3 - 296 - WHAT DOES EQUITY IN HEALTH MEAN? Gavin Mooney3 Introduction Is health for all a goal that can be achieved? Taking the question literally, the answer is clearly no. So why has WHO chosen "health for all" as its apparently prime target ? Presumably because by sloganizing in this way, WHO increases the probability of achieving its real goal. Such a procedure is of course wholly legitimate and it is not the intent of this article to be critical of this tactical device. In so far as the paper is critical of WHO, it is solely with regard to the lack of clarity about the equity objective that lies behind "health for all". An unjust comment? Perhaps, but surely not for the rational reader. It is possible to express means as a slogan, but it is potentially dangerous, and perhaps even impossible, to do so with objectives. It is here that WHO has to be taken to task. What is the Organization's real equity goal? The lack of certainty and clarity about the WHO position becomes apparent when various WHO documents are examined. For example, in the European strategy for health for all it is stated: "The target on health inequalities presents a challenge: to change the trend by improving the health opportunities of disadvantaged nations and groups so as to enable them to catch up with their privileged counterparts" (1). There seems little scope for interpreting this in any way other than that the target is equal health. Yet it seems legitimate to ask what that general level of equal health will be and whether more equitable sharing of health might not mean overall less health for the same quantity of resources. Maybe it is better just to treat this statement as a slogan and not a real goal, and to seek other definitions of equity in WHO documents. In the Global Strategy for Health for All (2) we read: "The existing gross inequality in the health status of people... must be drastically reduced" (emphasis added). There is thus a change: no longer is there to be a catching up, but rather a drastic reduction. That may be less clear but almost certainly it is more feasible. Within the European document (1) it is also stated that the goal of equity is to be achieved partly "by ensuring that everybody has access to primary health care". Thus equity of access to the health-care system is introduced and supplements health as the dimension through which equity is to be achieved and/or defined. But the Global Strategy document (2) proposes yet another view of equity, one which is fairly commonly encountered in individual country strategies, that "health is a fundamental human right". While that is stated with clarity it is less readily comprehended with clarity. The concept of a right to health care is one that is readily understood, but a right to health per se is not so easy to grasp. These introductory comments are not intended to be critical of WHO; rather they point to the difficulties that s Professor of Health Economics, Institute of Social Medicine. University of Copenhagen, Copenhagen, Denmark. GU'EST-CE QUE LÉQUITÉ EN MATIĚRE DE SANTÉ? Gavin Mooney3 Introduction La santé pour tous est-elle un objectif realisable? Si Ton prend I'expression á la lettre, la réponse est évidemment non Alors, pourquoi I'OMS a-t-elle apparemment choisi pour objectif principal la « santé pour tous » ? Sans doute parce qu'en lancant ainsi un slogan, elle augmente ses chances ďattein-dre son objectif reel. Un tel procédé est tout á fait legitime et le propos du present article n'est pas de critiquer cette tac-tique. Si tant est que I'auteur ait á faire une critique ä I'OMS. elle concerne uniquement le manque de clarté de l'objectif ďéquité sur lequel repose la notion de «santé pour tous» Est-ce lá une remarque injuste? Peut-étre, mais certaine ment pas pour un lecteur rationnel. On peut en effet adopter un slogan pour exprimer des moyens, mais il est dangereux voire impossible, d'exprimer ainsi ses objectifs. Et c'est bien sur ce point que I'OMS préte le flanc á la critique: quel esf en réalité son objectif ďéquité? Cette incertitude et ce manque de clarté quant á sa position sorft évidents ä la lecture de plusieurs documents de I'OMS Ainsi, Ton peut lire dans la strategie européenne de la santé pour tous: « Pour atteindre l'objectif de réduire les inégalités sanitaires, il est impératif de renverser cette tendance en améliorant les atouts sanitaires des nations et des groupes désavantagés pour les mett.e en mesure de rattraper les pays et les groupes plus favorisés»/7,/. L'objectif serait done 1'éga lité devant la santé car il ne semble pas y avoir d'autre inter prétation possible. On peut cependant se demander quel ser;i ce niveau general de santé égal pour tous et si un partage plus equitable des ressources de santé ne risque pas de signifie» moins, dans I'ensemble, pour la méme quantité de ressour ces. Peut-étre vaut-il mieux considérer qu'il s'agit bien d'un slo gan et non d'un objectif reel et chercher d'autres definitions de 1'équité dans les documents de I'OMS. Dans la strategie mondiale de la santé pour tous (2), nous lisons: «Les inécja lités flagrantes dans la situation sanitaire des peuples ... doi vent étre fortement reduites» (souligné par I'auteur). II fie s'agit done plus de rattraper un retard mais bien de réduire fortement les inégalités. C'est peut-étre moins clair mais il nsi ä peu pres certain que c'est plus realisté. Revenons au document relatif a la strategie européenne qui stipule que l'objectif ďéquité sera atteint grace en partie á une action garantissant l'acces de tous aux soins de santé primaires. Voilá qui soulěve la question de 1'équité de l'acces au systéme de soins de santé et qui complete la notion de santé en indiquant ä quel niveau 1'équité doit se situer, c'est ä-dire étre obtenue et/ou définie. Le document sur la strategie mondiale (2) propose une autre definition de 1'équité, que Ton retrouve assez frequem ment dans les strategies nationales, et qui est la suivante: «ia santé est un droit fundamental de l'etre humain». Cela, cer tes, s'exprime clairement mais risque d'etre compris moins clairement. Si la notion de droit aux soins de santé est facile a saisir, celle de droit á la sanfé řouf court n'est pas auss< explicite. Ces quelques remarques liminaires ne se veulent pas critiques á 1'égard de I'OMS; I'auteur a surtout voulu montrer 3 Professeur ďéconomie de la santé, Institut de médecine sociale. U'W' sité de Copenhague, Copenhague. Dänemark. Ftapp. trimest. statist, sanit. mond.. 40 ( - 297 - i'vcii iliat Organization has in being both consistent and clear about equity in health care. Perhaps as important, an examination of policy statements on equity from national governments and health-care agencies reveals similar difficulties in clarifying the meaning of equity. There is a need to be more explicit about what health policy is, or should be, attempting to achieve as an equity goal. There have been numerous efforts to measure both equity per se and whether and how it is changing over time; and some attempts to measure differing degrees of equity across different countries. But there should be concern about what is being measured: if it is equal health, there are obvious difficulties in measuring health even before attempting to determine whether its distribution is fair or unfair. If we standardize by age and sex, how "different" can the health status of an octogenarian male be to be considered "fair"vis-a-vis the health status of an 8-year-old girl? And if we take access as the dimension of fairness what does it mean when we compare different geographical areas (remote mountain villages with densely populated metropolitan districts) or different social classes with vastly varying transport and other forms of resources at their disposal? Can we justifiably choose "equal utilization for equal need" as our criterion of measured equity? Certainly utilization is relatively easily measured, even if need may not be. And do we need to consider equity in terms of the suppliers? Is it equitable to attempt to force/persuade some health-care professionals to work in locations where they would not otherwise choose to go? Should middle-class, city-born, bred and educated doctors be left free to decide where to practise or be compelled, cajoled or given financial incentives in the cause of equity to work in a remote village or urban slums? Not all of these questions are addressed in this article. They are presented to indicate that clarifying what equity means or should mean is a difficult but important task There is no single, uniquely correct answer and no attempt is made to provide it here. However the process of discussing and highlighting the different possible ways of looking at equity should help to make the choice of equity definitions, dimensions, goals and measurement more rational, which is the purpose of this article. Some initial (largely ethical) concerns As a starting point, the following definition by Aday et -al. (3) may be taken as a basis for considering equity in ■alth care: "An 'equitable distribution' of health-care services is one in which illness (as defined by the patient and his family or by health-care professionals) is the major determinant of the allocation of resources". While one would want to incorporate prevention and health promotion in this view, the statement reflects what often seems to lie behind concerns with equity —essentially that no particular group in society (the poor, some ethnic minority, women, etc.) should be excluded from gaining access to the health-care system either when they are ill or when their health status is threatened. Accepting illness and health promotion as a major determinant of any view of equity in health care is thus uncontroversial. Consequently the above definition although helpful still leaves open a wide range of possible definitions. A key issue is whether to adopt a "demand" or a "need" stance. The former is normally seen as involving the preferences (through willingness and ability to pay) of the patient and perhaps