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Health inequality cannot be fully comprehended until the understanding of the concept of health inequity. The former is an unfair allocation of healthcare resources, and the latter is moral in nature. The marginalized individuals, groups and populations in developed and underdeveloped nations remain devoid of equal access to vital healthcare services based on their economic status, gender, age, ethnicity, and class, which determine how an individual would receive health equality. These disparities have the power to wield impact across generations, exert rippling effects on the entire nation, and, remarkably, affect minorities, specific gender, race, ethnicity, class, and individuals with disabilities. Particularly when the world has faced the changes during COVID-19, the governments implementing identifiable strategies to exercise nationwide interventions are somehow successful in decreasing these health disparities, even though still a systematic and structural action plan is to be mandated to achieve long-lasting change by addressing the health determinants of inequality. In the modern era of artificial intelligence, there is a dire need for healthcare organizations to advance and appraise their digital policies and accessible connectivity modes through a wide variety of determinants associated with the digital gap, financial and remote accessibility, and device preferences to the disadvantaged people, especially in rural areas.
Applied Psychology Department, National University of Modern Languages, Rawalpindi, Pakistan
Anila Mubashir
Applied Psychology Department, National University of Modern Languages, Rawalpindi, Pakistan
Aleena Khalid Ghori
Applied Psychology Department, National University of Modern Languages, Rawalpindi, Pakistan
Anam Bibi
Applied Psychology Department, National University of Modern Languages, Rawalpindi, Pakistan
*Address all correspondence to: erum.bibi@numl.edu.pk
1. Introduction
Health inequality is a prevailing global concern that pertains to the unequal distribution of health resources, but it cannot be better understood until we comprehend the foundational concept of health inequity for the terms “health inequalities” and “health inequities” are used precisely in Literature. According to WHO (2000), health inequality can be understood as “systematic differences in the health status of different population groups” [1]. Health inequity/injustice refers to biased, unfair, and unnecessary health inequalities that are not unavoidable or natural but are the ultimate outcome of human behaviour; however, inequality generically depicts the uneven dissemination of resources [2]. Health inequity can also be deduced as a specific subset of health inequality which passes a moral judgement that the health inequality is ethically objectionable [3]. These inequities and inequalities wield substantial social and economic impact on marginalized and disadvantaged individuals, demographic groups, and nations. Health inequality denotes that certain groups of individuals may experience more excellent rates of diseases, reduced access to quality healthcare, and poorer health outcomes compared to other more advantaged and privileged groups. This can pave the way for unfair dissemination of health resources among individuals, eventually continuing a cycle of disadvantage, partial prospects for prevention and treatment and barriers to well-being for those who are facing systemic impediments [4].
Understanding inequality is imperative as it encapsulates the nature of the disparities manifest in intersectional, intergenerational, and interterritorial phenomena. Health inequality is intersectional because inequalities have the power to interact. It is intergenerational for passing over time from one generation to another. Lastly, it is considered to be as interterritorial as holds geopolitical and spatial implications [5].
The two prospective modules of health inequalities are emphasized across the world: inequalities that occur among groups of the same society, and inequalities between nations. The higher the level of health inequality, the poor life expectancy, low productivity, poor education and what is not expected from a geopolitical nation [4]. This inequality poses a threat not only to the developing country individuals with lower socioeconomic status but also to the policymakers matters that even the developed countries have not come out of the race of intersectional, intergenerational, and interterritorial inequality [6].
2. Historical perspective and contemporary perceptions
Health equity and equality were a keystone of the Sustainable Development Goals (SDGs) and a cornerstone of the Millennium Development Goals (MDGs) [6]. In 1948, for the first time, the notion of health as an individual’s right was highlighted in the United Nations General Assembly’s Universal Declaration of Human Rights and since then, has been echoed in laws, treaties, policies, national constitutions, domestic/internal laws, and agendas in countries across the globe [7]. This concept further laid the foundations for equality in health. Meltsner’s article, “Equality and Health,” first coined the term “health equality” in 1966 [8]. Further, the matter of health inequalities got attention for the first time with the publication of the Black Report in the United Kingdom [9]. Black subsequently developed, elaborated, and refined these primary philosophies about artefact, structural, behavioural, and cultural inequalities [6]. Further, the WHO distinguished health equality as precedence in the formation of the Commission on Social Determinants of Health in 2005, which gathers and integrates international data on the social dynamics of health/well-being and endorses arrangements that report health disparities [10].
