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Scoping review of the World Health Organization’s underlying equity discourses: apparent ambiguities, inadequacy, and contradictions

• Michelle M. Amri   ORCID: orcid.org/0000-0001-6692-3340 1 , 2 , 3 ,
• Geneviève Jessiman-Perreault   ORCID: orcid.org/0000-0002-2755-7891 1 ,
• Arjumand Siddiqi 1 , 4 ,
• Patricia O’Campo   ORCID: orcid.org/0000-0003-4549-7324 1 , 5 ,
• Theresa Enright 6 &
• Erica Di Ruggiero   ORCID: orcid.org/0000-0002-8935-7908 1  

International Journal for Equity in Health volume  20 , Article number:  70 ( 2021 ) Cite this article

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Background and objective

Given the heightened rhetorical prominence the World Health Organization has afforded to equity in the past half-century, it is important to better understand how equity has been referred to and its conceptual underpinning, which may have broader global implications.

Eligibility criteria

Articles were included if they met inclusion criteria — chiefly the explicit discussion of the WHO’s concept of health equity, for example in terms of conceptualization and/or definitions. Articles which mentioned health equity in the context of WHO’s programs, policies, and so on, but did not discuss its conceptualization or definition were excluded.

Sources of evidence

We focused on peer-reviewed literature by scanning Ovid MEDLINE and SCOPUS databases, and supplementing by hand-search.

Results demonstrate the WHO has held — and continues to hold — ambiguous, inadequate, and contradictory views of equity that are rooted in different theories of social justice.

Conclusions

Moving forward, the WHO should revaluate its conceptualization of equity and normative position, and align its work with Amartya Sen’s Capabilities Approach, as it best encapsulates the broader views of the organization. Further empirical research is needed to assess the WHO interpretations and approaches to equity.

Introduction

Since the late 1970s, equity in the context of health has become a central objective for the World Health Organization (WHO), largely attributed to the Alma-Ata Declaration of 1978, which emphasized the unacceptable nature of gross global health inequality and called for an acceptable level of health for all by the year 2000 [ 1 ]. A little over a decade after the declaration, the WHO commissioned a definition of inequity that has come to be widely cited globally: “differences which are unnecessary and avoidable, but in addition, are considered unfair and unjust ” ([ 2 ], p. 5).

With the more recent Commission on the Social Determinants of Health (CSDH), convened by the WHO from 2005 to 08 to focus on equity [ 3 ], there is better recognition that social and economic inequality reduces social cohesion, unfairly distributes life chances, and results in inequalities in health outcomes [ 4 ]. Arguably, this has heightened the prominence of the social determinants of health and equity in the context of health.

Looking to the Whitehead [ 2 ] definition and others, a central difference between inequality and inequity is the moral imperative (unfair and unjust). Whereas inequality is a measured difference, inequity is a political concept with a moral commitment to social justice [ 5 ]. In other words, to determine if an inequality is an inequity, a moral judgment is required to determine what aspects of an inequality are unjust and unfair [ 5 ].

However, despite this distinction, there is little global consensus on the definitions of “health inequity,” “health inequalities,” or “health disparities” ([ 6 ], p. 167 [ 7 ];) and substantial differences remain in how health equity is defined and operationalized [ 8 ]. Notably, in international discourse and implementation, inequity and inequality are used interchangeably [ 9 ].

Evidently, even across shared terminology, discourses can vary drastically, as seen with health promotion discourses in WHO charters [ 10 ] and the aforementioned distinction between inequality and inequity. This is highly problematic, as differing underlying discourses (and potentially alignment with different theories and approaches) can yield different public policy implications for action [ 11 ]. Accordingly, different approaches can have implications in measurement and accountability [ 7 ]. Therefore, working to eliminate misunderstandings and move towards a shared understanding becomes increasingly important to bridge action.

Given that “the relative dominance of specific ontological, epistemological and praxiological stances in the global agenda for health equity are rarely discussed and often limited to rather linear accounts on the historical development of a specific agenda or a specific field of research” ([ 12 ], p. 3), an investigation into the WHO’s concept of equity is needed to better understand the root(s) of their stance(s). Accordingly, this study aims to map scholarly literature that critically examines the WHO’s conceptualization and interpretation of “equity” in the context of health (with an investigation into the WHO not restricted to one issue or division). This scoping review, to the best of our knowledge, is the first to review and examine the literature on how this global organization conceptualizes equity.

Literature search and search strategy

This scoping review, as described by Grant and Booth [ 13 ], is a preliminary review to assess the size, scope, nature, and extent of available literature. This type of review employs a systematic and comprehensive search process to ensure no citations are missed. However, in addition to traditional scoping reviews, this review seeks to include a conceptual analysis and critical insights, in addition to narrative commentary.

The research process was based on the PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation [ 14 ] and guided by Arksey & O’Malley’s [ 15 ] five procedural steps for scoping reviews. The scoping review protocol for this study was published in a peer-reviewed journal (Amri, Siddiqi, O’Campo, Enright, & Di Ruggiero, 2020). First, the research question was identified. Second, relevant literature was identified through a search of electronic literature databases (complemented by additional hand-searching). Third, independent iterative selection was undertaken by two reviewers, M.A. and G.J.-P., and final articles were also approved by A.S. and P.O. Fourth, charting pertinent data by M.A. independently. And lastly, key findings were collated using NVivo 12 and results summarized by M.A.

Electronic literature databases

The search was conducted from database inception to October 7, 2019, using two electronic literature databases: SCOPUS, an interdisciplinary database, and Ovid MEDLINE, a medical science database. These databases were selected through consultation with a research librarian, as they are believed to yield the most relevant and largest results.

In SCOPUS, the following search string was used to search in titles, abstracts, and by keywords:

“World Health Organization” AND “equit*” OR “inequit*” OR “equalit*” OR “inequalit*”, yielding 1875 citations.

Similarly, in Ovid MEDLINE, the following search string was used to search titles and abstracts:

“World Health Organization”.tw AND equit*.tw OR inequit*.tw OR equalit*.tw OR inequalit*.tw, yielding 739 citations.

Additional search procedures

In addition to these two databases, two influential papers were searched in Google Scholar to include papers that cited these two papers and contained “equity” in their title. From the 108 papers that cited “What does equity in health mean?” [ 16 ] on Google Scholar, 33 contained “equity” in the title.

From the 3176 papers that cited “The concepts and principles of equity and health” [ 17 ] (please note: this is the same text as Whitehead [ 2 ]), which contained 16 versions on Google Scholar, 500 contained “equity” in the title.

Elimination of duplicates

After removing duplicates from the identified papers (both using EndNote X9 and manual elimination), this resulted in 2538 non-duplicate citations. An additional 20 citations were included through hand-searching, largely drawn from other articles’ citations, yielding 2558 articles for which the critical review of the literature was undertaken.

Eligibility

Inclusion criteria.