his family. Need, on the other hand, is based on the »alue judgements of health-care professionals on behalf of the patient and his family combien il est difficile, méme pour cette Organisation, d'etre á la fois coherent et clair sur un sujet comme l'équité en matiěre de soins de santé. Une analyse des declarations de principe des gouvernements ou d'organismes de soins de santé sur 1'équité révěle d'ailleurs les měmes difficultés á clarifier le sens de ce terme. II faut done définir avec plus de precision I'objectif ďéquité que la politique sanitaire vise ou devrait viser. De nombreuses tentatives ont été faites pour mesurer á la fois 1'équité et son evolution éventuelle dans le temps; on a également tenté de mesurer les différents degrés ďéquité d'un pays á 1'autre. Encore faut-il bien savoir ce que Ton mesure. Prenons 1'égalité en matiěre de santé: il est déjá bien malaisé de «mesurer» la santé, de sortě que Ton imagine sans peine les difficultés auxquelles on va se heurter pour determiner si elle est équi-tablement ou inéquitablement distribuée. Si Ton veut des données corrigées de I'age et du sexe, quel devra étre 1'état de santé d'un octogénaire pour qu'on puisse le considérer comme «satisfaisant» par rapport á celui d'une fillette de 8 ans? D'autre part, si I'acces aux services est la base de comparaison, quelle sera la valeur de cet exercice dans les cas ou Ton prend en consideration des zones géographiques différentes (villages de montagne écartés et métropoles den-sément peuplées) ou des classes sociales différentes (dispo-sant de moyens de transport ou d'autres ressources trěs variables) ? Est-il justifié de choisir comme eritěre ďéquité: «á besoin égal, utilisation égale»? L'utilisation est certes relati-vement facile á mesurer, mais il n'en va pas forcément de méme pour le besoin. Par ailleurs, devons-nous considérer 1'équité par rapport aux prestateurs? Est-il equitable de vouloir forcer ou persuader certains professionnels de la santé de travailler lá oů ils n'auraient pas normalement choisi de s'installer? Doit-on lais-ser á un médecin d'un milieu aisé qui est né, a été élevé et a fait ses etudes en ville, le libre choix du lieu oú il va exercer, ou bien faut-il, au nom de 1'équité, le forcer ou I'encourager — que ce soit en le flattant ou en lui offrant des incitations financiěres — á aller travailler dans des villages écartés ou dans des quartiers déshérités des villes? Toutes ces questions ne sont pas abordées ici et si je les pose, e'est pour montrer qu'il est difficile, mais néanmoins important, de bien préciser le sens du terme «équité». Car il n'existe pas de réponse qui soit la seule correcte et mon propos n'est pas ici d'en apporter une, mais I'examen et la mise en evidence des différentes approches possibles de 1'équité devraient permettre de choisir de facon plus ration-nelle les definitions, les dimensions, les objectifs et les mesu-res de cette équité, ce qui est I'objet du present article. Quelques premisses ďordre éthique Pour analyser 1'équité en matiěre de santé on peut prendre comme point de depart la definition suivante de Aday et al. (3): «11 y a distribution equitable des services de soins de santé lorsque la maladie (définie comme telle par le patient et sa famille ou par des professionnels de la santé) est le principal eritěre d'allocation des ressources». On serait tenté d'en ajouter deux autres: la prevention et la promotion de la santé, mais cette definition n'en reflěte pas moins la preoccupation essentielle qui est le plus souvent á la base du souci ďéquité — á savoir qu'aucun groupe de la société (pauvres, minoritě ethnique, femmes, etc.) ne doit étre přivé d'un accěs au systéme de soins de santé si l'un de ses membres est malade ou si sa santé est menacée. Děs lors, dire que la maladie et la promotion de la santé doivent étre des considerations fondamentales dans toute approche de 1'équité en matiěre de soins de santé ne prěte pas á controverse et la definition ci-dessus, si elle est utile, n'est que I'une des nombreuses definitions possibles. L'une des questions fondamentales est celle du choix entre le point de vue de la demande et celui des besoins. La demande est généralement percue comme reflétant les preferences du patient et parfois de son entourage (lesquels sont disposes á payer et en ont les moyens). Les besoins, en revanche, sont determines sur la base de jugements de valeur V lh statist, quart.. 40 11987) - 298 - and/or society at large. The definition by Aday et al. embraces both. Accepting the distinction between demand and need, any of the following might be incorporated within their definition: — equal expenditures/resources for equal need/demand (i.e. allocating resources to a particular group or geographical area in proportion to its health needs/demands); — equal access for equal need/demand (i.e. ensuring that for all individuals with the same need/demand, they will have the same opportunity to use health services); — equal utilization for equal need/demand (which would involve devising a system whereby use of health services would be allocated pro rata with need or demand); — equality in health (which would presumably have to be adjusted in certain ways and standardized at least for age and sex). Each of these (even the last because the concept of health will vary depending on whether it is seen from a demand or a need perspective) incorporates two potentially different definitions: one based on demand, the other on need. The list is not intended to be exhaustive; nor is it the intent to examine each of these definitions in detail (although it is worth noting in passing that the definition which seems most often to be adopted as a policy objective in health-care systems is that related to equality of access). Rather what it shows is that within the generally acceptable but broad definition of equity provided by Aday et al., there remains plenty of scope for disagreement and further debate. Let us take the question of demand vs. need a little further. While it would be possible —especially from a philosophical standpoint of utilitarianism —to pursue equity in health care in terms of demand, i.e. based on the preferences of consumers directly, the very nature of equity as a socialas opposed to an /nd/wdua/phenomenon points to the adoption of some social view of need in any basis for defining equity. If illness is to dominate the eauity_concern, then to leave each individual (different for example" in terms of his ability to pay for health care because of different income levels) to determine alone his own preferences and willingness to pay for health and health care would seem to run counter to the equity argument. Consequently, this article concentrates on equity defined in the context of need. Beyond these concerns, which reflect both ethical and more practical issues, we need to consider which ethical theories of distributive justice have potential relevance to the discussion of equity in health care. These are summarized by Veatch (4). ft) Entitlement theory. This is largely a theory of "nonequity" since it proposes that individuals are entitled to what they have, provided they acquired it justly. It would thus seem to be a largely conservative theory defending the status quo. According to this theory, for example, it would seem that in capitalist countries market forces, largely unregulated, could be left to determine the allocation of health-care resources. (ii) Utilitarianism. This is based on the principle of the greatest good of the greatest number and as such is normally (but see the discussion of Margolis below) seen in terms of efficiency (maximizing social benefit from the available resources) rather than equity. Indeed it is the basis of much neoclassical (largely free-market) economics which is frequently criticized because of its lack of concern with issues of redistribution. prononcés par des professionnels de la santé au nom du patient et de sa famille ou de la société dans son ensemble. La definition de Aday et al. associe ces deux points de vue. Si Ton accepte la distinction entre demande et besoins, on peut incorporer dans la definition I'un quelconque des princi-pes suivants: — á besoins ou demande égaux, dépenses ou ressources égales (c'est-a-dire que les ressources sont allouées á un groupe ou á une zone géographique particuliers pro-portionnellement á ses besoins ou á sa demande dans le domaine de la santé); — á besoins ou demande égaux, accěs égal (c'est-a-dire que tous les individus ayant les měmes besoins aient les měmes possibilités ďaccěs aux services de santé); — á besoins ou demande égaux, utilisation égale (ce qui suppose que Ton concoive un systéme permettant ďutiliser les services de santé au prorata des besoins ou de la demande); — égalité devant la santé (laquelle devra sans doute ětre corrigée de certaines variables et en tout cas de I'age et du sexe). Chacun de ces principes se prěte á deux definitions poten-tiellement différentes, I'une fondée sur la demande et I'autre sur les besoins, y compris le dernier car la notion de santé risque de varier en fonction de I'optique choisie. Cette liste ne se veut pas exhaustive; I'intention n'est pas non plus d'analyser chacune des definitions dans le detail (encore qu'il soit intéressant de noter au passage qu'appa-remment, le principe le plus souvent retenu comme objectif par les systěmes de soins de santé soit 1'égalité ďaccés). Cette liste est plutót destinée á montrer que la definition acceptable pour tous rnais un peu vague de 1'équité qui nous est donnée par Aday et al. préte largement le flanč á la critique et devrait faire 1'objet ďune analyse plus poussée. Essayons ďapprofondir 1'opposition demande/besoins Alors qu'il serait possible — en particulier si 1'on se place ďun point de vue utilitariste — de chercher á fonder 1'équité en matiére de soins de santé sur la demande, c'est-a-dire direc-tement sur les preferences des usagers, la nature měme de 1'équité en tant que phénoměne social, et non individuel, contraint á adopter dans toute