Health equality vs health equity (no, they're not the same)

Health equality is when doctors spend the same amount of time with each patient, but health equity is when the doctor spends the appropriate amount of time with each patient according to their needs. — 123rf.com

International Women’s Day is commemorated on March 8 annually to celebrate women’s social, economic, cultural and political achievements.

It also calls for action to educate and raise awareness for women’s equality, for positive change to advance women, and to accelerate gender equality.

The theme for 2023 is “Embrace Equity”.

The discussion is particularly important with the focus on healthcare in the Budget debates in Parliament.

Healthcare equality and equity are not the same, although the terms are interpreted and used interchangeably by many politicians and policymakers.

This column seeks to address the misperception and misinterpretation of health equality and equity.

Health equality

Health equality means providing everyone the same health resources, regardless of their background, circumstances, need or outcome.

In practice, this means everyone receives the same access to care, health resources, health education and so on.

It suggests that everyone has the same opportunities for positive health outcomes, and assumes all people receive equal treatment.

Examples of health equality include:

• The outpatient charges in all government clinics are the same.
• A doctor spends an equal amount of time with each of their patients.
• A vaccine is available to all eligible persons in a community.
• All patients are provided the same informational brochure on a health condition.

However, what if:

• Patients cannot afford the transport and other costs of seeking healthcare from any government clinic?
• A doctor spends equal time with each patient, but actually, some patients require more time because they have more serious health issues?
• A vaccine is available to eligible persons in a community, but some segments of the population are at increased risk of infection, compared to others?
• All patients are provided the same informational brochure, but some have different language skills?

  This is particularly so in Malaysia where there are even regional variations in Bahasa Malaysia.

The premise of health equality is that everyone starts from the same place.

However, the fact of life is that everyone has different backgrounds, education, incomes and access to healthcare facilities.

The interpretation of the term “inequalities” is more diverse, and the concept often overlaps with the concept underpinning inequities.

An illustration of the difference between equality and equity is to consider the distribution of free rice to a group of 100 families.

For the same number of meals, those with smaller families could probably utilise the bag of rice with some to spare, but it might be insufficient for those with larger families.

While the rice was equally distributed to every family in the group, it was not equitable because it was insufficient for those with more people in their family.

The concept of health equality assumes that everyone starts from the same place; however, in life, some of us can afford a car; some, just a motorcycle; while others can only afford public transportation, for example. — Filepic

Health equity

The World Health Organization (WHO) defines health equity as “the absence of unfair, avoidable or remediable differences in health among population groups, defined by social, economic, demographic or geographic characteristics”.

It means providing everyone with the support they need to access the same level of healthcare.

In other words, it involves providing healthcare for an individual or group to assist them achieve the same health outcome as other individuals or groups.

Examples include:

• Access to emergency services irrespective of gender, age, physical appearance, ability to pay, or even dress.
• A healthcare facility with language assistance for those with poor language skills.
• Alterations in treatment for those without regular access to nutritious food.
• Availability of vaccines to anyone at risk irrespective of citizenship status.

In addressing health inequity, which doctors do daily, consideration has to be given to the non- medical factors that affect health outcomes.

These are termed social determinants of health (SDHs).

These are the conditions in which people are born into, grow, work, live and age, as well as the wider forces and systems shaping the conditions of daily life.

These forces and systems include economic policies and systems; social norms and policies; development and other agendas; and political systems.

SDHs can be categorised into few broad groups that include:

• Healthcare

  What is the level of access?

  What is the quality and safety of care?

• Education

  What is an individual’s education level?

  What is the level of access to health information?

• Environment

  Is the living and working environment safe?

  Is there access to basic health resources like safe housing, access to nutritious food, clean water, etc?

• Economics

  What is an individual’s financial resources?

  Is there sufficient income for life’s necessities, safe housing, access to food and transport?

• Social and community life

  Is there discrimination based on age, gender, religion, sexual orientation, financial status, etc?

According to the WHO, SDH account for 30-55% of health outcomes.

One SDH that affects health equity is the level of education a person has. — Filepic

Addressing health inequities

Health inequities accumulate throughout the life cycle, i.e. from birth to death.

These inequities can be addressed by actions on the structures and processes underpinning them.

It requires political will to address the inequitable distribution of power, money and resources in society; and to enable and promote societal empowerment and participation.

The WHO has a health inequality monitor that can be used by its member states to identify health inequalities and their drivers.

It noted that only half of countries worldwide have data disaggregation in their published national health statistics reports.

There is a gender gap for many health conditions.

For example, the British Heart Foundation reported that “at every stage – diagnosis, treatment and aftercare – women who have heart attacks receive poorer care than men”.

The Institute of Strategic and international Studies (ISIS) Malaysia reported in 2021 that “97% of more than 100,000 registered nurses are female, yet awareness about certain diseases that affect women, such as breast cancer, HPV (human papillomavirus) infections, and period pains or menstrual cramps, remains woefully low”.

The World Economic Forum’s Global Gender Gap Report 2022, which benchmarked the evolution of gender-based gaps in four domains, surveyed 146 economies.

The four domains were economic participation and opportunities, educational attainment, health and survival, and political empowerment.

Malaysia was ranked 103rd, behind Indonesia (92), Thailand (79), Laos (53) and the Philippines (19).

In the domain of health and survival, Malaysia was ranked 68th, behind Laos (55), Thailand (37) and the Philippines (30), but ahead of Indonesia (77).

Malaysia is a member of the United Nations’ Human Rights Council and holds the vice-president’s post at the World Health Assembly, the governing body of WHO.

It behooves us to set an example for other countries through positive actions to embrace equity and address the SDHs, as well as ensure that transparent disaggregated data on the gender gap are provided in health reports.

Dr Milton Lum is a past president of the Federation of Private Medical Practitioners Associations and the Malaysian Medical Association. For more information, email [e-mail]. The views expressed do not represent that of organisations that the writer is associated with. The information provided is for educational and communication purposes only, and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.