Perspective Chapter: Addressing Global Health Inequalities – A Public Health Perspective

Abstract

The concept of public health covers all services offered to protect and improve the health of individuals and society and to provide the best services in the field of treatment/rehabilitation. In this way, all situations that are common in society, frequently lead to death, create a burden on the health economy, and in short, affect the health welfare of the society and are considered as the subject of public health. All steps to be taken to protect and improve the health of individuals, societies, and countries are evaluated within the framework of public health. Although the systematics and organization of health services vary from country to country, they are basically classified as preventive, therapeutic, and rehabilitative services. The provision of health services should be accessible, sustainable, and inclusive of all humanity. Otherwise, if there is no balanced policy in service delivery, the desired goals will not be achieved. In order to bring a health principle based on the principle of equality to certain standards throughout the world, basic targets are determined and countries organize studies to achieve these targets. The aim is to provide healthcare services equally to everyone and more to those in need. Health services should be urgently provided by all countries in the world, especially in regions where health needs are felt intensely, such as ongoing wars and mass deaths in many parts of the world today. Failure to understand and persistence of inequalities in health care, it will first affect individuals and societies, and this effect will spread all over the world.

1. Introduction

Health, which is one of the fundamental human rights and freedoms, has maintained its importance throughout history. This importance has led to changes in the definition of health over time [1]. In ancient times, health was defined as the absence of illness, but according to the World Health Organization (WHO), the definition of health has become more comprehensive. In its current form, health is defined not only as the absence of disease and disability but also as a state of complete physical, mental, and social well-being [2]. According to this definition, the preservation and improvement of the health of individuals and society require collaboration in multiple fields and a multidisciplinary approach. As the definition of health has changed, there have been changes in health policies around the world. The aim of the changes is to produce more equal and applicable policies and to increase the health level of individuals and society. While in the past years, more years of death or life expectancy were taken into consideration instead of healthy life [3], the concepts of social well-being, quality life, and healthy aging have become topics discussed in terms of equal health service provision in recent years [4]. In order to make evaluations about health issues more understandable, it has been felt necessary to use different concepts in addition to the definition of health. One of these concepts is quality-adjusted life year (QALY), which takes into account the opinions of individuals regarding the quality of life, and the other is disability adjusted life years (DALY), which represents the years lost due to disability [5].

2. Initiatives for health equity

For countries to pursue a common path in terms of health protection and improvement, the Ottawa Charter was established during a meeting held in Geneva in 1986 [1]. The promotion and encouragement of health encompass the entire process of individuals making informed decisions about their own health, increasing and enhancing their control over it [2]. This process necessitates making social, economic, and environmental conditions conducive to health in addition to actions aimed at increasing individuals’ health skills and capacity. The concepts introduced in the Ottawa Charter have been updated in the Jakarta declaration, which now encompasses all countries worldwide. According to the Jakarta declaration, the five priorities for health promotion are as follows: promoting social responsibility for health, increasing investments in health development, expanding partnerships for health promotion and development, enhancing community capacity and empowering individuals, and ensuring infrastructure for health promotion and development [2]. The decisions of the Jakarta declaration were taken to cover all the country’s populations, that is, all humanity. The desired goals can be achieved when these decisions are implemented without allowing any inequality between countries and people. These concepts, which are expected to be planned for the entire population, have necessitated the importance and priorities of public health to be known.

According to public health principles, actions aimed at improving, protecting, and enhancing the current health status of individuals, and the community should be implemented within a multidisciplinary approach. In this context, public health encompasses all individual and environmental conditions that are common, frequently fatal, and pose a threat to the overall health of the community [3]. In the context of public health, along with environmental, political, and social regulations, the dedicated participation of individuals is of great importance in addressing crucial and prioritized issues. To achieve this, the necessary conditions can be considered as the right political approaches, a health-supportive environment, a suitable social context, and individuals with a high level of health literacy.

When collaborative efforts are made with stakeholder institutions in the field of public health, desired goals can be achieved. This necessitates countries to adopt a multidisciplinary approach both in terms of health and from social and economic perspectives. Inequality in terms of responsibilities among institutions included in the health delivery plan can hinder the goals of public health. Similarly, the unequal provision of services to the entire community can lead to adverse situations in public health. All of these approaches should be considered as a threat to humanity with different consequences from small communities to the global scale.