Drawing on the 2558 citations, article titles and abstracts were first reviewed for relevance using a priori inclusion and exclusion criteria by two independent reviewers, M.A. and G.J.-P., and all potentially relevant articles were read in full to determine and ensure alignment with these criteria. Articles were included if they met inclusion criteria — chiefly the explicit discussion of the WHO’s concept of health equity, for example in terms of conceptualization and/or definitions. Articles which mentioned health equity in the context of WHO’s programs, policies, and so on, but did not discuss its conceptualization or definition were excluded. As such, the seminal Whitehead [ 2 ] paper which was used in the search strategy was excluded from the review. Final papers included in the scoping review were also reviewed and approved by A.S. and P.O. to ensure suitability with inclusion criteria.

Please note, this study intentionally did not restrict the selection of articles by type of paper (commentaries, editorials, literature reviews, analysis papers, etc.) nor by year, to aid in understanding if and how work in this field and broader understanding changed over time, particularly with the development of the CSDH. Only papers available in English were included.

Exclusion criteria

Studies were excluded if they did not meet the inclusion criteria identified above. Some papers that were excluded include those that:

State the definition of equity without any further analysis or discussion. This includes those where the WHO’s definition of equity is drawn on as a side-point or casually referred to without additional interrogation and those that discuss equity broadly and are not specific to the WHO. For example, papers that highlight the need for action to tackle health inequalities (but no critique or discussion around the meaning of equity). Or, those which reiterate what the WHO is already doing about equity (without discussing the underlying discourses).

Solely focus on specific inequities (e.g. inequity of genetic testing) instead of a discussion on equity, equity in health, or health equity more broadly. This also includes articles that discuss a specific health issue/disease/condition and concludes that there are implications for equity (e.g. inequitable distribution of health care professionals, asthma, tuberculosis).

Solely focus on the measurement of inequity or inequality, some of which include: epidemiological/statistical, case-control, cross-sectional studies, the study of one country/population group, etc. However, papers that drew on a discussion of measurement to delve into discourse, theory, normative positions, etc. were included (e.g. “A Problem with the Individual Approach in the WHO Health Inequality Measurement” [ 18 ]).

Were unavailable in English — due to resource restrictions.

After applying the inclusion and exclusion criteria to the initial screen of titles and abstracts, 2325 articles were excluded (including eight abstracts that were unavailable in English and 30 abstract texts that were either unavailable or unable to access). After conducting a full-text screening of the 233 abstracts that were identified for full-text review, 212 articles were excluded (including 42 full texts that were unavailable in English and five full texts that were either unavailable or unable to access). During the data extraction process, two citations were excluded due to repetition of full text in another article. There were 23 articles included in the final review that met the inclusion criteria (see Table  1 ).

Excluding authors based at the WHO/PAHO and World Bank as listed in their stated affiliation ( n  = 4/23; 17.4%), only two papers ( n  = 2/19; 10.5%) had authorship from a non-high-income economy (as determined by the World Bank [ 37 ]) -- and in fact, both of these were from upper-middle-income economies (one paper authored by a scholar in Colombia [ 12 ] and another authored by scholars in Guatemala and Mexico [ 28 ]).

Looking to the authors’ affiliations at the time of publication, the majority has authorship at a university ( n  = 19/23; 82.6%). Three were based at the WHO/PAHO ( n  = 3/23; 13%) and one was authored by an individual at the World Bank (n = 1/23; 4.3%).

Reviewing the timeline of publications included in this scoping review, only 13 articles were published from 2005 and onwards ( n  = 13/23; 56.5%) and only seven were published from 2009 to present ( n  = 7/23; 30.4%) (which is noteworthy, given that the CSDH convened from 2005 to 2008).

Figure  1 provides an overview of the search strategy employed, detailing how papers were identified, screened, deemed eligible, and included.

Search strategy based on the PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation [ 14 ]

From the final 23 articles, data on key study descriptors were extracted [e.g. author(s) and year of publication, author’s/s’ institution(s), title, type of publication, place published, reflections on the WHO’s approach to equity, and conclusion(s)].

Critical review of the literature

This scoping review of the academic literature is designed to yield insights on the depth of interrogation of the WHO’s discussion of equity. It aims to identify key discussions in the field and identify any gaps, if they exist, so that they can be addressed to improve global health policy.

As such, in addition to article data abstracted in Table 1 , deeper information through reading and interpreting, such as comparing, analyzing, and synthesizing critiques of the WHO’s approach (es), were focused on (e.g. in discussion around the definition by Whitehead [ 2 ] and any perceived normative or theoretical positions of the WHO).

From the academic papers meeting the inclusion criteria of this study, as outlined in Table 1 , key ideas were illuminated that will be discussed in this section.

Widespread use of Whitehead definition

A large majority of papers referred to Whitehead’s formative definition [ 2 ] commissioned by the WHO, which was expressed to be defined the same way by the Pan American Health Organization (PAHO) [ 28 ].

While originally intended to raise awareness and debate among a wider general audience [ 7 , 38 ], this definition provides an understanding that inequalities produced by the social system are inequities, while inequalities produced by nature are not inequities [ 18 ]. In other words, inequities are not only unnecessary and avoidable (inequality), but are unfair and unjust (inequity). Consequentially, the recognition and acceptance of inequities being unjust in Whitehead’s definition has a moral undertone because a value judgement must be made to determine what is an inequity versus inequality [ 31 ], demonstrating the close link between equity and social justice [ 25 ].

The widespread acceptance of Whitehead’s definition was clear, whether this was done by explicitly referring to Whitehead and quoting the definition (e.g. [ 23 , 26 ]) and expressing the widespread acceptance of the definition itself (e.g. [ 25 , 34 ]), or indirectly, by recognizing the “general agreement” that inequalities are unjust (e.g. [ 19 ]). This Whitehead definition has been recognized as having the key strengths of being accessible, concise, intuitive, and easily communicated [ 6 ]. Despite several definitions of equity in the literature, Whitehead’s has been widely taken up [ 6 ], demonstrating the role this definition had in providing a widely accepted baseline of understanding for inequity in health or health inequities.

WHO’s approach is ambiguous and inadequate

Prior to Whitehead’s definition, Mooney [ 16 ] raised concerns that the WHO’s Health for All initiative was unclear about equity. While Whitehead’s definition of equity has been widely accepted since its development in 1990, it has become apparent through this review that it is highly ambiguous and inadequate.