definition une conception ((sociále)) des besoins. Si la notion de maladie doit dominer le souci ďéquité, en laissant á chaque individu (par exemple en fonction de sa capacité á payer les soins de santé, c'est-a-dire de son niveau de revenu) le soin de decider par lui-měme, on semble aller á 1'encontre du principe ďéquité. Cest pourquoi on s'en tiendra, dans le present article, á 1'équité considérée du point de vue des besoins. Au-delá de ces questions, qui sont á la fois d'ordre éthique et pratique, il nous faut nous demander quelles theories éthi-ques de la justice distributive pourraient étre appliquées a 1'étude de 1'équité en matiěre de soins de santé. Ces theories ont été résumées par Veatch (4). i) La théorie du droit á 1'acquis. Cest essentiellement une théorie de la non-équité puisqu'elle part du principe que les individus ont droit á ce qu'ils ont acquis, pour autant qu'ils I'aient fait légitimement. On peut done considérer qu'il s'agil la d'une théorie trěs conservatrice favorable au statu quo. En vertu de cette théorie, par exemple, le libre jeu des forces du marché, en grande partie incontrolées, pourrait determiner dans les pays capitalistes I'allocation des ressources sanitai-res. ii) Utilitarisme. Le principe en est le suivant: un maximum d'avantages pour un maximum de gens; on raisonne done généralement (voir cependant I'analyse de Margolis ci-aprěs) en termes d'efficience (accroTtre au maximum les avantages sociaux tires des ressources disponibles) plutót que ďéquité Cette théorie, dont s'inspirent nombre de theories économi-ques néoclassiques (essentiellement libéralistes), est sou-vent critiquée parce qu'elle fait peu de cas des questions de redistribution. Rapp. trimest. statist, santt. mottct.. 40 (198 (Hi) Maximin theory. This is often exemplified by Rawls' i theory of justice (of which more below) with its idea that the goal is to maximize the minimum position, in other words, give priority to the least well-off in society. It is very clearly a positive theory of just distribution. (iv) Eyality. This theory of justice is concerned with equality, which in the context of health care can be presumed to mean equality in health. Again it is immediately clear that such a theory is positively concerned with fairness in distribution. It would seem that (i) and (ii) above are rather limited in their relevance to equity of resource allocation in health care, especially the entitlement theory. Despite that, those systems of health care which rely primarily on market forces are based largely on this entitlement theory. This merely emphasizes the fact that the problems and prospects of pursuing equity will vary in nature and difficulty under different organizational and financing structures. Some theories of distribution There are various theoretical and conceptual underpinnings for a defence of or at least a debate on the inclusion of equity in resource allocation as a suitable goal for health care. Since these all involve philosophical standpoints, the existence of more than one argument is not surprising. Given changing premises it is also unsurprising that getting agreement on any particular concept, definition or objective will be difficult. While this article does reach some conclusions about an appropriate definition, they are inevitably laced with value judgements. But that then points to what might be considered the first and most basic conclusion about equity: that it is a value-laden concept which has no uniquely correct definition (in some objective and/or scientific sense). Equity is difficult to define. Nonetheless it wins almost universal approval as an objective in principle in health care Equity (however defined) has something to do with justice. While it also has links to equality, equity is not the same as equality, which may well be an advantage in winning approval from those concerned about the potential dangers of egalitarianism. Few would disagree, at least in principle, that "fair" and "just" are adjectives with a desirable ring to them, especially in the context of health and health care. Who could deny the virtuous ring of "health for all" ? Various theories have been put forward for considering ■quity in the distribution of health-care resources. Here we will examine just five. A theory of maximin In recent times, the name most clearly associated with the philosophy of equity and inequality is that of Rawls (5). His theory rests on the principle of maximin, i.e. maximizing the position of the worst-off in society. Rawls' theory is concerned with a separation of society's responsibility from the individual's. Indeed this question of the distribution of "property rights" on the decision-making process regarding equity is important. In other words: whose responsibility is it to define equity and pursue policies to promote equity? Rawls considers a set of goods which he suggests are the responsibility —for production and distribution —of society at large rather than of individuals. These include: basic liberties; freedom of movement and of occupation ; powers and prerogatives of office; income and wealth; and the basis of self-respect. For these so-called "primary goods" Rawls suggests that there is some wish or responsibility in society to do well for the worst-off (hence the notion of "maximin", of Hi) La théorie du «maximin». L'exemple souvent cite est celui de la théorie de la justice de Rawls (décrite ci-aprěs) selon laquelle il faut faire le maximum pour ceux qui n'ont que le minimum, cest-á-dire accorder la prioritě aux plus défavo-risés. II s'agit á 1'évidence ďune théorie positive de la juste distribution. iv) Egalité. Cette théorie de la justice est soucieuse ďéga-lité; dans le cas des soins de santé, on peut supposer qu'il s'agit de 1'égalité devant la santé. Lá encore, il est evident que cette théorie vise une juste distribution. II semblerait done que les theories i) et ii) ci-dessus ne reflětent qu'imparfaitement la notion ďequité dans la distribution des ressources en soins de santé, surtout la premiére. Or, les systěmes de soins de santé qui sont largement tribu-taires des lois du marché reposent en grande partie sur cette théorie du droit á I'acquis. II n'en est que plus evident que les problěmes et les perspectives de la recherche de 1'équité sont de complexité et de nature variables selon les infrastructures institutionnelles et les modes de financement. Quelques theories de la distribution Divers arguments théoriques et conceptuels peuvent étre invoqués pour faire de 1'équité dans la distribution des res-sources un objectif des services de santé ou du moins pour qu'un debat s'instaure sur cette question. Etant donné que tous ces arguments impliquent des prises de position philo-sophiques, il n'est pas surprenant qu'il y en ait plus d'un et vu la diversité des hypotheses de depart, on ne saurait non plus sétonner de la difficulté á se mettre d'accord sur un concept, une definition ou un objectif. Si le present article contient un certain nombre de conclusions sur une definition appropriée, celles-ci sont inévitablement entremélées de jugements de valeur. Ceci nous conduit á ce que Ton peut considérer comme la premiére et la principále conclusion sur 1'équité: e'est une notion hautement subjective pour laquelle il n'existe pas de definition (objective et/ou scientifique) applicable á tous les cas. Léquité est difficile á définir. On peut toutefois dire qu'il s'agit dun objectif de principe universellement admis dans le domaine des soins de santé. L'equite (quelle qu'en soit la definition) n'est pas trěs éloignée de 1'idée de justice. Elfe a également un rapport avec 1'égalité, sans en étre synonyme, ce qui pourrait bien étre un avantage aux yeux de ceux qui s'inquietent des dangers possibles de 1'égalitarisme. Rares sont ceux qui disconviendront, du moins sur le pian des prin-cipes, que les adjectifs « equitable » et «juste » n'aient une connotation positive, surtout dans le contexte de la santé et des soins de santé. Et qui songerait á nier la connotation morale de la « santé pour tous»? Plusieurs theories militent en faveur de 1'équité dans la distribution des ressources sanitaires. Nous nous contenterons d'examiner ici cinq ďentre elles. La théorie du «maximin » Le nom le plus souvent associé ces derniěres années á la philosophie de 1'équité et de 1'inégalité est celui de Rawls (5). Sa théorie repose sur le principe du « maximin», qui consiste á améliorer au maximum la situation des plus mal lotis dans la société. Elle dissocie la responsabilité de la société et celle de lindividu. II importe en effet de savoir á qui il appartient de decider de ce qui est equitable ou non. En d'autres termes, qui va définir 1'équité et appliquer les politiques propres á la pro-mouvoir? Rawls estime que e'est la société dans son ensemble et non I'individu qui doit assumer la responsabilité (production et distribution) d'un certain nombre de «biens»: libertés fon-damentales; liberté de mouvement et liberté du travail; pou-voirs et prerogatives liés á la fonction; revenu et richesse; et ce qui constitue la base de la dignité personnelle. Pour ce qu'il appelle ces «biens essentiels», Rawls pense que toute la société a, consciemment ou non, une responsabilité á légard des plus défavorisés (ďoú la notion de «rnaxi- d hllh statist, quart., 40 (1987) 300 - maximizing the position of the minimum person). In such a society, individuals would ignore their own position and choose to maximize the welfare of the worst-off, at least in respect of these primary goods. Now as Daniels (6) points out, health care is not present in Rawls' list of primary goods. Indeed, as he indicates, in Rawls' idealized case "there is no distributive theory for health care because no one is sick". It could of course be added to the list but that would change the nature of Rawls' position quite markedly and could lead to the impoverishment of a society. Rather than abandon Rawls, Daniels suggests that health-care institutions be included among the basic institutions whose task it