Abstract

PIP: The author posits some ethical concerns and theories of distribution in order to gain some insight into the meaning of equity in health, as referred to in WHO documents. It is pointed out that the lack of clarity in the WHO positions is evidenced by examining 1) the European strategy document, which focuses on giving equal health to all and equity access to health care, and 2) the Global Strategy for Health, which talks about reducing inequality and health as a human right. The question raised in document 1 is whether more equal sharing of health might mean less health for the available quantity of resources. The question raised in document 2 is whether there is a right to health per se. The question is how does one measure health policy effects. Health effects are different for an 8-year-old girl and an octogenarian. How does one measure the fairness of access to health care in remote mountain villages versus an urban area? Is equal utilization which is more easily measured comparable to equal need as a measure? How does one distribute doctors equitably? The author espouses the determinant of health as Aday's illness and health promotion, which is not biased by class and controversy. The Aday definition embraces both demand and need, although his definition is still open to question. Concepts of health with distinction between need and demand are made. Theories of Veatch which relate to distributive justice and equity in health care are provided as entitlement theory (market forces determine allocation of resources), utilitarianism (greatest good for the greatest number regardless of redistribution issues), maximum theory (maximize the minimum position or giver priority to the least well off), and equality (fairness in distribution). Different organizational and financing structures will influence the approach to equity. The conclusion is that equity is a value laden concept which has no uniquely correct definition. 5 theories of equity in distribution of health resources are discussed: 1) a theory of maximum (Rawl's theory modified to include health care institutions providing opportunity as the social good), 2) altruism as a basis for equity (Titmuss' Kantian view of national responsibility to provide equitable service delivery altruistically or equal access), 3) a fair share theory of distribution (Margolis' process utility theory of doing one's fair share or equality of access for equal need, 4) commitment to equity (Sen's focus on sympathy and commitment to another's ill health status and access), and 5) equity as externality (Culyer's health care consumption where government determines the merit good or extent of consumption). If policy objectives are not clear and the definitions muddy, resources may be badly wasted or misdirected and the pursuit of equity unfulfilled, even though there is agreement in principle.