IN A NUTSHELL
Author's note
…Health equity cannot be achieved simply by increasing resources, expanding services, or improving average health indicators. It depends fundamentally on how health-related resources, opportunities, risks, costs, and benefits are distributed across different groups within society.
The pathology of health equity shifts attention from merely measuring inequalities to identifying the mechanisms that create and reproduce them. Such an approach requires simultaneous consideration of access, quality of care, financing, resource allocation, governance, power, social participation, intersectoral policies, health-system reforms, digital technologies, and multidimensional vulnerability…
By Fahriba Shahraki Sanavi 1, 2
1.Associate Professor, Health Promotion Research Center, Zahedan University of Medical Sciences, Zahedan, Iran. Orcid No: 0000-0002-6937-0793. Email: faribasanavi@gmail.com
2.Center for Development and Studies, Academy of Medical Sciences of the Islamic Republic of Iran, Tehran, Iran
The Pathology of Health Equity: The Foundation of Equitable Governance
Introduction
Health equity is a fundamental component of fair and effective health systems. Despite remarkable advances in medical science, health technologies, and access to healthcare services, unjust differences in health outcomes persist across societies and, in some contexts, have even widened. These differences are not merely reflections of variations in individual health status; rather, they reflect how opportunities, resources, power, and responsibilities are distributed across society.
Health equity cannot be reduced to equal access to healthcare services or the provision of identical care to everyone. Equity requires that all individuals, regardless of their social, economic, geographic, cultural, or political circumstances, have a fair opportunity to attain and maintain good health. From this perspective, health policies and programmes should consider not only their overall effects but also how their benefits, costs, and risks are distributed across different population groups.
The fundamental question, therefore, is not simply how successful a health system is, but who benefits from its achievements, who remains excluded, and what mechanisms create or reproduce these differences. This perspective shifts health equity from a broad normative aspiration to a subject of systematic analysis and pathology.
Health Equity: Beyond Equality
Equality and equity in health are closely related but conceptually distinct. Equality refers to the uniform distribution of resources, services, or opportunities, whereas equity takes into account differences in needs, living conditions, and the barriers faced by different population groups.
Consequently, providing identical services to groups with different needs, resources, and social circumstances does not necessarily produce equitable outcomes. Advancing equity may require allocating greater resources to populations experiencing greater deprivation, vulnerability, or structural barriers.
From this perspective, assessing equity requires moving beyond population averages. National or regional averages may indicate an overall improvement in health while substantial gaps between social groups remain. Examining how health-related opportunities, resources, benefits, and costs are distributed across populations is therefore an essential component of equity assessment.
Social and Structural Determinants of Health
Health does not develop in a vacuum. The economic, social, environmental, and political conditions in which people are born, grow, work, and live fundamentally shape their opportunities to achieve good health.
Income, education, employment, housing, food security, the physical environment, social support, and access to resources are among the factors that can produce divergent health trajectories across population groups. Yet these factors themselves are shaped by broader structures of power, policymaking, and decision-making.
Consequently, analyses of health inequalities are incomplete without considering their structural and political determinants. Economic policies, tax systems, labour-market policies, social protection programmes, resource-allocation decisions, and governance structures can directly or indirectly influence the distribution of opportunities for health.
Recent research on the political determinants of health further demonstrates that governance, decision-making processes, power relations, political discourse, and structures of democratic participation are important forces shaping health equity (Duric et al., 2026).
The Pathology of Health Equity
The pathology of health equity can be understood as an approach to identifying, analysing, and explaining the mechanisms through which avoidable and unjust differences in health are created, sustained, or reproduced.
Within this approach, equity is not merely an anticipated outcome of health policies; it becomes an explicit object of systematic assessment. It is necessary to determine which components of the health system or broader social structures generate unjust gaps, where these gaps become amplified, and which population groups bear the greatest burden of disadvantage.
The pathology of health equity can be examined across several major domains.
- Equity in Access to Healthcare Services
Equitable access extends beyond the physical availability of services. Geographic distance, direct and indirect costs, waiting times, service capacity, cultural and linguistic barriers, and access to health information can all influence people’s actual ability to use healthcare services.
The presence of a healthcare facility in a particular area does not necessarily guarantee equitable access for its residents. If low-income populations, people living in deprived areas, older adults, or specific social groups are unable to use services because of cost, transportation constraints, or cultural barriers, nominal availability has not translated into meaningful access.
- Equity in Quality and Care Experience
Equity concerns not only whether people receive care, but also the quality of the care they receive.
Two groups may have access to the same type of service while experiencing differences in quality of care, communication with healthcare professionals, respect for patient preferences, time devoted to care, involvement in decision-making, and overall care experience.
