Framing Health Equity in the SDG Era: Justice through Health Systems?

Author: Beverley Essue, University of Toronto

Here I consider how equity is conceptualized, defined, and operationalized within the Sustainable Development Goals (SDGs), with health systems and SDG 3, ensuring healthy lives and promoting well-being for all, as a critical site of inquiry. While the SDGs are framed as universal, they rely on contested and politically loaded definitions of equity, whether interpreted through lenses of fairness, need, redistribution, or capabilities. This shapes how policies are designed and whom they serve. Scholars have a vital role not only in generating evidence but also in questioning these underlying assumptions and how they translate into practice and influence health policies’ impact.

In the context of health systems’ development, academics are uniquely positioned to reveal the tension between equity as a rhetorical commitment and equity as an implemented reality. For instance, efforts to expand universal health coverage under SDG 3 may improve aggregate outcomes but still entrench structural exclusions if they fail to address systemic barriers related to race, gender, migration, or economic marginalization. Research that maps inequities, engages communities, and tracks who benefits and who does not, functions both as a diagnostic tool and as a political intervention. 

Moreover, the processes by which health policies are designed and implemented, through co-creation, participatory governance, and local adaptation, are not simply technical or managerial. They are, in themselves, expressions of theorizing about equity. These processes embody normative claims about whose knowledge is valued, whose needs are prioritized, and what justice demands. As such, scholars must go beyond technocratic prescription to work in solidarity with those most affected by inequity, producing context-sensitive knowledge that informs both local actions and global accountability. 

The work of Amartya Sen and Esther Duflo, discussed in Professor Mariana Prado’s piece “Sustainable Development Goals: The End of Theory?” offers contrasting yet complementary frameworks for making sense of these challenges. ^[1] Sen’s capabilities approach shifts the equity debate away from narrow conceptualization of efficiency or utility to a concern with real freedoms — what people are actually able to be and do. This lens is particularly resonant in the SDG 3 context, where the mere expansion of health services can mask persistent capability deprivations driven by structural injustices. Sen’s emphasis on substantive freedoms encourages a more critical and justice-oriented reading of SDG 3. 

Duflo, by contrast, focuses on empirically grounded, incremental solutions, often tested and through randomized controlled trials. Her work has improved our understanding of what interventions “work” in practice and in complex conditions. While impactful, this approach can risk reinforcing a technocratic vision of equity that optimizes outcomes without grappling with the root causes of exclusion and the process-related conditions that impact implementation, which Sen’s work foregrounds. 

These tensions are further illuminated by initiatives like the Disease Control Priorities (DCPs), which provide global guidance on cost-effective health interventions. While designed to inform policy decision-making in resource-limited settings, DCP’s utilitarian framework can sideline interventions that benefit structurally marginalized populations but yield lower Disability Adjusted Life Years ^[2] averted per dollar compared to other interventions (though the adoption of more equity-focused methods such as the extended cost-effectiveness analysis framework is working to address this, at least in part). In privileging aggregate efficiency, the DCPs may inadvertently perpetuate the very inequities SDG 3 claims to challenge. The DCPs’ assumptions, such as the neutrality of resource allocation or the universality of its recommendations, can overlook the realities of political economy, donor conditionalities, and historical legacies. 

Scholars have a role to play in reclaiming space to interrogate and redefine equity in ways that resist depoliticization. This includes critiquing global policy frameworks, advancing intersectional methodologies, and working with communities to co-produce knowledge that makes visible the lived realities of structural exclusion. It also could involve recognizing that the process of implementation — how policies are enacted and by whom — is a site of theorizing in itself, not merely of application. 

Theorizing equity in the SDG era should not call for a single universal framework, but for a pluralistic, reflexive, and politically engaged scholarship. I would argue that equity is not a fixed end state but an evolving process. Thus, the contestation, co-creation, and structural transformation that is required to advance the SDGs beyond aspiration should, in principle, also enable them to serve as tools for justice.

“Theorizing equity in the SDG era should not call for a single universal framework, but for a pluralistic, reflexive, and politically engaged scholarship. I would argue that equity is not a fixed end state but an evolving process. Thus, the contestation, co-creation, and structural transformation that is required to advance the SDGs beyond aspiration should, in principle, also enable them to serve as tools for justice.” – Beverley Essue, University of Toronto

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References

^[1] Mariana Mota Prado, “Sustainable Development Goals: The End of Theory?” Reach Faculty Reflections, Reach Alliance, Toronto, 2025. <https://reachalliance.org/commentary/sustainable-development-goals-sdgs-the-end-of-theory/>

^[2] Disability-Adjusted Life Years are a summary measure of population health that combines years of life lost due to premature death (YLL) and years lived with disability (YLD) to quantify total health loss.

About the Faculty Mentor Paper Series

This paper is part of the Reach Alliance faculty reflection series, Reimagining the Future of Sustainable Development, in response to Mariana Prado’s Sustainable Development Goals:The End of Theory? Featuring contributions from leading scholars across the Reach Alliance global academic consortium, the series opens a timely dialogue on the evolving role of universities in shaping the future of sustainable development theory and practice. Developed as part of Reach’s commitment to advancing research-to-impact and fostering interdisciplinary collaboration, these reflections aim to engage higher education professionals in shaping the future of the Sustainable Development Goals.