Equality of what in health policy? Conflicts between the contenders

Most people agree that equity has something to do with equality – but equality of what? This paper discusses five relevant “respects” according to which horizontal or vertical equity for individuals or groups of people might be achieved: marginal willingness to pay, per capita expenditure, need as ill-health, need as capacity to benefit, and need as the resources required to exhaust capacity to benefit. They are shown, in general, to conflict with one another (though not with cost-effectiveness) and also to conflict with a sixth, and in my view preferable, relevant respect whose objective is to promote greater equality in the distribution of health in the community. This sixth criterion foes not necessarily conflict with cost-effectiveness either. A seventh principle, equality of access, is also shown to be inadequate. The sources of these equity conflicts, in a health care system that maximises health gain given a stock of resources, are interactions between differences in people’s initial health endowments, their wealth, their preferences, their health production functions, and the budget constraint, a change in any one of which ceteris paribus may change the distribution of both health and health gain. The general conclusion is that cheapness (rather than equality) in initial accessibility of health care is a necessary condition for equity but that inequality in resource distribution is also generally required to achieve equity in health.