Introduction to “Health Disparities and Health Equity: Concepts and Measurement”
This influential paper by Paula Braveman, published in the Annual Review of Public Health, addresses the significant lack of consensus surrounding the meanings of “health disparities,” “health inequalities,” and “health equity”. The author emphasizes that the definitions used for these terms are not merely academic concerns; they carry important practical consequences. These definitions dictate which health measurements are monitored by governments and international agencies, and subsequently, which activities receive funding to address these issues.
The core purpose of the paper is to clarify these concepts, focusing on how different definitions impact measurement and, therefore, accountability in public health initiatives.
Key concepts clarified in the paper include:
- Health Disparity/Inequality: Braveman specifies that not all differences in health constitute a health disparity. A health disparity or inequality is a particular type of difference in health—or in the most important influences on health that could be shaped by policies—where disadvantaged social groups systematically experience worse health or greater health risks than more advantaged social groups. Examples of such disadvantaged groups include the poor, racial/ethnic minorities, and women. “Social advantage” refers to one’s relative position in a social hierarchy determined by wealth, power, and/or prestige. These differences include comparisons between the most advantaged group and all other groups, not just the best- and worst-off.
- Health Equity: The paper defines pursuing health equity as actively striving for the elimination of these specific health disparities/inequalities. It implies that everyone should ideally have a fair opportunity to achieve their full health potential, and that no one should be disadvantaged from reaching this potential if it can be avoided.
- Conceptual Foundations: The paper draws upon Margaret Whitehead’s widely useful definition from the early 1990s, which describes health inequalities as differences that are “unnecessary and avoidable but, in addition, are considered unfair and unjust”. Braveman expands on this, proposing a more explicit definition that incorporates the relevance of social position and specifies the particular comparisons that should be made. This proposed definition highlights that the relevant differences are those that adversely affect a priori disadvantaged social groups, compounding their disadvantage.
- Measurement Implications: The author stresses that measuring health disparities typically involves comparing health indicators between disadvantaged and more advantaged social groups, often using the most advantaged group (e.g., the wealthiest or dominant racial/ethnic group) as the reference point. This approach is rooted in ethical concepts of distributive justice (prioritizing the improvement of the most disadvantaged) and human rights principles, particularly the right to health and nondiscrimination.
The paper critiques alternative measurement approaches, such as the one proposed in the World Health Report 2000, which suggested measuring health inequalities across ungrouped individuals without comparing predetermined social groups. Braveman argues this removes ethical and human rights considerations and could lead to misdirection of resources away from social justice concerns. Ultimately, the paper provides a robust framework for defining and measuring health disparities to enhance accountability and guide effective policy and action.
Reference for the article:
Braveman, P. (2006). Health disparities and health equity: Concepts and measurement. Annual Review of Public Health, 27, 167–194. https://doi.org/10.1146/annurev.publhealth.27.021405.102103