is to provide equality of opportunity, but it is important to note that in the context of these institutions "opportunity, not health care or education, is the primary social good" (6). That would then point to a distribution of resources for health care based on some concept of opportunity and thereby a definition of equity which was seen to be in terms of equality of access to health care, presumably related to some health or illness concept which might be designated "health need". min»: on veut ameliorer au maximum la situation de ceux qui n'ont que le minimum). Dans une telle society, les membres choisiront d'ignorer leur propre situation et voudront accroi-tre le plus possible le bien-etre des desherites, au moins en ce qui concerne ces biens essentiels. Mais comme le fait observer Daniels (6), les soins de santo ne figurent pas sur la liste des biens essentiels de Rawls. Ainsi qu'il le fait remarquer, dans I'idea) de Rawls «il n'existe pas de theorie distributive des soins de sante car personne n'es; malade». On pourrait bien entendu les ajouter a la liste msis cela modifierait assez sensiblement la position de Rawls et risquerait d'entraiher une pauperisation de la societe. Plutot que de renoncer a la theorie de Rawls, Daniels sug-gere que les etablissements de soins de sante figurent parmi les institutions de base qui ont pour tache d'assurer I'egalite des chances, mais il convient de noter que, dans le contexte de ces institutions, «c'est I'egalite des chances qui est le bien social essentiel, et non les soins de sante ou l'education» (6) Cela conduit a fonder la distribution des ressources sanitaires sur une notion d'opportunite et done a definir I'equite en ter-mes d'egalite d'acces aux soins de sante en la rattachani sans doute a une notion de la sante ou de la maladie que Ton pourrait appeler «besoins sanitaires ». Altruism as a basis for equity Titmuss' (^concern for equity arose from his interest in the provision of blood under different health-care systems and societies and, in particular, voluntary (unpaid) donation versus commercialism (payment of donors). He used this as a basis to build a defence of the National Health Service (NHS) in the United Kingdom and thereby a defence of equity in health care (or as he called it "the gift relationship"). Indeed the width of his view of health care is as great as that of Rawls. An important difference between them is that while Rawls emphasizes opportunity, essentially a demand-side phenomenon, i.e. one seen from the perspective of those who do or may use the system —patients or potential patients, Titmuss emphasizes the supply side. Thus the establishment of the NHS (and its concerns for equity) "has allowed and encouraged sentiments of altruism, reciprocity and social duty to express themselves; to be made explicit and identifiable in measurable patterns of behaviour by all social groups and classes". It can be argued that this is essentially a Kantian view of the world with a strong emphasis on a duty or responsibility to provide an equitable health-care system. Thus in the context of voluntary blood donation, if each individual realized how small was the impact on a blood-transfusion service of giving blood himself, then few if any would bother to do so. But realizing in turn that if everyone failed to give blood the impact would be great, the individual feels duty bound, or one might say altruistic, and gives blood. In the specific context of blood donation it is relatively easy to see that if Titmuss is right then a system of voluntary blood donation may well be more effective and efficient than one based on paying donors. It is in the widening of this process to health care as a whole that there are some question marks, particularly in respect of individuals' stock of altruism, whether it is increased by use (essentially Titmuss' view) or in limited supply and therefore one altruistic act has an opportunity cost in terms of a forgone alternative altruistic act. It is evident that Titmuss saw a national health service as a morally superior way of delivering health care but largely on the grounds of its being a morally superior way not just of delivering but also of encouraging'altruism. This may be more an emotional than a rational basis for defending equity in health care but, returning to some of the statements made by WHO in the context of health for all, that in itself does not make it an inappropriate response to a defence of equity, at least in terms of equality of access. L'altruisme, fondement de i'equite Le souci ďéquité de Titmuss (7) lui a été inspire par son intérét pour le don de sang dans différents systěmes de soins de santé et différentes sociétés et en particulier pour le don de sang bénévole (non rémunéré) compare á la vente du sang (retribution des donneurs). II s'est base sur cet exemple pour construire sa defense du National Health Service (NHS) au Royaume-Uni et partant, sa defense de 1'équité en matiěre de soins de santé (qu'il appelle la relation basée sur le don). La largeur de ses vues sur les soins de santé est certes égale á celle de Rawls. La principále difference est que Rawls met I'accent sur 1'opportunité, qui est essentiellement un phéno-měne intéressant la demande (e'est-a-dire ceux qui utiliseni ou peuvent utiliser le systéme — patients ou patients even-tuels) alors que Titmuss met I'accent sur loffre. Ainsi, In creation du NHS (et son souci ďéquité) «a encourage les sentiments d'altruisme, de réciprocité et de devoir social ei leur a permis de s'exprimer dans tous les groupes et classes de la société, sous la forme de schémas de comportement qui peuvent étre identifies et mesurés». On peut arguer que e'est la, essentiellement, une conception kantienne du monde qui met nettement I'accent sur le devoir ou la responsabilité que représente la mise en place d'un systéme de soins de santé equitable. Ainsi, dans le cas du don de sang bénévole, si chacun avait conscience du faible impact qu'a son propre don du sang sur le service de transfusion sanguine, rares seraient ceux qui se donneraient la peine de s'y rendre. En revanche, le sentiment de ce qui se passerait si personne ne donnait son sang, fait que chacun se sent moralement oblige, mu par ce que Ton peut appeler l'altruisme, de donner son sang. Dans le cas particulier du don de sang, il est assez facile de voir que si Titmuss a raison, un systéme de don de sang bénévole pourrait bien étre plus efficace et plus rentable qu'un systéme fonde sur la remuneration des donneurs. Cest I'extension de ce processus á I'ensemble des soins de santé qui suscite certaines reserves, notamment en ce qui concerne la capacité d'altruisme d'un individu: augmente-t-elle avec I'usage (point de vue de Titmuss) ou bien est-elle limitée? Dans ce cas, tout acte d'altruisme aurait un coůt d'opportunite dans la mesure ou il obligerait a renoncer á un autre. II est evident que si Titmuss considěre un service national de santé comme un moyen de dispenser des soins de santé qui est moralement preferable, e'est surtout parce que outre sa fonction de prestateur de soins, il encourage l'altruisme Peut-étre est-ce lá un argument subjectif et peu rationnel en faveur de 1'équité en matiěre de santé mais, si Ton considěre certaines declarations faites par I'OMS dans le contexte de la santé pour tous, cela n'en fait pas un mauvais argument en faveur de 1'équité, du moins si on la considěre en termes Flapp. trimest statist, sanit, mond., 40 (198?! IUI es 01- ce ite isi de ■st lis et 9-nii ite te 911 % ss fr- Mt hi IS le 9 jr u e a ä !t Thus if one accepts the notion of Titmuss' altruism the most likely dimension of it is in terms of individuals having - equal opportunity (for equal need) to use health-care facilities. The fair shares theory of distribution For a more utilitarian as opposed to the rather Kantian view of Titmuss, there is Margolis' (8) theory of "fair shares" which, while he does not directly apply it to health care, is relevant in this context. The idea is simple. Individuals obtain utility or satisfaction in two ways: first they yet utility from normal acts of consumption of goods and services and consequently devote some of their income, time and efforts to pursuing such acts and deriving utility from the outcome of such acts; second, satisfaction is derived from doing their fair share for some wider group such as society at large —taking part in various social and charitable functions and acts, voting in elections for local and national representatives, etc. It is this second form of utility which appears to be unique to Margolis' theory. It is important to stress that the utility in this idea of fair sharing is process utility and not as in the former case outcome utility. In other words in the second instance the relevant source of the utility lies in the participation process itself, not in its outcome. Just as »the individual devotes some of his income, time and efforts to consumption for outcome utility, so will he similarly devote income, time and efforts to participating in wider social acts. The driving force in the latter case is a desire to "do one's bit"for the social group where the individual has an equal chance of benefiting along with everyone else. Of course there is then a prospect that more selfish individuals (i.e. those who derive little utility from doing their fair share) can exploit the more selfless individuals. Where this problem arises, there may be a case for some form of coerced solution (e.g. a national health service). Health care may well be a social activity where the desire to do one's fair share is strong. This may be partly because of the basic health aspects: we are concerned as individuals for the suffering of our fellow human beings. It may be that it has more to do with a desire to allow individuals to have relatively easy access to health-promoting facilities, i.e. primarily health services. It may also be because of a general lack of knowledge on the part of individuals about health and health care and the prospect