How to achieve health equity

WASHINGTON, DC — In 2015, the world committed to achieving the Sustainable Development Goals (SDGs) — a comprehensive agenda covering virtually all aspects of development — by 2030. But the world has yet to embrace the kind of deliberate, systematic and inclusive approach that is needed to eliminate inequities that prevent billions of people from enjoying a long and healthy life.

Last year’s United Nations report on progress toward achieving the SDGs showed that the number of people facing hunger is actually growing, as is the number of malaria cases. Moreover, according to the Intergovernmental Panel on Climate Change, the consequences of climate change are emerging much faster than anticipated. The world’s poorest and most vulnerable will be disproportionately affected.

This is no way to fulfill the pledge contained in the SDG framework, called the 2030 Agenda for Sustainable Development, that “no one will be left behind.” But it should not come as a surprise. The world has made limited efforts to eliminate inequities, including in health. The SDGs’ predecessor, the Millennium Development Goals, brought modest improvements in health equity for many countries, but in a substantial minority of countries, poorer segments of the population fell even further behind.

In Nigeria, access to basic reproductive, maternal, newborn and child health interventions remains five times higher for those in the top wealth quintile than those in the lowest (68 percent, compared to 13 percent). In Bangladesh, 74 percent of the wealthiest quintile has access to skilled childbirth care, whereas only 18 percent of the poorest does.

Serious health inequities persist even in the advanced economies. In the United States, residents of Baltimore’s largely white and wealthy Roland Park neighborhood can expect to live 16 years longer than residents of the largely black, impoverished Greenmount East neighborhood, located just a few miles away.

Ensuring that the SDGs succeed where the MDGs did not demands a carefully designed, comprehensive and inclusive response that directly tackles “the inequitable distribution of power, money and resources” that underlies health inequities. The health equity programs of action framework, proposed by the O’Neill Institute for National and Global Health Law at the Georgetown University Law Center, aims to facilitate the development of just such a response.

Grounded in countries’ human rights obligations, the programs of action could be implemented through national health plans or through national development, SDG, or social inclusion strategies. They would adhere to seven principles:

• Enable empowering participation and inclusive leadership. People from disadvantaged and marginalized populations would be decision-makers, helping to lead all relevant structures and processes.

• Maximize health equity. Disparities in rates of all diseases and other health threats must be addressed, as must the structural determinants of health.

• Health systems and beyond. The full range of social, cultural, environmental, economic and political determinants of health must be considered.

• Every population counts. Beyond addressing common causes of health inequities—such as discrimination, poverty, inadequate housing and unequal access to education—factors that are particular to any one or several populations must be addressed as well.

• Actions, targets and timelines. Actions must be specific and linked to measurable, time-bound targets.

• Comprehensive accountability. Actions and targets must be incorporated into sectoral strategies and encompass thorough monitoring and evaluation (including by independent entities), capacity-building and structures that embed accountability at all levels of the health system and other relevant systems.

• Sustained high-level political commitment. Programs of action can be implemented only if political leaders have the will to work consistently and systematically over a prolonged period, allocating the relevant resources as needed.

We have less than 12 years to achieve the SDGs. Without a comprehensive and steadfast effort to eliminate health inequities—the kind promoted by health equity programs of action—we will fail. That is why countries should urgently adapt the seven principles to their circumstances and incorporate them into their health and development planning processes. To this end, they can take advantage of the newly released implementation framework for health equity programs of action.

The UN and the World Health Organization—whose principles are consistent with those of the health equity programs of action—should encourage governments to adopt this framework. So should development and funding agencies, including the Global Fund to Fight AIDS, Tuberculosis and Malaria, as well as civil society organizations.

Health inequities are not inevitable. They are the product of injustices that people have created. Eliminating those injustices is within our power as well. —Project Syndicate

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Eric A. Friedman is the global health justice scholar at the O’Neill Institute for National and Global Health Law at Georgetown University Law Center.