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EQUITY IN HEALTH CARE
EQUIDAD EN SALUD
Virginia La Rosa-Salas*
Sandra Tricas-Sauras
Departamento de Enfermería Comunitaria y Materno Infantil.
Escuela Universitaria de Enfermería,
Universidad de Navarra, Pamplona. (España).
*vlarsal@alumni.unav.es
Resumen
Es ampliamente conocido que un gran segmento de la población disfruta de un
mayor status de salud y de una mayor calidad de cuidados para su salud que otros.
Para resolver este problema, priorizar es inevitable, sin embargo el problema surge al
pensar en la manera de llevar a cabo estas prioridades. Lo más racional sería buscar la
equidad entre toda la población, la manera en que toda la gente reciba el mismo cuidado
para la misma necesidad. Equidad en el cuidado de la salud es un imperativo ético
no sólo por el valor intrínseco que tiene el poseer una buena salud, sino que sin una
buena salud las personas serían incapaces de disfrutar de otros benefi cios que la vida
les puede proporcionar. Este artículo también explica cómo la efi ciencia en el cuidado
para la salud también es importante, pero al mismo tiempo, cualquier innovación y
racionalización llevada a cabo para la provisión del sistema de salud debería estar basada
en la dignidad humana, haciendo a la persona prevalecer sobre criterios económicos.
Por lo tanto, este artículo está basado en derechos humanos fundamentales. El
principal objetivo es asegurar que aquellos que tienen deberes públicos implementen
los derechos esenciales de la persona humana. Desde este punto de vista, equidad
sugiere igualdad: igualdad en acceso a los servicios y tratamiento, e igualdad en la
calidad del cuidado proveído. En conclusión, este artículo intenta poner juntos la
dignidad humana y la efi ciencia en el contexto de equidad reconciliándolos en un
terreno común.
Palabras clave: Equidad, efi ciencia y dignidad humana.
Cuad. Bioét. XIX, 2008/2ª 355Virginia La Rosa-Salas y Sandra Tricas-Sauras
Abstract
It has long been known that a segment of the population enjoys distinctly better
health status and higher quality of health care than others. To solve this problem,
prioritization is unavoidable, and the question is how priorities should be set.
Rational priority setting would seek equity amongst the whole population, the
extent to which people receive equal care for equal needs. Equity in health care is
an ethical imperative not only because of the intrinsic worth of good health, or the
value that society places on good health, but because, without good people
would be unable to enjoy life’s other sources of happiness. This paper also argues
the importance of the health care’s effi ciency, but at the same time, it highlights how
any innovation and rationalization undertaken in the provision of the health system
should be achieved from the consideration of human dignity, making the person
prevail over economic criteria.
Therefore, the underlying principles on which this health care equity paper is
based are fundamental human rights. The main aim is to ensure the implementation
of these essential rights by those carrying out public duties. Viewed from this angle,
equity in health care means equality: equality in access to services and treatment, and
equality in the quality of care provided. As a result, this paper attempts to address
both human dignity and effi ciency through the context of equity to reconcile them
in the middle ground.
Key words: Equity, effi ciency and human dignity.
3It has long been known that a segment those with limited access to care , those
4of the population enjoys distinctly with language barriers and members of
5better health status and a higher quality certain racial and ethnic groups .
of health care than the others. These
of Uninsurance, Board on Health Care, Institute of disparities have been documented and
Medicine. Washington DC (2002): National Acade-
have persisted for many years, most my Press.
notably among those with limited 3 Millman M ed. Access to health care in Ame-
1 2 rica. Washington DC (1993): National Academy income or education , the uninsured ,
Press.
