Nov 02, 2019 Volume 394Number 10209p1591-1684, e34
Achieving health equity: democracy matters
Johanna Hanefeld, Aaron Reeves, Chris Brown, Piroska Östlin
Progress on health equity in the European region in the past two decades has been slower than expected. Indeed, some countries have even seen health inequalities widen.1 This slow progress is, to some extent, surprising because there is almost unanimous political commitment to addressing health inequities and many countries have made great strides in implementing policies to reduce the health gap.1, 2 Europe, as a region, is on track to achieving the Sustainable Development Goals (SDGs) overall, but countries are not attaining SDG 10 and SDG 3 because ensuring healthy lives for all is impossible without reducing health inequities.
The report of the WHO European Health Equity Status Report Initiative (HESRI), launched on Sept 10, 2019, reviews achievements on the road to health equity to understand how to further accelerate action, and to discuss how to influence decisions related to fiscal policy and industrial strategy in order to deliver healthy, prosperous lives for all.3 The findings of the HESRI report3
show that the evidence on how to best tackle health inequity is clear and overwhelming, even more so in Europe, where we can draw on a wealth of health inequalities research.4 We know the size of the gaps in life expectancy, the social gradients in the burden of disease across the European region, and the root causes of these health inequalities, the social determinants of health.
The root causes of health inequities are driven by policies that structure access to the social determinants of health. Five conditions are necessary to reduce health inequity: good-quality and accessible health services; income security and an appropriate, fair level of social protection; decent living conditions; good social and human capital; and decent work and employment conditions.3 Of these, the two most important determinants are precarious housing and living conditions,5 and low income and weak social protection.6 When people live in unaffordable, cold, and unsafe housing on insecure contracts, their health is worse and they die prematurely.7 When people cannot make ends meet and when social protection systems are stigmatising and inadequate, their health suffers.8 Inadequate access to health services, conditions of employment, and personal and community capabilities are all important too. Health outcomes improve when people can access the care they think they need; when people work in secure employment with a living wage; and when people have someone to turn to for help and feel they have a voice in decision-making processes.9,10
The drivers of health inequity are all too prevalent across the region. This situation is not inevitable. These determinants of health inequalities are all modifiable through policies focused on the five areas identified in the report:3 health services, social protection, decent living conditions, social and human capital, and decent employment. Why, then, has progress been so slow?
Emerging evidence indicates that policies to address health inequalities do not emerge out of thin air, rather they are the result of a country’s or region’s wider political economy.11, 12
Policies are the product of people in particular socioeconomic contexts interacting with political institutions that shape the political process in a given location—be that a community, city, region, or country. Where these institutions are not accountable, transparent, participatory, or coherent, we will be far less likely to see the policy change necessary to deliver health equity. Governments and other stakeholders must actively work to alter how we incorporate the voices, lived experiences, and passions of the child, the young person, or adult who is not able to thrive and prosper because of health inequities. Democratic institutions, such as free and fair elections, are part of establishing the conditions that empower individuals and communities, ensure participation is meaningful, and establish decision-making processes that are accountable. Furthermore, accountable and transparent decision-making processes generate coherent policies by making participation inclusive. Beyond consulting people, participation can only be inclusive where economic barriers to participation are alleviated and where we alter the governance structures of policy processes to ensure the communities affected by policy decisions have a meaningful voice that influences outcomes in these processes.
There are countervailing forces, however. Vested interests, such as commercial actors or those who oppose health-enhancing policies, will seek to subvert efforts to address health equity.13m
Crucially, the influence of these groups depends on how our political systems are organised.14
Addressing health inequity requires a restructuring of our political systems so that we can deepen democracy through making our decision-making processes more inclusive.15, 16
To allow all people in Europe to prosper and flourish in health and in life, we need to recognise both the centrality of equity in health to the sustainable development of Europe and that political institutions are one of the essential conditions that make health equity possible.