Finding a balance : Health and social determinants of health

Abstract

There is a puzzling disconnection between health economics and socio-economic determinants of health. This is quite interesting because there is a general agreement that socio-economic status has great effect on health status. Modern health economics can be said to be one of the most salient and a powerful tool for health policies around the western world. However, health economics have been seen not to be taken active part in these discussions. One likely reason why this is happening is the tendency for health economics to see the health system as a virtual entity surrounded by scientific and economic mirage of cost and benefits. Health efficiency has become a banner under which health economics are defending economic evaluations of health against claims for equity in the distribution of health. This thesis begins with the task of reminding health economics of the impact of socio-economic status and health. It outlines the evidence and studies around the world about the systematic way in which the status of the individual on the social ladder affects mortality levels. The argument is that, this difference is found even in countries with universal access to health. This becomes a matter of concern since there is the tendency for policy makers to equate access to health to equitable distribution of health. I have proposed that, if access to health fails to explain this variation, we should rather look at the needs of the individuals as way of understanding the situation. The thesis also outlines the theoretical underpinnings of economic evaluation as a tool for priority settings. Welfare and Extra welfare economics provide the nominal foundation for ranking individual utility and needs based on the maximum capacity to benefit. Here, it is argued that, when health assessment is based on the individual utility, it ignores the basic inherent difference among individuals to utilize goods. The implications of these are examined in the fourth chapter where the limitation of using QALYs in decision making in health is explored. It is clear now that, the health equality is the objective of most countries, and yet the drive for efficiency has overshadowed this objective. There is the need for an alternative approach. It is obvious that there is no simple way to achieving this. I conclude that, we should not only concentrate on the outcome of distribution; but also we should direct our attention to the process of setting priorities if we hope to find any balance in our quest for efficiency and equity.