The United Nations (UN) has endorsed the explicit significance of health inequality by propagating the agenda of the United States to address inequality in gender-related health disparities and healthcare since 2015 [7]. Social Class theorists proposed a series of studies in the United States to explore how an individual or community structure can be better pronounced in terms of collaborations between different individuals and how they create biases against each other [11], resulting in the classification of social groups which helped in explaining the core indicators for health inequality between socially advantaged and marginalized groups [12]. Moreover, this series of scientific exploration led theorists to inquire about the influence of social class on the ecological mapping of schizophrenia [13] and variances in the management of mental illness [14].
Two epidemiological theories by Antonovsky (1967) [15] and Kitagawa & Hauser (1973) [16], respectively, from 1966 to 1990, identified societal class disparities in mortality as pivotal works. The era between 1991 and 2018 can be marked as a period of development and expansion in “social epidemiology” as a new perspective to tackle health inequalities. Diverse theorists from across the world played a leading role: 30 percent of researchers were from the Netherlands, many theorists (50.0%) were from the United Kingdom, and 40.0% were from the United States. However, this period gave rise to the prevailing social factors of healthcare structure and the health services deployment framework and triggered legislative and scientific interventions through public health law-enforced actions [6, 12].
3. Theoretical framework for understanding health inequalities
Health inequalities tend to travel from one generation to another, and from one country to another, yet they characterize the completest and most profound discriminations. For instance, in the United Kingdom, variations in the healthcare sector and its grounds were intensely inspected in detail in the late 1980s and have been the categorical motivation of policymaking till 1997 [17]. The Black Report [9] identifies four fundamental theories highlighting how the discrimination started. These were artefact, selection, structural, and behavioural [9]. The ideology of health inequality cannot be grasped deeply until we attempt to evaluate the existing theories and models that evolved historically, comprising the most current explorations, using rudimentary epidemiological reasoning concerning relationship, causation, and confounding. The detailed discussion of these theories is as follows:
3.1 The artefact theory
This theory tends as a statistical artefact to assess the connection between indicators of social position and health consequences emphasizing the social status which has been classified over time. Though this model has been critically challenged by the Black Report [9] for the pervasive evidence of inequalities in health outcomes, it has added more adequate information regarding diverse statistical trials of social standing such as social class, annual income, area scarcity, qualification, and occupational group [6]. Modern research demonstrates that as compared to the notion of the Black Report, the significance of artefact theory in assessing mortality differentials is greater, impactful, and principally complex [6, 18]. This theory believed that within different social groups, any divergence in healthcare would depend on the method of measurement of both social class and health [19, 20]. However, these health inequalities are frequently contemporary even when diverse practices are engaged when determining an individual’s social class [21, 22].
3.2 Selection theory
Selection theory proposes a reverse causation that there is an observed linkage between social selection/status and poor health [23, 24]. This theory paves the theoretical framework for longitudinal theories, which attempt to assess pre-morbid social prominence through a connection [25] with consequent rates of illness (morbidity) and death (mortality) and is also a major proponent of intelligence by presenting the hypothesis that intelligence and health are closely correlated with each other based on chance reverse causation, genetic endowment, and early life experiences [26, 27]. The chance can be reduced because of the accumulative and statistically significant indication of a relationship [28, 29] whereas reverse causation indicates dissimilarities in pre-morbid intelligence caused by differences in health outcomes. Intelligence due to genetic makeup determines health along with other variables like education, social status, and income. Early life experiences or stressors have the tendency to affect the relationship between health and intelligence [30, 31]. Once the association between health and intelligence is significantly accounted for predictors of socioeconomic status, consequently, in some cohort studies this connection with mortality declines and vanishes entirely in others [32].