From this perspective, quality and equity are not separate concepts. High-quality care has meaning from an equity perspective only when it is attainable across population groups. Research on diversity-sensitive care likewise highlights the importance of responding to cultural, social, and individual differences and taking patients’ experiences into account (Lauwers et al., 2024).
- Equity in Health Financing
The way healthcare is financed is one of the major pathways through which inequalities can either be created or reduced. Financing arrangements may place a disproportionate economic burden on groups that are already financially vulnerable.
Out-of-pocket payments, co-payments, and other direct payments may restrict the use of essential services among low-income households and increase the risk of financial hardship associated with healthcare expenditure.
Recent systematic reviews indicate that the distribution of healthcare payments across socioeconomic groups can be highly unequal and that financing systems should explicitly consider their distributional consequences (Luyten & Tubeuf, 2025; Shaltynov et al., 2024).
- Equity in Primary Care Financing
Primary care occupies a central position in reducing health inequalities because it is often the first point of contact with the health system and can play an important role in prevention, early diagnosis, and the management of chronic conditions.
However, the allocation of resources to primary care does not always correspond to population need. Areas experiencing greater socioeconomic deprivation may have greater health needs while receiving fewer financial and human resources.
Evidence from an umbrella review indicates that primary care funding arrangements can influence health inequalities and that resource-allocation mechanisms should account for differences in population need and deprivation (Holdroyd et al., 2025).
- Resource Allocation and Equity
Resource allocation in health systems inevitably involves choices among competing needs under conditions of limited resources. Decisions concerning budgets, workforce, infrastructure, technologies, and services should therefore be assessed not only in terms of efficiency but also in terms of their distributional consequences.
A policy may be highly effective on average while widening health gaps if its benefits are distributed disproportionately. Thus, policy effectiveness does not necessarily imply policy equity.
An equity-oriented analysis requires examining which groups derive the greatest benefits from resource allocation and which groups are less likely to benefit.
- Governance and the Distribution of Power
Health equity is closely linked to who holds decision-making power, whose voices are heard, and which groups are less visible in policymaking processes.
Political, economic, and institutional power can shape health priorities, resource allocation, and policy design. Accordingly, an analysis of equity that does not examine power remains incomplete.
Evidence from systematic research on the political determinants of health indicates that governance structures, decision-making processes, and power relations play important roles in defining and shaping health equity (Duric et al., 2026).
Social Participation: From Presence to Influence
Social participation is an important principle of equitable governance; however, the presence of people in decision-making processes does not, in itself, constitute meaningful participation.
Participation can contribute to equity when individuals and communities have not only opportunities to express their views but also genuine capacity to influence decisions and policy priorities.
A distinction should therefore be made between presence, being heard, and having influence. Tokenistic participation, without meaningful transfer of power or influence over decision-making, may even contribute to reproducing existing inequalities.
A systematic review of social participation in health likewise highlights the importance of assessing the quality and degree of influence in interactions between communities and policymakers (Gupta et al., 2023).
Intersectoral Governance and Health in All Policies
Many important determinants of health lie outside the health sector. Education, transport, housing, employment, the environment, agriculture, and social policies can all influence health and its distribution across society.
Responsibility for achieving health equity therefore cannot rest solely with ministries of health or the healthcare system. The Health in All Policies approach seeks to incorporate the health implications of decisions made across sectors into policymaking processes.
However, effective implementation requires mechanisms for intersectoral coordination, accountability, political commitment, and institutional capacity. Evidence suggests that policymaking processes, relationships between organisations, and interactions among political actors can influence the implementation of Health in All Policies (Lilly et al., 2023).
Equity in Health-System Reform
Health-system reforms are often undertaken to improve efficiency, control costs, enhance quality, or expand access. Yet any reform may have different consequences for different population groups.
Equity should therefore be considered from the design stage through implementation and evaluation, rather than treated as a secondary outcome to be examined after a policy has been implemented.
A recent scoping review indicates that systematically incorporating equity into the design and implementation of health-system reforms can help identify and mitigate unequal consequences of reform initiatives (Bouckley et al., 2025).
Assessing the Distributional Consequences of Policies
Health-policy evaluation should not focus exclusively on average or aggregate outcomes. It is essential to determine how a policy affects different social, economic, and geographic groups.
This requires disaggregated analyses according to income, sex, age, place of residence, social position, and other characteristics associated with vulnerability.
Within such a framework, the central question is not simply, “Is the policy effective?” but rather:
For whom is it effective, who benefits from it, who bears its costs, and does its implementation reduce or widen existing health gaps?