4 Doty MM Hispanic patients’ double bur-1 National Center for Health Statistics. Death
den: lack of health insurance and limited English. rates for all causes, according to sex, race, Hispanic origin
New York: Commonwealth Fund (2003).and age: United States, selected years 1950-2001 and
5 Smedley BD, Stith AY, Nelson AR eds. 1950-2000. Hyattsville MD (2003): National Center
Unequal treatment: confronting racial and ethnic dispa-for Health Statistics.
rities in health care. Committee on Understanding and 2 Institute of Medicine. Care without coverage:
Eliminating Racial and Ethnic Disparities in Health too little, too late. Committee on the Consequences
356 Cuad. Bioét. XIX, 2008/2ªEquity in health care
However, what is less clear, it is larger question is how priorities are set.
whether society at large appreciates the This raises policy questions about what
scope of the problem. For instance, in makes some people more deserving of
a 1999 survey of the public conducted health care than others.
by the Kaiser Family Foundation, 43% Rational priority setting would seek
of respondents thought that the health the ideal balance between what the World
care system rarely or never treats people Health Organisation terms the ‘goodness’
6 9unfairly based on race or ethnicity . An and ‘fairness’ of health systems . The fi rst
even larger proportion of physicians, is the extent to which a system improves
69%, gave this answer in a 2001 survey, health, on average, for the population.
suggesting that the medical community The second addresses equity, the extent
7is even less attuned to the problem . to which people receive equal care for
Whereas 47% of the public believed that equal need.
the health care system at least «somewhat It is the aim of this paper to address
often» treats people unfairly, based on together both human dignity and
race or ethnicity, only 29% of physicians effi ciency through the context of equity to
thought so. reconciliate them in a middle ground.
In order to improve the situation, many This paper is arranged as follows.
options are being considered to make the In section 1, this document will focus
health care system better, but the need on defining equity and illustrating
to choose among them is unavoidable. key concepts of equity in health. This
Not every problem is correctable at once, section is of particular relevance, given
and resources for improvement—time, the growing interest in equity among
8human energy, and money—are limited . national and international health org
10,11,12,13Prioritization is thus inescapable, and the anizations . In section 2, it will
explain why there should be a concern
Care, Board on Health Science Policy, Institute of
Medicine. Washington DC (2003): National Acade-
my Press.
9 World Health Organisation. World Health 6 Kaiser Family Foundation. Race, ethnicity
Report. Geneva (2000). & medical care: a survey of public perceptions and
10 Acheson D, Barker D, Chambers J, et al., experiences. Menlo Park CA (1999): Henry J. Kaiser
The report of the independent inquiry into inequalities Family Foundation.
in health. London (1998): The Stationary Office.7 Kaiser Family Foundation. National Survey
11 Evans T, Whitehead M, Diderichsen F, et al., of Physicians. Part I: Doctors on disparities in medical
eds. Challenging inequalities in health: from ethics to care. Menlo Park CA (2002): Henry J. Kaiser Family
action. Oxford University Press, New York, (2001).Foundation.
12 Braveman PA, Tarimo E «Social inequalities 8 Almeida C, Braveman P, Gold M, Szwar-
in health within countries: not only an issue for cwald C, Ribeiro S, Miglionico A, Millar J, Porto S,
affluent nations». Sociology Science Medicine 54, Costa N, Rubio V, Segall M, Starfield B, Travessos
(2002), 1621-35.C, Uga A, Valente J, Vicaba F. «Methodological con-
13 Kawachi I, Kennedy BP. The health of nations: cerns and recommendations on policy consequences
why inequality is harmful to your health. The New of the World Health Report 2000» Lancet 357 (9269)
Press, New York, (2002). (2001), 1692-7.
Cuad. Bioét. XIX, 2008/2ª 357Virginia La Rosa-Salas y Sandra Tricas-Sauras
about equity in health care. Section 3 groups with the outcomes of their more
will describe some of the assumptions advantaged counterparts.
and implications that are embedded Moreover, it is important to distinguish
in equity-effi ciency trade-off. It will be between equity and equality. The concept
particularly interesting to identify some of equity is inherently normative—that
16,17circumstances under which equity and is, value based while equality is not
18,19,20,21efficiency may not trade-off against necessarily so . Often, the term
each other. Finally, it is worth pointing health inequalities is used as a synonym
out some ideas about the relationship for health inequities, perhaps because
between equity and human dignity. This inequity can also have an accusatory,
22section will also address the concern to judgemental, or morally charged tone .