Although the Black Report rejects this theory, it continues to impact the latest research in this domain. The two supplementary concerns confront the position of human intellect as the primary source of health inequalities. The former is the “Flynn Effect” [33, 34], which is an increase in the levels of intelligence observed in several people, while the latter is variances in the levels of intelligence between populations over time. Hence, socioeconomic, and circumstantial descriptions are more expected to explain the altering population distinction in the trials of intelligence [35].
3.3 Cultural and behavioural theory
Cultural theories propose that culture shapes behavioural patterns, which further tend to become intergenerational, fixed patterns, and rather defiant to remediation. If we look at Durkheim’s theory of “anomie” [36, 37], Oscar Lewis’s “culture of poverty” [38], and more prominently, the “dependency culture” [39], theory of Charles Murray [40], which denote that culture shapes the behaviour and its choices. Each philosophical paradigm debates that few underprivileged populations are inclined to cultivate abnormal cultural patterns that have damaging and harmful inferences for societal and ultimate health outcomes [41]. For instance, Lewis’ concept of a “culture of poverty” is self-perpetuating, which allows for better health-related equalities if the stronger structural environment is changed. While Murray’s, notion of a “culture of dependency” suggests new responsibilities for the poor on the part of a government. The new reforms in the United Kingdom are already implementing those laws for the equality of underprivileged people [6].
Cultural-behavioural features are frequently interrelated, as proposed by Bourdieu (1983) in his conception of habitus [42]. “Habitus” is conveyed and expressed in everyday existence choices, preferences, mindfulness, and consumption patterns. Discrepancies in approaching social capital, cultural, and economic are fundamental to the improvement of habitus patterns according to social class. According to Bourdieu, there exists a significant relationship between higher levels of educational execution and health-encouraging behaviours.
Health equalities are primarily suffered by differentiations in the occurrence of specific health-related behaviours such as diet, physical activity, smoking, and unlawful drug and alcohol consumption between groups of the dominant cultures. Many analysts advocate that risk factors like smoking elucidate a large amount of the inequality in health consequences; surprisingly, the most disadvantaged countries have the most frequent smokers [41, 42]. Unhealthy and risky behaviours such as smoking/tobacco consumption, having five times higher prevalence in lower socioeconomic status groups, lead to behavioural risks and increasing mortality rates [43]. Similarly, the damage produced by tobacco is a key factor in the life expectancy gap between advantaged and disadvantaged countries. Additionally, the bond between adverse behaviours and poorer socioeconomic status has nearly faded over the passage of time in some of the populations without diminishing the association between mortality and lower social status [44].
3.4 Structural theory
The structural theory provided a dominant paradigm in the United Kingdom in the 1970s [6, 18, 45]. The theory proposes that if an individual meets uncertainty in socioeconomic circumstances such as power, income, class, wealth, and environmental access throughout his life, he/she faces huge disparities in health outcomes [46, 47]. The structural theorists working on health inequalities do not see much relevance in culture and intelligence; however, they do appraise a correlation between structural elements and health predictors, but they are not successful in identifying the contributory roots of health inequalities [48]. This hypnotizes that the profound levels of structural equality led to fewer health inequalities, so the secret is to give more resources to the communities to reduce structural inequalities as those with more capital and resources enjoy life expectancy and access to good healthcare [49, 50].
The power imbalances lead to health inequalities, which raises further questions about the systems and how they perform well in tackling those health disparities [51, 52, 53]. Some theorists have urged that for the last 30 years, the propagation of health discrimination is directly concomitant to the shrinking of wider self-governing controls over the desired primacies of the rich and dominant [6, 54].
The determinants that form the core cause of health inequality are global, interdependent, multifaceted, and diverse, with the tendency to evolve. Health inequalities or inequities can be catalogued in two main clusters (Figure 1) [55].
Figure 1.
Two categories of health inequality.
The influence of structural inequalities tends to make a person or population either resource-rich or resource-poor. Good education is a crucial factor of health that generally affects race and socioeconomic status and significantly shapes the life trajectory and the health of children and adults; similarly, race and class-differentiated access to clean, safe, resource-rich neighbourhoods, and schools is an essential ingredient in producing health inequality. These structural inequalities boost the large and avoidable differentiations in health metrics like life expectancy and follow everyone “from womb to tomb” [56].