Despite inequities being understood to be “not only unnecessary and avoidable, but in addition, are considered unfair and unjust” [ 2 ], it is immensely difficult to determine what is in fact, “unnecessary and unfair vis-à-vis what is inevitable and unavoidable” [ 21 ]. For example, ‘avoidability’ has several subcategories: technical, financial, and moral [ 21 ]. Similarly, Wilson [ 36 ] has expressed that the addition of “unnecessary and avoidable” is unhelpful and can be eliminated to simply remain “unjust inequality”. This was also argued by Braveman and Gruskin [ 7 ] who expressed that ‘avoidability’ should not define health inequities because: (i) avoidability is implied through being unfair and unjust, (ii) given that many inequities require structural changes, avoidability may hinder action on inequities, and (iii) avoidability is unclear about who it is avoidable by. Evidently, the Whitehead definition, while useful, is only beneficial if agreement can be reached on what constitutes avoidable and unfair [ 24 ], and determining which inequalities are unjust is a difficult and complex task [ 36 ]. As such, it leaves the exact meaning of health inequity open [ 20 ]. Similarly, these terms are open to varying interpretations which can be problematic [ 6 , 19 , 34 ]. For example, determining whether or not an inequality is unfair rests on the degree of choice [ 35 ] or the idea that inequalities with a social versus natural cause are amenable to intervention [ 36 ], both of which have been criticized.

Further, the WHO’s approach to inequities (measuring inequalities between individuals as opposed to groups) may miss inequalities that most would consider to be injustices, and therefore, should be considered inequities [ 18 ], demonstrating it is not only ambiguous but also inadequate. On the contrary, Sadana and Blas [ 32 ] point out that regardless of where the determination is made of what constitutes an inequality vs. inequity, action needs to be taken to reduce unfair health disparities.

In addition, ambiguities in the WHO’s approach to equity are present on a superficial level. Ridde, Guichard [ 31 ] draw attention to the translations of the Ottawa Charter, noting the French version refers to “equality in health”, whereas the English version refers to “equity in health”. Footnote 1 Evidently, not enough attention has been given to studying why an inequality may be unfair and the implications of this characterization are [ 21 ]. And ultimately, ambiguities present in the WHO’s approach to equity were fraught with key contradictions, as discussed below.

Key contradictions in the WHO’s approaches

“[..] if an idea has an essential ambiguity, a precise formulation of that idea must try to capture that ambiguity rather than lose it” [ 39 ] .

The WHO’s differing approaches to equity present three key contradictions that the literature highlighted, which centred around: (1) individual versus group measurement of health inequalities, (2) striving for a baseline level of health for all or striving for a baseline level of health for all AND reducing inequality, and (3) focus on socioeconomic status versus considering various social determinants of health.

Individual versus group measurement of health inequalities

The WHO has employed an approach centred on measuring differences across individuals at times, while measuring differences between groups in other instances. This is most evident through Braveman’s contrasting of the WHO’s 1995–1998 initiative on Equity in Health and Health Care, which specifically indicated equity as minimizing disparities between groups (with mention of those who have different levels of power, wealth, prestige), with researchers at the WHO from 1998 to 2003 who emphasized differences between individuals and not groups [ 6 ].

Individual measurement

Asada [ 20 ] points to researchers at the WHO which proposed to measure inequalities across individuals rather than groups through the World Health Report 2000 due to methodological (e.g. ease of international comparisons) and moral reasons (i.e. due to health being special, the role of health equity in justice, and health inequality being an indicator for broader societal injustice). Through undertaking measurement of inequalities across individuals, Asada [ 20 ] infers that the WHO implies that health should be prioritized over other goods, which can be considered to be specific egalitarianism or a direct approach.

However, the measurement of health differences at the individual-level undertaken by the WHO does not allow for a determination of what differences are, in fact, determined by nature (inequality) versus socially-determined (inequity) [ 18 ]. In other words, the WHO’s argument for measuring inequalities by individuals rather than groups does not afford consideration of health equity and does not reflect values of fairness or justice [ 7 ]. As a result, Asada and Hedemann [ 18 ] hold the theory that the WHO does not use social factors to qualify inequalities as inequities, but rather, whether or not causes of differences are susceptible to human intervention . Asada and Hedemann [ 18 ] refer to instances in WHO texts that support this view, providing two examples to illustrate their point. First, inequalities caused by genetic makeup are considered inequities by the WHO given that genetic manipulation in the “era of the human genome project” is possible, despite these not being socially-determined [ 18 ]. And second, they give a hypothetical example where systematic discrimination in a state may result in health inequalities, and purport that the use of the WHO’s measure of inequality at the national level these differences would not be apparent and would determine it is an inequality rather than inequity [ 18 ].

Group measurement

In seeking to scientifically measure inequality, there is a decision made incorporating normative or causal assumptions in considering which questions are of moral importance [ 18 ]. In other words, while some measures are value-free (inequality), how we determine what is important to look at and address (inequity), has a moral component; with the analogy of measuring the height of trees given – where measurement data is unimportant until it is compared, ranked, and aspects to address are identified [ 18 ]. Because the concept of equity implicitly contains the issue of measurement [ 30 ], there appears to be a normative position that the WHO holds (i.e. what becomes worthy of our moral attention), despite claiming to be value-free. For example, through the WHO’s measurement of group differences at the national level, intra-group inequalities are missed [ 27 ]. This is not to say that it is unscientific, but rather that there are embedded values in how this science is conducted.

Striving for a baseline level of health for all versus striving for a baseline level of health for all AND reducing inequality

Striving for a baseline level of health for all.

It is unclear as to whether or not the WHO approaches equity in health as envisioning individuals as having a baseline level of health or not. Mooney [ 16 ] provided the example of the European Strategy for Health for All, which Mooney claims the target seems to be equal health, raising questions around how this level of health is determined. This was supported by Gwatkin [ 25 ], who notes the WHO has also mentioned the need for a basic minimum level for all individuals across the population, and also raised by Alleyne [ 19 ], who explains Health for All forced a consideration of what was truly meant by “All” and implied distributive justice and a minimum level of health. He also states that equity in health aligned with the egalitarian approach and that he “confess [es] to my bias in this direction” [ 19 ] — which is noteworthy as he was a director of the PAHO.

Ridde, Guichard [ 31 ] also support this claim, as they perceive the 1986 Ottawa Charter for Health Promotion to be based in values of distributive justice given the social construction of inequalities (with distributive justice either denoting equal material goods for all or diverging when it allows for those worse off to benefit more than in the former scenario [ 40 ]). This is further supported by Hashimoto and Kawakami [ 26 ] who observe that the PAHO interprets inequity as a difference in the opportunity or means to achieve health (i.e. equity equates to equal opportunity to achieve health). Through the PAHO’s approach, the notion that equity is perceived by the WHO as one in which individuals have a baseline level of health is clear and yields a clear approach to combatting inequity.

Striving for a baseline level of health for all AND reducing inequality

Mooney [ 16 ] points to a contrast between the WHO’s European strategy for health for all, which focuses on raising up those who are not as privileged, and the WHO’s Global Strategy for Health for All, which focuses on reducing inequality between people’s health status.

Gwatkin [ 25 ] also notes this inconsistency by noting how the definition of health equity developed by Whitehead [ 2 ], which called for improving the health of the disadvantaged, was developed alongside another definition that focused on reducing differences between groups. Similarly, Gwatkin [ 25 ] observes that the WHO’s 1996 health equity document gives importance to differences between the poor and rich, rather than just focusing on enhancing the health of those with lower socioeconomic status.

