Health Equity and Access

Health equity is the principle that differences in health and in the use of health care should not arise from unjust or avoidable social disadvantage, and access is the actual ability of people to obtain the care they need. The two are linked: inequitable access — by income, geography, ethnicity, or other social position — is a major route through which health disparities are produced and sustained.

Definition

Health equity is the absence of unfair and avoidable differences in health and in access to health care across social groups; access is the degree to which people who need care are able to obtain appropriate services in a timely way.

Scope

The entry covers the distinction between equity (a normative judgement about which differences are unfair) and disparity (an observed difference); the dimensions of access, including availability, affordability, and acceptability; how access barriers map onto social determinants; and how equity in financing and use is measured. It is a reference topic on concepts and measurement, not a programme of intervention or advocacy.

Core questions

• Which differences in health and care count as inequitable rather than merely unequal?
• What dimensions determine whether people can actually obtain needed care?
• How do social determinants shape access and health disparities?
• How is equity in the financing and use of health care measured?

Key concepts

• Health equity versus health disparity
• Avoidable and unfair differences
• Dimensions of access (availability, affordability, acceptability)
• Social determinants of health
• Horizontal and vertical equity
• Equity in financing and use
• Healthcare disparities

Mechanisms

Equity is a normative concept: an observed difference becomes an inequity when it is both avoidable and unfair, typically because it tracks social disadvantage. Braveman and colleagues distinguish the descriptive measurement of disparities from the value judgement of equity, and define equity in terms of differences linked to social position. Access translates need into use through several gates — services must be available where people live, affordable given their resources, and acceptable to them — and barriers at any gate can block care. Because these gates are shaped by income, education, geography, and discrimination, the social determinants of health operate partly through access, so inequitable systems reproduce health disparities even when aggregate spending is high. Equity is assessed by examining how the financing burden and the use of services are distributed across social groups relative to need.

Clinical relevance

Patterns of inequitable access shape which patients reach care, how late they present, and the disparities a clinician observes across populations, forming part of the context of clinical practice. The entry describes these concepts and their measurement for reference and does not prescribe interventions or individualised care.

Epidemiology

Disparities in access and outcomes by income, geography, ethnicity, and other social positions are documented within and across countries, and the financing and use of care are frequently distributed less favourably to poorer and more disadvantaged groups. Cross-national analyses show that whether a system advances equity depends heavily on how its financing is raised and on who is able to use services relative to need.

Evidence & guidelines

The conceptual and measurement literature on equity, together with the World Health Organization Commission on Social Determinants of Health, provides the principal references, complemented by cross-national studies of equity in financing and use. These sources describe how disparities arise and are measured and are used here for orientation rather than as prescriptive guidance.

History

Concern with unequal access has a long history, but the modern framing of health equity was sharpened in the late twentieth century, drawing on welfare economics and the work of figures such as Amartya Sen. Braveman and colleagues clarified the conceptual distinction between disparity and equity in the early 2000s, and the World Health Organization's 2008 Commission on Social Determinants of Health placed action on the social roots of inequity at the centre of the international agenda.

Debates

When is an unequal health outcome inequitable?

Not every difference in health or care is unjust; defining which differences are avoidable and unfair, and distinguishing them from differences due to choice or biology, is a foundational and contested normative question in the field.

Key figures

• Paula Braveman
• Sofia Gruskin
• Michael Marmot
• Amartya Sen
• Anne Mills

Seminal works

• braveman-2006
• braveman-2003
• who-2008-csdh

Frequently asked questions

What is the difference between health inequality and health inequity?

A health inequality is any measurable difference in health between groups; a health inequity is the subset of those differences that are avoidable and unfair, usually because they track social disadvantage. Equity is a value judgement applied to observed inequalities.

What does 'access to care' actually mean?

Access is the real ability to obtain needed care, which depends on services being available where people are, affordable given their resources, and acceptable to them. A barrier at any of these dimensions can prevent people from getting care even when it formally exists.