It is common for African American females to give birth to malnourished and low-weight infants who experience higher child death rates, which do not align with any genetic or biologic differences, even after considering socioeconomic factors [57]. One of the leading factors is “stress,” which is dealt with differently by societies, leading to these persistent differential birth outcomes [58]. One of the leading indicators of life expectancy is graduation after attending high school, which differs hugely in the divisions of class, race, and ethnicity, as do the rates of academic institution and occupational school participation. This shapes future income, employment, and individual and intergenerational wealth [59].
In elementary school, there are consistent differences across racial and ethnic divisions, especially in adverse childhood experiences like chronic stress and trauma. These early-age traumas affect a child’s school performance and learning ability through environmental exposures, which ultimately bring differences in the intelligence quotient of an individual (IQ) [60]. Structural inequities also influence hiring policies based on colour, gender, racial, and physical ability divisions. Not only this, but these inequalities also impose explicit and implicit bias in lending policies, which lead to differences in asset development, home possession, and small corporate growth. Moreover, these systematic and structural inequalities tend to influence national strategy and governmental decision-making, and the most vital characteristic of our democracy and polling selection. Consequently, these prejudices create discrepancies in healthcare service delivery and affect the efficiency of care provided, including a dearth of social competency. It is evident that the better health of populations is widely contingent on the elements of health. Health inequities exist. In short, these structural and systematic disparities incorporate culture, governance, policy, and law and signify race, gender, or gender character, class, ethnicity, sexual orientation, and other domains [61].
Drawing a line between the predictors of inequalities in developing and non-developing countries is essential, as they both experience inequalities at different levels. The Organization for Economic Cooperation for Development (OECD) [62] highlights that inequalities in health status have been reported because of low-income and other major socioeconomic factors. Developed countries took themselves out of this muddle through education, healthcare knowledge, and skill training. On the contrary, in the Middle East, Sub-Saharan Africa, and South Asia, the epidemiological transition is still in its early stages to shift the burden of disease from communicable to non-communicable conditions [63]. With very limited resources and evidence-based healthcare interventions, they are aiming at reducing the socioeconomic causes of the inequalities in chronic diseases. On the other hand, in Asian countries especially Pakistan, inequality in health is inescapable. Pakistan is ranked the lowest, i.e., 5%, representing that Pakistan spends less capital than sub-Saharan countries on healthcare, living necessities, life expectancy, education, and child health equality [64]. The WHO’s eye-opening analytics reveal that all the destitute countries classified as the lowest in child health equality are present in sub-Saharan Africa. However, unfortunately, Afghanistan and Pakistan are territories with higher child mortality rates, considering the reasons as difficult and accessible rural and urban locations, low literacy, poor education, gender disparity, and poverty [1, 64].
In the 1980s, the governments of different countries commenced considerable attention to the disparities in the health sector; however, still marked differences in the provision of health facilities can be witnessed in the modern era [65], especially addressing different social identities such as gender, race, class, disability. This idea of “intersectionality” was originally proposed by Kimberlé Crenshaw to emphasize how fundamental legal and policy concepts of discernment disregarded the legal laws of Black American women [66]. According to him, it refers to the crucial perception that class, race, gender, ethnicity, sexuality, nation, skill, aptitude, ability, and age function not as solitary, conjointly distinguishing entities but rather as mutually building facts [67]. Not only disparities in health are higher in gender, but longstanding structural and systemic inequalities and inequities entrenched in ethnicity and racism have been documented for decades.
In United States [68, 69], the data show that AIAN, Hispanic, and Black people were subject to worse health as compared to White people. Similarly, White people accounted for 7 percent of non-insurance for health services as compared to non-elderly Hispanic (19%) and AIAN (21%) as of 2021. Again, in the same year, White adults 52% were privileged to avail of mental health services, whereas Black received 39%, Hispanic only 36%, and Asians with 25%, respectively, showing great inequality in the provision of this facility. Approximately, very less individuals among Hispanic (62%), AIAN (59%), and Black (58%) received flu vaccine during 2021–2022 in contrast to 46% White adults.