Looking to more recent work of the WHO, Shiell [ 33 ] also makes a similar observation through looking at the work of the CSDH. Shiell [ 33 ] notes that the CSDH was only concerned with reducing inequity (particularly inequalities in health between countries and groups within countries), and not concerned with prioritizing certain groups (with the exception of prioritizing for efficiency) — despite Marmot and Friel [ 29 ] expressing that the work of the CSDH was focused on both reducing societal inequities (i.e. reducing the gap) and improving the health of the whole of society (i.e. improving everyone’s health).

While the WHO approach to equity is a normative one focused on reducing inequalities in social position, one may argue equity should not only be focused on reducing disparities (e.g. can focus on improving the health of the impoverished) [ 25 ]. Further, Mooney [ 16 ] draws attention to the goal of “drastically reduced” gross inequality in health expressed in the WHO’s Global Strategy for Health for All, to explain that while this is still unclear, it is more feasible than the European Strategy for Health for All goal of achieving equal health. Bommier and Stecklov [ 23 ] also note that the wider literature points to an understanding that a fair distribution of health does not equate to equal health status for all, but rather around reducing or eliminating avoidable differences, which they state is implicit in the work of the WHO through the Global Strategy for Health for All resolution (WHA32.30), WHO Health for All, and Whitehead definition. Irrespective, the differing approaches to health equity by the WHO becomes apparent.

Focus on socioeconomic status versus considering various facets of inequity

Focus on socioeconomic status.

As Braveman [ 6 ] highlights, while Whitehead does not explicitly mention “disadvantage”, her notions and examples of “avoidability,” “injustice,” and “unfairness” are intended to demonstrate inequalities in socioeconomic status. This is supported by equity in health focusing on reducing disparities among those with different levels of social advantage and privilege, with the examples of differing levels of power, wealth, and privilege, given by the 1995–98 WHO initiative on Equity in Health and Health Care [ 6 ]. Similar language is employed by both the WHO’s European Strategy for Health for All, which strives to allow “disadvantaged nations and groups [ …] catch up” [ 16 ] and was present in the 1984 targets for the WHO Regional Office for Europe [ 25 ].

Interestingly, the European context in which the Whitehead [ 2 ] definition was created emphasizes inequalities between those of differing socioeconomic status, and rarely gender and ethnicity [ 6 ]. In the same vein, Pappas and Moss [ 30 ] called for the WHO to develop socioeconomic measures that consider culture and economic development, highlighting the limited consideration for each individual’s unique situation.

Considering various social determinants of health

However, despite Mooney’s claims, Linares-Péreza and López-Arellano [ 28 ] make an astute observation that Whitehead [ 2 ] indicated that not all individuals should utilize the same degree of resources, nor the same level of health, and instead, each individual’s needs should be considered.

Arguably, the WHO attempts to approach equity through consideration of the health needs of different societies (i.e. through differences in ethnicity, religion, socioeconomic status, gender, geography, and age), instead of social privilege [ 28 ]. This is supported by the assertion made by Daniels, Kennedy [ 24 ], that the WHO’s efforts are aimed at remedying “true inequities” (i.e. health inequalities among socioeconomic status and racial/ethnic groups). This approach of considering various facets of inequity is clear through Hashimoto & Kawakami’s [ 26 ] discussion of equity in the context of health, where they discuss alignment between the WHO’s International Classification of Functioning, Disability and Health and the Capabilities Approach, developed by Amartya Sen, as it treats inclusion as a functioning/key aspect. Braveman [ 6 ] also notes researchers at the WHO from 1998 to 2003 argued against focusing on inequality and inequity of socioeconomic status, but instead, defining inequity as an avoidable difference between individuals without social grouping.

Further, through looking at the work of the CSDH, Sadana and Blas [ 32 ] point to the use of the CSDH’s conceptual framework in demonstrating how various health determinants contribute to inequities. In particular, pointing out that the ninth knowledge network focused on priority public health conditions largely focused on treatment and only partially on vulnerabilities of groups, except for violence & injury prevention and tobacco, which addressed the upstream social determinants of health [ 32 ].

When discussing equity in the context of health care , Dahlgren and Whitehead [ 38 ] indicate “fair arrangements that allow equal geographic, economic and cultural access to available services for all in equal care of need”. This statement points to an expanded vision of equity from one focused on wealth, to one which considers these three dimensions.

The WHO’s apparent values and conceptual underpinning

It is important to note that how inequities are “conceived, conceptualised, researched and proposed to be transformed, and consequently mobilise different political, social and economic agendas” [ 12 ]. For example, different definitions of health equity align with different paradigms, which have different practical implications [ 7 ]. While the unfair and avoidable aspect of differences in health are becoming more apparent and greatly acknowledged [ 41 ], the WHO’s discussion and approach to equity is evidently quite ambiguous, inadequate, and contradictory.

The WHO approach to inequity aims to be scientific, but it is not value-free [ 27 ] — despite the WHO’s claims its measurement of health inequality is value-free [ 18 ] — illustrated through the explicit mention of the CSDH being guided by the underlying value that health inequities are a matter of social justice [ 29 ]. The WHO is not “wedded to any specific empirical theory of inequality” [ 27 ], but its normative position “can be interpreted as a quite expansive view of justice” [ 18 ]. Through the adaption of the Whitehead definition to the Irish national health strategy, Smith and Normand [ 35 ] reiterate this sentiment, by expressing that while it is difficult to discern exactly which theoretical perspective the definition is based in, it is unlikely to be aligned with a libertarian philosophical perspective and resonates with Rawls’ theory of social justice. While the Whitehead definition of health equity is inadequate normatively, which may result in inconsistent or conflicting action (and potentially the creation of inequities) [ 34 ], it is not just merely the Whitehead [ 2 ] definition that has an ambiguous or contradictory theoretical underpinning.

Through striving for a baseline level of health for all (as discussed above), the WHO’s approach aligns with notions of strict egalitarianism, which seeks to ensure the same level of goods and services for all [ 40 ], or specific egalitarianism or a direct approach [ 20 ]. Similarly, through the WHO’s enhanced focus on eliminating differences due to socioeconomic status, this aligns with Rawls’ approach [ 42 ], which focuses on “primary goods” (such as income and wealth). His Difference Principle allows inequality only to raise those most disadvantaged in society [ 40 ], which is believed to align with the WHO’s approach to equity [ 23 ]. While these approaches have merit, they fail to consider the diversity among individuals (i.e. two individuals with the same level of primary goods may have different freedoms to achieve their potentially unique perceptions of a good outcome) [ 39 ].

