Health Inequities: Can it be Addressed Through Health System Reforms?

Health is a universal human aspiration and a basic human need everybody should enjoy. In today’s world the development of society can be judged by the quality of its population’s health, how fairly health is distributed across the social spectrum, and the degree of protection provided from disadvantage due to ill health, and not only by the gross national products. Attaining a full health potential, therefore, is a human right every individual in this globe should have the opportunity to achieve. Governments, societies, individuals and health systems should aim at health equity to the population they serve. Health equity means that everyone has an equal or a fair opportunity to live a long, healthy life. It implies that health should not be compromised or disadvantaged because of an individual or population group’s race, ethnicity, gender, income, sexual orientation, neighbourhood or other social condition (1).

The root of health inequities is poverty. Whatever, the quality and quantity of the service provided by the country’s health system, socio-economically disadvantaged individuals and families will suffer poor health and have some difficulties in fully accessing the needed health services. Achieving health equity, therefore, requires creating those fair opportunities for health and eliminating gaps in health outcomes between different social groups. Although health systems can play a crucial role, the main part of the solution is outside the health system functions: the socioeconomic status in the form of education, housing, income, transportation and all the opportunities for healthy living. Health equity through action on social determinants is central to this premise and to the work of the commission on social determinants of health and its report in 2008 (2). The successor of the UN millennium development goals, the 17 sustainable development goals (SDGs) adopted by the UN in 2015 and launched in January 2016 recognised that fully and aimed at ending poverty in all its forms everywhere; ending hunger, achieve food security and improved nutrition, and promote sustainable agriculture; and ensure healthy lives and promote wellbeing for all at all ages, among many other goals to reduce inequities and inequalities. Wide range of actions was proposed in goal 3 through healthy living and health improvement. The health systems can play a major part in this but most importantly that governments should ensure universal health coverage (UHC) to the entire population. In 2012 the WHO director general, Dr Margaret Chan asserted, “universal coverage is the single most powerful concept that public health has to offer. It is our ticket to greater efficiency and better quality. It is our saviour from the crushing weight of chronic non-communicable diseases that now engulf the globe” (3). UHC paves the way for health care equity and ensuring the financial protection every person needs to prevent health-related financial catastrophes.

In this issue of the journal, Joulaei and his colleagues in a systematic review on equity and health system reforms concluded that “socioeconomic and political determinants play on the success of health system reforms”. They emphasised the crucial role primary health care, but they were cautious about a wholesale reforms if to achieve equity (4). Although all the papers they reviewed have based their assessments of reforms on UHC as the main platform to achieve equity, at least health care equity, this was not one of their five key recommendations.

Equity in health care, as equal access to available care for equal need, equal utilization for equal need, equal quality of care for all (5), can not be achieved without UHC (6). Such UHC can not be credible and address the social inequalities and build on fairness, social justice and solidarity, if it based on social insurance where everyone with income will pre-pay equal percentage of their total income (taxation, social insurance, national insurance) rather than a premium based insurance, in which everyone pay the same annual sum. UHC means full financial protection on all health and health related issues and services should be free at time of delivery or with a small and manageable co-payment. Furthermore, any health reform, which is not based on comprehensive primary care service with, integrated public health that covers the entire population (7, 8); will not achieve its main objective of a healthy population. Primary care is the root of social justice and equity in health.