In 2010, Japanese men expected 70.6 years of full health life expectancy, twice as long as Haitian men, with a 27.8 average life expectancy [69]. On the other hand, statistics of India again depict such health disparities among upper- and lower-income classes after statistically accounting for the contributing variables: gender, age, and other social factors, where 86% of poor Indian families are more likely early than the wealthiest fifth of Indian families [68, 69].
Over the years, global health advocators have inclined the whole world to create equality for gender, especially during the COVID-19 pandemic which posited challenges that are unparalleled to the cultures at large in terms of morbidity and mortality [70]. Gender inequalities are significantly associated with lifestyle choices, gender biases in health systems, healthcare access, health-risk behaviour patterns and inequities in clinical data collection resource distribution, and health research. Different international organizations have strived to create a balance to diminish this disparity, and the United Nations Development Program (UNDP) is one of those which has approved “Gender Equality” as its 5th Goal in the Sustainable Development Goals (SDGs) 2015–2030 [71].
Women face poorer health than men as they face a greater risk of major depression and anxiety-related disorders, while the risk of cardiovascular diseases is higher in men. Age-standardized mortality rates are more likely to be higher in the male gender than in females, excluding diabetes. Similarly, the risk factors for smoking prevalence and high blood pressure are higher in men than in women suggesting these disparities may be linked to gender stereotypes. The world is striving towards decreasing gender inequalities; however, the disparity in the health sector is notably greater and vast in Eastern Mediterranean and African regions than in the United Kingdom, United States, and Europe [72].
The world’s 1.3 billion (16%) population experiences disability in any form today. Persons with special needs deserve health’s highest attainable standards. The socio-ecological model of disability theorizes that an individual’s environmental, social, and physical predictors and the interplay of these factors influence one’s outreach to health facilities. Though the new world is realizing and progressing in providing them with modern health standards, these individuals have challenging life patterns with poorer health facilities, higher early death ratios, and mobility issues in day-to-day life [73, 74]. Approximately 80% of individuals with disabilities are nationals of low- and middle-income countries where the provision of health services is inadequate; thus, prospering health inequities in those disadvantaged geopolitical countries is challenging. In most of such destitute countries, women with disabilities suffer more than disabled men, while children with disabilities reported adequate levels of mortality rate (80%) [75]. The 2018 Learning Disabilities Mortality Review [76] found that the average mortality age for men is 60, whereas 59 for women respectively between 2017 and 2018. People with disabilities are in dire need of proper rehabilitating programmes which give them equal rights in laws and policies in healthcare.
Research [59, 70, 75] highlights that health inequalities have significant economic implications:
These disparities have the tendency to lead to high healthcare costs and marked losses to productivity, advancement, welfare, growth, and development, no matter what the current economic conditions of a country could be.
It is imperative that specific investments in such programmes to reduce health disparities would have significant economic benefits.
The patent revolutions and progression can be viewed in globalization, financial markets, trade agreements, and commercialization of health services due to these costs and benefits [61, 75].
An individual’s health, healthcare system providers, and positive health outcomes are not spared from the complicated effects of globalization. These positive and negative effects must be scrutinized when plummeting the disparities in health between rich and poor people [77, 78]. There are also threats to global health as the transmission of infectious diseases brought on by people’s increased morbidity can now be accounted for as the greatest danger to everyone. Other global and natural systems such as animal and/or ecosystem health and their effects on human health should not be overlooked when discussing globalization and its effects [78]. At all imaginable spatiotemporal scales, it is the interactive co-evolution of numerous technological, cultural, economic, institutional, social, and environmental trends. As we are neglecting and underestimating the global system, which may be out of date, the identification of all potential health effects of globalization development goes far beyond the existing aptitude of our mental capability to apprehend the dynamics of our global system [79].