Further, by the WHO’s aim to consider individuals’ unique needs, as noted by Linares-Péreza and López-Arellano [ 28 ] (as discussed above), the WHO’s approach aligns well with the Capabilities Approach developed by Amartya Sen. Sen’s Capabilities Approach posits that a person’s capability to achieve “functionings” that they value, ranging from basic needs (e.g. avoiding morbidity) to complex achievements (e.g. having self-respect) — provides a valuable approach to assessing (in) equality [ 39 ]. The approach considers how choices are made, rather than simply welfare [ 26 ] and aligns with the idea that the distribution of health has moral significance, which was expressed by WHO researchers [ 20 ]. And in fact, Sen not only served as a Commissioner on the 2005–2008 CSDH, but his thinking is regarded as being influential in setting up the CSDH [ 43 ].

As it may now be apparent, Sen’s approach seemingly best aligns with the views of WHO key figures (e.g. Alleyne [ 44 ] and Dahlgren and Whitehead [ 38 ] Footnote 2 ) — who indicate geographic, economic, and cultural factors, among others, should be considered in striving for health equity. Given that there are various philosophical perspectives on health equity, determining a perspective for which to align policy with is recommended (i.e. not only for aligning sought-out policy outcomes but also because health inequality data can be interpreted in different ways) [ 20 ]. As such, grounding and aligning the WHO’s approach in the Capabilities Approach, as opposed to one unitary theory of social justice, may aid in clarifying a path forward. This may be aided by discussions around fairness and equality, which can help clarify what the WHO means by equity [ 30 ].

If the WHO were to align their approaches to equity with that of Sen’s Capabilities Approach, it may aid in various pursuits. For example, Pappas and Moss [ 30 ] called for the WHO to ensure progress is measured through specific, qualifiable, and culturally-appropriate targets (e.g. develop socioeconomic measures that consider cultural and economic development). By approaching the measurements of systematic differences with Sen’s Capabilities Approach as a lens, this call could potentially be even better addressed. Similarly, neither the Ottawa Charter of 1986 [ 31 ] nor the WHO’s Health for All in the Twenty-first Century policy [ 30 ], clarify how equity will be addressed in explicit ways or describe clear actions to achieve equity. Through broadening the view to equity to one that considers an individual’s broader society, considerations for enhancing equity can more easily (and should) focus on political contexts (including oppression and exploitation), as called for by Borde and Hernández [ 12 ]. This could potentially aid in filling the gap identified by Ridde, Guichard [ 31 ] that there is a “permanent invisibility” of inequalities in health politically and by Pappas and Moss [ 30 ] to provide the much needed clarity on how policy can be used to achieve health equity.

In fact, Asada and Hedemann [ 18 ] concluded that “if the World Health Organization’s health inequality measure is to be interpreted meaningfully in a policy context, its conceptual underpinning must be re-evaluated”. For example, Asada [ 20 ] asserts that in terms of measurement, the Capabilities Approach focuses on those below a minimum versus the whole distribution of health, demonstrating how theories of justice can have direct implications on policy and practice. Further to this, Borde and Hernández [ 12 ] highlight that the WHO focuses on technical solutions, seeks win-win solutions for governance, and renders politics apolitical. Instead, the WHO should clarify its principles and foundations (ethical, political, etc.) and focus on the social determinants of health inequities, or causes of causes (i.e. unequal power relations or capitalism) [ 12 ]. This is supported by an observation made by Blakely [ 22 ], that while the CSDH final report focuses on power, sexism, and discrimination, the mention of “power” and “racism” is removed in the final diagram of the social determinants of health (and used as a model of health inequalities), despite the CSDH including “power”, “class”, “racism”, and “discrimination” in a prior working diagram.

Potential promise of the rights-based approach

In the review of these papers, the role of the human rights-based approach in striving for equity was raised by a few authors. This approach emphasizes legislative and legalistic actions (e.g. through targeting constitutions, laws, and court action) [ 30 ]. In doing so, equity moves into the domain of law and the responsibility of government, rather than strictly an act of goodwill [ 12 ].

Pappas and Moss [ 30 ] note there may be an opportunity for the WHO to draw on the rights-based approach, like the United Nations Children’s Fund (UNICEF), to clarify how policy can achieve health equity and guide its actions. With Sadana and Blas [ 32 ] explicitly pointing to the alignment of a social determinants of health approach with the promotion of human rights (such as around healthcare, education, safe water, and a decent standard of living). However, Mooney [ 16 ] explains that while the WHO Global Strategy for Health for All asserts that “health is a fundamental human right”, parameters to a right to health are unclear, as opposed to healthcare.

Limitations

While this scoping review employed a systematic and rigorous search strategy, there were two limitations to the study.

First, because only articles available in English were included in the study due to resource constraints, only English-speaking voices, perspectives, and analysis were collated. Particularly because the WHO is a global organization, and with equity being rooted in different traditions of social justice across the world [ 30 ], additional efforts are needed to review papers published in other languages.

Second, because some articles were written by individual authors (e.g. Dr. George Alleyne) who were employed at the WHO, this blurs the lines of what constitutes the organization’s position versus individual authors’ views. However, careful consideration was paid to the purpose of each article and the author’s voice [e.g. Alleyne explicitly presented his views, e.g. “I confess to my bias in this direction” [ 19 ], as opposed to the views of the broader organization].

As Dahlgren and Whitehead [ 38 ] indicate, the original document containing Whitehead’s formative definition of equity was intended to raise awareness and debate among a wider general audience. Now that this goal has largely been accomplished, the WHO needs to clarify not only what equity in the context of health means to the organization, but what values and theory of justice underpin this. Sen’s Capabilities Approach has been expressed to represent the values of the organization by prominent players but does not represent the organization’s policy and program actions.

In assessing the literature that this scoping review analyzed, the need for more discussion among scholars from the global south and representation of these voices is glaring. Given different traditions of social justice across the world [ 30 ] and cultural differences and approaches to equity in health, there is a dire need for more voices represented and contributing to these discussions in shaping global policy discourse, measurement, and ultimately, action.

An analysis of authors’ affiliations at the time of publication may demonstrate a further need for discussions around the WHO’s concept of equity to be interrogated and analyzed by those based in the organization, particularly at other regions of the WHO outside of the PAHO, who may yield a novel perspectives by nature of being privy to internal discussions.

In addition, from the articles included in this scoping review, only one had a research methods section [ 12 ], despite referring to itself as an essay. This is noteworthy, as it highlights the dire need for empirical research investigating how the WHO has conceptualized equity.

Given that only seven articles in this review were published from 2009 and onwards, when renewed attention to equity was afforded following the CSDH (which convened from 2005 to 2008), it is important to analyze the WHO’s more recent conceptualizations of equity. Similarly, to determine if this differs from the prior approaches and normative positions held by the WHO, particularly following the Alma Ata Declaration in 1978, where “health for all” was coined.

