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ORIGINAL ARTICLE
What can health services contribute to the reduction of
inequalities in health?
Martin McKee
London School of Hygiene and Tropical Medicine/European Observator y on Health Care Systems, London, UK
Scand J Public Health 2002; 30: 54± 58
Policies to reduce inequalities in health are needed in many diVerent settings, one of which is the healthcare setting. This
paper, drawing on the conclusions of the Copenhagen conference, explores the contribution that such policies can make
within the healthcare system. In doing so it examines four themes. It begins by exploring the contribution that healthcare
makes to health. It challenges the widely held view that this contribution is small, arguing that there have been major
advances in the eVectiveness of medical care and the use of evidence-based healthcare, so that interventions of proven
eVectiveness are increasingly delivered to those who will beneŽ t. Unfortunately, there is growing evidence that the beneŽ ts
of modern healthcare do not beneŽ t all groups equally. Thus, there is an unŽ nished agenda in many countries to enhance
the equitable distribution of access to eVective healthcare. Second, it explores the dynamic relationship between illness and
poverty and, speciŽ cally, the impoverishing nature of illness in the absence of eVective mechanisms to ensure solidarity and
to provide social safety nets. It identiŽ es how all elements within a healthcare system have a part to play. Those responsible
for healthcare Ž nancing should ensure that funds are obtained in an equitable manner. Those who provide healthcare can
do much to promote access for the disadvantaged and to use their facilities to promote health as well as cure disease. Third,
it considers the speciŽ c needs of disadvantaged populations, and especially those whose needs are least visible, such as illegal
migrants. It concludes by reviewing the need for better information to document the scale of inequalities, to evaluate
interventions designed to reduce them, and to disseminate evidence of good practice.
Key words: equity, health promotion, health services.
Martin McKee, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK.
E-mail: [email protected]
INTRODUCTION
Policies to reduce inequalities in health require action
in many diVerent settings. Four were explored by participants at the conference: the workplace; healthcare
services; local communities; and cities, with a focus on
urban development. This paper explores the contributions that healthcare services can make, drawing on
the proceedings of one of the conference workshops.
The workshop on healthcare services considered four
sets of topics. The Ž rst encompassed a series of basic
questions about the relationship between poverty,
health, and healthcare, and their implications for
policy. The second explored the optimal organization
of healthcare and the roles that diVerent actors can
contribute to reduce health inequalities. The third
addressed the speciŽ c needs of disadvantage d populations. The Ž nal topic was the need for further
knowledge to inform policy.
BASIC QUESTIONS
Perhaps the most basic question is whether healthcare
actually makes any diVerence to health. This question
is not as simple as it might seem. Some commentators
have argued that healthcare contributes little or is actually damaging to health. This view commonly draws
on the work of McKeown who, writing in the 1960s,
argued that the historical reductions in mortality owed
most to improvements in living conditions (1).
SpeciŽ cally, he showed that the largest falls in deaths
from infectious disease predated the introduction of
widespread immunization. Subsequently Illich popularized the term iatrogenic, or physician created, disease,
arguing that modern healthcare was actually harmful,
with those subjected to it suVering from side-eVects of
drugs, hospital-acquired infections, and surgical
errors (2).
Although Ž rst advanced over a quarter of a century
ago, these views have remained extremely in uential.
There is, however, a contrary view, that while they
may have had some validity when they were Ž rst put
forward, they do not take account of the enormous
changes in healthcare that have taken place in the
intervening years (3). These advances encompass new
means of diagnosis and of treatment but, equally
Ñ Taylor & Francis 2002. ISSN 0301-7311
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Contribution of health services to reduction of inequalities
important, an explosion of information on what does
and does not work, and for whom. The growth in
evaluative research, brought together through initiatives such as the Cochrane Collaboration ( 4), has identiŽ ed many established treatments that are ineVective as
well as eVective ones that should be used more widely.
When fed into processes such as purchasing of
healthcare and quality assurance programmes, this has
changed the nature of healthcare immensely.
