1. Health equity An introduction

2. Health equity is an issue of social justice

3. Why the focus on health equity ? Differences in health status arise not simply as a result of individual differences in genetic and biological makeup, life styles, exposure to disease causing organisms and health. Inequities in social status make a significant contribution to inequities in health. The relationship between race/ caste/ ethnicity, gender, class and health status have been observed by many studies The disadvantages suffered in access to resources and power across population sub-groups in turn translate into differences in risk of exposure and vulnerability to diseases, as well as in differential access to adequate and appropriate health care.

4. Equality and equity in health Equality is the state of being the same, whereas equity implies fairness and justice. There are bound to be differences in health status between individuals for a number of reasons, many of these random or biological. When the health indicators of one social group differ from that of another social groups, we may say that there is inequality in health status between these two groups. One example of this would be age-based differentials in health status.

5. Equality and equity in health When does inequality become inequity ? When an entire social group is observed to consistently have a lower health status, and this social group does not have the same access to the many social conditions and other resources necessary for healthy living, then we may call this health inequity. The very term ‘inequity’ implies a value judgment signifying an absence of fairness, and needs to be used with caution.

6. Equity in ‘health’ vs. equity in health care The literature on equity in health and health care sometimes does not distinguish between health and health care, using these interchangeably to indicate health care alone. This may be a consequence of the underlying assumption that health care alone is necessary for good health. From this premise a conclusion that an equitable distribution of health care is one which gives rise to an equal distribution of health seems tenable.

7. Approaches to studying health equity Comparing health indicators of social groups which are apriori known to suffer disadvantages vis-à-vis a comparion group : eg. by race, gender or rural/urban residence Comparing health indicators of ‘deprived’ areas, through construction of deprivation indices: also known as ‘ecological’ studies Comparing health indicators across ‘classes’ – defined according to varying criteria

8. Need for considering various dimensions of health Morbidity Health seeking behaviour and utilization of health care services Health consequences Social consequences

9. Need for a range of indicators for each dimension Example: prevalence, incidence, progress from infection to disease, nature of morbidity, severity – are all morbidity indicators Differentials that do not show up in one indicator often show up in another. Eg. Prevalence vs. incidence. A low prevalence can coexist with high incidence if there is higher case fatality. Differentials that do not show up in one kind of stratification of data may show up in another. Cross tab by additional variables becomes necessary (eg. Age and SES, birth order and SES etc.)

10. Need for a range of indicators for each dimension Example: In health seeking behaviour and utilization of health care services, one may explore observed differentials across groups in: Whether any external care sought Delay in seeking care from the time of appearance of symptoms Type of provider or facility approached for first level care (e.g. formal/ informal; within formal, nurse/ general practitioner/ specialist; public/ private) Whether treatment completed