The concept of inequality, which is expected to lead to negative outcomes, is of particular importance in public health and needs to be defined. Health inequality is the occurrence of preventable and unacceptable deteriorations in the health of individuals/societies due to various reasons. According to the World Health Organization (WHO), the key determinants of health inequality are income, education, occupation, social class, and gender [4]. Healthcare service disparities and social inequalities should be evaluated as a whole, and outcomes resulting from uncontrollable factors, such as age and gender, should be described as “differences” in health rather than “inequalities” [5, 6]. These definitions are of great importance in determining service delivery. For example, differences arising from the characteristics of the female gender also change the health services provided for them. The principle of “equality” should be adopted when providing the health conditions necessary for a healthy birth to all female genders, and there should be “difference” in terms of the services offered to the male gender in terms of the type of service.

Concepts of difference and inequality can be affected by factors such as demographic structures, historical structures, and development levels of countries. Health-related expectations consist of combinations of all these factors. Underdeveloped countries cannot act independently in the field of health as in every field. Countries whose resources were once exploited by other countries have still not achieved their development and demographic transformation today. These countries are in the first phase of demographic transformation and life expectancy at birth is short and infant mortality rates are high. In these countries, health-related expectations are mostly about childhood services and measures to prolong life. In developed countries, the last phase of demographic transformation is experienced and life expectancy at birth is 80 years and above. In such societies, there is a greater need for health services for old age or healthy aging.

Dahlgren and Whitehead’s influential health determinants on health inequalities are depicted in a rainbow model [7]. According to this model, the factors influencing health are diverse, encompassing individual lifestyle choices, community influences, living and working conditions, and broader social circumstances.

Studies on the determinants of health can vary around different and common components. In essence, these components should be classified to formulate health delivery policies accurately. Some studies classify them as “social determinants and healthcare services,” while others categorize them as “modifiable and non-modifiable factors” [6].

In the field of public health, when evaluating health inequalities, the first step is to embrace the idea that health is a fundamental right for everyone, and individuals have equal rights to access healthcare services with more services provided to those in need. With this understanding, the components of an effective healthcare system include finance, organization, management, and policy.

Finance is one of the fundamental components of the healthcare system. Different countries provide healthcare services with various financing models. The proportion of a country’s income allocated to healthcare or the total amount of money spent on healthcare is closely related to health indicators. It is important to note that free primary healthcare services should cover the entire population. For example, when essential primary healthcare services, such as immunization services, are not provided to the entire population, the desired level of effectiveness is not achieved, leading to increased healthcare costs. In areas where vaccination is incomplete or vaccine refusal is high, preventable diseases, such as measles, may see an increase in prevalence, especially among high-risk groups.

The organization of healthcare services and the management model derived from it, when tailored to the needs of communities, will yield meaningful results in terms of public health. This can be illustrated with an example from Turkey’s healthcare history. In the early 1900s, a vertical organization model was adopted for healthcare management, and dispensaries were established to combat common and deadly diseases. In the early 2000s, a horizontal organization model was embraced, and approaches suitable for the demographic structure and prevalent diseases were adopted. Starting in 2005, screening programs covering the entire population were initiated for diseases with a high prevalence and for which treatment is possible when detected. Additionally, all individuals under the age of 18 began to be evaluated under general health insurance. Innovations in the field of health have shown themselves with interesting results in the country. For example, with the new vaccines added to the vaccination calendar, there has been a dramatic decrease in some diseases (Figure 1) [8].

Figure 1.

Number of reported mumps cases (2005–2017) [8].

When the evaluation and provision of services are extended to the entire population, health indicators show positive changes. Providing equal and more services to individuals and the community in the field of public health raises the overall level of health. Could a service that was not spread throughout the society still produce the same results?

After achieving equality in healthcare through the components of the healthcare system, equality should also be applied to the social determinants of health. Social determinants of health should be evaluated across a wide spectrum of factors affecting health. It should be remembered that even the most effective healthcare system will face failure in health indicators if an appropriate social environment is not provided. At this stage, the first step in achieving equal and just healthcare for the public should be to understand the community in all its dimensions. While understanding the community, factors, such as needs, behaviors, social norms, and cultural structures, should be analyzed, and concrete criteria, such as health literacy, should be utilized. Otherwise, services provided without a thorough understanding of communities will not be effective. For example, the use of products containing pork derivatives in medical treatments and vaccines is against religious beliefs in Muslim communities, and such products would not be preferred, making it difficult to achieve effective results in vaccination programs. To avoid such situations, international organizations or nongovernmental organizations can be used to determine needs. In order to prevent the disruption of vaccination services in Muslim-majority countries, the Organization of Islamic Cooperation issued an international fatwa. It has paved the way for vaccination when necessary for health, even if it contains pork additives [9]. Perhaps the question we should not be asking, especially for civilians killed or denied healthcare in war zones. “How can internationally recognized bodies be better used to advocate or protect fundamental health rights?”

