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Table 1 Papers collated from scoping review (n = 23)

From: Scoping review of the World Health Organization’s underlying equity discourses: apparent ambiguities, inadequacy, and contradictions

  Author(s) Author’s/s’ institution(s) Title Type of publication Place published WHO’s definition or approach to equity Conclusions
1 Alleyne [19] The Pan American Health Organization (PAHO) Equity and the goal of Health for All Speech Pan American Journal of Public Health Equity sought through Health for All focused on distributive justice/an egalitarian approach, which may not be beneficial. What is needed is attention to the unequal distribution of the determinants of health inequalities and concept of equity in health that cannot be separate from equity in broader human development (aligned with Amartya Sen’s Capabilities Approach).
2 Asada [20] Dalhousie University Is Health Inequality Across Individuals of Moral Concern? Journal article Health Care Analysis The Whitehead definition makes the distinction that health inequities have a moral judgment (i.e. not all inequalities are inequities), while leaving the exact meaning of health inequity open. The WHO implies that health should be prioritized over other goods through seeking to measure health inequalities across individuals versus groups, which can be considered to be specific egalitarianism or a direct approach. Health inequity is of moral concern (as the WHO purports) due to the role of health equity in justice and health inequality being an indicator for broader societal injustice. Ultimately, how health inequalities are measured implies certain moral perspectives. As such, policy makers should determine which perspective is suitable. For example, while the Capabilities Approach is rooted in equality and justice, it focuses on those below a minimum versus the whole distribution of health.
3 Asada and Hedemann [18] University of Wisconsin-Madison A Problem with the Individual Approach in the WHO Health Inequality Measurement Journal article International Journal for Equity in Health By measuring inequalities between individuals, as opposed to groups, the WHO’s health inequality measure is not value-free and represents an “expansive view of justice” that sees inequities as those amenable to intervention. The conceptual underpinning of the WHO’s health inequality measurement/index needs to be re-evaluated.
4 Bambas and Casas [21] The Pan American Health Organization (PAHO) Assessing Equity in Health: Conceptual Criteria Report chapter Equity & Health: Views from the Pan American Sanitary Bureau Whitehead’s definition is a robust concept of equity but has controversial parameters. Equity should be considered on a spectrum from “misfortune” to “inequity”.
5 Blakely [22] University of Otago Iconography and Commission on the Social Determinants of Health (and health inequity) Journal article Journal of Epidemiology and Community Health While the CSDH final report focuses on power, sexism, and discrimination, the mention of “power” and “racism” is removed in the final diagram of the social determinants of health (and used as a model of health inequalities), despite the CSDH including “power”, “class”, “racism”, and “discrimination” in a prior working diagram. The CSDH report, which is rooted in values of fairness and altruism, provides an authoritative account of health inequalities, both in terms of knowledge to-date and what actions need to be taken, and has the potential to be a landmark report.
6 Bommier and Stecklov [23] Institut National d’etudes Démographiques & Hebrew University of Jerusalem Defining health inequality: why Rawls succeeds where social welfare theory fails Journal article Journal of Health Economics The WHO, through the Global Strategy for Health for All resolution (WHA32.30), WHO Health for All, and Whitehead definition, implicitly indicates that a fair health distribution entails reducing avoidable health differences, not equal health status for all individuals (given differing individual endowments). The social welfare approach is inconsistent with a social justice approach’s notion of a just or fair distribution. Authors propose an alternative approach which they state seemingly aligns with the WHO’s approach to equity and Rawls’s ethical principles.
7 Borde and Hernández [12] Universidad Nacional de Colombia Revisiting the social determinants of health agenda from the global South Journal article Global Public Health The WHO’s approach to equity has been driven by the CSDH approach, which is rooted in Anglo-Saxon European Social Medicine, as opposed to other approaches, such as the Latin American Social Medicine and Collective Health approach. Authors also note the WHO’s approach aligns with Amartya Sen’s notion of health as a “special good”. In seeking to address equity, the WHO focuses on technical solutions, seeks win-win solutions for governance, and renders politics apolitical, but should focus on the social determinants of health inequities, or causes of causes (i.e. unequal power relations or capitalism). As such, the principles and foundations (ethical, political, etc.) need to be clarified and engage with ‘invisibilized’ approaches.
