Introduction

Both equity in health and equity in health care matter. Yet it is clear that recently in many countries policy has been rather neglectful of both of them. It is also the case that health economics has not contributed to equity policy as it might have. This book has drawn attention to these issues, globally and in some nation states, Brazil and Thailand in particular.

The authors in this book have sought to explain why equity has been failing and also why health economics has not made more of a contribution to equity policy. Yet more importantly, each in his or her own way has indicated how things might proceed better in future.

In this concluding chapter it is not the intent to summarize the contents of this book but rather to highlight what we as editors see as the key issues for improving health equity in the future. In particular, we present some concrete ideas on what health economists could be doing or doing better to promote equity in health and health systems. We have identified seven key messages.

Neo-liberalism is bad for our health and our health systems

Given that the extent and nature of economic development can have a dramatic impact on health status, health economists need to get more involved than they have in the past in macroeconomic policy debates. We not only have a right, but an obligation to engage in such debates.

Summary

This chapter argues that the construct of health and the nature of health care systems and, in turn, of equity in health and health care are in significant part cultural phenomena. This is in distinction to the universalism with respect to these issues that is usually the case in health economics assessments of both health and equity.

Acknowledgement that these are cultural phenomena, and that the literature on the social determinants of health indicates that being comfortable in one's culture is good for our health, means that globally there is a need to protect the diversity of societies and of cultures. Further, the nature of a society and its culture are heavily influenced by the economic system in which they exist. This chapter, therefore, argues that an important way of protecting the diversity of societies and of cultures is through the preservation of the diversity of economic systems.

Such preservation of diversity can be undermined by the impact of neo-liberalism's individualism and its adverse effects on the development of a sense of community. This can result in reducing social capital, which in turn can adversely affect population health and its distribution.

In the light of these observations, a new paradigm for the economics of health equity is proposed, based not on the values of individuals qua individuals, but more on the values of communities. Adopting a communitarian stance provides a new and potentially more useful approach to the economic analysis of equity in health and health care.

Equity in health and equity in health care have been ill-served in recent years. While for many health care systems equity is stated to be an important goal, in several of these equity in policy terms has been paid little more than lip-service. While it is also the case that there has been an increasing research interest in the social determinants of health, the extent to which the recognition of the impact of these on health has led to action at a policy level has been limited. Poverty and inequality are now well recognized in the academic literature, especially in social epidemiology but in public health more generally, as contributing to population ill health. National and global policy makers, however, have been all too little concerned to address poverty and inequality and, inevitably, even less concerned to do so for reasons purely of improving health.

Health economists have contributed considerably to debates about the construct of equity in health care, be this seen in terms of health, access or use and whether horizontal or vertical equity. Beyond considerable success in the 1970s and 1980s in assisting methodologically to improving equity in health care through needs-based, RAWP-type resource allocation formulae (DHSS 1976), policy on equity in health care has been a field where health economists have made relatively little impact.

Considerations of ‘need’ were initially very useful in RAWP-type resource allocation formulae and indeed the scene of most policy success by economists on equity in health care.