Keeping equity in our sights
On 7 April 2023, World Health Day, the World Health Organization (WHO) observed its 75th anniversary. As well as reflecting on the public health successes that have improved quality of life during the last seven decades, it is also an opportunity to motivate action to tackle the health challenges of today ̶ and tomorrow. WHO is calling for a renewed drive for health equity as part of health for all efforts and in the face of unprecedented threats such as COVID-19.1
What does health for all mean? Is it the same as ‘leaving no one behind’ as part of the Sustainable Development Goals? Is it the same as universal health coverage? And why is equity relevant?
Few would disagree that “Everyone has the right to a standard of living for health and well-being.”2 or the “right to enjoyment of the highest attainable standard of health … without distinction of race, religion, political belief, economic or social condition”3 for all 4 . In the context of COVID-19, none of us is safe until all of us are safe. How we assess who is being left behind or left out or is not safe, is not always straightforward. We often use an aggregated lens to look at gains in population health. Even when we break down the data by characteristics such as age or sex or presence of a chronic condition, we can still miss people who are not using services for a particular reason e.g. people without rights to use the health and social care system such as informal workers or undocumented migrants.
The Millenium Development Goals (MDG) provided a salient lesson in this regard. Many countries made significant progress overall with regard to goals but the MDGs lacked indicators for looking at differences within countries in terms of equity and who was being left behind.5 This was flagged in the development of the Sustainable Development Goals with the cross-cutting and separate SDG 10 of leaving no one behind i.e. looking at health inequalities.6
In health this is reflected in the goal and related targets of universal health coverage. Ideally everyone in a country should be able to access the same range of services on the basis of their need and pay for these services on the basis of their income.7 In response to COVID-19 there were calls to address inequities between countries in terms of access to PPE and vaccinations.8 There was less discussion about what happened once countries received support to address these challenges and whether strategies were rolled out with attention to both need and equity/inequity.
When the call for health for all was first made and in subsequent redeclarations, the data available was limited, greater resources were required for collection and recording, and information technology was not as accessible as it is today. Disaggregated health data are a key starting point for beginning to identify, quantify and assess inequities in a defined population. In the past 20+ years, there has been a concerted and collective effort to improve health information systems and bringing together information that helps us better disaggregate data to see who might be missing or who might be doing better, and sometimes the rate of change.
This week WHO HQ launches the Health Inequality Data Repository the largest global collection of disaggregated data about health and determinants of health. The Repository has nearly 11 million data points across more than 2000 indicators. There are datasets for the following topics – COVID-19; Reproductive, maternal, newborn and child health; HIV, tuberculosis and malaria; immunisation; water, sanitation and hygiene (WASH) indicators; and country datasets.9 The site also contains a range of training materials and support resources.
While there are many gaps in what is collected, it is a sound starting point. We can use this data to both take action on what we can quantify and assess as well as identifying further gaps in our knowledge.
We need to move to action. The repository is a reminder of the importance of paying attention to equity as part of health for all efforts.
Sarah Simpson is a Senior Technical Advisor, Nossal Institute for Global Health. Her work with the Social & Cultural Dimensions of Health Systems team is focused on the practical integration of equity, gender and wider determinants into public health and health systems for greater inclusion and improved health outcomes for all.
 Loewenson R, Simpson S (2020) “Chapter 4. Understanding and Acting on Social Determinants of Health and Health Equity” in Global Health. Diseases, Programs, Systems, and Policies, Merson M, Black RE, Mills AJ (eds), pp.95-130. Fourth edition. Burlington, USA: Jones & Bartlett.
 Fehling M, Nelson BD, Venkatapuram S. (2013) ‘Limitations of the Millenium Development Goals: a literature review’, Global Public Health, Dec;8(10); 1109-1122. doi:10.1080/17441692.2013.845676
 Loewenson & Simpson, 2020.
 See Bergen N, Johns NE, Chang Blanc D, Hosseinpoor AR. (2022) ‘Within-Country Inequality in COVID-19 Vaccination Coverage: A Scoping Review of Academic Literature.’ Vaccines 2023, 11, 517 for example