Table Of ContentHEALTH EQUITY
THE KEY FOR TRANSFORMATIONAL CHANGE
AN ATLAS THROUGH GRAPHS AND MAPS REVEALING THE NEED
FOR AN INTERNATIONAL, NATIONAL AND SOCIAL CHANGE TO ENABLE THE
UNIVERSAL RIGHT TO HEALTH
JUAN GARAY
NEFER KELLEY Y DAVID CHIRIBOGA
COLLABORATORS
WA525
G212e Garay Amores, Juan
Equidad en salud, la llave para un cambio
transformacional = Health equity, the key for
transformational change / Juan Garay Amores. – -
San José, C. R.: EDNASSS-CCSS, 2015.
260 p.; il.; 21 x 27 cm.
ISBN: 978-9968-916-55-4
1. EQUIDAD EN SALUD. 2. ESTADÍSTICAS DE SALUD.
3. SALUD GLOBAL. I. Título
Editing by:
©Editorial Nacional de Salud y Seguridad Social (EDNASSS). 2015
Centro de Desarrollo Estratégico e Información en Salud y Seguridad Social (CENDEISSS)
Caja Costarricense de Seguro Social
Tel.: (506)2221-6193 Ext. 217
Arts and impression: Litografía e imprenta Lil S.A.
All rights reserved.
This publication was authorized on May 04th, 2015, by Juan Garay, intellectual author.
Prologue by Dra. María del Rocío Saénz Madrigal, Executive President, Caja Costarricense de Seguro Social,
San José, Costa Rica.
EDNASSS: an editorial at service of health and social security
To Nefer, my life companion in all,
and constant inspiration.
To my parents, who always encouraged me
to follow my dreams.
México City, 2015.
This image is a work made by my father, Enrique Garay. It represents the multiple, perhaps endless, equity curves that coexist in
the universe. The distortion that the human species suffers from extreme hoarding of their resources and depletion of nature that
sustains it, all this has a tragic price in avoidable deaths. But mostly, it is a tribute to my father and his constant inspiration
and support in my life. Juan Garay.
(cid:1)
TABLE OF CONTENTS
About the author(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)....................(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)..(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1).(cid:1).(cid:1)... 7
Prologue(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1). 9
Foreword(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1) 11
I. Summary.(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)..(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1).(cid:1)..(cid:1) 13
II. Introduction to the challenge of health equity.(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1).(cid:1)(cid:1)(cid:1). 14
III. Rescuing and updating the ethical principles of health in XXIst Century.(cid:1)(cid:1).(cid:1)(cid:1)(cid:1)(cid:1)(cid:1). 16
Updating the World Health Organization definition of health.(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)...... 16
Recognition and operationalization of the right to health: State, international, social and
individual responsibilities.(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)..(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)..(cid:1)...... 17
Setting principles of global health.(cid:1)(cid:1).(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)..(cid:1)(cid:1)(cid:1). 18
IV. Equity vs inequality.(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1). 21
The neutral statistical approach (cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)..(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1). 21
Main health influencing variables(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1).. 26
Inequalities across disaggregating variables(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)... 29
Inequality vs inequity.(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1).(cid:1). 31
The relevance of estimating the burden of health inequity.(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)............. 32
Burden of health inequity by best standards of influencing variables(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1).. 32
Burden of inequity by thresholds of feasibility and sustainability(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1).. 36
V. The burden of global health inequity.(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)..(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1). 44
Burden of inequity in loss of life expectancy(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1) 44
Burden of global health inequity in avoidable deaths(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1). 45
Number of avoidable deaths due to global health inequity(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1).(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1).(cid:1). 46
Proportion of deaths which are avoidable(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)...(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1).(cid:1)(cid:1) 49
Burden of global health inequity by life years lost(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1). 54
Distribution of avoidable life years lost by age groups, sex and time..(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1).(cid:1)... 55
Demographic pyramid deviations due to global health inequity.(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1).. 56
VI. Economic equity to enable global health equity and the universal right to health.(cid:1).(cid:1).. 57
World´s national average GDP pc distribution(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1).....(cid:1)..(cid:1)(cid:1)(cid:1)(cid:1). 57
