Health Equity: A Foundation for Sustainable Societies
Health equity is both a moral imperative and a practical necessity for sustainable human development. It refers to the absence of avoidable or remediable differences in health among groups of people, regardless of their social, economic, demographic, or geographic background1. The global community has recognized this by incorporating it into the United Nations’ Sustainable Development Goals, particularly SDG 3: Good Health and Well-being, with universal health coverage as a crucial target2.
Within the Doughnut Economics framework, health is one of twelve essential social foundations, a prerequisite for social and economic participation within planetary boundaries3. This highlights that health equity isn’t solely about healthcare delivery; it’s a comprehensive vision of well-being encompassing access to preventive care and the environmental and social conditions that foster good health. Health equity intersects with other social foundations like education, housing, and clean water, creating a web of interconnected factors that either support or undermine population health.
The pursuit of health equity challenges us to move beyond traditional healthcare metrics and consider how our social, economic, and environmental choices contribute to or detract from ensuring everyone has a fair opportunity to achieve their full health potential.
A Historical Shift in Public Health Thinking
The 20th century saw a transformation in public health thinking, moving from a focus on infectious diseases and basic sanitation to recognizing persistent health disparities among different populations4. The World Health Organization (WHO) played a pivotal role, with the 1978 Declaration of Alma-Ata proclaiming health as a fundamental human right5.
The following decades deepened our understanding of the complex relationships between social conditions, economic circumstances, environmental factors, and health. Health outcomes were no longer viewed solely as individual choices or medical care access but as deeply intertwined with the entire fabric of society6. This led to the establishment of the WHO Commission on Social Determinants of Health in 2005, which crystallized the understanding of how factors like education, income, housing, and environmental conditions profoundly influence health6. These social determinants act as the roots of a tree, influencing the visible branches of health outcomes.
This evolution underscores why achieving health equity requires a comprehensive approach today. We’ve moved from treating diseases to recognizing that true health equity demands addressing fundamental social and economic inequalities.
Persistent Disparities in a World of Progress
Despite significant progress in global health, substantial disparities persist both within and between countries. These are evident in life expectancy, maternal and child mortality rates, and the prevalence of non-communicable diseases7.
Stark Contrasts in Global Health
Recent WHO data reveals stark contrasts in health outcomes, highlighting a deeply concerning pattern of global health inequality. For instance, life expectancy at birth ranges from 53.1 years in the Central African Republic to 84.3 years in Japan8—a 30-year gap representing a generation of life opportunity. Additionally, under-five mortality rates are 74 per 1,000 live births in low-income countries compared to 5 per 1,000 in high-income countries9. This means that children in low-income countries are nearly 15 times more likely to die before their fifth birthday. The disparity in maternal health is similarly stark. The maternal mortality ratio is 462 per 100,000 live births in low-income countries, compared to 11 per 100,000 in high-income countries10, meaning that women in low-income countries face a risk of death during childbirth that is more than 40 times higher.
These disparities also exist within countries, reflecting socioeconomic inequalities, racial and ethnic differences, and geographical variations in access to healthcare services11.
COVID-19: A Magnifying Glass on Inequity
The COVID-19 pandemic served as a powerful lens, magnifying existing health inequities. Marginalized communities, including racial and ethnic minorities, low-income populations, and those with pre-existing health conditions, were disproportionately affected12.
The pandemic exposed how essential workers, often from lower-income communities, faced greater exposure risks, often living in crowded conditions. Those with pre-existing conditions, often linked to long-term socioeconomic inequities, faced higher risks of severe illness. The pandemic intensified existing patterns, acting as a stress test for healthcare systems.
Disparities became even more apparent during vaccine rollout efforts. The pandemic highlighted the urgent need for robust public health systems and universal health coverage to ensure equitable access to healthcare services and vaccines13. Differences in healthcare access, digital literacy, transportation, and work flexibility created barriers to vaccination for many.
COVID-19 served as a catalyst for change, demonstrating why universal health coverage is a practical necessity for public health. It made clear that individual health is linked to community health—none of us are protected unless all have access to adequate healthcare.
The Power of Social Determinants
Social determinants of health—the conditions in which people are born, grow, live, work, and age—act as powerful forces shaping health outcomes. Research underscores their significant impact, with factors like education, income, housing, and environmental conditions playing crucial roles14.
Education provides a clear example. A recent study found that individuals with lower educational attainment have a life expectancy several years shorter than those with higher education15. This reflects how education connects to job opportunities, income, health literacy, and the ability to navigate complex healthcare systems.
These determinants create “cascading effects.” Poor housing can lead to respiratory problems, causing missed school days, leading to reduced educational achievement, resulting in limited job prospects, and perpetuating the cycle of health inequity.
Understanding social determinants helps us see why traditional medical interventions alone often fall short. True improvements require addressing the fundamental social and environmental conditions that create the context for health and illness.
