Tackling health inequity? It’s about changing the dynamics of political power

Continuing the Croakey series on health inequalities, Marilyn Wise, manager of the healthy public policy team at the Centre for Health Equity Research Training and Evaluation (CHETRE) at UNSW, suggests that there are several possible ways forward.

But if we really want to prevent health inequities, she says we need to consider ways of expanding “the political power of the people and populations who have been excluded by our current structures and processes from decision-making about the distribution of social resources”.

She writes:

“Marmot (2010), reporting on the findings of the Fair Society, Healthy Lives review published recently, wrote that, ‘the more favoured people are (socially and economically) the better their health’. This link between social conditions and health is not a footnote to the ‘real’ concerns with health – health care and unhealthy behaviours – it should become the main focus’ of action by governments, in particular.

Evidence of this link is not new, however.  Nor is the call to action.

What seems to be missing, always, from such analyses is acknowledgement that the inequalities in health are socially determined. That is, governments and organisations, acting on behalf of society as a whole or of particular communities of interest, have made and continue to make decisions that distribute resources (such as access to health care, or to high quality education, or ability to purchase a home, or secure employment) unequally, or, alternatively, that result in unequal access to resources (even if unintended). On one hand, this is discouraging – to feel that such injustice has been created deliberately. On the other, it is encouraging – the remedies, too, can be created deliberately.

It is important to acknowledge, here, that there is a huge body of evidence of what people and communities need in order to thrive and flourish. There is no question about the factors that determine individuals’ and populations’ health and life expectancy. Although new factors may be added to what is known already, there is no mystery about what people and communities need if we are to become and stay as healthy as possible – the combination of material resources, social and political inclusion and support, and respect for and tolerance of differences in aspirations.

On the contrary, the questions are, now, how to influence the decisions being made by society, so that all citizens of Australia (and other countries) have equal opportunities to acquire and/or use these resources?  How to avoid creating unjust inequalities in the distribution of our societies’ collective goods and benefits and to reduce the harm already done?

One way is to establish requirements to include people who have been denied access to social decision-making in government and in governing bodies – as members of boards and committees and parties. And as a corollary of this approach is the need to build capacity to formulate and propose preferences at community and small group levels and to assertively seek inclusion.

A second way is to assess public policy for its impact on equity before it is implemented in order to maximize the likelihood of equitable outcomes and to minimize inequity – equity focused health impact assessment.

A third way is for governments to develop patiently and respectfully, structures and processes through which to work explicitly with communities currently experiencing the greatest disadvantage to develop policy, service, and program options across all sectors and to invest significantly in these over time.

A fourth way is to require organisations to investigate the extent to which their policies and practices contribute to equity or inequity – from recruitment policies and practices, through to the services or programs that are sold or delivered. The current debate about ‘women in boardrooms’ is one example of such an investigation.

These are not ‘interventions’ in the guise of programs or projects to reduce or eliminate existing harms resulting from inequity although these are, of course, also much needed.

But if it is to be possible to prevent health inequity, it is necessary to expand the political power of the people and populations who have been excluded by our current structures and processes from decision-making about the distribution of social resources.

Finally, although evidence is limited, increased political incorporation has been found to be associated with reductions in relative and in some cases absolute health inequities (Beckfield, Krieger 2009, p. 167).”