Questions: Equity in Healthcare

Question 1

Two patients with identical symptoms of appendicitis present to different hospitals. Patient A (high-income, insured) receives surgery within 2 hours. Patient B (low-income, uninsured) waits 8 hours in the emergency department. This violates which equity principle?

• A. Vertical equity — the patients have equal need but should receive different treatment
• B. Horizontal equity — patients with equal need should receive equal treatment regardless of their socioeconomic characteristics
• C. No equity principle is violated — faster service for paying customers is normal market behavior
• D. Allocative efficiency — resources are not being used optimally

Answer: (B)

Horizontal equity requires equal treatment for equal need. Both patients have the same clinical condition (appendicitis) and the same need for surgery, but they receive different treatment because of their income and insurance status. This is a paradigmatic violation of horizontal equity. The market-based defense (option C) illustrates why healthcare is not treated as a normal market good in most societies — the principle that access should be based on need, not ability to pay, is foundational to health equity.

Question 2

The concentration index for healthcare utilization in a country is -0.15. This means healthcare utilization is concentrated among the poor (pro-poor distribution). Does this indicate an equitable system?

• A. Yes — any negative concentration index indicates equity
• B. Not necessarily — if the poor are sicker (greater need), a pro-poor distribution of utilization may simply reflect horizontal equity (equal care for equal need). A truly equitable system would have a need-adjusted concentration index near zero
• C. No — utilization should be equally distributed regardless of income
• D. Yes — the poor should always receive more healthcare

Answer: (B)

Raw utilization distributions must be interpreted relative to need. The poor generally have worse health and greater healthcare needs. A concentration index of -0.15 might reflect that the poor use slightly more healthcare — but if their need is substantially greater (concentration index of need = -0.30), they may actually be receiving less care relative to their need. The horizontal equity index compares actual utilization to need-predicted utilization, adjusting for the fact that equal utilization is not equitable if need is unequal.

Question 3

Explain why the distinction between health inequality and health inequity is normative rather than empirical.

Model answer: Health inequality is any measurable difference in health outcomes between groups — it is a descriptive, factual statement (men die younger than women, rural residents have higher mortality). Health inequity adds a value judgment: the difference is unjust, avoidable, and caused by systemic social disadvantage. Whether a specific inequality is an inequity depends on the cause: if men die younger partly due to biology, that is an inequality but arguably not an inequity. If Black Americans have higher infant mortality due to structural racism and unequal access to care, that is an inequity. The distinction requires normative reasoning about what differences are morally unacceptable, which cannot be settled by data alone.

This distinction matters for policy: not all health inequalities require policy intervention (we do not expect to equalize biological sex differences in lifespan), but health inequities demand action because they result from unjust social arrangements. The WHO Commission on Social Determinants of Health (2008) defined health inequities as differences in health 'which are not only unnecessary and avoidable but, in addition, are considered unfair and unjust.'