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Redistributing health through public health policies in latin america: fair to whom and fair how?

Public health aims to protect, promote, and restore health. It is a combination of sciences, skills, and beliefs directed at maintaining and improving health through different actions. This discipline has four characteristics: decision-making processes based on evidence, a focus on populations rather than on individuals, a goal of social justice and equity, and an emphasis on prevention rather than on curative care (1).

There is growing global interest in equitycentered health policies (2). This interest is particularly relevant to the Latin American region, one of the most unequal and inequitable regions in the world (3). Redistribution of health in particular implies various aspects such as improving the health of all on average (aggregate estimates with global population estimates), improving the health of those in the most deprived socioeconomic conditions (specific antipoverty policies focused on reducing the gap between the poorest and the wealthiest), and improving the health of everyone who is not at the highest socioeconomic level in the social hierarchy (policies that focus not only on the poorest ones but also on everyone else excluded from the top of the social ladder, as they frequently do not experience the degree of good health they could have if they were located at the top). Choosing overall improvement in health does not necessarily reduce the gap or the gradient according to socioeconomic status. In contrast, choosing interventions aimed at improving the health only of those in the poorest conditions significantly reduces the gap but ignores the health needs of those in the middle of the gradient. Choosing to improve the health of everyone who is not in the top socioeconomic stratum is possibly the most important way to reduce the effect on the gradient and overall health indicators, but it is an exceptionally complex process. It usually requires a set of simultaneous equity-centered policies that are anti-absolute poverty (aiming at the gap) and anti-relative poverty (aiming at the gradient).

It is relevant to assess who is receiving the benefit of health policy interventions and who is being negatively affected by them. One approach for deciding how to tackle health policy interventions in a world with budgeting constraints is driven by classic cost-benefit analysis. This approach is grounded in the principles of neoclassical welfare economics, in which improvements are assessed according to the Pareto principle and compensation criteria (4). The Pareto criterion holds that one policy ought to be preferred over another if at least one individual's welfare is improved as long as no individual's welfare is negatively affected. The compensation criterion states that a policy is adequate if the gains obtained by the winners are high enough to compensate the losers, even though the benefits are not transferred from winners to losers. Application of the Pareto and compensation criteria in health care policies not only does not address distributional concerns about benefits across the population (i.e., across the socioeconomic ladder) but can also increase the unfair health gap between different socioeconomic groups. Given the important financial constraints faced by most countries in Latin America, government authorities will need economic assessments of such policies. From the health authority point of view, cost-effectiveness analysis can be used, which is aimed at supporting allocation of resources. From the financial authority point of view, cost-benefit analysis can be used, which takes a broader perspective by comparing health interventions in different areas (e.g., education, labor). Regardless of the debate about which of the two approaches for economic evaluation is more appropriate, none of them considers distributional aspects.

The purpose of this letter is to advocate for an equity-centered public health approach to decision making. In Latin America, evidence-based policy decision making is still being developed and most countries follow the experiences of developed countries. Because equity considerations in the evaluation of health policies are also underdeveloped in high-income countries, there is a risk of delaying implementation of equity assessment in public health policies. Local authorities, especially health authorities, must adopt a more innovative position, implementing a process in which systematic evaluation of redistribution of health should be considered as a formal dimension. This process leads to two further salient considerations: defining who the lower socioeconomic groups are (i.e., how to adequately measure socioeconomic status in different Latin American populations and the reliability of those measurements across countries) and analyzing how to adequately measure such groups in public health research. The complexity involved in this subgroup analysis should not be underestimated and needs meticulous epidemiologic, statistical, and evidence-based synthesis (5).

We are aware of the complexity of the decision-making process in public health. A debate on the link between equity assessment, research evidence, social values, and the policy decision-making process needs to be maintained and expanded in the region in order to promote public health policies that are conscious of all possible courses of action in terms of redistribution of health in the population.


(1.) Last J, ed. A dictionary of epidemiology. New York: Oxford; 2001.

(2.) Marmot M. Fair society, healthy lives. London: Marmot Review; 2010.

(3.) Centro Latinoamericano para el Desarrollo Rural. Poverty and inequality: Latin American report 2011. Santiago: RIMISP, IDRC IFAP; 2011. Available from: http://www.rimisp. org/proyectos/seccion_adicional.php?id_proyecto=180&id_sub=183 Accessed 23 March 2012.

(4.) Boardman A, Greenberg D, Vining A, Weimer D, ed. Cost-benefit analysis: concepts and practice. 1st ed. Upper Saddle River, New Jersey: Prentice Hall; 1996.

(5.) Petticrew M, Tugwell P, Kristjansson E, Oliver S, Ueffing E, Welch V. Damned if you do, damned if you don't: subgroup analysis and equity. J Epidemiol Community Health. 2012;66(1):95-8.

Baltica Cabieses

Universidad del Desarrollo

Facultad de Medicina

Santiago, Chile

Manuel Espinoza

Pontificia Universidad Catolica de Chile

Hospital Urgencia Asistencia Publica de Chile

Santiago, Chile
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Title Annotation:Letters
Author:Cabieses, Baltica; Espinoza, Manuel
Publication:Revista Panamericana de Salud Publica
Date:Nov 1, 2012
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