inequalities between age groups. A brief However, it is important to recognise
discussion and thoughts arising from this that, strictly speaking, these terms are
essay will be carried out at the end. not synonymous. Equity means justice,
giving everyone what belongs to them,
1. Equity and recognizing the specifi c conditions or
characteristics of each person or human
Equity in health has been concep- group/sex, gender, class, religion or age.
tualized and defi ned in several ways, as It is recognition of diversity, without this
its principles derive from the fi elds of providing a reason for discrimination.
philosophy, ethics, economics, medicine,
public health, and others. Common to
16 Whitehead M «The concepts and principle most defi nitions of health equity is the
of equity in health». International Journal of Health idea that certain health differences (most
Services 22, (1992), 429-445.
often called inequalities in health) are 17 Braveman P, Starfield B, Geiger HJ «The
World Health Report 2000’s ‘health inequalities’ unfair and unjust. Equity in health means
approach removes equity from the agenda from equal opportunities to be healthy, for all
public health monitoring and policy» British Medical
14,15populations groups . Equity in health Journal 323, (2001), 678-81.
thus implies that resources are distributed 18 Whitehead M. The concepts and principle
of equity and health. Regional Office for Europe. and processes are designed in ways most
Copenhagen World Health Organisation (1992).
likely to move towards equalising the 19 Evans T, Whitehead M, Diderichsen F, et al.,
health outcomes of disadvantaged social eds. Challenging inequalities in health: from ethics to
action. Oxford University Press, New York (2001).
20 Braveman P, Starfield B, Geiger HJ «The
World Health Report 2000’s ‘health inequalities’
approach removes equity from the agenda from 14 Ngwena C «The recognition of access to
public health monitoring and policy». British Medical health care as a human right in South Africa: is it
Journal 323, (2001), 678-81.enough?» Health Human Rights 5, (2000), 26-45.
21 Chang W-C «The meaning and goals of eq-15 Torres M «The human right to health, na-
uity in health». Journal of Epidemiology of Community tional courts and access to HIV/AIDS treatment:
Health 56, (2002), 488-91.a case study from Venezuela». Chicago Journal of
22 Braveman y cols., op.cit. 20.International Law 3, (2002), 105-14.
358 Cuad. Bioét. XIX, 2008/2ªEquity in health care
On the other hand, equality refers to the prerequisite of equity. Moreover, the
similarity of one thing to another in terms achievement of equity through equality of
of quality and quantity. The achievement something among individuals or groups
of the object of equality is more than might require inequality in something else
26the absolute prohibition or elimination among the sssaaammmeee iinnddiivviidduuaallss oorr ggrroouupp . For
of discrimination. To provide equality example, one equity principle in a system
it is necessary to make a constant and of taxation might be to impose equal rates
dynamic effort. of taxation of all individuals. But where
23In addition, the WHO defined income differs among individuals this
inequity as differences (in health status), equity principle would imply unequal
which are unnecessary and avoidable, burdens of taxation among individuals.
but in addition are considered unfair Considerations such as these have lead
and unjust. Some disparities result to the separate but related concepts in
from genetic variation and other non- the research literature of ‘horizontal’ and
24modifi able factors . In others words, of ‘vertical equity’. Horizontal equity requires
the determinants of health differentials the like treatment of like individuals and
between populations groups or vertical equity requires the unlike treatment
individuals, those related to biological of unlike individuals, in proportion to the
27variation and freely chosen health- differences between them . The former of
damaging behaviour are not likely to be these is concerned with ensuring that two
considered inequitable because they are individuals, who are alike in all respects,
either unavoidable or «fair». However, including their health status, are treated
differentials due to health damaging equally. The latter is concerned with
behaviours not based on informed the extent to which individuals who are
choices, exposure to unhealthy living and unequal should be treated differently. In
working conditions, or inadequate access health care it can be refl ected by the aim
28to health and social services are more of unequal treatment for unequal need ,
likely to be judged avoidable and unfair i.e. more treatment for those with serious
25and thus constitute health inequality . conditions than for those with trivial
But at the same time, inequality with complaints.