So does modern healthcare contribute measurably
to health in a way that it did not do so previously?
The most widely used approach is to identify those
conditions from which death should not occur if
healthcare is provided appropriately (5). Such deaths
are described as avoidable or amenable to medical care.
Mackenbach and colleagues have shown how the
decline in deaths from conditions amenable to medical
care contributed substantially to the overall improvement in life expectancy in The Netherlands between
1950 and 1984 (6). Similar Ž ndings have been reported
from several other countries (7). Other researchers
have linked falls in deaths from certain diseases to the
introduction of speciŽ c treatments, such as thrombolysis (8). More recently, the political transition in
Eastern Europe has provided a series of natural experiments in which changes in the organization of
healthcare can be shown to have brought demonstrable
changes in mortality, both positive and negative (9).
If modern healthcare does impact measurably on
health, how does this in uence health inequalities?
There is evidence from several countries that traditionally disadvantage d groups have reduced access to interventions known to be eVective. One example that has
been studied extensively is that of invasive cardiovascular procedures, where women (10), those living in
deprived areas ( 11 ), and people from minority ethnic
populations (12) all have lower levels of utilization
than would be expected. Even when access is obtained,
it may be at a later stage in the disease or may be less
intensive. Several such factors come together to explain
the consistent Ž nding that cancer survival is worse
among the poor (13). Thus, studies of deaths from
conditions amenable to medical care have typically
found that social class gradients are greater than for
deaths from other causes (14 ).
As this brief review shows, healthcare, as presently
provided in many countries, may serve to exacerbate
inequalities by beneŽ ting disproportionatel y the better
oV. This is clearly not inevitable and argues strongly
for those responsible for health services to review what
they can do to redress this balance.
The second basic issue relates to the dynamic interaction between poverty and ill health. There is now a
wealth of evidence to show that poverty is an important
cause of disease as well as to disentangle the mechan-
55
isms involved ( 15 ). There has, however, been less
attention to the economic consequences of disease. The
onset of serious disease often causes loss of employment and resulting income. In some countries, the Ž nancial implications are exacerbated by the cost of
obtaining care. Separately or together, these can be a
major cause of impoverishment. Poverty can, in turn,
make it diYcult or impossible to access eVective care,
creating a downward spiral that may aVect not only
the aVected person but also his or her family (16). This
scenario is most likely in countries that have failed to
implement eVective social safety nets, whether intentionally or not. While it may most obviously aVect
those aZicted by catastrophic illness, such as cancer
or stroke, the consequences for those with less severe
but long-lasting illnesses, such as diabetes, should not
be overlooked. Thus, equitable and aVordable health
services form an essential part of an integrated
anti-poverty strategy.
Unfortunately, fuelled by the process of globalization, many countries have adopted increasingly
deregulated employment regimes and have weakened
existing safety nets (17) so that the scope for ill health,
and especially minor psychiatric illness, to impoverish
families has been increased greatly.
THE ORGANIZATION OF HEALTHCARE
If healthcare is an important contributor to inequalities, what can be done to make it a force for good?
The Ž rst concern is how to make the Ž nancing of
healthcare equitable. Healthcare Ž nancing systems in
all industrialized countries incorporate some element
of redistribution. Society accepts that the poor and
sick will never be able to pay for the care they need.
Some resources must always be obtained from the
healthy and rich. The extent to which societies are
willing to put this argument into practice does, however, vary and diVerent Ž nancing methods achieve
diVerent results. SpeciŽ cally, systems funded from general taxation tend to be more equitable than those from
social insurance (18).
The 1980s and 1990s were characterized, in many
countries, by a quest for ``cost-containment ’’ in
healthcare ( 19 ). This is an entirely laudable goal.
Money saved by reducing ineVective care can be redirected with overall beneŽ t. In reality, however, many
policies labelled as ``cost-containment ’’ have really
been cost-shifting, transferring the burden of care from
pooled resources to the individual or, in other words,
from the well rich to the sick poor. This is best illustrated by the promotion of user fees, ostensibly as a
means of reducing ``inappropriate ’’ use of services
despite the evidence that it deters equally the use of
eVective and ineVective care (16). There are, however,
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56
M McKee
many less obvious manifestations, such as policies that
increase travel or social support costs to the individual.