8 Braveman [6] University of California (San Francisco) Health Disparities and Health Equity: Concepts and Measurement Journal article Annual Review of Public Health Expresses the acceptance of Whitehead’s definition but indicates the context in which it was created emphasizes inequalities between those of differing socioeconomic status, and rarely gender and ethnicity. Need for a new definition that specifies the importance of social position, types of comparisons to be made across and within groups, and has explicit criteria. This can be done by drawing on the right to health (i.e. using the most privileged as a reference group).
9 Braveman and Gruskin [7] University of California (San Francisco); Harvard University Defining equity in health Journal article Journal of Epidemiology and Community Health The Whitehead definition has raised awareness of the meaning of health inequities, but ‘avoidability’ should not define health inequities because: (i) avoidability is implied through being unfair and unjust, (ii) given that many inequities require structural changes, avoidability may hinder action on inequities, and (iii) avoidability is unclear about who it is avoidable by. In addition, the WHO’s argument for measuring inequalities by individuals rather than groups does not afford consideration of health equity and does not reflect values of fairness or justice. Clarity is needed to ascertain how definitions of health equity align with paradigms and determine what the practical implications of such definitions are.
10 Daniels, Kennedy [24] Harvard School of Public Health; Cambridge, MA; & Harvard School of Public Health Health and Inequality, or, Why Justice is Good for Our Health Book chapter Public Health, Ethics, and Equity The Whitehead definition, while useful, is only beneficial if agreement can be reached on what constitutes avoidable and unfair. Broadly, the WHO’s efforts are aimed at remedying true inequities. Drawing on Rawls theory of justice can be beneficial in determining which health inequalities are inequities. Policy should be intersectoral to address social conditions and provide equality of opportunity, capabilities, or positive freedom (rather than strictly healthcare).
11 Gwatkin [25] The World Bank Health inequalities and the health of the poor: What do we know? What can we do? Journal article Bulletin of the World Health Organization While the WHO approach to equity is a normative one largely focused on reducing inequalities in social position, there are also aspects focused on improving the health of the impoverished. Need for the development of relevant equity-oriented health objectives (e.g. % reduction of disparities and improving conditions among poorer groups) (which are rare compared to goals expressed as improving or reducing rates in specific indicators across a population) and enhanced information collection and tracking.
12 Hashimoto and Kawakami [26] University of Tokyo Health equity Book chapter Oxford Textbook of Public Mental Health Observes that PAHO interprets inequity as a difference in the opportunity to achieve health (i.e. equity equates to equal opportunity to achieve health). Health equity should not be focused solely on the equal distribution of health status, but also functionings and freedoms, as expressed in the Capabilities Approach.
13 Hausman, Asada [27] University of Wisconsin-Madison Health Inequalities and Why They Matter Journal article Health Care Analysis The WHO approach to measuring inequalities is not value-free and only measures group differences at the national level, missing intra-group inequalities. Measuring of inequality should be done by assessing health outcomes at various life stages and in relation to other factors, rather than studying the distribution of health expectancies.
14 Linares-Péreza and López-Arellano [28] Universidad del Valle de Guatemala & Universidad Autónoma Metropolitana Unidad Xochimilco Health Equity: Conceptual Models, Essential Aspects and the Perspective of Collective Health Journal article Social Medicine The WHO attempts to approach equity through consideration of the health needs of society, instead of just social privilege. A comprehensive vision of health equity that considers both the field of health (equity in outcomes, access, and care) and environment (equity in social, economic, cultural, and political determinants and daily living conditions) is needed.
15 Marmot and Friel [29] University College London; (Friel’s affiliation not listed) Global health equity: evidence for action on the social determinant of health Journal article Journal of Epidemiology and Community Health The CSDH was guided by the underlying value that health inequities are a matter of social justice. Both reducing societal inequities (i.e. reducing the gap) and improving the health of the whole of society (i.e. improving everyone’s health) are important.
16 Mooney [16] University of Copenhagen What does equity in health mean? Journal article World Health Statistics Quarterly There is a lack of clarity behind the WHO’s Health for All objective(s). Need to clarify concepts of equity in practical terms and be more explicit about policy goals for health equity.