of exploitation through ignorance. Given the emphasis that Margolis places on his concept »f "participation utility", the most likely dimension of .quity to emerge from his theory is equality of access for equal need. It is difficult to say precisely because he does not consider health care specifically (for more discussion of Margolis applied to health care see Mooney (9)). A commitment to equity In the context of equity generally but especially in the case of health care, there is a potentially crucial distinction to be made between what Sen (W) calls "sympathy" and "commitment". There are, even though Sen appears not to make the distinction, parallels here between a utilitarian and a Kantian view of the world. In that sense it may be possible to interpret Titmuss in terms of commitment. Sympathy is not wholly unselfish in the sense that if another individual's welfare increases and we sympathize with that individual then we gain utility from that individual's gain in welfare. Conversely, and more simply, a sympathetic individual is saddened by another's sadness. It is clear in this context that the use of the term "wholly unselfish" has to be treated with caution: it can easily be argued that a society in which individuals gain (lose) utility from others' happiness (sadness) is a more caring society 301 - d'ögalitö d'acces. Des lors, si Ton admet la notion d'altruisme de Titmuss, son expression la plus probable sera, ä besoins egaux, l'egalite des chances d'utilisation des sources de soins de sante. Theorie de la distribution dite des «justes parts» La theorie des «justes parts » de Margolis (8) precede d'une conception plus utilitaire, qui s'oppose ä la conception kan-tienne de Titmuss. Si elle ne s'applique pas directement aux soins de sante\ eile presente cependant un inte>et dans ce contexte. L'id^e en est simple. II y a, pour I'individu, deux fapons d'obtenir un avantage ou une satisfaction: premiere-rnent, il tire avantage de la consommation normale de biens et services et y consacre done une partie de ses revenus, de son temps et de ses efforts; deuxiemement, il tire 6galement une satisfaction de sa contribution pour une juste part ä ce qui se fait au profit d'un groupe — par exemple la societe en general — en prenant part ä diverses manifestations sociales et cha-ritables, en eTisant des reprösentants locaux et nationaux, etc. C'est cette deuxieme forme d'avantage qui semble etre particuliere ä la theorie de Margolis. II faut souligner en effet que I'avantage en question est alors Ii6 ä un processus et non plus, comme dans le cas precedent, ä un resultat. En d'autres termes, la source de I'avantage reside, dans le second cas, dans le processus de participation lui-meme et non dans son resultat. De meme qu'il consacre une partie de son revenu, de son temps et de ses efforts ä la consommation pour en tirer un avantage, I'individu consentira aussi des sacrifices pour participer ä des activites interessant le reste de la societö. II est alors mü par le desir de faire son devoir dans le groupe social oü chacun a une chance ögale de profiter de ce qui est fait par tous. Certes, on risque alors que les 6goTstes (e'est-a-dire ceux qui tirent peu d'avantages de leur juste part de I'effort com-mun) exploitent les plus desinteresses. Lorsqu'un tel Probleme se pose, on peut devoir recourir ä une forme de contrainte (par exemple, un service national de santö). Les soins de sante peuvent tres bien Stre consideTes comme une activity sociale ä laquelle chacun souhaite vive-ment apporter sa juste contribution, en partie sans doute parce que la sante touche ä quelque chose de fundamental: en tant qu'etres humains, nous sommes sensibles ä la souf-france de nos semblables. Mais il se pourrait que cela releve davantage d'un dösir de garantir un acces relativement ais6 ä des moyens de promotion de la sante, c'est-ä-dire surtout aux services de sante\ Cela peut aussi etre le rösultat d'un manque de connaissances sur la sant§ et les soins de santö chez les individus en general, et la peur de l'exploitation li§e ä l'ignorance. Compte tenu de l'accent mis par Margolis sur la notion d' «avantage tire de la participation)), il est vraisemblable que l'öquite dans sa thöorie sera a besoin 6gal, l'ögalite' d'acces. II est difficile de l'affirmer car les soins de sant6 ne sont pas expressement visas (pour une analyse plus approfondie de la theorie de Margolis appliquöe aux soins de sante, voir Mooney (9j). Engagement en faveur de l'äquite Pour l'equite en general mais surtout l'equitö en matiere de soins de sante, il peut etre essentiel d'operer une distinction entre ce que Sen (10) appelle la «compassion» et I" ((engagement)). Bien que Sen lui-meme ne semble pas faire cette distinction, il y a ici des similitudes entre la thöorie utilitariste et la conception kantienne du monde. En ce sens, on peut interpreter la theorie de Titmuss en termes d'engagement. La compassion n'est pas totalement d6sinte>ess£e en ce sens que si nous nous rejouissons du bonheur de quelqu'un, nous en tirons done un avantage. Inversement, et plus sim-plement, une personne compatissante sera attristee par la peine d'autrui. II est evident que dans ce contexte I'expres-sion «totalement desinte>ess6e» doit etre utilised avec precaution : on peut aisement arguer que la society dans laquelle les individus tirent un avantage du bonheur d'autrui ou per-dent cet avantage devant sa tristesse est une societe plus Wldhlth statist, quart.. 40 (1987) - 302 - than one where this is not the case. There is consequently no intended pejorative content in the phrase selfish as it is used here. It means egoistic in a simple descriptive sense. As Sen (10) states: "behaviour based on sympathy is in an important sense egoistic, for one is pleased at others' pleasure and pained at others' pain, and the pursuit of one's own utility may thus be helped by sympathetic action". On the other hand, commitment entails an actual loss of utility to the individual making the commitment. It involves an individual doing something for others which does not benefit that individual. Sen (10) thus defines it in terms of "a person choosing an act that he believes will yield a lower level of personal welfare to him than an alternative that is also available to him". In health care, it can be argued that the dimension of sympathy is most likely to be health itself, i.e. we are more likely to be sympathetic to an individual's ill-health status directly, than to questions of an individual's access to or utilization of health services. In the case of commitment, the most likely dimension is access since improving access for those in need is something to which individuals can reasonably contribute their efforts and resources. Equity as an "externality"? A final way to view equity is provided by Culyer (1 1) in the notion of an "externality". An "externality" arises in circumstances where the utility of others enters an individual's utility function. As Culyer states: "individuals are affected by others' health status for the simple reason that most of them care". Hence he refers to this idea as the "caring externality". It is thus very similar to Sen's concept of sympathy. Yet, as an explanation of equity it is problematic in practice since it is difficult to see health or health status as the appropriate dimension of redistribution. How can we directly redistribute health per se across different groups in society? Culyer (12) elsewhere suggests health-care consumption as the appropriate dimension. This changes the perspective and implies that health care is a form of merit good, i.e. one for which some elite (a government, or the medical profession) determines the extent of consumption because, left to their own preferences, individuals (or at least some individuals) would consume less than is socially optimal. Equity would then be defined in terms of equality of utilization for equal need. What then is equity? What then is the meaning of equity in health care? The above discussion suggests that various definitions and dimensions are possible. It is difficult to say which is correct—what is "right" is a value-laden question. However, most of the theories tend to emphasize equity in terms of access rather than health or health-care consumption. Such a conclusion is potentially important for policy in the area. However more important still is the need to clarify what definition of equity is to be and/or is being adopted as an objective of health policy, even if that definition is not couched in terms of access. Lack of such clarification can only blunt the attack on inequities and lead to unnecessary confusion. There are dangers that resources will be badly deployed in pursuing equity if the objectives are not clear. There will be different policies for different equity goals and the potential for conflict between efficiency and equity in health policy will vary depending on how equity is defined. Lack of clarity in the meaning of equity has led to measuring equity in the wrong or inappropriate dimensions (for example, if the goal is equality of access it is not directly relevant to monitor health-care consumption per se). charitable qu'une autre ou tel ne serait pas le cas. II n'y a done aucune connotation pejorative dans le terme ögoiste — ici purement descriptif. Comme I'explique Sen (10): «|e comportement fondö sur la compassion est en grande partie egoi'ste car I'individu se rejouit du plaisir de l'autre et souffre de sa douleur, et la recherche de son propre interet peut etre favorisee par une attitude compatissante». A I'inverse, I'engagement suppose que linteresse renonce ä un avantage, qu'il fait quelque chose pour autrui sans en tucr d'avantage direct. Sen (10) parle d' «une personne choisis-sant d'accomplir un acte en sachant qu'il lui procurera per-sonnellement un degre de bien-etre inferieur ä celui qu'elle tirerait d'un autre egalement ä sa portee». Dans le domaine des soins de sante, on peut penser que e'est sur la sante elle-meme et, plus precisement, la mauvaise