respect to something else might be a
26 Birch S, Eyles J, Newbold B «Equitable ac-
cess to health care: Methodological extensions to the
analysis of physician utilization in Canada». Health 23 World Health Organisation (2000) World
Economic, (1993), in press.Health Report. Geneva
27 Culyer AJ «Equity-some theory and its 24 Buchard EG, Ziv E, Coyle N, et al. «The
policy implications». Journal of Medical Ethics 27, importance of race and ethnic background in bio-
(2001), 275-83.medical research and clinical practice» New England
28 Raine R, Hutchings A, Black N «Is publicly Journal of Medicine 348, (2003), 1170-5.
funded health care really distributed according to 25 Whitehead M «The concepts and principle
need? The example of cardiac rehabilitation in the of equity in health». International Journal of Health
UK». Health Policy 67, (2004), 227-35. Services 22, (1992), 429-445.
Cuad. Bioét. XIX, 2008/2ª 359Virginia La Rosa-Salas y Sandra Tricas-Sauras
In order to explain the global prepon- Proposed pathways include the envi-
derance of health inequities, many ronment in which people live, such
authors have attempted to elucidate the are their living conditions and the
pathways by which inequities in health distribution of income in their country
37,38,39come to be and are perpetuated. One or state . Still other hypothesized
of the most prevalent theories concerns pathways involve the political and policy
the role of socio-economic status, context, including the extent of primary
29 30 40measured by education , occupation , care , the geographic distribution and
31 41,42,43,44and/or income . Other explanations mix of health services , the fairness
involve social discrimination based
32,33,34 35,36on gender or race/ethnicity .
29 Mackenbach JP, Kunst AE, Groenhof F,
Borgan JK, Costa G, Faggiano F, et al. «Socioeconomic
inequalities in mortality among women and among 37 Wilkinson RG «Income distribution and
men: an international study». American Journal of life expectancy» British Medical Journal 304, (1992),
Public Health 89 (12), (1999), 1800-6. 165-68.
30 Sacker A, Bartley M, Firth D, Fitzpatrick 38 Ross N, Wolfson M, Dunn J, Berthelot
R «Dimensions of social inequality in the health J, Kaplan G, Lynch J «Relation between income
of women in England: occupational, material, and inequality and mortality in Canada and the United
behavioural pathways». Social Science and Medicine States: cross sectional assessment using census
52, (2001), 763-81. data and vital statistics» British Medical Journal 320,
31 Turrell G, Mathers C «Socioeconomic (2000), 898-902.
inequalities in all-cause and specific-cause mortality 39 Lochner K, Pamuk E, Makuc D, Kennedy
in Australia: 1985-1987 and 1995-1997». International B, Kawachi L «State-level income inequality and
Journal of Epidemiology 30 (2), (2001), 231-9. individual mortality risk: a prospective, multilevel
32 Standing H «Gender and equity in health study» American Journal of Public Health 91 (3), (2001),
sector reform programmes: a review». Health Policy 385-91.
and Planning 12, (1997), 1-8. 40 Shi L, Starfield B «Primary care, income
33 Mackenbach JP, Kunst AE, Groenhof F, Bor- inequalities, and self-rated health in the United
gan JK, Costa G, Faggiano F, et al. «Socioeconomic States: a mixed-level analysis» International Journal
inequalities in mortality among women and among of Health Services 30 (3), (2000), 541-55.
men: an international study». American Journal of 41 Braveman P, Tarimo E «Health screening,
Public Health 89 (12), (1999), 1800-6. development and equity» Journal of Public Health
34 Kawachi I, Kennedy B, Gupta V, Prothrow- Policy 17 (1), (1996), 14-27.
Stith D «Women’s status and the health of women 42 Kinman E «Evaluating health service equity
and men: a view from the States» Social Science and at a primary care clinic in Chilimarca, Bolivia» Social
Medicine 48 (1), (1999), 21-32. Science and Medicine 49 (5), (1999), 663-78.
