Social Determinants, Health Equity and Human Development

The importance of equity in health necessitates concise definitions of concepts and tools used either to describe the distribution of ill-health as a phenomenon in time and space, or to understand the causes underlying unfair and avoidable inequalities in order to act on them. Consequently, the measures of health inequalities depend on the approach adopted to distinguish different groups of a population (by sex, socioeconomic status, education level, residence area, income, ethnic groups, …), the health variable to be described (mortality, morbidity, expectancy, quality of life, nutrition, access to services, …), and the methods and tools for description and analysis (absolute numbers, relative differences, odd ratios, concentration index, regression, component analysis, discriminant analysis, …). This first chapter is dedicated to the main concepts and indicators related to health measurements. Illustrative examples are given and clarifications are provided through remarks and discussions.

Between and within countries, disadvantaged people are the most affected by health risks globally. Underweight, micronutrients deficiency, lack of hygiene, unsafe water, inadequate sanitation, work and road accidents, violence and sex abuse, are clearly more prevalent among children, women, elderly, poor and less educated people, workers with low occupations, and other discriminated groups on the basis of ethnicity, culture, religion, and other. More globally, under nutrition, overweight, blood pressure, high cholesterol, tobacco, alcohol, illicit drugs, low fruits and vegetables intake, physical inactivity, unsafe sex, work injuries, road accidents, violence and environmental hazards constitute important health risks which illustrate the link between social determinants, health equity and development. Millions of deaths and tens of millions of disability years can be saved by tackling these factors worldwide in general and in developing countries in particular.

Equity in health has become a central issue. However, equity can mean different things to different people. Moreover, the principles underlying its definition and conceptualization may vary according to economic, medical, philosophical, political, ethical and other considerations. During the last decades, the literature on health equity has known an exponential increase. Although the majority of publications are produced in developed countries, the part devoted to developing countries is rapidly increasing

This chapter is dedicated to a selection of recent papers published on equity and social determinants underlying it. Our intention is not to give an exhaustive panorama of all papers which dealt with the theme of equity, rather we have selected some of the papers that could help the reader to easily get an overview of the multidimensional aspects of equity as illustrated by the large number of publications dealing with definitions and concepts of equity, the difference between inequalities and inequities, inequity in access to health services and health status, and many other aspects.

For each paper cited, we have tried to summarise the method used, the main results and the conclusion. When a detailed abstract was available, we have used it in a slightly different and concise form.

The papers reviewed were grouped into sub topics:

1. Definitions and Concepts, 2. Social determinants of Health, 3. Diseases and equity, 4. Equity and children health, 5. Maternal health and violence, 6. Geographic disparity, 7. Migrants and heath equity, 8. Equity and finance.

The contrast between life expectancy of 43 years for a woman in sub-Saharan Africa compared with 86 years for a woman in Japan is inconceivable and unfair. This is not a mere inequality it is one kind of health inequities existing between developed and developing countries. A multitude of other such health inequities are given by maternal mortality, infant mortality, diseases burden and access to different basic health services such as vaccination, antenatal care, postnatal visits, hospital beds, number of health personnel. Health inequity, however, is not a special feature characterizing the difference between rich and poor countries, neither is poor health confined to those worst off. In all countries, independently of their income and level of development, health and illness follow a social gradient. For instance, in the U.K, the 28 year life expectancy gap between men living in two different cities is incredible.

Diabetes and obesity currently threaten the health, well-being and economic welfare of virtually every country in the world. Worldwide, overweight and obesity are increasing at alarming rates. As a disease, obesity diminishes both quality of life and life expectancy, but it is also a common risk factor for other diseases like Cardio Vascular Diseases, arthritis, diabetes and many types of cancer. The incidence of diabetes linked to obesity has jumped significantly during the last two decades. Moreover, obesity and type 2-diabetes are affecting people all over the world including children and adolescents. Diabetes and obesity are associated with increased morbidity and mortality in the general population. The twin epidemics constitutes one of the major public health problems challenging all concerned social and economic groups, including scientists, health decision makers, nongovernmental organizations, industry associations, public and private sectors and volunteers.

Among the re-emergent diseases, dengue fever/dengue haemorrhagic fever is one of the most important by its wide spreading, the frequency of its epidemics and the complexity caused by the four virus serotypes associated with it. With more than 2.5 billion at risk, the global burden of dengue is growing dramatically. The literature associated with different aspects of dengue is abundant, this paper is a review of a large part of publications dealing with dengue and environmental health, the burden of disease and mathematical modelling mainly during the last decade.

Health and education constitute a cornerstone for human development of nations worldwide and especially for developing countries. In this context very few studies are devoted to Algeria, Egypt, Libya, Morocco and Tunisia as a group of countries forming what is called North Africa. These countries are often included in other regions like the Arab World, Africa, World Health Eastern Mediterranean Region (WHO-EMRO) and Middle East and North Africa (MENA). Belonging at the same time to Africa, Mediterranean Region, Arab World and Islamic countries, North African countries share language, religion and social and cultural custom. Consequently, it would be interesting to carry out a comparative study on their achievements in terms of human development and underlying components such as education, health, social welfare and violence.

Like many other developing countries, Morocco is struggling to achieve the main targets fixed by the Millennium Development Declaration for 2015. The report published in 2006 on “Fifty years of human development in Morocco and perspectives 2025” was a bold and praiseworthy initiative but it failed to carry out an equity analysis that indicates how to tackle the causes of the causes of persistent inequalities and disparities engendering underdevelopment. In this commentary, we give few examples illustrating the need to go beyond goals fixed in terms of average numbers, by tackling also the crucial problem of unfair and avoidable inequalities.

During the last century, several international human rights conventions and political declarations have been adopted on children’s rights alongside with regular reports released by organizations worldwide. The child rights were either stressed specifically or implicitly included as rights concerning all human beings. The spectre of children’s rights is very wide, comprising, but not limited to, early development, education, health, recreation, physical, mental and spiritual development as well as protection against all kinds of exploitation, discrimination, cruelty and neglect. It is also constantly stressed that children should be entitled to these rights, without distinction or discrimination on account of race, colour, sex, language, religion, political or opinion. More attention is often devoted to children with specific needs like girls, orphans, disabled and those belonging to minorities or living in countries under war and conflicts. However, despite this arsenal of declarations and conventions, millions of children are still lacking the basic rights entitling them to a decent life with sufficient food, education, health facilities, dignity and other children’s needs.

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