The Health Equity Dilemma and the Well-being Economy: Are We on the Right Track?

Editorial

“The difficulty lies, not in the new ideas, but in escaping from the old ones, which ramify, for those brought up as most of us have been, into every corner of our minds.” John Meynard Keynes (1936).

In today’s world, where questions about the appropriate level of economic regulation continue to dominate policy debates, the social storms raging in many countries provide a growing breeding ground for ensuring health for the vulnerable, the fair distribution of goods, the sustainable use of resources, the efficient organisation of systems and public policies that contribute to collective well-being with equity.

In discourse; for the design, implementation and operational evaluation of public policies, equity in health means that everyone has a fair chance to be as healthy as possible; in other words, it can be defined as the absence of disparities in health (and its key social determinants) that are systematically associated with social advantage/ disadvantage [1]; while collective wellbeing is a holistic way of better understanding the overall health of a community where its members can define their own identity, which also means deciding their own sense of welfare [2].

In practical terms, this means that all people should have opportunities to reach their health potential and that no one should be disadvantaged; to achieve this, barriers to collective well-being, such as poverty, social exclusion and their consequences, including feelings of powerlessness and lack of access to good jobs with fair incomes, quality education and housing, safe environments and health care, must be removed [3, 4].

These statements, validated by policy commitments, while correctly identified as multidimensional impacts on wellbeing/health, predominantly react by intervening on the consequences of health determinants, including huge differences in life expectancy, infectious disease incidence, under-five mortality rates and the distribution of chronic diseases, rather than intervening on the known causes of inequities. The policies that emerge, by prioritising health care, do not necessarily address the question of whether those who need it actually get it efficiently in the right quantity [5, 6]. Similarly, equity is often neglected in comparison to various aspects of quality. One effect of this is that quality improvement projects can sometimes increase health disparities, resulting in intervention-generated inequities [7, 8].

The difficulty is further compounded when assessing equity compared to cost-benefit. While it can be complicated to determine whether equity or efficiency considerations justify a policy intervention of moral value, traditionally this concept is linked to economistic technical indicators, such as Gross Domestic Product (GDP) focused predominantly on improving health service delivery, without considering the other structural dimensions that drive and sustain poor health and health inequities, and premised on the assumption that higher output growth leads to positive effects on human development [9].

And while this premise is true to some extent, especially in societies characterised by mass deprivation, studies have shown that there is very little correlation between growth and well-being once a certain threshold of basic needs is reached.

While GDP growth may be correlated with prosperity, it does not take into account income distribution, social disparities and ecological impacts on future generations [10, 11]; therefore, in recent years there has been an attempt to advance a set of concepts and sub-concepts compiled in a model from economics and political science, called Well- Being Economy.

In its vision, the Well-Being Economy recognises health as more than just the absence of disease. It recognises the economic, environmental, cultural and social dimensions of our health and well-being, and combines them in the idea of reshaping the economy to ensure happiness with underlying goals of equity, inclusion and sustainability - all of which are crucial to developing healthy, fairer and more prosperous societies in which people can thrive [12]. In this regard, some governments have already taken important steps to adopt this approach in their public policies, and most countries have also made significant progress in collecting new data to provide more information on social well-being and health equity in line with international frameworks such as the 2030 Agenda of the Sustainable Development Goals (SDGs) [13].

While progress has been made in designing national development plans with a multidimensional perspective, more needs to be done to put social, health and environmental objectives on an equal footing with fiscal and economic objectives. This is the only way to unlock the potential for a well-being economy that aims to achieve health equity. In this respect, there are no magic formulas, since each community is the master of its own inequity and each government is part of the population that shares its social policies. Perhaps the development of participatory governance tools that promote a transformation of systems thinking to recognise the interconnectedness of the causes and impact of problems, and undertake supportive actions that lead to mutually reinforcing positive outcomes and balanced decisions about trade-offs, would help to overcome the various situations of inequity, allowing for long-term planning and adherence to a sustainable vision of the well-being economy [14].

Our brief manuscript is intended to generate a debate that will allow us to reflect on the need to reshape public policies towards a broad vision of health and well-being economics as a catalyst for political commitment to equity. In this sense, it would be pertinent to think about John Meynard Keynes’ enunciation [15], with which we began our article.