35 Davey Smith G, Neaton JD, Wentworth D, 43 Hippisley- Cox J, Pringle M «Inequalities in
Stamler R, Stamler J «Mortality differences between access to coronary angiography and revascularisa-
black and white men in the USA: contributions of tion: the association of deprivation and location
income and other risk factors among men screened of primary care services» British Journal of General
for the Multiple Risk Factor Intervention Trial Practice 50 (455), (2000), 449-54.
(MRFIT)» Lancet 351 (9107), (1998), 934-9. 44 Gravelle H, Sutton M «Inequality in the
36 Mclntyre D, Gilson L «Redressing dis-ad- geographical distribution of general practitioners
vantages: promoting vertical equity within South in England and Wales 1974-1995» Journal of Health
Africa» Health Care Analysis 8 (3), (2000), 235-58. Services Research & Policy 6 (1), (2001), 6-13.
360 Cuad. Bioét. XIX, 2008/2ªEquity in health care
45 54of health fi nance and political, social ‘utilisation’. Maynard stated that a need
46,47and economics relationship . for medical care exists when there is an
As a consequence, it is not appropriate effective and acceptable treatment or cure.
to determine for instance, access to care by However, a demand for care exists when
willingness and ability to pay nor merits an individual considers he has the need
of individuals based on judgements about and wishes to receive care. Utilisation is
their contribution to society. However this understood when an individual receives
can be replaced by a rationing mechanism the care needed. Need is not necessarily
48,49,50based on ‘need’ . Unfortunately, expressed as a demand, and demand is not
as numerous authors have noted, the necessarily followed by utilisation, while,
concept of ‘need for health care’ is far on the other hand there can be a demand
51from unambiguous . However, it can and utilisation without a real underlying
be concluded that need refers to some need for the particular services used.
circumstances requiring some course of In Spain, for example, the utilisation of
action, particularly in health, some care health system without a real necessity can
52,53or treatment . often be seen in the case of older people
A more fi nal distinction has to be made when visiting GPs, where the ‘need’ could
55among ‘need’ for medical care, ‘demand’ be many times questionable .
for care and form of use of services or
2. Why there should be a concern about
equity in health care?
45 Rice N, Smith P «Capitation and Risk
Adjustment in Health Care Financing: An
International Progress Report» The Milbank Quarterly Given the above distinctions, it is time
79 (1), (2001), 81-113. to refl ect on some foundational questions.
46 Navarro, V «Health and equity in the world
Why be concerned with equity in health in the area of «globalization». International Journal
of Health Services 29(2), (1999), 215-26. care? Should we be more concerned about
47 Lynch J, Davey Smith G, Hillemeier M, inequalities in health care than about
Shaw M, Raghunathan T, Kaplan G «Income
inequalities in other dimensions such as inequality, the psychosocial environment, and
income?health: comparisons of wealthy countries» Lancet
358, (2001), 194-200. Part of the fi rst answer is that health
48 Culyer AJ Need and the National Health care serves a signifi cant mean to recover
Service. Martin Robertson, London, (1976).
56or maintain individuals’ health . In 49 Braybrooke D Meeting Needs. Princeton
University Press, Princeton, (1987).
50 Goddard M, Smith P «Equity of access to
54 Maynard A «Rationing health care: an health care services: theory and evidence from the
exploration» Health Policy, 49 (1-2), (1999), 5-11.UK» Social Science & Medicine 53, (2001), 1149-62.
55 Fernández-Mayoralas G, Rodriguez V, Rojo 51 Culyer AJ «Need — the idea won’t do— but
F «Health services accessibility among Spanish we still need it» Social Science & Medicine 40, (1995),
elderly» Social Science & Medicine 50, (2000), 17-26. 727-30.
56 Culyer AJ «Equity- some theory and its 52 Guillon R Philosophical Medical Ethics. Wiley,
policy implications. Journal of Medical Ethics 27, New York, (1985).