Minimum dignity threshold(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1).. 61
Equity (fair inequality) thresholds and ethical redistribution of GDP(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1) 61
Distribution of the world´s population in relation to the equity thresholds(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)... 63
Distribution of the world´s GDP in relation to the equity thresholds(cid:1)(cid:1)..(cid:1)(cid:1)(cid:1).(cid:1)(cid:1)(cid:1)(cid:1)....(cid:1). 66
World´s population and GDP in the "equity zone"(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1).(cid:1)(cid:1)(cid:1)(cid:1).(cid:1) 70
Ethical GDP redistribution required to enable global health equity(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1).. 71
Redistribution from excess (hoarding) countries to deficit (below mDTh threshold) countries.(cid:1) 74
Redistribution levels if lower limits of HFS models are taken as minimum dignity threshold....... 76
Comparative analysis of ODA with redistribution required for global health equity...................... 79
Health equity, the key for transformational change 5
VII. National health equity(cid:1)(cid:1).(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1).(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)..(cid:1). 82
Avoidable deaths by global health equity, due to national inefficiency/inequity(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1).(cid:1) 82
Life expectancy adjusted to inequality(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1).. 83
Health equity monitor(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1).(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1).(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)........... 84
Framework for international reporting on national health equity(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1).. 86
VIII. Holistic health index(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1).(cid:1). 87
Methodology(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1).(cid:1)(cid:1)(cid:1)(cid:1).(cid:1)(cid:1)(cid:17)(cid:17)(cid:17) 87
Estimates of hoarding and exhausting negative impact on others health (cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)..(cid:1)... 87
Relation between hoarding and exhausting and the questioning of economic growth beyond
the hoarding threshold(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)..(cid:1)(cid:1)...(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)..(cid:1)(cid:1)(cid:1). 88
Dimensions of the holistic health index(cid:1).(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)..(cid:1).(cid:1)(cid:1)(cid:1).... 90
Holistic health index(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1).(cid:1) 93
IX. Conclusions and political proposals(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)..(cid:1). 96
Conclusions(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)..(cid:1) 96
Proposals(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)..(cid:1)(cid:1)(cid:1) 97
Research agenda(cid:1)(cid:1)(cid:1)(cid:1)(cid:1).(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)..(cid:1). 98
International level.(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1) 98
National level..(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)..(cid:1) 98
Community and individual levels(cid:1)(cid:1)(cid:1)(cid:1)..(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1).(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1).(cid:1)... 99
X. Annexes(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)... 100
Annex 1: Burden of global health inequity in loss of life expectancy(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)... 100
Annex 2: Burden of global health inequity in loss of life expectancy(cid:1)(cid:1)(cid:1)...(cid:1)(cid:1)(cid:1)(cid:1)........(cid:1)... 105
Annex 3: Burden of global health inequity in proportion of deaths which are avoidable by
GHE(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)..(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)..(cid:1)(cid:1)... 110
Annex 4: Deficit or excess (-ve) GDP by global health equity economic thresholds(cid:1)(cid:1)(cid:1)(cid:1)(cid:1) 115
Annex 5: Holistic health index 2012(cid:1)(cid:1)(cid:1)(cid:1)...(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)..(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1) 120
Annex 6: List of tables..(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1).(cid:1)(cid:1)(cid:1). 123
Annex 7: List of figures(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1) 124
Annex 8: List of acronyms(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)..(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1)(cid:1) 127
6 Health equity, the key for transformational change
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ABOUT THE AUTHOR
Juan Garay is a medical doctor from Spain, specialized in internal medicine, infectious diseases and
public health. Since the 80s, he has combined clinical, public health, research and design on health
systems (as some of the early AIDS treatment programs in Africa), in many countries in Europe, Africa
and America, with governments, universities and non-state actors.