The wide globalization framework includes global markets, global communication and information dissemination, global mobility, cross-cultural interaction, and global environmental changes, which affects the healthcare systems [79, 80]. The provision of quality healthcare may be significantly impacted by the growing trade in health services. Although some developments are thought to increase consumer choice, others are thought to pose long-term risks, including the creation of a two-tiered health system, the transfer of medical professionals from the public to the private sector, unequal access to healthcare, and the undermining of national health systems. Potential health risks include the sale of illegal drugs and the provision of online access to controlled substances. Additionally, as a result of labour migration from developing to developed regions, the globalization process may also cause a “brain drain” in the health sector [80, 81]. However, it is generally accepted that faster economic growth will accelerate advancements in healthcare. The spread of information has led to an increase in (technological) knowledge, which can help with disease prevention and treatment of all kinds [77, 81].
The healthcare system is under the increased burden of addressing health inequalities through equal provision of high-standard digitalization by reducing the biases against age, specific class, ethnicity, community, culture, and financial status [82]. Through this process, more and more disadvantaged individuals and groups can be engaged with healthcare services, but this is solely possible if these technological advancements do not increase the accessibility concerns as the main aim is to make digitalization in the capacity of especially those who are financially or educationally not well quipped [83]. To deal with this problem, the modern digital framework should include self-referrals, delivery of face-to-face diagnosis along with treatment, remote modality, and easy digital accessibility to communities that are hard to reach. For that purpose, digital education is a must!
Few countries that are experts in digitalization have put equal efforts to embark on the provision of easily operating smart devices to marginalized populations [77]. This strategy has worked for a few of the nations; however, in developing countries where buying mobiles or tablets, access to broadband, telehealth pods, and signals connectivity in rural areas is still questionable, consequently making this initiative a big failure. This could be dealt with by expanding groundwork grants to improve support in increasing Internet connectivity near or in the patients’ homes [77, 82].
One of the leading factors to address the concern of digitalization is to have a better comprehension of the social determinants. By scrutinizing these social indicators, organizations may ensure that they are working on and escalating the right/accessible technology, digital equipment, and infrastructure to support populations simultaneously, interacting with the patients on the basis of their health priorities. Through this, they can collect ample data, which will help them to have easy access to not only patients’ detailed clinical profiles but also a fair idea of sociodemographic profiles along with the population’s complete health profiles [84]. These platforms, assisted by machine learning, would align the development of composite risk scores and a patient’s proper care plans. Eventually, this digital homework can educate health systems and healthcare service providers in excluding care variation and disparity along multiple dimensions of health inequality [85]. This will not only provide a workable framework but also means to eliminate waste in healthcare provision. Once the healthcare systems establish a great number of metrics aligned with the visibility of health equity and equality performance, the next stage is the assessment of scorecards and dashboards, then identification of outlier performance, and finally, the systems could then work to loopholes and close gaps. Further, proactive risk scores assessment can be scrutinized to assess how to connect patients with useful resources to prevent unnecessary hospital arrival and the doctor’s office [83, 84, 85].
The COVID-19 pandemic urged us to invent and imply new technical modalities to use digital channels for the successful delivery of healthcare services virtually by learning from COVID-19 control solutions of social distancing and lockdowns. This new crisis made us learn from new ideas, refining them and turning them into detailed systemic modalities that enhance access of marginalized individuals towards technology usage. During those lockdowns in COVID-19 healthcare organizations could deliver their facilities remotely. Although it was something new in crisis, the world learnt the ways to reach the possibility of connecting rural patients to the healthcare system virtually. After the pandemic, lockdowns are not a matter of urgent concern, yet the solutions devised during the pandemic continue to connect and treat patients across the globe. Using that paradigm, we can still enhance health equality [84].
The rapid popularization of some technologies and approaches focuses on maintaining health equality by connecting marginalized populations to healthcare professionals. The leading approach is telemedicine. Though remote doctor-patient consultations will never suffice the need for physical visits and hospitalization, they can help medical triage and respond to the patients’ needs more swiftly, efficiently, and professionally. Seeing a physician digitally at home improved access to those living in remote areas by reducing mobility concerns, transportation issues, and unusually long working schedules [85].