Those who act as agents for the public to pay for
healthcare, such as sickness funds and health authorities, also have a role to play. Traditionally, many have
adopted a passive role, simply reimbursing costs
incurred. There is, however, a growing recognition of
the beneŽ ts that can be achieved by adopting a more
active role that has been termed strategic purchasing
( 16 ). This has been described as encompassing three
challenges. What interventions to buy? From whom to
buy them? And how to buy them?
Strategic purchasing envisages a shift from a traditional demand-based pattern of provision to one in
which purchasers actively seek to assess need for
healthcare and determine how best they can be met.
Speci Ž cally, this oVers a means of giving voice to those
who would otherwise fail to express their needs as
demand. Strategic purchasing by agencies that genuinely act on behalf of the public redresses the balance
of power between patient and provider. Purchasers can
also use this power to ensure adherence to patient
rights and as a basis for advocacy on behalf of disadvantaged groups.
Providers form another element in the system. The
pattern and nature of provision can play an important
part in the generation or amelioration of health
inequalities. One question has attracted particular controversy. In many countries the role of the private
sector is increasing. This has two quite diVerent interpretations (20). One is that an expanded private sector
is welcome, bringing additional money into healthcare
and lightening the burden on the public sector as the
wealthy take their custom elsewhere. An alternative
view is that a private sector is a parasite, beneŽ ting
from public resources that have been used to train staV
and develop knowledge. Furthermore, by divorcing the
wealthy from the public system they undermine support
for that system. The wealthy, and thus electorally vocal,
then become immune to a gradual decline in the public
system. Clearly the latter is always a risk and, indeed,
is a major reason for the situation that pertains in the
United States, but it is also true that the private sector
can contribute meaningfully within a system that is
primarily public. Much will depend on the speciŽ c
context.
In the same way that purchasers must change, so
there is much that providers can do. Again, this will
require a shift from a reactive model to one that reaches
out to address unvoiced health needs. This is exempliŽ ed by the actions of the Health Promoting Hospitals
movement (21).
Change can be as straightforward as banning
smoking in health facilities. As well as reducing the
risk to others from passive smoking, this sends out a
very clear message about the acceptability of smoking.
Failing to do so has precisely the opposite eVect. There
is, however, much more that can be done (22). Advice
by health professionals on changing lifestyle can be
eVective, especially when it is part of a properly
designed programme (23). Success will, however,
require an increased emphasis in basic training on the
contribution that physicians, nurses, and others can
make to health promotion.
Healthcare providers can also take a lead in developing and implementing preventive programmes, such as
screening, although it is essential that these are population based and include mechanisms to reach those in
greatest need (D Post, personal communication) . If
not they will be either ineVective or will actually widen
inequalities (24). It must, however, be accepted that,
in some countries, there are real diYculties in doing
so. In some countries the memory of state abuses in
the 1930s has made it diYcult to implement populationbased programmes with active outreach ( 25 ). In these
countries there is a need to tackle these obstacles while
respecting genuinely held concerns about individual
freedom and privacy.
Providers can also do much to enhance access to
care. This may include consideration of where to locate
facilities and linkage with public transport facilities. It
also requires thought about access once the patient
enters hospital. Examples include the use of signposting
in appropriate languages for ethnic minority populations and of appropriate design for the visually
impaired. It also includes ensuring that those with
impaired mobility can move around the hospital, free
from hazards and obstacles.
Finally, health providers can act as advocate s for
health. Health professionals are respected Ž gures who
are seen as having authority to comment on healthrelated matters. For example, in the 1960s the Royal
College of Physicians in England played a major part
in the acceptance of tobacco as a major threat to health
(26). Unfortunately , as Ibsen’s Dr Stockman showed,
such advocacy involves tackling powerful vested interests and is not always popular (27).