Evidently, the WHO’s discussions of equity (extending beyond Whitehead’s formative definition) are highly ambiguous, inadequate, and contradictory, which has led some scholars to question the normative position held by the WHO. While the WHO has expressed alignment with Sen’s Capabilities Approach, this does not seem to be the case in assessing their statements and actions, as their approaches also align with other approaches and theories of justice (e.g. Rawls’ [ 23 ]). Further research is needed to empirically investigate the normative position of the WHO. In addition, the WHO should consider striving for reconsideration of the normative and theoretical approaches to equality employed and ensuring consistency.

Sources of funding for the included sources of evidence

From the collated sources included in this review, six declared funding: Asada [ 20 ] who reported “This project was supported by grant number 1 R03 HS 13116 from the Agency for Healthcare Research and Quality, and the Canadian Institute of Health Research Training Program for Ethics and Health Policy and Research”; Borde and Hernández [ 12 ] who reported “this work was supported by Departamento Administrativo de Ciencia, Tecnología e Innovación: [grant number Colciencias 727]”; Ridde, Guichard [ 31 ] who reported “Valéry Ridde holds a Fellowship in Global Health Research Initiative from the Canadian Institutes of Health Research (FGH-81585)”; Smith [ 34 ] who reported “This work was supported by Fondation Brocher, a Canadian Institutes of Health Research Frederick Banting and Charles Best Canada Graduate Scholarship, and the Lupina Foundation’s Comparative Program on Health and Society at the Munk School of Global Affairs, University of Toronto”; Smith and Normand [ 35 ] who reported “This research was funded by the Irish Research Council for the Humanities and Social Sciences”; and Daniels, Kennedy [ 24 ] who reported “Norman Daniels, Bruce P. Kennedy, and Ichiro Kawachi are recipients of Robert Wood Johnson Foundation Investigator Awards in health policy research”.

Sources of funding for the scoping review

The authors received no specific funding for this work.

Availability of data and materials

Not applicable/Data sharing is not applicable to this article as no datasets were generated or analysed during the current study.

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Youth Gender Medications Limited in England, Part of Big Shift in Europe

Five European countries have recently restricted hormone treatments for adolescents with gender distress. They have not banned the care, unlike many U.S. states.

By Azeen Ghorayshi

Azeen Ghorayshi reports on transgender health and visited the world’s first youth gender clinic in Amsterdam this fall.

The National Health Service in England started restricting gender treatments for children this month, making it the fifth European country to limit the medications because of a lack of evidence of their benefits and concern about long-term harms.

England’s change resulted from a four-year review released Tuesday evening by Dr. Hilary Cass, an independent pediatrician. “For most young people, a medical pathway will not be the best way to manage their gender-related distress,” the report concluded. In a related editorial published in a medical journal, Dr. Cass said the evidence that youth gender treatments were beneficial was “built on shaky foundations.”

The N.H.S. will no longer offer drugs that block puberty , except for patients enrolled in clinical research. And the report recommended that hormones like testosterone and estrogen, which spur permanent physical changes, be prescribed to minors with “extreme caution.” (The guidelines do not apply to doctors in private practice, who serve a small fraction of the population.)

England’s move is part of a broader shift in northern Europe, where health officials have been concerned by soaring demand for adolescent gender treatments in recent years. Many patients also have mental health conditions that make it difficult to pinpoint the root cause of their distress, known as dysphoria.

In 2020, Finland’s health agency restricted the care by recommending psychotherapy as the primary treatment for adolescents with gender dysphoria. Two years later, Sweden restricted hormone treatments to “exceptional cases.”

In December, regional health authorities in Norway designated youth gender medicine as a “treatment under trial,” meaning hormones will be prescribed only to adolescents in clinical trials. And in Denmark, new guidelines being finalized this year will limit hormone treatments to transgender adolescents who have experienced dysphoria since early childhood.

Several transgender advocacy groups in Europe have condemned the changes , saying that they infringe on civil rights and exacerbate the problems of overstretched health systems. In England, around 5,800 children were on the waiting list for gender services at the end of 2023, according to the N.H.S.

“The waiting list is known to be hell,” said N., a 17-year-old transgender boy in southern England who requested to withhold his full name for privacy. He has been on the waiting list for five years, during which time he was diagnosed with autism and depression. “On top of the trans panic our own government is pushing, we feel forgotten and left behind,” he said.

In the United States, Republican politicians have cited the pullback in Europe to justify laws against youth gender medicine. But the European policies are notably different from the outright bans for adolescents passed in 22 U.S. states, some of which threaten doctors with prison time or investigate parents for child abuse. The European countries will still allow gender treatments for certain adolescents and are requiring new clinical trials to study and better understand their effects.

“We haven’t banned the treatment,” said Dr. Mette Ewers Haahr, a psychiatrist who leads Denmark’s sole youth gender clinic, in Copenhagen. Effective treatments must consider human rights and patient safety, she said. “You have to weigh both.”

In February, the European Academy of Paediatrics acknowledged the concerns about youth gender medicine. “The fundamental question of whether biomedical treatments (including hormone therapy) for gender dysphoria are effective remains contested,” the group wrote. In contrast, the American Academy of Pediatrics last summer reaffirmed its endorsement of the care, stating that hormonal treatments are essential and should be covered by health insurers, while also commissioning a systematic review of evidence.

Europeans pioneered the use of gender treatments for young people. In the 1990s, a clinic in Amsterdam began giving puberty-suppressing drugs to adolescents who had felt they were a different gender since early childhood.

The Dutch doctors reasoned that puberty blockers could give young patients with gender dysphoria time to explore their identity and decide whether to proceed with hormones to ultimately transition. For patients facing male puberty, the drugs would stave off the physical changes — such as a deeper voice and facial hair — that could make it more difficult for them to live as women in adulthood. The Dutch team’s research, which was first published in 2011 and tracked a carefully selected group of 70 adolescents, found that puberty blockers, in conjunction with therapy, improved psychological functioning.

That study was hugely influential, inspiring clinics around the world to follow the Dutch protocol. Referrals to these clinics began to surge around 2014, though the numbers remain small. At Sweden’s clinic, for example, referrals grew to 350 adolescents in 2022 from around 50 in 2014. In England, those numbers grew to 3,600 referrals in 2022 from 470 in 2014.

Clinics worldwide reported that the increase was largely driven by patients raised as girls. And unlike the participants in the original Dutch study, many of the new patients did not experience gender distress until puberty and had other mental health conditions, including depression and autism.

Given these changes, some clinicians are questioning the relevance of the original Dutch findings for today’s patients.

“The whole world is giving the treatment, to thousands, tens of thousands of young people, based on one study,” said Dr. Riittakerttu Kaltiala, a psychiatrist who has led the youth gender program in Finland since 2011 and has become a vocal critic of the care.

Dr. Kaltiala’s own research found that about 80 percent of patients at the Finnish clinic were born female and began experiencing gender distress later in adolescence. Many patients also had psychological issues and were not helped by hormonal treatments, she found. In 2020, Finland severely limited use of the drugs.