Among the social determinants of health, income level, education level, individual behavioral traits, geographic conditions, workplace factors, employment status, environmental health, and political approaches are considered fundamental. These are the headings that communities and countries should consider when implementing the principle of health equality. Taking these factors into account, the United Nations established the “Sustainable Development Goals” in 2015, aiming to achieve them by 2030 [10]. All of these goals contain concepts that may affect human health. When all targets are implemented equally and in an integrated manner, concrete steps can be taken toward human health. Fighting hunger and poverty is one of the basic needs of health, and it should be provided more to everyone who needs it equally. The indispensable nature of protecting and improving health can be achieved by providing qualified education to all humanity. In addition, in order to prevent inequality in health, policymakers must be equipped with quality education. Clean and drinkable water is the basic building block of health and development. Access to clean water for all humanity, without exception, is one of the fundamental human rights. Sustainable, clean energy, and other sustainable development goals aim to provide a clean infrastructure and environment to protect human health. Presenting all these goals within the framework of the principle of equality will ensure success in health. Among these goals, the third goal, which specifically focuses on health, and its sub-steps are discussed below. The third goal among these is the “good health and well-being goal,” consisting of nine main targets and four sub-targets [11].

The first target in the field of health is to reduce the global maternal mortality ratio to less than 70 per 100,000 live births. It is noteworthy that the first health target is identified as a special group in terms of gender and age. From a public health perspective, the significance of maternal mortality as an important indicator among health indicators highlights the importance of the issue. To achieve success in this regard, countries should prioritize premarital screenings, family counseling, and contraception services. Subsequently, services related to planning and maintaining a healthy pregnancy, such as pregnancy monitoring and checkups, as well as screenings for fetal anomalies, should be provided [11]. To ensure a healthy pregnancy concludes with a healthy childbirth, it is necessary to provide suitable conditions (such as all pregnant women giving birth with the assistance of a healthcare professional and providing lodging services for those residing in areas with difficult access to healthcare facilities during the period close to childbirth) [12]. The postpartum period, which includes the 40 days following childbirth and should be controlled irrespective of the mother’s risky condition, requires regular health checkups for the mother. Maternal deaths can be direct, indirect, or accidental. To provide services related to maternal mortality without allowing health inequality, the existing pregnancy conditions should be established for all pregnant women worldwide. Conditions that directly lead to maternal deaths should be determined country-wise, and policies should be developed to address these causes. The most common direct cause of maternal death is known as “hemorrhage.” To prevent deaths due to hemorrhage, it is necessary to provide services with trained healthcare professionals who use appropriate techniques during antenatal, childbirth, and postpartum periods. Another common cause is “eclampsia/preeclampsia.” For this cause, blood pressure monitoring during pregnancy, dietary measures to control salt intake, and increasing the health literacy of expectant mothers for effective implementation would be appropriate approaches. Actions should be planned for the existence of other causes that may vary from country to country. Efforts should be made to provide the necessary food and services to communities and countries where pregnant women are at risk due to inadequate nutrition. The inequality in terms of maternal mortality between countries is strikingly presented as the maternal mortality rates of the countries in 2019 are shown (Figure 2) [13].

Figure 2.

Maternal mortality rates by country, 2019 [13].

Ensuring that mothers, who are one of the most important groups in terms of public health, have equal opportunities worldwide is crucial for the healthy and quality lives of future generations.

In the second target of the Global Goals “good health and well-being” goal, it is stated that by 2030, reduce the neonatal mortality rate to at least as low as 12 per 1000 live births, and under-5 mortality rate to at least as low as 25 per 1000 live births in all countries. Children are the most vulnerable and affected group when it comes to health inequalities worldwide. When equal healthcare is provided, mothers and children are the groups that benefit the most. Therefore, one of the most important indicators among a country’s health indicators is the infant mortality rate. The infant mortality rate indicates how many of 1000 live-born babies die within a year. Since childbirth can occur anywhere in the world, the infant mortality rate is one of the most crucial indicators in assessing health inequality. When countries do not provide equal and inclusive healthcare services to the entire population, there will be disparities in the distribution of maternal and infant deaths. It would be appropriate to make assessments by conducting relevant surveys to evaluate the provision of equal services to the entire country. Other health indicators considered alongside the infant mortality rate include perinatal mortality rate, neonatal mortality rate, and under-5 child mortality rate. According to the United Nations, the global average infant mortality rate is 49.4, and the under-5 child mortality rate is 73.7. While the World Health Organization (WHO) counts every baby showing signs of life at birth as a live birth, some countries apply their own standards [14].