sante, que s'exercera tres probablement la compassion, et non pas sur des questions comme l'acces de telle personne aux services de sant§ ou son utilisation de ces services Quant ä I'engagement, il sera vraisemblablement dirige sur l'acces aux soins de sante car ameliorer cet acces pour ceux qui en ont besoin est un objectif ä la realisation duquel des individus peuvent raisonnablement contribuer par leurs efforts et leurs ressources. L'equite est-elle une «externalite»? Une derniere conception de l'equite nous est donnee par Culyer (1 1)avec la notion d' «externalite». II y a «externalite« \ lorsque I'avantage d'autrui coincide avec celui de l'intöresse Selon Culyer: «Si les individus sont touches par l'etat de sante des autres, e'est tout simplement parce que la plupart s'y Interessent». Cette notion est tres proche de Celle de la compassion chez Sen. Dans la pratique toutefois, eile peut difficilement servir ä expliquer le Probleme de l'equite car il est malaise de considerer la sante ou l'etat de sante comme une dimension appropriee de la redistribution. Comment peut-on en effet redistribuer directement la sante en tant que telle entre differents groupes de la societe? Culyer (12) suggere ailleurs de choisir comme dimension la consommation de soins de sante. On change ainsi de perspective et les soins de sante deviennent une sorte de bien tutelaire, e'est-a-dire qu'une elite (le gouvernement ou le corps medical) determine le niveau de la consommation car s'ils etaient libres d'agir ä leur guise les individus (ou du moins certains individus), consommeraient moins que ce qui est juge socialement optimal. L'equite serait alors deTinie en ter-mes d'egalite d'utilisation ä besoin egal. Que faut-il alors entendre par equite? Quel est done le sens du mot equite dans le contexte des soins de sante? L'analyse qui precede a degage plusieurs definitions et dimensions possibles. Dire laquelle est correcte est difficile et implique un jugement de valeur. Quoi qu'il en soit, la plupart des theories ont tendance ä definir l'equite en termes d'acces plutöt qu'en termes de sante ou de consommation de soins de sante. Une telle conclusion peut etre importante pour l'elaboration de la politique dans ce domaine. Plus importante encore est la question de savoir quelle definition de l'equite doit ou va etre adoptee comme objectif de la politique sanitaire, meme si l'equite n'est pas definie en termes d'acces. A defaut d'une telle precision, la lutte contre les inegalites sera moins efficace et I'on risque de sombrer dans la confusion. Si les objectifs ne sont pas clairement enonces, le deploiement des ressources se fera mal; differentes politi-ques seront adoptees pour des objectifs differents et le danger d'un conflit entre la recherche de l'efficience et celle de l'equite dans la politique sanitaire variera selon la definition de l'equite. Une definition peu claire de l'equite a conduit ä mesu-rer celle-ci de facon erronee ou inappropriee (par exemple, lorsque I'objectif est I'egalite d'acces, cette dimension ne peut pas etre appliquee directement au contröle de la consommation des soins de sante). flapp. trimest. statist, sanit. mono., 40 (198?) - 303 - Ulic ici «le rtie ice irer ■is-er-älle lue se et ne ;s. .ur ux es 3f- lt can readily be argued that most people, health-care professionals, governments and other agencies associated with the delivery of health and health care would not vote against equity in principle. The extent to which in practice it is achieved while not the subject of this article is more problematic. Part of the reason for this gap between principle and practice is that too little thought has been given to what equity means and/or should mean in health and health care. In this field, ill thought-out objectives only lead to confusion which in turn often leaves the pursuit of equity little further forward. Most people would agree with the promotion of equity by WHO and with the use of a slogan such as health for all to create the climate to allow equity to flourish. Going further involves clarifying what fairness, justice, equity-call it what one will —in health and health care are to mean in practical terms. That requires some hard thinking about equity goals. Perhaps this article is best seen as an attempt to stimulate and encourage such thinking. On objectera que la plupart des gens ainsi que les profes-sionnels de la santé, les pouvoirs publics et les organismes associés á la prestation de soins de santé ne se prononceront pas en principe contre 1'équité. Dans quelle mesure celle-ci sera-t-elle réalisée en pratique est un autre probléme qui sort du cadre du present article. Cet écart entre théorie et pratique résulte en grande partie de ce que Ton n'a pas assez réfléchi au sens que Ton donne ou doit donner á 1'équité dans le domaine de la santé et des soins de santé. Ici en effet, des objectifs mal concus ne peuvent conduire qu'a la confusion, source d'immobilisme dans la procedure de 1'équité. La plupart des gens approuveront I'OMS si elle s'attache á promouvoir 1'équité et adopte un slogan tel que la santé pour tous pour créer un climat propice á I'instauration de 1'équité. Mais avant d'aller plus loin, il importe de définir ce que Ton entend dans la pratique par égalité, justice et équité — quel que soit le terme retenu — en matiěre de santé et de soins de santé. Cela exige une reflexion approfondie sur les objectifs de 1'équité, et, de fait, le present article se veut surtout une incitation á la reflexion. REFERENCES - REFERENCES ar é Je irl la u! St ie in le la i- n e ir s ;t . World Health Organization Targets for health for all: targets in support of the European regional strategy for health for all. Copenhagen, WHO Regional Office for Europe, 1985. Organisation mondiale de la Sante Les buis de la sante pour tous: buts de la Strategie regionale europeenne de la sante pour tous. Copenhague, Bureau regional OMS de I'Europe, 1985. World Health Organization Plan of action implementing the Global Strategy for Health for All. Geneva, WHO, 1982. (Health for All Series No. 7). Organisation mondiale de la Sante. Plan d'action pour la mise en ceuvre de la Strategie mondiale de la sante pour tous. Geneve, OMS, 1 982. (Serie sante pour tous N" 7). Aday. L. A. et al Health care in the US: equitable for whom? Beverly Hills, Sage, 1980. Veatch. R. M. A theory of medical ethics New York, Basic Books, 1981. 5. Rawls, J. A theory of justice. Oxford, Oxford University Press, 1972. 6. Daniels. N. Just health care. Cambridge, Cambridge University Press, 1985. 7. Titmuss. R. M. The gift relationship. London, George Allen & Unwin, 1 970. 8. Margolis. H. Selfishness, altruism and rationality. Cambridge, Cambridge University Press, 1982. 9. Mooney. G. H. Economics, medicine and health care. Brighton, Wheatsheaf, 1986. Sen. A. K. Rational fools; a critique of the behavioural foundations of economic theory. Philosophy and public affairs, 6: 317-344 (1977). Culyer. A.J. Need and the National Health Service. Oxford, Martin Robertson, 1976. 12 Culyer. A. J. The political economy of social policy. Oxford, Martin Robertson, 1980. 10 1 1 hlth statist, quart. 40 11987) Increasing Social Variation in Birth Outcomes in the Czech Republic After 1989 A B S T R ACT Objectives. This study investigated social variation in birth outcome in the Czech Republic after the political change of 1989. Methods. Routinely collected records on singleton live births in 1989, 1990, and 1991 (n = 380 633) and 1994, 1995, and 1996 (n = 286 907) were individually linked to death records. Results. Mean birthvveight fell from 3323 g to 3292 g (P<.001) between 1989 and 1991 and then increased to 3353 g by 1996. The gap in mean birthweight between mothers with a primary education and those with a university education, adjusted for age, parity, and sex of infants, widened from 182 g (95% confidence interval [CIJ = 169, 194) in 1989 to 256 g (95% CI = 240, 272) in 1996. Similar trends were found for preterm births. Postneonatal mortality declined most among the better educated and the married. The odds ratio for postneonatal death for infants of modiers with a primary (vs university) education, adjusted for birthweight, increased ft-om 1.99 (95% CI = 1.52, 2.60) in 1989 through 1991 to 2.39 (95% CI = 1.55, 3.70) in 1994 through 1995. Conclusions. Despite general improvement in the indices of fetal growth and infant survival in the most recent years, social variation in birth outcome in the Czech Republic has increased. (Am J Public Health. I998;R8:I343-1347) Ilona Koupilová, MD, PhD, DrMeJSc, Mariin Bobák, MD, PhD, Jan llolčík, MD, DSc, Hynek Pikhart, MSc, and David A. Leon, PhD Inequity in health within populations has been identified by the World Health Organization as a prime obstacle to its Health for All by the Year 2000 strategy.' The reduction of inequalities in health can be seen as an overall strategy for the improvement of a population's health and as helpful in maintaining and improving the population's human capital.2 Infant mortality is a key indicator of health status and has long been sliown to reflect socioeconomic circumstances. Similarly, birthweight is considered to be an important measure of the health status of a population; birthvveight is a strong predictor of both mortality and morbidity in infancy and reflects nutritional status and growth rates.3 More recently, indices of fetal growth have taken on a new significance in light of evidence suggesting that they may be predictive of chronic disease in adult life.4'5 We previously reported a significantly lower mean birthweight of Czech newborns and greater social variation in size at birth and frequency of preterm birth in the Czech Republic, compared with Sweden6 These findings indicated an unfavorable state of general health of the Czech population in the late 1980s. 