EQUITY AND FAIRNESS IN

HEALTH CARE
JOKO MULYANTO
DEPARTMENT OF PUBLIC HEALTH & COMMUNITY MEDICINE
FACULTY OF MEDICINE, UNIVERSITAS JENDERAL SOEDIRMAN
OUTLINE
Concept of Equity
Ideological Perspectives of Equity
Economic Perspectives of Equity
Equity in Health Care
Equity in Health
CONCEPT OF EQUITY
Equity is a complex concept
Part of the justice concept
Based on distributive or social justice concept
Heavily depends on the ideology of society
Related terminology: justice, fairness, equality
Justice
Justice is the the maintenance or administration of what is just especially by the impartial
adjustment of conflicting claims or the assignment of merited rewards or punishments.
The state, ideal, or quality of being just, impartial, and fair.
Originated from Latin word “justitia”, the name of god in Rome that represented fairness
Type of Justice
Distributive Justice
Procedural Justice
Retributive Justice
Restorative Justice
Social Justice
Distributive Justice
The fair allocation of society resources among diverse members of society
What can be considered as “fair” will greatly depend on the ideology of the society
Procedural Justice
Concern with ensuring that a fair process is conducted for every member of society when they
are making decision and settling disputes in resources allocation.
Retributive Justice
Concept of justice that emphasizes on punishment for those who commit certain kinds of
wrongful act
It is morally deserved for those individuals to suffer proportionate punishment
Restorative Justice
Concept of justice that emphasizes on repairing harm caused or revealed by criminal behaviour
Social harm and social harmony
Social Justice
Form of distributive justice
Every member of society deserves equal opportunities and rights in economic, politics , and
social
Every individual has to fulfil their role in the society, and deserve what was due from the society.
Equity vs. Equality
Equity is “fairness”
Equality is “sameness”
Equity concern with equal opportunity or right
If every member of society has equal right and opportunity to access society resources, it can be
considered as “fair”, although it is not necessary they will get the equal outcome.
Equity vs. Altruism
Equity is about a person’s right and responsibility in the society
Altruism is about individual’s preferences
It is morally right to ensure that every member of society contributes their resources to the
society, to the extent which is deemed as necessary by the society, although it is beyond their
personal preferences.
IDEOLOGICAL PERSPECTIVES OF EQUITY
The concept of equity heavily depends on the ideology perceived by society
Two major views: Libertarian vs. Egalitarian
Authoritarian
Libertarian
Utilitarian
Egalitarian
Restorative
Authoritarian View
What is decreed by the authority (which usually has absolute power such as in absolute
monarchy) is considered as just
Libertarian View
Libertarian support the individual freedom
Resources should be allocated as reward system for the individual effort in the society.
Those who have greater effort will get greater resources, and will be able to access more goods.
Distribution of goods according ability to pay
Minimum of state intervention
Utilitarian View
Utilitarian support the idea of “maximum benefit/utilisation”
Resources should be allocated for the most beneficial purpose of the greatest numbers of the
society.
Given the same amount of resources, which purpose will serve the greatest numbers of the
society member.
It considers to be just to sacrifice the minority, for the greater benefit of majority of the society.
Supported majorly by the economist, closely related to the term “efficiency”
Priority setting
Egalitarian View
Socialist view, Marxist view
The idea that everybody in society should have the equal access to the resources that
considered as basic necessities to optimize their life capacity.
It justify the state/government intervention to distribute several resources regarded as common
goods for the society members who need it most, regardless their status.
Distribution of goods according to need
Widely supported in welfare states
Restorative View
Society should prioritise resources for the previously disadvantaged society groups.
Usually implemented in society with history of civil conflict
ECONOMIC PERSPECTIVES OF EQUITY
Concern with resources allocation, due to its scarcity
Trade off between equity and efficiency, “welfare loss”
Horizontal equity
Vertical equity
Horizontal Equity
Given the equal need, every member of society should enjoy equal distribution of resources,
regardless their background
Vertical Equity
There should be unequal distribution of resources for unequal need
Those who need more, should be allocated more resources
What is Need?
Need is the amount of resources required by individual, in order to exhaust capacity to benefit.
Capacity to benefit means that someone has the same capability and opportunity compare to
other individuals to gain maximum benefit in their life.
EQUITY IN HEALTH CARE
Equity of health or health care?
Equity in health care delivery
Equity in health care financing
Why Should Health Care?
Health care is regarded as common/public good
Health care is the instrument to achieve health
Health is regarded as the condition for people to function
Health is basic need and human rights
Therefore, state/government should play the major role to distribute healthcare to society,
based on principle of social justice
Health care should be distributed based on the individuals need, not their ability to pay
Equity in Health Care Delivery
Horizontal equity: equal treatment for equal need.
Every member of the society should have the equal access to health care, irrespective their
socio-economic background.
Given the same health condition (disease), every individuals should receive the same treatment
(same resources allocation).
Vertical equity: unequal treatment for unequal need
For different health condition (disease), there should be different treatment (allocation of
resources).
What is Access?
Access refers to the opportunity
Access to health care is the maximum level of health care consumed by the individual, given
individual’s income, time, money price associated with consuming medical care.
Access is not only influenced by individual’s financial capability, but also determined by
geographical, social, cultural factor, but exclude individual’s preferences.
Equity in Health Care Financing
Horizontal equity: Individuals in society which have equal ability to pay, make the equal
contributions (payments) to health care.
Vertical equity: Individuals in society with have unequal ability to pay, make the unequal
contributions (payments) to health care.
The better off should pay more than the worse off
Progressive financing system
Solidarity principles
EQUITY IN HEALTH
Equity in health care is not necessary lead to equity in health (health outcome/health status)
Health is complex, multi dimensional concept, influenced by multiple determinants.
Equity in health implies that ideally everyone should have a fair opportunity to attain their full
health potential and, more pragmatically, that no one should be disadvantaged from achieving
this potential, if it can be avoided.
Inequity in health refers to health status/outcome disparities that considered as unnecessary,
avoidable, and unjust
What is considered as unjust will depend on the context of the society
Criteria of Inequity in Health
The disparities is avoidable.
The disparities is not reflect free choice.
There is link between disparities and responsible agent.
Avoidability
Technically avoidable: current science and knowledge provides proven successful intervention.
Financially avoidable: there are sufficient resources exist to satisfy fair condition.
Morally avoidable: the proposed redistribution would not violate some other, greater, sense of
justice.
Choice
Sufficient resources to establish free choice
Legal right to utilize the resources
Agency
Responsible agent;
Culpable entity
Accountable entity
Spectrum of Health Disparities
CONCLUDING REMARKS
Equity is concept of justice, mostly based on principle distributive / social justice
What is considered as equitable will depend on the ideology of society, but egalitarian view is
the most dominant paradigm
In economic term, equity can be measured as vertical and horizontal equity
Equity in health care is regarded as the most realistic and operational approach to apply equity
principles in health.
Inequity in health should be judged based on disparities that unnecessary and avoidable
THANK YOU
@JKMULYANTO