework, discussion of equity in global health would need to consider at least these factors:
1) Outcome or process?
Equity can be about outcomes or about procedures followed to get to certain outcomes. On the first option, the same process can be equitable or unequitable depending on what outcome it produces. On the second option, the same situation could be equitable or unequitable depending on how it was reached. Viewing equity primarily as a process could place greater emphasis on participation, representation and whose voices are included in decision-making, whereas focusing on outcomes shifts attention to the results those processes are intended to achieve.
What counts as an equitable outcome or equitable process depends on what criteria are taken to be defining of equity.
2) Criteria for equity
Another aspect of equity is the criterion itself with which we define what counts as equitable. There are two types of criteria, which we might call the ‘currency’ of equity and the “distribution principle” of equity.
Currency. An underlying principle typically invoked more or less explicitly– including in our workshop – is ‘equal consideration for equal needs’. While the concept of “need” is typically considered central in assessing the equity of a certain situation, it is not the only one. For instance, those who need a resource the most are not necessarily those who would benefit the most. The longer your life expectancy, for instance, the more you would benefit from a life-saving treatment. If equity was based primarily on ‘benefit’, a factor like life-expectancy would need to be given high priority. If equity was primarily about need, then life expectancy would not be a prominent factory in equity assessment.
Distribution principles. We have just considered equity as a matter of prioritizing certain groups on the basis of need. This is what philosophers usually call a prioritarian distribution principle: higher priority to the worse off. But there are other distribution principles. The most notable ones are the sufficientarian and the utilitarian one. The first one prioritizes the worse off, but only up to the point where their needs are met to a minimum standard, or they benefit enough from a certain intervention; after that, their prioritization no longer applies. The utilitarian principle simply aims at maximising the total impact of an intervention, irrespective of internal distribution.
3) Restorative vs transformative
If equity was primarily a reparative project, then certain inequalities in the distribution of burdens and benefits could be justified by the requirement of redressing past injustices. This might require, for instance, the prioritization of the needs of some people to compensate for past injustices, or the prioritization of the benefit for some people (for instance in accessing vaccines) for the same reason, even when these people do not need the most or stand to benefit the most from the good in question.
However, if equity was primarily a transformative project, then the cost and benefits of the pursuit of global health goods would be less sensitive to what happened in the past.
For instance, on a transformative approach to equity, based on a utilitarian distribution principle and on benefit as the relevant ‘currency’, a vaccine should be distributed in a way that is most effective at containing the relevant disease on a global scale. On a reparative approach to equity, however, it might be that certain populations are owed priority access to the vaccine as compensation to past health injustices, even if this was not the most effective strategy to contain the spread of the disease globally and even if other groups would need the vaccine equally (or indeed more).
4) Emergency interventions vs structural interventions
In global health, the choice is often between addressing structural problem of injustices and addressing current situations in an emergency mode. The former is arguably more difficult and expensive to do and often requires additional effort and resources to reach those who are left behind. The aforementioned example of lasting insecticide treated bed nets for malaria prevention as the favoured humanitarian intervention exemplifies well the two different understanding of equity.
Is a definition needed, after all?
The problems with finding a neutral, shared definition of equity suggests that providing the factors that contribute to our understanding of equity could be the best that we could do. And after all, a shared definition might not be needed, as long as we agree on what kind of factors should be considered. Shared conceptualisations of equity in global health are feasible even if we do not quite agree on a shared concept.
However, participants to our interdisciplinary workshops suggested that a shared conceptualization of equity in global health should be based on the following:
Equity is not an outcome but a process.
Equity should reflect lived experiences, needs, and contexts.
Equity should both challenge structural issues and determinants and seek transformative change.
Equity should consider power, privilege, positionality.
Equity assessments require interdisciplinary approaches and methodologies, drawing varied understandings across various disciplines.
Abstraction and conceptualisation of equity needs to focus on the people on the ground and the local realities.