Digital Equity and Health Technologies
The expansion of digital technologies, telemedicine, health-information systems, and mobile health applications has created new opportunities to improve access to and the quality of care.
However, technology does not automatically produce equity. Differences in access to the internet and digital devices, digital literacy, financial capacity, technological skills, and infrastructure quality may result in those with the greatest needs benefiting least from digital innovations.
Digital equity should therefore be considered from the earliest stages of technology design. Evidence from assessments of digital-health interventions also indicates that socioeconomic differences in intervention effectiveness remain insufficiently addressed in many studies (Abdelmalak et al., 2024).
Multidimensional Vulnerability and Intersectional Equity
Vulnerability is rarely attributable to a single factor. Individuals may simultaneously experience multiple forms of disadvantage, including poverty, older age, migration, social isolation, or limited access to services.
These factors can interact and reinforce one another, producing disproportionate health consequences. Equity analysis should therefore move beyond single-dimensional approaches and consider interactions among different social and economic factors.
An intersectional approach to health equity can help identify groups located at the intersection of multiple dimensions of vulnerability who may remain invisible within conventional analyses and policymaking processes (Conduah & Ofoe, 2025).
Equity, Diversity, and Quality of Care
The social and cultural diversity of populations requires health systems to recognise and respond to differing needs.
Equitable care requires respect for cultural, social, and individual differences, effective communication with patients, and the creation of conditions in which all people can receive high-quality care without discrimination.
From this perspective, attention to diversity is not a peripheral concern but an integral component of quality of care. A system that provides inappropriate or discriminatory care experiences to particular groups cannot be considered equitable merely because it meets high technical standards (Lauwers et al., 2024).
Equity, Economic Evaluation, and Resource Decision-Making
Health-system decisions are often made under conditions of resource scarcity, and economic evaluation can support the selection of efficient interventions. However, a narrow focus on efficiency may overlook the distributional consequences of such decisions.
An intervention may be highly cost-effective while delivering most of its benefits to groups that are already socially and economically advantaged.
Efficiency and equity should therefore not be treated as entirely separate objectives. Where possible, economic evaluations should also consider the distributional consequences of interventions, and decision-makers should understand which groups benefit from a policy choice and which groups may bear its disadvantages (Muir et al., 2024).
A Proposed Framework for the Pathology of Health Equity
Based on the preceding discussion, the pathology of health equity can be conceptualised as a multidimensional framework through which equity is examined across different levels of the health system and policymaking.
The framework comprises six major domains:
- Identifying inequalities: Identifying populations and groups experiencing disadvantage in health outcomes, access, quality, or resources.
- Identifying mechanisms that generate inequalities: Examining the social, economic, organisational, political, and structural factors that create or reproduce inequalities.
- Analysing the distribution of resources and opportunities: Assessing how health-system resources, services, benefits, and costs are distributed across different population groups.
- Analysing power and participation: Identifying actors who influence decision-making and assessing the extent to which different groups have meaningful participation in setting priorities and shaping policies.
- Assessing the distributional consequences of policies: Examining how health policies and reforms affect different population groups and whether they reduce or widen health gaps.
- Continuous equity monitoring: Establishing mechanisms for ongoing measurement of health gaps and assessment of the health system’s response to them.
This framework can transform equity from a broad normative principle into an operational dimension of analysis, decision-making, and accountability. Within such an approach, equity is not a secondary outcome but a core criterion for evaluating the performance of health systems and public policies.
Conclusion
Health equity cannot be achieved simply by increasing resources, expanding services, or improving average health indicators. It depends fundamentally on how health-related resources, opportunities, risks, costs, and benefits are distributed across different groups within society.
The pathology of health equity shifts attention from merely measuring inequalities to identifying the mechanisms that create and reproduce them. Such an approach requires simultaneous consideration of access, quality of care, financing, resource allocation, governance, power, social participation, intersectoral policies, health-system reforms, digital technologies, and multidimensional vulnerability.
Within this framework, an analysis of health equity without an analysis of power is incomplete, and an effective policy is not necessarily an equitable policy. Likewise, quality and equity should not be regarded as entirely separate objectives, because genuine quality of care is achieved only when all population groups have a fair opportunity to benefit from high-quality services.
From this perspective, efficiency and equity should be considered together in decisions concerning health resources and policies. Evaluation of health-system performance should also move beyond population averages and demonstrate how health gains are distributed across society.
Ultimately, an equitable health system is one in which no population group is systematically denied a fair opportunity to attain and maintain good health because of its social, economic, geographic, cultural, or political position.
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