Emerging Trends Shaping the Future
Several powerful trends are emerging that will shape the future landscape of health equity, presenting both challenges and opportunities. Technological advancements are poised to revolutionize healthcare delivery. Innovations such as artificial intelligence, telemedicine, and personalized medicine hold immense potential to improve diagnostics, treatment, and overall patient care16. However, ensuring equitable access to these advancements will be crucial to prevent a widening of existing disparities, where only privileged populations benefit from cutting-edge technologies. Concurrently, climate change is emerging as a significant force impacting health, with rising temperatures, extreme weather events, and shifting disease patterns likely to disproportionately affect vulnerable populations, thus exacerbating health inequities17. The impacts of climate change, such as heat-related illnesses or the spread of infectious diseases, will require adaptive strategies to protect the most at-risk communities.
In addition to technological and environmental shifts, demographic changes are also reshaping the future of health equity. Many countries are experiencing a significant demographic shift towards aging populations, which presents new challenges for health systems. Ensuring equitable access to long-term care and addressing the unique health needs of older adults will be paramount18. This includes providing specialized geriatric care, managing chronic conditions effectively, and supporting healthy aging in place.
Rapid urbanization, particularly in low- and middle-income countries, presents a complex duality of opportunities and challenges for health equity. While urban centers often boast better access to healthcare services compared to rural areas, they can also be associated with increased exposure to environmental pollutants, unhealthy lifestyle factors, and socioeconomic disparities that impact health19. These trends, in their totality, represent both significant challenges and unique opportunities to reimagine how we deliver healthcare and promote health equity in an evolving world. They demand innovative solutions and proactive policies to ensure that progress benefits all members of society.
Navigating the Challenges Ahead
Achieving health equity faces a complex web of interconnected challenges that must be addressed systematically. One of the most prominent obstacles is the persistence of disparities in access to quality healthcare services. These disparities manifest in various forms, including geographical barriers that limit access for those in remote areas, financial barriers that make care unaffordable for many, and cultural or linguistic barriers that hinder effective communication and understanding between patients and providers20. These access issues often lead to delayed or forgone care, exacerbating health problems and reinforcing inequalities.
Beyond access to healthcare, deeper social and economic inequalities are significant drivers of health disparities. Addressing these root causes requires coordinated action across multiple sectors, including education, housing, and employment, to create a more equitable society overall21. Furthermore, health workforce shortages, particularly in rural and underserved areas, represent another critical challenge, hindering healthcare access and quality22. Without sufficient healthcare professionals, communities struggle to provide timely and comprehensive care.
The lack of comprehensive, disaggregated data on health outcomes and their determinants hinders efforts to identify and address disparities effectively23. Without accurate and detailed information, it becomes difficult to understand the nuances of health inequities and to tailor interventions that are truly effective. These interconnected challenges highlight that achieving health equity requires a multifaceted approach, one that addresses both immediate healthcare needs and the broader societal factors that shape health outcomes.
Opportunities for Transformative Change
Despite the significant challenges, there are several promising opportunities to advance health equity, offering a pathway toward meaningful progress. One of the most impactful is the expansion of universal health coverage. By implementing comprehensive coverage, we can significantly reduce financial barriers to healthcare access and, importantly, protect individuals and families from the devastating consequences of catastrophic health expenditures24. This ensures that healthcare becomes a fundamental right rather than a privilege determined by economic status.
Furthermore, addressing the complex web of social determinants of health necessitates a collaborative approach that transcends traditional sectoral boundaries. Intersectoral collaboration, bringing together expertise and resources from health, education, housing, and environmental sectors, can have a powerful impact on health equity25. For instance, joint initiatives between healthcare providers and housing authorities can address environmental triggers for chronic diseases within homes, while educational programs can be aligned with public health goals. Moreover, empowering communities to take an active role in health decision-making and program implementation can lead to more effective and culturally appropriate interventions26. Local voices are crucial for tailoring programs to meet specific needs and building trust within the community. The rise of digital health solutions also presents exciting new possibilities. Leveraging digital technologies can improve healthcare access in remote or underserved areas, enhance health education through innovative platforms, and facilitate more efficient health system management27.
Adopting a Health in All Policies approach, where health considerations are integrated into policymaking across all sectors, can help address the broader determinants of health and promote health equity28. This ensures that decisions in areas like transportation, urban planning, and education are made with a conscious understanding of their potential impact on population health. When these various opportunities are pursued thoughtfully and in combination, they have the potential to create transformative change, moving us closer to a future where health equity is a reality.
Conclusion: Health Equity in the Doughnut
The pursuit of health equity is a crucial challenge, intersecting social justice, sustainable development, and human wellbeing. It forms a vital part of the social foundation in the Doughnut Economics model. The disparities in health outcomes show how far we are from achieving this foundation, but the path forward offers reason for hope.
Opportunities like telemedicine, community health workers, and the Health in All Policies approach create a comprehensive toolkit for addressing inequities. However, health equity cannot be achieved in isolation. Challenges like climate change and urbanization demonstrate how intertwined health is with other social and environmental factors.
This brings us back to the core principle of Doughnut Economics: meeting everyone’s needs within our planet’s ecological boundaries. We can’t achieve true health equity without addressing social determinants or protecting environmental systems.
Moving forward means embracing this complexity and working across sectors to create integrated solutions. We need approaches that address immediate healthcare needs while building long-term resilience. By viewing health equity through the lens of Doughnut Economics, we gain a clearer understanding of the challenges and opportunities. This framework reminds us that achieving health equity isn’t just about providing medical care—it’s about creating a world where everyone can thrive while preserving the ecological systems that make human health possible.