Richard Skolnik – Author of Global Health 101
Equity and equality issues are central to Global Health and we want all of our students to be able to take an “equity lens” to Global Health concerns. Thus, it is critical to introduce equity and equality early in our courses and to reinforce these themes throughout the courses.
In my Global Health courses, I first try to help students gain an understanding of the importance of equity and equality issues and how they might best be defined. Although the piece is a bit difficult to read and might be seen as too philosophical by some, I ask my students to read “Why Health Equity", by the Nobel Laureate in Economics, Amartya Sen.
For those wishing to read more of the most influential articles on health equity, I refer them to a wonderful piece by Davidson Gwatkin called: “10 best resources on … health equity”.
Usually, we then turn to examining the groups that might be subject to inequities and, therefore, inequalities in health opportunities or in health outcomes. Here, the goal is to help students go beyond identifying only the groups with which they are likely to be most familiar. Most students, for example, will readily identify women, lower income, less educated, ethnic minority, and rural people as likely to suffer health inequities and inequalities. However, it may take a little provocation of the students to help them to also identify people from sexual minorities, prisoners, or those who suffer from stigmatizing conditions, such as obesity, fistula, TB, HIV, leprosy, or mental health problems.
We then take a look at the ways in which health systems might treat people inequitably and in a manner that leads to inequitable outcomes. Here, you will find that most students understand access and coverage issues. However, fewer students will have a good feel for issues related to quality, the respect and cultural sensitivity shown to patients, utilization of services, the fairness in the way the health system is financed, or the overall relationship between who pays for health services and who benefits from them.
The next thing we do is look together at some of the key data from another piece that Davidson Gwatkin and his World Bank colleagues prepared in 2007 but which remains exceptionally helpful to the study of health equity and equality in low- and middle-income countries. This is “Socio-economic Differences in Health, Nutrition, and Population Within Developing Countries” available at http://siteresources.worldbank.org/INTPAH/Resources/IndicatorsOverview.pdf
This piece provides data on a range of coverage, utilization, and outcome issues for 56 low- and middle-income countries.
As we go over some of the data in this piece, I ask my students to identify the main themes that emerge. One important theme on which I dwell is that “not all inequalities are created equal.” Rather, we see that while there are very wide disparities in access to a skilled birth attendant by income quintile, the disparities in use of oral rehydration therapy are relatively small. I then probe the students to examine why this might be the case, what implications this finding has for policy, and how they would make their country a “positive outlier” if they were the Minister of Health or Finance.
We usually end our initial discussions of health equity and equality by examining a number of countries from an equity and equality perspective. To guide us, we use is a piece by Abdo Yazbeck called “Attacking Inequality in the Health Sector, A Synthesis of Evidence and Tools,”
Available at: http://siteresources.worldbank.org/INTPAH/Resources/Publications/YazbeckAttackingInequality.pdf
On page 139, the piece lays out what I find to be a very useful analytical checklist for examining issues in health inequality.
We use this piece to take a kind of “speed dating” approach to country cases. Although my courses focus on low- and middle-income countries, I usually ask the students to examine the US, Canada, and Australia. I then also ask them to look at cases from low- and middle income countries, such as Guatemala, Bolivia, Brazil, South Africa or India. Normally, we break the class into groups, give each group a certain amount of time to prepare their country case, and then have them present to the whole class. In their 6-minute presentation, I ask them to briefly - but with evidence - comment on the following:
- What are the main issues in health equity and equality?
- Who suffers them most?
- Why does this happen?
- What efforts has the country made to address inequities and inequalities in health?
- What has been their effect?
- What can other countries learn from the experience of this country?
Although this approach could be a bit shallow, generally we find that the students learn a great deal quickly about how to think conceptually about health equity and inequality, about how to apply an equity and equality lens to different countries, and about how these issues play out in a number of countries. I then try to reinforce these lessons throughout the rest of the course, as noted earlier.
Thanks to Rachel Skolnik Light for her comments on the draft of this blog.
Richard Skolnik is a Lecturer at the Yale School of Public Health, where he teaches global health courses at the undergraduate and graduate levels. Richard was previously an Instructor in Global Health at The George Washington University, the Vice President for International Programs at the Population Reference Bureau, and the Executive Director of the Harvard School of Public Health PEPFAR program. Richard worked at the World Bank from 1976 to 2001, last serving as the Director for Health and Education for South Asia. Richard is the author of Global Health 101, a comprehensive, introductory text on global health.