Around the same time, the Swedish government commissioned a rigorous research review that found “insufficient” evidence for hormone therapies for youth. In 2022, Sweden recommended hormones only for “exceptional cases,” citing in part the uncertainty around how many young people may choose to stop or reverse their medical transitions down the line, known as detransitioning.

Even the original Dutch clinic is facing pressure to limit patients receiving the care. In December, a public documentary series in the Netherlands questioned the basis of the treatments. And in February, months after a far-right political party swept an election in a country long known as socially liberal , the Dutch Parliament passed a resolution to conduct research comparing the current Dutch approach with that of other European countries.

“I would have liked that the Netherlands was an island,” said Dr. Annelou de Vries, a psychiatrist who led the original Dutch research and still heads the Amsterdam clinic. “But of course, we are not — we are also part of the global world. So in a way, if everybody is starting to be concerned, of course, these concerns come also to our country.”

In England, brewing concerns about the surge of new patients reached a boiling point in 2018, when 10 clinicians at the N.H.S.’s sole youth gender clinic, known as the Tavistock Gender Identity Development Service, formally complained that they felt pressure to quickly approve children, including those with serious mental health problems, for puberty blockers.

In 2021, Tavistock clinicians published a study of 44 children who took puberty blockers that showed a different result from the Dutch: The patients given the drugs, on average, saw no impact on psychological function.

Although the drugs did not lessen thoughts of self-harm or the severity of dysphoria, the adolescents were “resoundingly thrilled to be on the blocker,” Dr. Polly Carmichael, the head of the clinic, said at a 2016 conference . And 43 of the 44 study participants later chose to start testosterone or estrogen, raising questions about whether the drug was serving its intended purpose of giving adolescents time to consider whether a medical transition was right for them.

In 2020, the N.H.S. commissioned Dr. Cass to carry out an independent review of the treatments. She commissioned scientific reviews and considered international guidelines of the care. She also met with young people and their families, trans adults, people who had detransitioned, advocacy groups and clinicians.

The review concluded that the N.H.S.’s standard of care was inadequate, with long waiting lists for access to drug treatments and few routes to address the mental health concerns that may be contributing to gender distress. The N.H.S. shuttered the Tavistock center last month and opened two new youth gender clinics, which Dr. Cass said should have a “holistic” approach, with more support for those with autism, depression and eating disorders, as well as psychotherapy to help adolescents explore their identities.

“Children and young people have just been really poorly served,” Dr. Cass said in an interview with the editor of The British Medical Journal, released Tuesday. She added, “I can’t think of another area of pediatric care where we give young people potentially irreversible treatments and have no idea what happens to them in adulthood.”

The changes enacted by the N.H.S. this month are “an acknowledgment that our concerns were, in fact, valid,” said Anna Hutchinson, a clinical psychologist in London who was one of the Tavistock staff members who raised concerns in 2018. “It’s reassuring that we’re going to return to a more robust, evidence-based pathway for decisions relating to these children.”

Some critics said that Europe, like the United States, had also been influenced by a growing backlash against transgender people.

In Britain, for example, a yearslong fight over a proposed law that would have made it easier for transgender people to change the gender on their identification documents galvanized a political movement to try to exclude transgender women from women’s sports, prisons and domestic violence shelters.

“The intention with the Cass review is to be neutral, but I think that neutral has maybe moved,” said Laurence Webb, a representative from Mermaids, a trans youth advocacy organization in Britain. “Extremist views have become much more normalized.”

Other countries have seen more overt attacks on transgender rights and health care. In 2020, Hungary’s Parliament passed a law banning gender identity changes on legal documents. Last year, Russia banned legal gender changes as well as gender-related medical care, with one lawmaker describing gender surgeries as the “path to the degeneration of the nation.”

In France this year, a group of conservative legislators introduced a bill to ban doctors from prescribing puberty blockers and hormones, with punishments of two years’ imprisonment and a fine of 30,000 euros, or about $32,600. And on Monday, the Vatican condemned gender transitions as threats to human dignity.

Azeen Ghorayshi covers the intersection of sex, gender and science for The Times. More about Azeen Ghorayshi

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• v.5(3); Jul-Sep 2016

Critical review of drug promotional literature using the World Health Organization guidelines

Puttaswamy ganashree.

1 Department of Pharmacology, Sri Devaraj Urs Medical College, Sri Devaraj Urs Academy of Higher Education and Research, Kolar, Karnataka, India

Krishnaswamy Bhuvana

Narayana sarala.

Drug promotional literatures (DPLs) are used as a promotional tool to advertise new drugs entering the market to doctors. The objective of the present study is to evaluate the accuracy of DPLs by using the World Health Organization (WHO) criteria.

An observational study was conducted from March to August 2014. The DPLs were collected from various departments at R.L. Jalappa Hospital and Research Centre attached to Sri Devaraj Urs Medical College, Kolar, India. The literature was evaluated based on 11 criteria laid down by the WHO.

Two-hundred DPLs were evaluated. Cardiovascular drugs (34 [17%]) were promoted the most, followed by antidiabetic drugs (31 [15.5%]) and antimicrobial agents (29 [14.5%]). Single drug was promoted in 134 (67%) and fixed drug combination in 66 (33%) brochures. Manufacturer's name was mentioned in 194 (97%), but their address was mentioned in 109 (54.5%) claims only. Drug cost was revealed only in 12 (6%) DPLs. Each ingredient's generic name, brand name, and dosage form were mentioned in 197 (98%) brochures. Indication for use was stated in 193 (96.5%) claims. Contraindications, adverse effects, precautions, and drug interactions were listed in 68 (34.5%), 65 (32.5%), 65 (32.5%), and 58 (29%) advertisements. References were cited in 133 (66.5%) brochures. Only 63 (31.5%) literatures had relevant pictures of drugs being promoted and 59 (29.5%) had a graphical representation of pharmacological properties. A total of 131 (69%) DPLs followed 50% of the WHO criteria.

Conclusion:

Majority of DPLs satisfied only half of the WHO criteria for rational drug promotion and none of them fulfilled all the specified criteria. Incomplete or exaggerated information in DPLs may mislead and result in irrational prescription. Therefore, physicians should critically evaluate DPLs regarding updated scientific evidence required for quality patient care.

INTRODUCTION

Large number of new drugs are introduced into the market every day.[ 1 ] Pharmaceutical companies use drug promotional literatures (DPLs) as a major marketing tool to promote their new drugs.[ 2 ] DPLs are claimed to provide vital drug information and are being utilized to convince health professionals to prescribe the new drug.[ 3 , 4 , 5 ] Many a times, it is the only source on which treating physicians depend on for updating their knowledge about the existing and novel drugs.[ 6 ] In 2005, a pharmaceutical industry in the USA has spent more than 30 billion dollars in marketing and promoting to enlighten the clinicians about their products.[ 7 ] Such marketing influences clinician's prescribing behavior with or without benefitting the patient.