(2001), 275-8353 Braybrooke D, op.cit. 49
Cuad. Bioét. XIX, 2008/2ª 361Virginia La Rosa-Salas y Sandra Tricas-Sauras
general, through the ages, health has can extend the lives of children and of
been considered a precondition for older people. It can make it possible for
57happiness. Descartes asserted that a person to walk, when, without health
health is the highest good. In «Discours care, that person would be permanently
de la Méthode» Descartes writes: «…the bedridden and, as said above, health care
preservation of health is …without doubt can reduce the pain and distress of people
the fi rst good and the foundation of all who are terminally ill.
58the other goods of this life.» Culyer has As a result, these arguments give
argued that good health is in general a the answer to the second formulated
necessary precondition for the attainment question in this section as well. Health
of happiness. Thus, equity in health care is a special good, which has both
is an ethical imperative not only because intrinsic and instrumental value. Health is
of the intrinsic worth of good health, or regarded to be critical because it directly
the value that society places on good affects a person’s well being and is a
health, but because, without good health, prerequisite to their functioning as an
people would be unable to enjoy life’s agent. Inequalities in health are thus
other sources of happiness. From the closely tied to inequalities in the most
second half of the XX Century most of basic freedoms and opportunities that
the states in the Western World assume people can enjoy. In contrast, for instance,
the responsibilities to provide the health there are reasons to recognise income
care which was before on the hands of inequalities.
religious institutions, charities, family or There are economic reasons why
private practitioners. According to this income inequalities must be accepted.
point of view, society would have an Economists often assert, with some
ethical duty to provide health care. justifi cation, that income incentives are
So, equity in the health care sector is needed to elicit effort, skill, enterprise
also really essential because the scarcity and so on. These incentives—and the
of resources means that choices have to be implied income inequalities-have the
made about who will be given the ‘right’ effect of increasing the size of total income
of access to care and who, as a result of from which, in principle, the society, as a
negation, will be left in a painful situation, whole, can benefi t (for example, through
59and, in the worst case, to die . Health care taxation).
But this incentive argument would
57 Descartes R Discours de la Mèthode, Sixiè- not seem to apply in the case of health.
me Partie. Paris. éd. Descartes: (Euvres et Lettres),
Inequalities in health do not directly (1637)
58 Culyer AJ «The rationing debate: Maximis- provide people with similar incentives
ing the heath of the whole community: The case for» to improve their health from which
British Medical Journal 314, (1997), 667-69.
society as a whole benefi ts. The problem 59 Culyer AJ «Equity- some theory and its
appears when, as the empirical literature policy implications» Journal of Medical Ethics 27,
(2001), 275-83.
362 Cuad. Bioét. XIX, 2008/2ªEquity in health care
60,61,62demonstrate , inequalities in income is determined by the extent to which the
do produce inequalities in health–with objective of the activity is achieved and
richer people generally having better the cost of resources used in undertaking
63 66health . One of the reasons for this can the activity . On the other hand, health
be that low income leads to poor living benefi t can be measured in units that
circumstances, less awareness of health refl ect the preferences of the community,
and higher level of risk. For instance, considering their desire for increased
tobacco and alcohol are consumed more longevity but also the value they place
by low social classes than higher classes, on limitation of function, pain and other
64which constitutes a high risk for health . dimensions of health-related quality of
67life . This procedure weights the health
3. Equity-effi ciency trade-off gains of each individual equally and leads
to a maximization of health gains.
