Promoting Health Equity

Whitehead’s landmark work on health equity of 35 years ago still best defines the concept of health equity and the means of promoting it: “Equity in health implies that ideally everyone should have a fair opportunity to attain their full health potential and, more pragmatically, that no one should be disadvantaged from achieving this potential, if it can be avoided.” 2 (p.67) For Whitehead there are two key components of health equity: equity in access to the living and working conditions necessary for health and equity in access to required health care. Barriers to equity are usually a result of systemic societal structures and processes.

Regarding access to the conditions necessary for health, the absence of health equity is the presence of health inequalities, which, since most are avoidable and unfair, are actually health inequities. Whitehead outlines four processes that create these inequities: (1) health-damaging behaviour where the degree of choice of lifestyles is severely restricted; (2) exposure to unhealthy, stressful living and working conditions; (3) inadequate access to essential health and other public services; and (4) health-related social mobility whereby sick people move down the social scale.

Whitehead identifies seven means of addressing health inequities which clearly involve the making and implementation of public policy: (1) improving living and working conditions; (2) enabling people to adopt healthier lifestyles; (3) committing to decentralizing power and decision making, thereby encouraging people to participate in every stage of the policy-making process; (4) assessing the health impacts of policies and implementing health-equity supportive ones through intersectoral action; (5) concern and control at the international level; (6) making high quality health care accessible to all; and (7) assuring equity policies based on appropriate research, monitoring and evaluation.

Thousands of works since then have provided a myriad of proposals for achieving health equity based on these concepts. The report of the World Health Organization’s Commission on Social Determinants of Health’s Closing the Gap in a Generation: Health Equity Through Action on the Social Determinants of Health is a core document offering these requirements: (1) improve daily living conditions; (2) tackle the inequitable distribution of power, money and resources; and (3) measure and understand the problem and access the impact of action. 17 (p. 2) More recent health equity work is documented in Bryant’s Handbook of the Social Determinants of Health; 18 for Canada in Raphael’s Social Determinants of Health: Canadian Perspectives; 19 the USA in Bezruchka’s Inequality Kills Us All; 20 ; and the UK in Walsh and McCartney’s Social Murder? Austerity and Life Expectancy in the UK. 21 The World Health Organization’s follow-up to its 2008 report, World Report on Social Determinants of Health Equity, 2025, is now available. 2

None of these make for happy reading. Increases in income and wealth inequality, employment insecurity and precarity, and housing and food insecurity have led to a polycrisis of living and working conditions in many nations -- and this is especially the case in the liberal nations of Canada, USA and UK – where the ongoing functioning of society is uncertain.13,14,22–24 Like others, we argue this failure is due in part to health equity researchers and advocates neglecting how the distribution of power and influence among societal sectors create the inequitable distribution of resources necessary for health and problematic aspects of the organization and delivery of health care.25–28

However, we also argue that even when unequal power and influence are considered in these works, there is frequently an unwillingness to acknowledge how these differences are integral features of the capitalist economic system and are unlikely to be remedied unless this system is radically transformed or replaced. 29 This unwillingness is rooted in the dominant models researchers and advocates use to understand public policy change that preclude consideration of radical transformations in existing economic and political systems.30–34

The models used to promote health equity used by many researchers and advocates adhere to the pluralist view that quality research informed by quality theory leads to progressive public policy.8,9 For example, pluralism implies that all who wish to influence public policy have the ability to do so and that governments will respond to evidence. This is a misguided and naïve view of the public policy process in which government is perceived as a benevolent ruler that carefully weighs evidence and makes decisions believed to be best for the whole of society. In short, pluralism has an underdeveloped understanding of inequality and its causes.

Others subscribe to the institutionalist view that by understanding processes of government policymaking, health equity-promoting public policy will be implemented through research and advocacy.8,9 Institutionalism is another rational public policy model that tends to be primarily concerned with the knowledge activities of upper-level policy analysts within government and those associated with think-tanks. It also provides a rather limited understanding of how the public policy process works. In short both pluralism and institutionalism tend to depoliticize the public policy process and how it can create and perpetuate social and health inequalities. Neither model considers the dominance of some groups such as the corporate and business sector and their considerable capacity to influence public policy decisions to protect its own class interests. Both models therefore, neglect issues of class relations.

We believe that in liberal welfare states where the dominant societal institution is the market, the public policy playing field is skewed in favor of the wealthy and powerful such that these models lack usefulness. This is because research and advocacy efforts often cannot overcome the power and influence of the corporate and business sector whose profitmaking would not be served by equalizing the distribution of economic and other resources. 4 Political economy models of public policymaking are more likely to address these larger issues.