Inequalities in health--future threats to equity

In discussions about equity there is a tendency to focus on the inequalities in health status that appear to be the result of the material and immaterial consequences of a lower income, professional or social status in society. If we look at publications such as the Black Report in the UK or Ongelijke gezondheid in The Netherlands, we have to accept that despite our universal access to healthcare and the existence in many Western countries of social security measures that preclude 'real' poverty, considerable differences in health continue to exist between socioeconomic groups. This is corroborated for many other European countries in the research carried out by a concerted action led by Mackenbach. These inequalities in health have been referred to in many countries as inequities, meaning that society finds them unjust and expects them to be 'avoidable' or amenable to policy interventions. However, the research on the causal networks underlying the occurrence and the avoidability of inequalities in health remains sparse and intervention studies seem to focus on policy measures that can be evaluated, but which will most likely have a limited impact on the inequalities measured at the population level. Thus the research community leaves policymakers with very little evidence on which to build policy initiatives that are nevertheless requested by many governments. The third element, which needs to be addressed in this context, is the ominous inequality in access to healthcare. Since the debate on equity in health has rightly been initiated in the context of a broader, more intersectoral approach to health policy, very little attention has been paid, so far, to the issue of universal access to quality healthcare services. This is because in the second half of this century most Western (European) countries have created a healthcare system with universal access, financed either through taxation or through social insurance schemes. It is these financing systems that will be threatened in the years to come by the considerable demographic shift occasioned by the ageing of the post-war baby boom and the incentives for risk selection that have been introduced in many systems as part of the 'market' mechanisms. The benefits of these incentives have clearly been a greater efficiency at the patient or service level, but there is still the question of whether it will be a more efficient system also at a population level if equity considerations continue to require a system of universal access to all the healthcare technology that will become available in the coming years. The other side of the coin of risk solidarity is the delimitation of the collective responsibility, thus of a basic benefit package. It is important to realize that equity has been a fundamental underlying value that has led to the creation of the healthcare systems as we know them but which may have become so accepted that it is no longer carefully considered when looking at issues of rationing or health reforms.