In 2002 he joined the European Union, working initially in the design of EU health cooperation policies
and programs. He gradually explored the roots of health in the areas of human rights -coordinating the
work towards the EU external policy on children rights- and the multisectorial dimensions of health which
led to his coordination in the development of the EU policy on global health. In relation to global health
challenges, he has focused on research on global health equity in the last years, now reflected in this
book. Since 2013 he works as head of EU cooperation in Mexico, with special emphasis on analysis and
policy dialogue on social cohesion.
In parallel to his responsibilities in the EU, Juan Garay is professor of global health in Granada and
Madrid, advisor to the South American Institute of Health Governance, visiting lecturer in UC Berkeley, as
well as guest lecturer in several universities in America and Europe, where he continues research and
academic activities in relation to health and social equity metrics.
His passion for justice and health, within and between generations, is reflected in a novel which mixes his
life experiences with his vision of the future (http://www.bubok.es/libros/209095/Valentia-y-Ternura-
Todos-somos-la-misma-energia).
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8 Health equity, the key for transformational change
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PROLOGUE
Regarding the health of our populations, there converge multiple social organizations, and academic and
labor sectors that debate and coordinate over a minimum basis of consensus, something that in recent
years we have considered sacred and immutable: the concept of health, its enjoyment as a fundamental
right, and its relevance as a part of sustainable development.
Starting from this common base, with somewhat less consensus, we attempt to define the organized
response of society to this collective aspiration of health. The role of the individual, the State, the private
sector, and intergenerational responsibility have a wider range of conceptual, ideological, and cultural
approaches; so, depending on how these factors come together, we also find a greater variance in
performance grades and justice of health systems.
The exponential speed of change as the main feature of our times, coupled with the inability we have had
to ensure optimal conditions for everyone, ironically, could have led us to an acceptance of such basic
concepts as "universal and timeless" or even -to those who often reject critical and creative thinking in
favor of the status quo- as an "unattainable aspiration", or, in other words, as unquestionable ideals to be
supported by all ages and generations.
However, those same justifications demand that we pause to deconstruct and review the foundation of
our actions. We must do it in such a way that we can understand if the broad marginal gaps of the
performance of our health systems originate from those paradigms that have governed modern health
management, and, therefore, could now contribute to their reduction by way of a revised and renewed
ethic, and from the challenges posed by this historical moment.
This exercise, deep and scientific as it may be, cannot ignore that there is a clear social demand for the
pragmatic implications of every effort we make in the construction and management of health. In this
sense, the debate on health equity (with its intrinsic framework of social justice) and sustainability in
health, and various complementary frameworks for action such as global health, must be a path to
produce viable policies, swift actions, useful tools, and concrete and measurable health impacts of
current and future populations from different areas of health management (the individual, the local
service networks, health systems, and the global community).
The work of Dr. Garay serves three main purposes in this roadmap. The first is to introduce the renewed
debate over our paradigms or basic concepts mentioned above: health, the right to health and
sustainable development. These should all be seen with a critical view of our new century and assuming
that it is an ethical responsibility to adapt our conception of the world into a vision focused on the health
needs of the people, understanding needs as a concept that reconciles the biases of supply and demand
in health through evidence and real participation.
The second purpose, addressed with an important proactive approach, is to propose a concrete
measurement of the discourse of (in) equity and the dimension -as yet ethereal- of the best achievable
status of health. Concepts such as the burden of inequity or the holistic health index make way for the
new generation of metrics to address the analysis of health systems, the management of public policies,
and their performance models, and move them toward more humanistic and sustainable approaches.
This idea, if it is good for any health system, is mainly valuable for middle- and low-income countries.
These two groups of countries urgently deserve strategies differentiated and tailored to the availability of
resources to organize their health systems, and a guarantee for their people of the best possible
performance in health status, without falling back on the old idea of "unsustainable spending focused on
disease care".
Health equity, the key for transformational change 9
