Equity in Health

Near the end of 2013, an outbreak of Zaire ebolavirus (EBOV) began in Guinea, subsequently spreading to neighbouring Liberia and Sierra Leone. As this epidemic grew, important public health questions emerged about how and why this outbreak was so different from previous episodes. This review provides a synthetic synopsis of the 2014–15 outbreak, with the aim of understanding its unprecedented spread. The authors present a summary of the history of previous epidemics, describe the structure and genetics of the ebolavirus, and review our current understanding of viral vectors and the latest treatment practices. They conclude with an analysis of the public health challenges epidemic responders faced and some of the lessons that could be applied to future outbreaks of Ebola or other viruses.

Accurate measurement of health inequities is indispensable to track progress or to identify needs for health equity policy interventions. A key empirical task is to measure the extent to which observed inequality in health – a difference in health – is inequitable. Empirically operationalising definitions of health inequity has generated an important question not considered in the conceptual literature on health inequity. Empirical analysis can explain only a portion of observed health inequality. This paper demonstrates that the treatment of unexplained inequality is not only a methodological but ethical question and that the answer to the ethical question – whether unexplained health inequality is unfair – determines the appropriate standardization method for health inequity analysis and can lead to potentially divergent estimates of health inequity.

Universal health coverage has been set as a possible umbrella goal for health in the post-2015 development agenda. In this editorial, the authors discuss the relationship between universal coverage and universal access. They argue that addressing the broader social determinants of health will also improve access to health services; differences in access in particular will be ameliorated by reducing poverty and income inequalities. These actions alone, however, will not guarantee that all people obtain the health services they need. Even if the services exist and people have access to them, they might not use them. Universal health coverage cannot be attained unless both health services and financial risk protection systems are accessible, affordable and acceptable. In turn, universal access, although necessary, is not sufficient. Coverage builds on access by ensuring actual receipt of services. Thus, universal health coverage and universal access to health services are complementary ideas. Without universal access, universal health coverage becomes an unreachable goal.

In this paper, the authors review the extensive body of literature regarding health systems research on equity of access as it relates to universal health coverage, identifying the issues addressed, methods used and specific findings. Most of the studies that were reviewed interpreted equitable access as equal utilisation for equal need across socio-economic groups and report that poorer social groups experience less health care than their needs require. However, the authors noted that evidence on the causes and specific barriers to access faced by specific groups is often lacking in the literature. Only a few studies evaluated the impact of specific policies or interventions on equitable access, but they had significant methodological limitations. These findings suggest a need to strengthen policy relevant research, which should go beyond simply reporting inequities in health care utilisation and assess equity in the overall process of access to explain the causes of differential access. The framework devised by the authors is proposed as a useful reference scheme for future research, providing guidance on areas and methodological approaches.