Health care policy makers consider Considering the following scene could
as goals of health services: effi ciency (the be helpful for discussion. Observed fl aws
production of health status improvement in tests and treatment for a patient’s heart
at lower cost), benefit and equity disease were claimed to have derived
65(‘fairness’) . The effi ciency of an activity from the attitudes of the health care staff
towards the patient’s age and dementia
60 Ross N, Wolfson M, Dunn J, Berthelot (there were undoubtedly shortcomings
J, Kaplan G, Lynch J «Relation between income
in the treatments provided, but these inequality and mortality in Canada and the United
States: cross sectional assessment using census could not be shown to derive from the
data and vital statistics» British Medical Journal 320, reasons claimed; admittedly, one of the
(2000), 898-902.
doctors who had treated the patient 61 Lochner K, Pamuk E, Makuc D, Kennedy
said in defence of his own conduct that B, Kawachi L «State-level income inequality and
individual mortality risk: a prospective, multilevel the hospital did not have the fi nancial
study» American Journal of Public Health 91 (3), (2001), resources to implant a pacemaker in
385-91.
every «demented old person»). The 62 Mellor JM, Milyo J «Re-examining the
evidence of an ecological association between «demented old person» in this case was
income inequality and health» Journal of Health actually a 60-year-old employed woman
Politics, Policy and Law 26 (3), (2001), 487-522.
whose paramnesia was largely due to 63 Lochner K, Pamuk E, Makuc D, Kennedy
B, Kawachi L «State-level income inequality and her depression, and partly to her chronic
individual mortality risk: a prospective, multilevel heart disease, of which she later died.
study» American Journal of Public Health 91 (3), (2001),
385-91.
64 Rodriguez E, Pinto JL «The social value of 66 Birch S, Eyles J, Newbold B «Equitable
health programmes: is age a relevant factor?» Health access to health care: Methodological extensions
Economics 9, (2000), 611-621. to the analysis of physician utilization in Canada»
65 Baiman R «Why equity cannot be separated Health Economic, (1993), in press.
from efficiency: the welfare economics of progressive 67 Patrick DL, Erickson P Health status and
social pricing» Review of Radical Politics Economics 33, health policy: allocating resources to health care. Oxford
(2001), 203-221. University Press, New York, (1993).
Cuad. Bioét. XIX, 2008/2ª 363Virginia La Rosa-Salas y Sandra Tricas-Sauras
In this case, it can be noticed one of the of care and not only of the number of
perversions of costs rationalization when patients attended.
affecting human beings forgetting that As a conclusion, as many authors
69,70they are persons. Indeed, to rationalize state it can be said that the goal of
the costs has the benefit of saving effi ciency (in this context maximizing
money that can be applied to aiding aggregate welfare) cannot be obtained
more patients. However, the saving without attention to equity (cross-
must not be done at the cost of other individual welfare comparison).
patients’ health and without objective Moreover, it is known that inevitable
criteria. In this example, to declare a inequalities are going to exist always.
woman of 60 years old and to reserve For instance, even if the cost of health
care for younger people is a mistake. care at the point of delivery is equal
Nowadays, it is acknowledged that due throughout a country, patients in
to the increase of the life expectancy predominantly rural populations will,
and to the aging of the population in on average, have to travel further to
the European countries, 60 years old is the hospital than patients in urban
a medium age. populations. Furthermore, even if the
When considering effi ciency, it also ‘time and disruption’ costs are the same,
worth paying attention to the issue of the proportionate burden of these costs
quality of care. For example, considering on the patient may differ (e.g. €15 is a
two equal sized groups of doctors seeing much more signifi cant burden to a poor
the same number of patients, it is easy patient than to a rich patient).
to think that both of them are working Health’s services have traditionally
with the same level of effi ciency. But it in Europe, for about 50 years, been a
could the possibility exist that patients function provided by the State to socialize
in one group recovered from their illness the medical care, which before was only
immediately, while those in the other accessible to the more favoured layers
71group died. Did they work with the same of the society . The national services of
effi ciency? So, as a result, the doctor’s health were created at the same time as
productivity will depend on the supply,
quality and use of other inputs (services
68provided) such as the number of nurses, 69 Feldstein MS «Equity and efficiency in
public sector pricing: the optimal two- part tariff» equipment, patient compliance, etc. In
The Quarterly Journal of Economics 86 (2), (1972), 175-general, it will depend on the quality
187.
70 Baiman R «Why equity cannot be separated
from efficiency: the welfare economics of progressi-
ve social pricing» Review of Radical Politics Economics68 Brommels M, Jaaskelainen M «Measures
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