Touching base: Concepts and approaches to health equity research TK Sundari Ravindran Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum

Objectives At the end of the session, participants will Have a shared understanding of basic concepts: disparity, equality and equity, vertical and horizontal equity; health equity and its many dimensions Be introduced to broad strands of health equity research Have an appreciation of health equity research as a political project

What good does it do to treat people's illnesses ... then send them back to the conditions that made them sick?

How would you describe the meaning of inequities in health ? Question 1 How would you describe the meaning of inequities in health ? How is this different from health inequalities?

Inequality in health Equality is the state of being the same, whereas equity implies fairness and justice. There are bound to be differences in health status between individuals for a number of reasons, many of these random or biological. One example of inequality in health status would be age-based differentials in health status.  

Health equity “Inequities are differences in health that are systematic, socially produced (and therefore modifiable) and unfair .” Essentially, all systematic differences in health between different socio- economic groups within a country can be considered unfair and, therefore, classed as health inequities. (Whitehead, 2014)

Health equity as social justice It is the absence of systematic disparities in health (or in the major social determinants of health) between groups with different levels of underlying social advantage/disadvantage. Assessing health equity requires comparing health and its social determinants between more and less advantaged social groups Braveman and Gruskin, 2003.

Disparities in health Disparities in health and its determinants are the metric for assessing health equity. Health disparities are systematic, plausibly avoidable differences in health status and its determinants according to race/ethnicity, skin color, religion, or nationality; socioeconomic resources or position (reflected by, e.g., income, wealth, education, or occupation); gender, sexual orientation, gender identity; age, geography, disability, illness, political or other affiliation; or other characteristics associated with discrimination or marginalization.

Vertical and horizontal equity Horizontal equity = Equal resources for equal need. This term refers to situations where there is equal health need, and therefore an equal need for resources. Vertical equity = Unequal resources for unequal need. This refers to situations when there are different needs. This means that the resources need to be adjusted to meet the different needs.

Inequities may be present in more than one dimension of health Inequities can be: Differences in health status; Disparities in access and utilisation of health care services; Differences in health care financing and resource allocation; Differences in quality of health care and delivery; Differential exposure to underlying health determinants, e.g. water, sanitation, food security, formal education, environmental or occupational hazards, behavioural risk factors.

Question two Think about and describe one example of inequity in health

Question 3 Give one example of health equity research that made an impact on you, and explain why

Health equity research -1 Includes, inter alia, research for   identifying disparities in health and health care across caste, economic status, gender and other relevant axes of social stratification Enquiring into the proximate and distal factors and mechanisms / processes (ideologies, stigma and prejudice, discrimination and social exclusion) across multiple levels contributing to health inequities Examining the intersection of multiple axes of deprivation/oppression in creating and reinforcing inequities  

Health equity research-2 Includes, inter alia, research for   Studying the outcomes of interventions aimed at reducing health inequities. Examining how the current trajectory of health governance impacts on accentuating or mitigating health inequities (e.g. position taken vis-à-vis promotion of privatization in health) and on whether and how health equity features as a priority objective for health and health research (e.g. awareness and understanding of policy makers and programme managers on health inequities and their determinants)  

Health equity research is a political project -1 From the framing of the research question, to the methods chosen, through to interpreting the findings, we are guided by our implicit or explicit worldview Framing research questions that tend to subtly “blame- the-victim”: e.g. Why is the uptake of child immunisation low among Muslim populations in district x? What are the social and cultural barriers to the utilisation of institutional delivery services by tribal women?

Health equity research is a political project -2 Taking existing categorisations as given, not querying the processes underlying the inequities, : Is the problem - Belonging to a certain caste, or with casteism? Being a minority population or the process through which minority groups are marginalized? Not considering the co-existence of multiple identities: What are the differences within the group of Muslim children? Tribal women? Not drawing adequately on the rich body of historical, anthropological, sociological and philosophical literature that explain social processes through which inequities are created: discrimination, stigma, exclusion, marginalisation

Health equity research is a political project -3 Interpreting associations emerging from statistical analysis based on one’s own preconceived notions Making policy recommendations on the basis of risk-factor analysis without unpacking the pathways and mechanisms that put some people at greater risk than the others Carrying out intervention research focused on proximate determinants, to the exclusion on structural or ‘upstream’ factors

Health equity research as a tool for social change Health equity research is more than an intellectual exercise. It is a tool for social change towards a more equitable society