'Hie purpose of the present analysis is to assess trends in social variation of several indices of fetal growth and infant mortality in the Czech Republic from 1989 through 1996. The period of study coincides with the political and economic changes that Czech society has undergone since the collapse of communism in November 1989. It is possible that pregnancy outcomes are affected by such profound social changes. The analyses presented here investigated this possibility. Methods The data used for analysis consisted of information on all singleton live births reported to the Czech Statistical Office in 1989 through 1991 and 1994 through 1996; data for 1992 and 1993 were not available. The Czech Republic uses the World Health Organization definition of live birth. All live-bom infants with birthweights of 500 g or more were included in this register until 1994; live-bom infants with birthweights of less than 500 g have been included since 1995 (n = 6 in 1995, n = 5 in 1996). Information on maternal age, birth order, sex of die child, single or multiple birth, birthweight, gestational age (based on date of last menstrual period), and mother's marital status and education is also available from the register. Birthweight is rounded to the nearest 10 g. The data on demographic and social characteristics are collected by the medical staff from medical records or identification cards or are reported by the pregnant women themselves. Maternal education was classified into 4 categories: primary education (up to 10 years of schooling), vocational training (an additional 2 to 3 years of apprenticeship), secondary education (A-lcvel equivalent), and university (at least 4 years of education after secondary school, and a completed degree). Mother's marital status was classified as single, married, divorced, or widowed. Tliroughout llona Koupilova ami David A Leon are with the European Centre on Health of Societies in Transition, London School of Hygiene and Tropical Medicine, London, England, llona koupilova and Jan Holeik are with the Department of Social Medicine and Health Care Administration, faculty of Medicine, Masaryk University, Brno, Czech Republic. Martin Hobak and llynck Pikliait aie with the International Centre for Health and Society. Department of Epidemiology and Public Health, University College London, London, England. Requests for reprints should be sent to llona Koupilova, MD, PhD. DrMedSc, Luropean Centre on Health of Societies in Transition, London School of I lygicne ami Tropical Medicine, Kcppcl Street, Loudon VVCIE 71IT. United Kingdom. This paper was accepted March 25, 1998. September 1948, Vol. 88, No. 9 American Journal of Public Health 1343 Koupilovi et al. TABLE 1—Distribution (%) of Age, Education, and Marital Status Among Mothers of Singleton Live-Born Infants In the Czech Republic, 1989-1996 1989 1990 1991 1994 1995 1996 (n = 125 873) (n= 128 008) (n = 126 752) (n = 104 558) (n = 94 034) (n = 88 315) Maternal age, y <20 13.7 14.2 15.6 13.5 11.1 9.1 20-24 45.6 45.0 44.8 44.5 44.0 43.5 25-29 26.3 26.9 26.4 26.9 28.3 29.7 30-34 10.4 9.9 9.2 10.7 12.1 13.0 35-39 3.5 3.5 3.4 3.6 3.7 4.0 40+ 0.5 0.5 0.6 0.7 0.7 0.8 Mother's education* Primary 14.4 13.7 13.4 13.6 14.0 13.9 Vocational 38.1 38.8 39.8 43.1 42.8 41.9 Secondary 38.4 38.6 38.2 35.1 34.4 35.0 University 9.1 8.9 8.6 8.2 8.8 9.2 Mother's marital status Single 5.5 6.1 7.2 10.7 11.4 12.5 Married 92.1 91.5 90.2 85.4 84.4 83.0 Divorced 2.1 2.2 2.4 3.6 3.8 4.2 Widowed 0.3 0.2 0.3 0.3 0.3 0.3 "Information on maternal education was missing for 2 infants born In 1996. the analyses, we used 5-year age categories (<20, 20-24,... 40+ years) and 6 categories of parity (parity 1,2,... 6+). Preterm birth refers to a birth occurring at a gestational'age of less than 37 weeks.7 '.lthough no formal evaluation of the quality of data from the Czech birth registry is available, the register is virtually complete and it is generally believed that the quality of the information is good. There was no indication that the quality of data in the register changed significantly over the study period. To permit the study of neonatal and post-neonatal mortality, data from the birth registry were linked to the death register for all except the 1996 births by means of unique personal numbers. The linkage was successful for nearly 90% of infant deaths. The infant ~^aths that were not successfully linked to the rth register included a high proportion of infants with extremely low birthweights and early neonatal deaths. Mean birthweight was lower among infant deaths not linked to the birth register (2038 g, SD = 1142 g) than among those successfully linked (2082 g, SD = 1083 g). The proportion of neonatal deaths was higher among those not linked to the birth register (79% vs 62%). Neonatal mortality is probably underestimated by 12% and postneonatal mortality by up to 6% in this study. If the unlinked deaths were more likely to be from multiple births (which is conceivable, given the lower birthweights among the unlinked deaths), the underestimation of mortality rates in our study would be even smaller. The effect of maternal characteristics on infants' size at birth was quantified by linear regression. Logistic regression was used to study the variation in risk of preterm birth and death in infancy (0-365 days), the neonatal period (0-27 days), and the postneonatal period (28-365 days). All analyses were performed with and without adjustments for potential confounders. Analyses were carried out with the Stata statistical package.8 The release of the data was in accordance with statutory obligations to protect confidentiality. Individuals could not be identified from the data provided for analysis. Results Demographic Characteristics Substantial demographic changes occurring in the Czech Republic over the study period are reflected in our data. There were 380 633 singleton live births reported to the Czech Statistical Office from 1989 through 1991, and only 286907 in the 3 years from 1994 through 1996. The mean age of mothers increased slightly, from 24.2 years (SD = 4.7) in 1989 to 24.7 years (SD = 4.9) in 1996 (P < .001). No appreciable changes were seen in parity: there were 47.9%, 37.3%, and 14.8% mothers of parity I, 2, and 3 or more, respectively, in 1989, and 47.1%, 38.4%, and 14.5%, respectively, in 1996. There was an increase in the proportion of mothers with vocational training and a slight decrease in the proportion of mothers with secondary education (Table 1). The most dramatic change concerns the proportion of infants bom outside marriage. In 1989, only 5.5% of live-bom singletons were bom to single mothers and 2.1% were bom to divorced mothers; these proportions rose to 12.5% and 4.2%, respectively, in 1996. The mean age of single mothers increased in the last 3 years of the study. The proportion of teenagers among single mothers was highest in 1991 (43.3%) and lowest in 1996 (30.7%). Birthweight After a slight decrease in overall mean birthweight between 1989 and 1991 (from 3323 g to 3292 g, P<.001), overall mean birthweight increased to 3353 g in 1996. The significant increase in mean birthweight between 1994 and 1996 was seen in all age groups except the oldest (40+ years). The. decrease in mean birthweight from 1989 to 1991 was experienced by all educational categories, the less educated women tending to be more affected. The subsequent improvements in birthweight were seen in all except the primary education category (Figure 1). The widening of the difference in mean birthweight between educational categories persisted after adjustments for maternal age, parity, and sex of the infant (Table 2). The effect of mother's marital status on birthweight was substantial and remained relatively constant over the study period. A mutual adjustment for education and marital status slightly attenuated the strength of the effects but did not change the trends observed. Preterm Births The overall proportion of preterm births increased from 4.3% to 4.8% between 1989 1344 American Journal of Public Health September 1998, Vol. 88, No. 9 Czech Birth Outcomes Birth Weight (g) 3450 n............. 3150 - 3100 Mother's Education: -*- Primary -a- Vocational -^-Secondary -x-University l I I-r—-1-1-1 1989 1990 1991 1992 1993 1994 1995 1996 Year FIGURE 1—Mean blrthwelght of singleton live births by maternal education: Czech Republic, 1989-1991 and 1994-1996. and 1991 but was 4.5% in 1994 through 1996. There was a tendency toward increasing variation in frequency of preterm births by maternal education. The odds ratio for preterm birth in mothers with a primary (vs university) education, adjusted for maternal age, parity, and sex of the infant, increased from 2.05 (95% confidence interval [CI] = 1.81,2.32) in 1989 to 2.53 (95% CI = 2.18, 2.94) in 1996. On the other hand, the age-, parity-, and sex-adjusted odds ratio for preterm birth in single, vs married, mothers was lowest in 1996 (1.78; 95% CI = 1.63,1.94). ,-Jnfant Mortality Both neonatal and postneonatal mortality decreased between the 2 time periods (1989-1991 and 1994-1995). The decline in neonatal mortality was greatest (from 5.6 to 3.8 deaths per 1000 live births) and affected all educational and marital status categories to a similar degree. The social variation in neonatal mortality was largely eliminated by adjustment for maternal age, parity, and sex and birthweight of the infant. In die population as a whole, postneonatal mortality decreased slighdy ova the study period. Among single mothers, postneonatal mortality increased between the 2 periods (1989-1991 and 1994-1995). There were marked and increasing differences in postneonatal mortality by maternal education and marital status (Table 3), which persisted after mutual adjustment for education and marital status. Discussion Our analyses of Czech national data for 1989 through 1996 show that despite overall improvements in indices of size at birth and infant survival, socioeconomic differences in mean birthweight and postneonatal mortality between infants bom to mothers with a primary education and those bom to mothers with a university education increased. Validity The validity of the time trend analysis clearly depends on the