THE NEEDS OF DISADVANTAGED
POPULATIONS
The third set of topics relates to the needs of disadvantaged populations. First, however, it is necessary to
consider the nature of disadvantage . For many, this is
a dynamic state. Over time people may move in and
out of poverty. Thus the total number of people who
will spend some part of their life in poverty is much
greater than those who experience poverty at a single
point in time. This should strengthen the argument for
solidarity as almost anyone is at risk of becoming
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Contribution of health services to reduction of inequalities
disadvantage d (28 ). Paradoxically, in societies where
social protection is largely privatized, insecurity may
push those who can aVord to protect themselves to do
so in ways that do not involve risk pooling. This will
exacerbate inequalities.
For others, disadvantag e is more long-standing . This
applies, in particular, to ethnic minority populations,
disabled people, and to groups such as prisoners (P
Mierzewski, personal communication) . The ideal
response is unclear and surrounded by controversy. Is
it better to design mainstream health services so that
they are inclusive and welcoming to all (29)? Or is it
more appropriate to recognize that some groups have
speciŽ c needs, whether on the basis of the diseases from
which they suVer, their cultural expectations, or otherwise (30). The answer must depend on the speciŽ c
context. In most cases, strengthening of mainstream
services will be desirable as long as it incorporates a
multicultural perspective but, for some groups and for
a limited period, speciŽ c services may be required.
An important contextual factor is the meaning of
citizenship in the country concerned (31). Within
Europe there are very diVerent beliefs about what is
expected of immigrants. Some countries have sought
to embrace multiculturalism, in which diversity is
accepted and services are expected to conform to cultural demands. Others take a more limited view of
citizenship, with immigrants expected to conform to
existing norms. In this case, it is the users that are
expected to conform to the ways that services are provided. The latter position clearly poses a challenge to
eVorts to reduce inequalities in access.
A related issue is the status of illegal migrants. Their
situation diVers widely within Europe. At a basic level,
their access to healthcare, to some extent, re ects the
nature of the entitlement of the majority population.
There is an important diVerence between systems
funded from general taxation, where entitlement is
based primarily on residence in the country in question,
and those based on social insurance, where entitlement
is based on contribution to a fund. Basic entitlement
is, however, only one of the problems faced by this
population. They often have speciŽ c health needs,
coupled with a fear of authority on the basis of previous
experience  eeing con ict or oppression (32 ). This creates many challenges for those responsible for the provision of healthcare and, in many countries, their needs
have been left to non-governmenta l organizations, such
as MeÂdecins sans FrontieÁres.
THE NEED FOR KNOWLEDGE
The Ž nal topic considered is the need for more knowledge that can inform policy ( F Didrechsen, personal
communication) . This means that more health and
57
social research should be designed, from the outset, to
inform the debate on health inequalities. This will
require a wider use of appropriate and valid explanatory variables, such as social class. It will also require
a more sophisticated approach to analysis, in particular
involving a greater recognition that while, for example,
health for the population as a whole may be improving,
it may be doing so solely because of gains among the
already advantaged ( 33 ).
Returning to the basic issues discussed earlier, there
is also a need for a focus on the economic consequences
of illness and, in particular, chronic illness. How can
the adverse impact of chronic illness on personal and
family income be alleviated? Finally, there is still very
little information on how eVective diVerent strategies
are in reducing health inequalities (34).
CONCLUSION
Health services can have an important impact on health
inequalities, both good and bad. There is, however,
much that can be done to increase the probability that
the net eVect will be beneŽ cial. This requires understanding better the reciprocal relationship between poverty and ill health, ensuring that the organization of
care is such that it collects resources fairly, enhances
access to care, and takes advantage of the opportunities
actively to promote health. Action is also required to
address the speciŽ c needs of disadvantage d populations, in a way that is contextually appropriate . As
always, there is a major need for further research.
ACKNOWLEDGEMENT
This report draws on the papers presented at the workshop as well as on the contributions of those who
attended it.
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