As the level of development in countries increases, a decrease in under-5 child mortality rates is observed. It is evident that infant deaths are related to the opportunities in healthcare service delivery. Therefore, a significant portion of the consequences related to health inequality concern infants and children. Studies on this topic are also mentioned in UNICEF reports. According to the report, maternal deaths in sub-Saharan Africa are 50 times higher than the global average for women, and infants in the same region are 10 times more likely to die within the first month following birth compared to high-income countries [15]. To address health inequalities related to this issue, it is essential to focus on groups at risk, identify the global support needs of affected countries, and organize collaborative assistance. Approaches aimed at addressing the causes of deaths should also be adopted.

Another crucial issue regarding health inequalities is the fight against infectious diseases, as specified in Goal 3 of good health and well-being. High rates of deaths due to infectious diseases are still observed worldwide, especially in low-income countries. Ending the epidemics of AIDS, tuberculosis, malaria, and neglected tropical diseases and combating hepatitis, water-borne diseases, and other infectious diseases are part of the Sustainable Development Goals by 2030. Infectious diseases, one of the most significant public health concerns, are affected much more by disparities in healthcare service delivery.

There are three fundamental methods for preventing infectious diseases. The first is to eliminate the pathogen at its source, the second is to take measures against the mode of transmission, and the third is to protect or prepare susceptible individuals. The combined application of these methods will lead to success in the fight against infectious diseases. Measures aimed at eliminating the source of infectious diseases are often related to environmental health issues. Healthy cities, adequate water and food sanitation, healthy housing conditions, personal hygiene education, and conditions are essential for preventing transmission. Ensuring access to clean and safe food and water is a common human need and a fundamental right for all humanity. The deadly consequences of health inequalities in this area continue to be alarming in today’s world.

Another crucial method of prevention concerning infectious diseases is the development of protective measures against the mode of transmission and teaching individuals these measures through appropriate health education. For airborne diseases, it is essential to provide individuals with the necessary health knowledge and protective equipment for prevention. To prevent diseases transmitted through the fecal-oral route, disinfection of water and food and facilitation of access to clean and safe food and water are necessary. Food sanitation and proper cold chain practices should be provided to individuals in the food industry through health education, and regular health checkups should be conducted for workers in this sector. For sexually transmitted diseases, individuals should be informed, and equal, accessible, and free family planning services should be offered.

One of the most critical steps in preventing infectious diseases is the delivery of vaccination services. Especially for diseases preventable by vaccines, equal opportunities should be provided to all countries. Throughout world history, humanity has only achieved victory against a single virus, smallpox, thanks to vaccination services. Despite advances in technology and countless microorganisms, the fact that only one virus has been eradicated highlights the inadequate and unequal provision of immunization services. Studies show that in societies with low income and inadequate social structure, the possibility of contracting the virus is higher in the presence of an infectious disease [16]. The most recent examples on the subject can be given from the COVID-19 period. While the disease burden has been reported to be higher in blacks, Latin Americans, immigrants, and Native Americans compared to whites in the USA, it has been reported that deaths due to COVID-19 are higher in people of Asian origin, blacks, and ethnic minority groups compared to whites in the UK [17]. For these reasons, the provision of vaccination services, especially for underdeveloped countries, should be free and cover all individuals.

When it comes to health priorities, particularly primary healthcare services, successful results can be achieved when they are applied equally and sustainably in all countries and communities.

Rehabilitation services are indeed of great importance in public health. These services are essential for disabled individuals and the elderly population, and their availability and scope can vary depending on the demographic structure of countries [18]. The increasing elderly population in developed countries has also affected healthcare service priorities [19, 20]. Desired outcomes can be achieved when healthy aging and treatment and rehabilitation services during the elderly period are applied equally to all individuals. While elderly control programs are more effectively implemented in developed countries worldwide, infrastructure efforts related to this issue are insufficient in less developed countries. Establishing a common infrastructure for providing suitable services for the elderly in all countries around the world will be an important step in addressing the inequality related to this matter.

Rehabilitation services for disabled individuals also vary depending on the level of development of countries. Inequality is not only limited to rehabilitation services alone but is also observed in areas such as healthy cities, disabled-friendly architectural structures, and public services [21, 22].

3. Conclusion

In conclusion, healthcare inequality is observed worldwide in all matters concerning public health. When countries formulate their health policies, they should plan in a way that eliminates all these inequalities. When making these international-level plans, the current situation of less developed countries must be taken into account. Measures that will eliminate inequalities for the benefit of individuals and all global communities should be urgently implemented.

We must know that no country will be able to reach the desired level of health unless all people receive equal health care. Equality is equality when it is applied always, everywhere, and toward everyone.