17 Pappas and Moss [30] Johns Hopkins University Health for All in the Twenty-First Century, World Health Organization renewal, and equity in health: a commentary Journal article International Health Agencies The WHO’s approach to equity in Health for All in the Twenty-first Century is divided along the historically-rooted lines of prevention and care, yielding philosophical and pragmatic implications. The WHO conceptualizes equity in an implicit way, yielding a lack of explicit policy actions. The WHO needs to clarify how policy can be used to achieve health equity, perhaps by drawing on the rights-based approach. The WHO should lead in ensuring validity, reliability, and timeliness of data from around the world, and ensure progress is measured through specific, qualifiable, and culturally-appropriate targets (e.g. develop socioeconomic measures that consider culture and economic development).
18 Ridde, Guichard [31] University of Montreal; Institut National de Prévention et d’Éducation pour la Santé; & Université Catholique de Louvain Social inequalities in health from Ottawa to Vancouver: action for fair equality of opportunity Journal article Promotion & Education Equity has moved towards achieving the best possible state of health for individuals instead of ultimate equality. As well, the Ottawa Charter for Health Promotion is founded on the principle of equity based in distributive justice. Fair equality of opportunity proposed by Rawls (i.e. not disadvantaging any individual in seeking to reach their full health potential), should be advocated for (opposed to equality of opportunity). There is a need to evaluate action on health equity.
19 Sadana and Blas [32] WHO headquarters; WHO Regional Office for Europe What Can Public Health Programs Do to Improve Health Equity? Journal article Public Health Reports Inequity reflects a value judgement and the CSDH determined that about 75% of health inequalities can be considered unfair and potentially unavoidable. In addition, the WHO Priority Public Health Conditions Knowledge Network determined that programs studied largely focused on treatment and partially on vulnerabilities of groups, with the exception of violence & injury prevention and tobacco, which addressed the upstream social determinants of health. Upstream action is needed and there is an opportunity for program areas of the WHO to intervene on shared social determinants of health. And regardless of where the determination is made of what constitutes an inequality vs. inequity, action needs to be taken on reducing unfair health disparities.
20 Shiell [33] University of Calgary Still waiting for the great leap forward Journal article Health Economics, Policy and Law The CSDH was only concerned with reducing inequity (particularly inequalities in health between countries and groups within countries), and not concerned with prioritizing certain groups (with the exception of prioritizing for efficiency) or competing ethical considerations (the authors imply the latter two are also needed). The CSDH also prioritizes social justice (as opposed to individual liberties). Economic evaluation evidence is needed for interventions that address the social determinants of health, as it can help reframe social justice and inequalities to combat ideas of constrained individual liberties in political debates. However, economic evidence is also not sufficient, as interventions targeting the upstream determinants are needed.
21 Smith [34] University of Toronto Health Equity in Public Health: Clarifying our Commitment Journal article Public Health Ethics The Whitehead definition of health equity is inadequate normatively (i.e. how are ‘unnecessary’ and ‘avoidable’ differences constituted?), and as a result, may result in inconsistent or conflicting action and potentially the creation of inequities. Clarifying health equity (particularly around fit with social justice and foundational concept of justice) will afford alignment of goals in policy and practice.
22 Smith and Normand [35] Economic and Social Research Institute (Ireland); Trinity College Equity in health care: the Irish perspective Journal article Health Economics, Policy and Law Determining whether or not an inequality is unfair rests on degree of choice, which is open to criticism. While it is difficult to discern exactly which theoretical perspective the Whitehead definition is based in, the definition is unlikely to be aligned with a libertarian philosophical perspective and resonates with Rawls’ theory of social justice (this definition was adapted for use in Ireland). Health equity is a difficult concept to define and has resulted in conflicting approaches. Lessons from Ireland can work to inform other jurisdictions.
23 Wilson [36] University College London Health inequities Book chapter Public Health Ethics: Key Concepts and Issues in Policy and Practice The Whitehead definition’s inclusion of “unnecessary”, “avoidable”, and “unfair” can be eliminated to simply remain “unjust inequality”. However, determining which inequalities are unjust is a difficult and complex task. Individuals who are worst off should be prioritized and their health (e.g. over socio-economic status) should be concentrated on (i.e. favouring a pluralistic theory of justice over a monistic one).