Healthcare Technological development has replaced some older equipment with smaller and portable devices for areas with less developed infrastructure, limited Internet access, or even lack of electricity. For example, the Butterfly iQ handheld ultrasound scanner is a prominent product that largely serves patients in Africa who have difficulty visiting physicians [84, 86].
A well-devised and efficient supply chain model plays an integral part in accomplishing health inequality. Without this, healthcare users will not be able to have access to the medications and vaccines they need at the right time. Cloud, as one of the prominent digital technologies, improves visibility, rerouting medicine, delivery, and the possibility of reacting to unexpected crisis situations. By the usage of a fit-for-purpose algorithm, most time- and cost-effective delivery routes can be planned, especially for rural communities [86].
Do a person’s cultural, economic, and social predictors influence [87] whether they would experience health equality or inequality? In this context, we must understand that Health inequalities are unfair due to the unequal dispersal of social resources and determinants such as income, employment, access to education, basic health facilities. Inequalities have the power to affect everyone. Circumstances that lead to significant and prominent health disparities have spillover effects on all individuals in a society. For instance, violence, crime, the spread of any contagious disease, and the devastating outcomes of alcohol and drug misuse. Inequalities are avoidable [88]. A government that takes advanced and preventive measures in improving health policies by considering alternative strategies such as healthcare funding, social welfare benefits, and tax policy finds identifiable modes to reduce health inequality. Thus, a serious national action plan is mandatory for policy interventions [89].
11. How to utilize digital technologies to improve health equality?
To achieve equality and avoid discrepancies in the provision of health, a focus should be highlighted on the patient’s perspective on the effort they put into to urge for digital as compared to the perceived effort necessary to participate. Therefore, a strong focus on both positive health outcomes and patient experience with the technology is necessary.
Recently, Imielski [83] has proposed a digitalized health equality framework for this purpose, which is based on six key components (Table 1).
S. No.
Key components
Explanation
10.1
Accessibility
The first stage is to design an alternative solution for those who have no reliable Internet access, email addresses, smartphones, or computers.
10.2
Affordability
The primary and ongoing affordable funding allocation to design solutions that are sustainable to the targeted population.
10.3
Trust
Few people have trust issues to share their sensitive information through digital channels, so a patient’s trust is to be gained for both the organization itself and digital solutions.
10.4
Digital literacy
Not every individual can use new modern applications and devices, especially people with disabilities, uneducated, and older age individuals. This can be addressed by providing training to assist the patients in becoming more familiar with the technology.
10.5
Engagement channels
The clients should be engaged through web browsers, mobile apps, etc., and ensuring flawless patient experience across all digital channels is the key.
10.6
Personalization
Suitable use access is mandatory since their needs differ significantly. A seamless and comprehensive digital design to cater to multiple users to build patients’ trust for an enjoyable user experience.
Table 1.
Six key components of a digitalized health equality framework.
12. Recent successful strategies for tackling health inequality: Global case studies
Several countries have been successful in implementing pertinent policies, plans, and strategies to tackle health disparities, though there is no one-size-fits-all solution (Figure 2) [92]. Cuba: (Franco-Giraldo et al., 2019).
Figure 2.
Countries implementing successful strategies [90, 91].
13. Future directions and research agenda
Health inequality is a universal concern that means the whole world is, on one hand or the other, facing the same disparities in the health sector for a certain population of their country. WHO [1, 92] is creating awareness through its different surveys and annual reports to present a workable solution to this gigantic concern, and entire nations cannot be successful until they follow WHO’s priorities. The first positive step towards success starts with prioritizing three things: better living standards for the poorer population, equal allocation of resources, and measuring the public health issue with a workable intervention.
The second step should be creating coordination between different healthcare and its specialities through different experimental and quasi-experimental investigations to assess complex interventions’ impacts on socioeconomic discrimination.
The third step would be to familiarize inequality impact cost-effective appraisals for evidence-based interventions in the health sector and to guarantee better access to low-cost pharmaceuticals. This will necessitate evaluating and improving the patent and property rights directives and support provision for developing country capability to assess and exchange for appropriate drug access.