According to the World Health Organization (WHO), medicinal drug promotion is defined as “all informational and persuasive activities by manufactures and distributors, the effect of which is to induce the prescription, supply, purchase, and/or use of medicinal drugs.”[ 8 , 9 ] Therefore, for the rational use of drugs, the WHO has laid down ethical criteria for medicinal drug promotion and has recommended pharmaceutical industries to implement these guidelines.[ 3 ] Organization of Pharmaceutical Producers of India, a self-regulatory code of pharmaceutical marketing practices, effective from December 2012, stated seven criteria which DPLs should follow.[ 10 ] Few studies have observed that information provided in DPLs are varying with the code of ethics.[ 11 , 12 ] This can affect the drug prescription, utilization, and sometimes can be irrational. Hence, this study was conducted to critically assess the accuracy of the promotional drug literature using the WHO guidelines.

An observational study was conducted by the Department of Pharmacology at R.L. Jalappa Hospital and Research Centre attached to Sri Devaraj Urs Medical College, Kolar, India, for a period of 6 months from March to August 2014, after the protocol was approved by the Institutional Ethics Committee. DPLs in the form of flyers, leaflets, and brochures were collected from various outpatient departments which were available in the hospital through medical representatives. Collected DPLs were assessed as per the WHO guidelines. Literature promoting medicinal devices and equipment (insulin pump, blood glucometer, and orthopedic prosthesis), ayurvedic medications, drug monographs, reminder advertisements, drugs’ name list, and literature promoting more than one drug or more than one fixed drug combination were excluded.

The following are the WHO criteria to be followed by pharmaceutical industries for the completeness of DPL:[ 13 ]

• The names of the active ingredients using either international nonproprietary names or the approved generic names of the drug
• The brand name
• Content of active ingredient per dosage form or regimen
• Name of other ingredients known to cause problems, i.e., adjuvant
• Approved therapeutic uses
• Dosage form or regimen
• Side effects and major adverse drug reaction
• Precautions, contraindications, and warnings
• Major interactions
• Name and address of the manufacturer or distributor
• Reference to scientific literature as appropriate.

The DPLs were also analyzed for additional information such as various pictures printed, cost mentioned, and source and year of references used to defend the DPL claims. Descriptive statistics were used to analyze the data. The data were expressed as percentage.

A total of 200 DPLs were collected and analyzed, which revealed 134 (67%) were single drug formulation and 66 (33%) were fixed dose combination. Figure 1 represents the most commonly promoted drug categories/or system wise. The extent to which DPLs followed the WHO criteria is shown in Table 1 . Drug cost was revealed only in 12 (6%) brochures. Pictures occupied considerable amount of space on all brochures. DPLs depicted photographs of drug formulation, disease or organ, healthy/depressed men and women, and others as shown in Figure 2 . Only 63 (31.5%) DPLs had relevant pictures of drugs being promoted and 137 (68.5%) had irrelevant representation in the form of car, women, men, and cartoons occupying major area. The pharmacological properties were represented in the form of graphs in 59 (29.5%) DPLs. The quality of paper used for DPLs were durable and the text was legible.

Most commonly promoted drug categories/or system-wise. Miscellaneous: includes hormonal agents, immunomodulators, and antihistamines. CNS: Central nervous system; GITs: Gastrointestinal tract system; NSAIDs: Non-steroidal anti-inflammatory drugs; RS: Respiratory system; CVS: Cardiovascular system; DPLs: Drug promotional literatures

Analysis of drug promotional literatures according to the World Health Organization criteria ( n =200)

Types of pictures depicted on DPLs. DPLs: Drug promotional literatures

In 133 DPLs, 267 references were mentioned [ Table 2 ]. Majority of references were quoted from journal articles, of which references published after 2010 were only 65 (32.5%) as represented in Table 2 . Ten out of 11 criteria of the WHO were followed by 30 (15%) DPLs. A total of 131 (69%) brochures satisfied 50% of the WHO criteria. None of the brochures adhered to all the criteria.

Source of various references in the drug promotional literatures

Marketing new drugs to physicians is an important strategy adopted by pharmaceutical companies.[ 14 ] DPLs are sometimes the only source about new drugs/new indications for old drugs. In our study, it was observed that none of the DPLs fulfilled all the criteria laid down by the WHO guidelines. A similar finding was reported in other studies.[ 2 , 3 , 6 , 8 ] This suggests that drug promotional companies are more involved in establishing a commercial relationship with the treating physicians wherein ethical educational aspect is compromised.[ 2 ] In the present study, 33% of DPLs promoted fixed drug combination, hence the physicians should consider the rationality of the drug combination before prescribing.

Cardiovascular agents, antidiabetic drugs, and antimicrobials were among the top three groups of drugs being promoted, indicating that pharmaceutical companies are targeting diseases which are widely prevalent. This finding was in concordance with a study conducted in Mumbai.[ 1 ] Treating physicians should be highly cautious while prescribing the drugs based on information given in DPLs to avoid irrational prescription, higher incidence of drug resistance, adverse effects, and to reduce the cost incurred by patients.[ 1 , 15 ]

It was observed that most of the DPLs had mentioned brand name, approved generic name, and active ingredient per dosage form, which is similar to a study conducted in Nepal.[ 11 ] In our study, none of the brochures had mentioned other ingredients that are known to cause problems. We observed that majority of DPLs quoted dosage schedule and therapeutic indications, but did not stress on adverse drug reactions, precautions, contraindications, and interactions. The above criteria are certainly necessary for the care of the patient and also manage physician time from looking into other source of information. Similar findings were observed in other studies.[ 2 , 3 , 6 , 12 , 16 , 17 ]

All the brochures were colorful and attractive, but had irrelevant pictures related to the drugs being promoted. DPLs had used nonspecific representations occupying major area, which could have been utilized appropriately for listing various properties of drugs, other studies have reported similar finding.[ 2 , 3 , 8 ] In this study, it was observed that unsubstantiated claims were made in the brochures regarding efficacy and safety. Recent references were mentioned in very few DPLs, but this is essential for updating the clinicians so as to expand their existing knowledge and practice evidence-based medicine.

In view of this study, it is of utmost importance for the treating physician to critically evaluate any source of drug information based on the established guidelines before accepting them as scientific piece of information. Regional Ethics Committee in various metropolitan cities in India collect complaints about unethical drug promotion and report the same to the Drug Controller General of India to take necessary legal steps to regulate pharmaceutical companies to publish DPLs fulfilling the WHO criteria.[ 2 , 3 , 8 , 9 ]

Sixty-nine percent of the advertisements satisfied only half of the WHO criteria for rational drug promotion. Hence, the treating physicians should learn the art of analyzing DPL to provide quality care for the patients.

AUTHORS’ CONTRIBUTION

P. Ganashree: Reviewing of literature, Data collection, analysis and manuscript preparation. K. Bhuvana: Study design, Reviewing of literature and manuscript editing. N. Sarala: Data analysis and Manuscript review.

Financial support and sponsorship

Conflicts of interest.

There are no conflicts of interest.

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