completeness and comparability of the data. The data were collected by a routine registration system that had been in operation since the mid-1980s. We are not aware of any administrative or other changes that would compromise the quality or completeness of the data in recent years. The inclusion of live births of 500 g or less in the register from 1995 did not appreciably affect the time trend. We have addressed the potential bias of mortality analyses in the Czech data due to the linkage failure. Analysis of the infant deaths that were not successfully linked indicated that the unlinked deaths were more likely to be from multiple births and were more likely to occur in the early neonatal period. In singletons, the likely underestimation of the risk of death was about 10% in the neonatal period and was considerably smaller in the postneonatal period. We conclude that link- age failure could not explain the strong social trends observed in our data. Decline in Fertility The substantial recent decline in fertility rates9-10 is reflected in the numbers of births over the period of our study. It is not known whether decreasing fertility affected different social groups to the same extent. Although the potential confounding effects of age and parity were taken into account in our analysis, it is conceivable that within the educational categories defined in our analyses, women with different levels of social resources or social support differed in their realized fertility. For example, it is possible that better educated women, who could foresee potential material or other difficulties related to child-bearing, were more likely to avoid or postpone pregnancy. Such hidden effects of the sociodemographic processes cannot be excluded and require closer attention in future research. The difference in mean birthweight between infants of single and married mothers did not seem to change appreciably over time, but the effect of mother's marital status on the risk of postneonatal death became stronger. The latter finding is surprising, as single mothers appear to have become a less marginal group: the proportion of single mothers in the population has increased, and the proportion of teenaged pregnancies among single mothers has declined. September 1998, Vol. 88, No. 9 American Journal of Public Health 1345 Koupilovä et al. TABLE 2- -The Effect of Maternal Education and Marital Status on Birthweight (In grams) of Offspring: Czech Republic, 1989-1991 and 1994-1996 1989 P(SE) 1990 ß(SE) 1991 ß(SE) 1994 ß(SE) 1995 ß(SE) 1996 ß(SE) Mother's education Primary* Vocational 143 (4) Secondary 178 (5) University 182(6) P for trend (1 df) <.001 Mother's marital status Single* Married 169(6) Divorced 28(12) Widowed 61 (28) P for heterogeneity (3 df) <.001 153(4) 197 (5) 203 (6) <.O01 191 (6) 34(11) 138 (29) <.001 159 (5) 199 (5) 209 (7) <.001 180(6) 59(11) 127 (28) <.001 172 (5) 223 (5) 236 (8) <.001 163(5) 51 (10) 140 (30) <.001 183(5) 228 (6) 237 (8) <.001 166 (5) 67(10) 92 (29) <.001 192 (5) 238 (6) 256 (8) <.001 165 (5) 47 (10) 92 (32) <.001 Note. This analysis was restricted to singleton live births. The regression coefficients were adjusted for maternal age, parity, and sex of the infant. 'Reference category TABLE 3—Mortality in the Postneonatal Period (28-365 days), by Maternal Education and Marital Status: Czech Republic, 1989-1991 and 1994-1995 1989-1991 1994-1995 No. of No. of Deaths . Deaths per 1000 OR (95% CI) Crude Adjusted* No. of Deaths No. of Deaths. per 1000 OR (95% CI) Crude Adjusted* Mother's education Primary 280 5.3 Vocational 392 2.6 Secondary 266 1.8 University1, 67 2.0 Pfor trend (1 df) Mother's marital status Single 100 4.2 Marriedb 854 2.5 Divorced 42 4.9 Widowed 9 9.1 P for heterogeneity. (3 dl) Total 1005 2.6 2.69 (2.06, 3.51) 1.33(1.03, 1.73) 0.92 (0.70, 1.20) 1.0 <.001 1.71 (1.39, 2.11) 1.0 2.00(1.47, 2.74) 3.74(1.93, 7.23) <.001 1.47(1.09. 1.96) 1.00 (0.76, 1.32) 0.79(0.60, 1.04) 1.0 <.001 1.25(1.01. 1.56) 1.0 1.34 (0.97, 1.86) 2.61 (1.33. 5.15) .007 143 226 96 24 101 353 34 1 489 5.2 2.6 t.4 1.4 4.6 2.1 4.6 1.7 2.5 No'e. OR = odds ratio; CI = confidence interval. This analysis was restricted to singleton live births. "Adjusted for birthweight, maternal age, parity, and sex of the Infant. bReference category. 3.68 (2.39, 5.67) 1.86(1.22, 2.83) 0.97 (0.62. 1.52) 1.0 <.001 2.21 (1.77, 2.75) 1.0 2.21 (1.56, 3.15) 0.79 (0.11,5.62) <.001 1.91 (1.19, 3.05) 1.47 (0.95, 2.30) 0.89 (0.56. 1.41) 1.0 <.001 1.60(1.26, 2.04) 1.0 1.43 (0.98, 2.07) 0.47 (0.06. 3.43) <.001 Increasing Inequity In light of the previous efforts to achieve equity in Eastern Europe, it is surprising to find such substantial differences in fetal growth indices between population subgroups in the Czech Republic at the beginning of the study period.6 It is plausible that the further divergence in birthweight and infant survival between socioeconomic groups in the Czech Republic is related to the divergence in living standards. This possibility is consistent with the literature, which has shown that both birthweight"'12 and infant mortality, particularly in the postneonatal period,13 are sensitive to socioeconomic factors. The changes in pregnancy outcomes coincided with socioeconomic changes. The average real income in the Czech Republic decreased by almost 20% between 1989 and 1993 and was still 10% lower in 1995 than in 1989; real wages followed a similar trend.' Although unemployment remained relatively low (around 3% in I995),M the socioeconomic differentials in the society clearly increased, as documented by an increase in the Gini coefficient (a measure of the degree of inequality of the distribution of earnings; 0 if total equality, 100 if total inequality) from 18.5 in 1989 to 23.4 in 1994.9 The economic benefits of education have clearly become increasingly important in the Czech Republic in recent years: fewer than 5% of university-educated persons, vs as many as 35% to 40% of those with a primary education, declare subjective poverty.15 Although the current income differences in the Czech Republic are still smaller than those in the West,16 their appearance at a time of declining average real income almost certainly increased the vulnerability of some in the society, including single mothers and the less educated. This situation, together with the decline in social benefits, may have produced substantial hardship with the potential to affect health. Our data provide some indication of the magnitude of the health impacts of social and economic reforms in the Czech Republic. i j46 American Journal of Public Health September 1998, Vol. 88, No. 9 Czech Birth Outcomes Infant mortality has not increased, even among the most disadvantaged, and the fall in birth-weight was about 60 g. However, the social shock related to the reforms in the Czech Republic was relatively low; most Central and Eastern European countries experienced substantially larger declines in living standards.9 It can be expected that in these countries the impact of the reforms on pregnancy outcome and other health indicators will be larger. There is evidence of increased social variation in the prevalence of smoking among Czech women from 1985 through 1992.17 While the overall prevalence of smoking remained unchanged Ihere was a marked drop in the proportion of university-educated women who smoked (from 20% to 11%) and an increase in the number of women with a primary education who smoked (from 24% to 30%). Thus maternal smoking, a powerful determinant of birthweight, may underlie some of the increase in social variation in birth outcome. Health Care The study period covered a transition toward a market economy, accompanied by a series of fundamental changes in the health care system. The main changes were the introduction of free choice of a general practitioner; direct access to specialists and specialist departments; a fee-for-service reimbursement system, which encouraged health care providers to increase productivity; and emergence of a private health care sector. Recent improvements in neonatology services have been associated with the observed decrease in perinatal mortality in the Czech Republic." Whether and how the recent organizational changes in health care translate into social variation in birth outcome is less obvious. It is conceivable, however, that in (lie new system, which assumes a much more active role for patients and introduces direct payments for services, those with higher education or better social positions will bene- fit most. Changes in health care may thus contribute to the widening social gradient in pregnancy outcomes. Conclusion We conclude that despite general improvements in the indices of size at birth and infant survival in recent years, there is a trend toward increasing social variation in birth outcomes in the Czech Republic. We suggest that the increase in social variation in birthweight and postneonatal mortality is related to the changing social circumstances of the families and mothers. Given the considerable extent of social variation in birth outcomes in the Czech Republic at the beginning of the study period, further widening of the social differences in recent years is a cause for concern. Trends in social inequalities should be further monitored and their underlying causes should be sought and addressed by policymakers. □ Acknowledgments This study was supported by a grant from the Internal Grant Agency of the Czech Ministry of Health (grant 4318-3). We are indebted to Mr Snick of the Czech Statistical Office and Mr Holub and Mr Kjopik of the Czech Institute for Health Information and Statistics for their help with preparation of Ihe data sets. We also wish to thank Laurent Chenet for comments on an early draft. References 1. World Health Organization Regional Office for Europe. Targets for Health for All. Targets in Support of Ihe European Regional Strategy for Health for All. Copenhagen, Denmark: World Health Organization; 1985. 2. Vagcrö D. 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