The fourth step could focus on developing better risk adjustment measurements for primary care of disadvantaged small areas. These healthcare centres may generate data on multiple morbidities to assess additional healthcare needs.
The fifth agenda is an assessment of social determinants. Adding, refining, and improving new indicators is another endorsement, which may disintegrate national inequality into between-area and within-area components. Similarly, it investigates the practice of statistical development of nonlinear functional forms, control methodology, and direct standardization methods.
Finally, there is a need for a worldwide evaluation and monitoring system to assess the root causes of health inequalities related to social determinants such as income group, region, ethnicity/race, age, and gender. Policies that promote an action plan to improve social, economic, cultural, and environmental determinants at all stages, initiating from organization to community to county, state, and nation, are successful in meeting the drastic effects of structural inequities. For this, we must choose a small set of key indicators for worldwide monitoring, which requires support for national data collection and analysis. This may inform equally multifarious, complex, and operational evidence-based interventions to endorse health equality.
14. Conclusion
It is crucial to accept the fact that health equality does matter for accomplishing targets of global public health. The numerical statistics can be mechanically achieved while the real-time data are left behind, and this is how the less privileged members of a nation can be neglected and bypassed. We should remember that inequality within a geopolitical boundary of a country exacerbates overall health. Fairness in health equality is posited to be the most persuasive argument in favour of exercising strategies to reduce disparities in health. Though the underlying mechanisms boosting the rise of health inequalities are not perfectly comprehended, enhancing equity would diminish the subjugating “spillover effect” on the nations at large. Subsequently, equality of the right to access healthcare services and evading ethnic, racial and gender bias is the dire need of structural and systematic reform resulting in applicable design to meet the basic needs of the disadvantaged geopolitical populations/groups/nations.
The right political interest in implementing nationwide strategies to lessen health inequalities is required with updated and latest knowledge. In this regard, governmental and non-governmental organizations are required to collaborate. New theories about bringing change in health disparities should have emerged with a vision to discover what and where necessary action to be taken, what might work, and whom to involve. In the areas where the causal pathway of illness is known, the scientific evidence must be refined in terms of gathering population health data, monitoring already implemented policies and explorations, planning new theories and policy options and evaluating the outcome of the distribution of health measurements across the whole population.
Another strategy is to endorse specific national areas of policy for food items that cause ill health but are somehow mandatory in modern daily usage—for instance, enhancing smoke-free cooking stoves and fuel usage. Further research is needed to explore effective strategies for banning or reducing the consumption of ‘junk’ food, sugary drinks, tobacco, alcohol, and similar products.
Specifying endorsements for a workable Aid-supported national action plan and implementation in the health sector. This action plan can remove user charges for fundamental and basic health facilities for disadvantaged users. It will advance the dissemination of facilities throughout regions and different populations. More emphasis could be given to the delivery of precautionary and preventive health facilities and education. A vital balance can be imposed between primary health and secondary healthcare, which will ultimately require streamlining the education of medical personnel.
Another valuable suggestion is to have more and more strategic planning on how to react to the crisis. There should be adjustment and sustaining programmes to protect access to health, education, and employment for the marginalized. We should learn from the transition of emerging countries in the 1980s and 1990s how they sustained expenditure on health and education, especially rudimentary necessities.
A deep understanding of the social determinants of health equality will be indispensable for healthcare organizations. Through this, governments and enterprises can peep into the provision of the right technology, facilities, and infrastructure to support patients. To spur the development of digital technology, the data gathered through machine learning related to clinical profiles, population, and sociodemographic profiles will contribute to health systems and healthcare providers in eliminating care variation along multiple magnitudes. Lastly, this cannot be achieved until we classify, accept, and prevent all sources of discrimination, be it age, gender, race, ethnicity, or any disability.
Conflict of interest
The authors declare no conflict of interest.
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Written By
Erum Bibi, Anila Mubashir, Aleena Khalid Ghori and Anam Bibi
Submitted: 31 August 2023Reviewed: 11 September 2023Published: 14 November 2023
Open access peer-reviewed chapter - ONLINE FIRST
