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Equity vs. Equality:

A Public Health Perspective

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Equity vs. Equality

The majority of all public health stakeholders have been faced with a type of confusion arising from the concepts of equity and equality. In such an ecosystem, these concepts are necessary to build the framework of public health amidst their distinct features.

For instance, during the class session, we went through an illustrative example that captured the differentiation effectively: a white bald-headed man conducts a meeting under a tree with various animals—each from distinct habitats and capabilities—including a monkey, a pigeon, an elephant, a fish, a seal, and a dog. The chairman announces, "For a fair selection, everybody has to take the same exam: Please climb that tree." This scenario provides deeper explanations about equality, where each participant is accorded the same task regardless of their inherent differences and unique needs. Through this scenario, a contrasting difference on equity would definitely involve tailoring a task to accommodate the unique abilities and circumstances of each participant, ensuring all have a fair chance to succeed.

Therefore, equality is a concept that aims for uniformity and often simplifies realities into one-size-fits-all solutions. Without considering underlying disparities and differences among individuals or groups, equality provides the same opportunities and resources across the playground, or for our scenario, under the tree. On the other hand, equity aims for fairness and justice by recognizing that differences exist but also adjusting supports to level the playing field (Ryder et al., 2020).

In health, understanding and distinguishing between structural and intermediary determinants is important so that an application of the concepts is forwarded to public health actions with goals to reduce health inequities. According to the WHO 2010 Framework, structural determinants include wider socio-economic, cultural, and environmental conditions that affect each and every individual's health outcomes. The framework includes the

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distribution of wealth, education, employment, social class, gender, and ethnicity as factors

that shape an individual's social position and consequently their health (Braveman et al., 2011).

In contrast, intermediary determinants directly affect an individual's health status.

These factors include material circumstances—such as the quality of housing and the work

environment—behavioral and biological factors—like nutrition and genetic predisposition—

and the health system itself, including access to quality health care. These are a few examples

that show how intermediary determinants are influenced by structural determinants even

though they are proximate to individual health outcomes.

Therefore, differentiating between the determinants mentioned above is necessary for

public health. The root causes of health disparities are often found in structural determinants,

while the mechanisms through which they affect health outcomes are captured in

intermediary determinants. For example, policies targeting intermediary determinants, like

improving access to healthcare, are important but not enough if structural inequities remain

untouched, as explained by Marmot et al. (2010). Clearly, actions must also confront

structural determinants, especially by improving education and economic opportunities, to

achieve sustainable health equity.

Going back to the example of the diverse animals facing an identical task shows how

necessary it is for such an approach to be applied in public health. Assuming all individuals

or communities start from the same position and face the same barriers, designing such health

interventions—as the task to climb a tree—will inevitably favor some while disadvantaging

others. Therefore, effective public health strategies must include both universal and targeted

approaches, as discussed in Fisher et al. (2022). These approaches will ensure that specific

needs and circumstances of different groups have been recognized and adapted to the

particular needs to reduce health disparities. Eventually, all individuals, regardless of their

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starting point, can achieve a similar level of health and well-being, adhering to principles of justice and fairness (Braveman et al., 2011; Marmot et al., 2010) that are central to public health ethics.

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References

Braveman PA, Kumanyika S, Fielding J, LaVeist T, Borrell LN, Manderscheid R, Troutman A. Health disparities and health equity: the issue is justice. American journal of public health. 2011 Dec;101(S1):S149-55.

Fisher M, Harris P, Freeman T, Mackean T, George E, Friel S, Baum F. Implementing universal and targeted policies for health equity: lessons from Australia. International journal of health policy and management. 2022 Oct 1;11(10):2308-18.

M. Marmot, J. Allen, P. Goldblatt, T. Boyce, D. McNeish, M. Grady, et al. Fair Society, Healthy Lives: Strategic Review of Health Inequalities in England Post2010 – the Marmot Review (2010) London, UK.

Ryder C, Mackean T, Hunter K, Williams H, Clapham K, Holland AJ, Ivers R. Equity in functional and health related quality of life outcomes following injury in children—a systematic review. Critical Public Health. 2020 May 26;30(3):352-66.