Scotland’s health inequalities reflect the imbalance of power in our communities

This article first appeared on The Courier on 22 May 2026.

Health in Scot­land is rarely out of the head­lines. Wait­ing times, work­force pres­sures and the sus­tain­ab­il­ity of the NHS dom­in­ate pub­lic debate. But beneath these imme­di­ate con­cerns lies a deeper and more uncom­fort­able truth: health inequal­it­ies in Scot­land are not simply about health­care deliv­ery; they are about place and power. Unless that is con­fron­ted, efforts will con­tinue to treat the symp­toms rather than the causes.

I have seen this dynamic play out when I worked abroad.

In the Demo­cratic Repub­lic of Congo, I saw first-hand how fra­gile health sys­tems reflec­ted deeper imbal­ances between cent­ral and local gov­ern­ment, between com­munit­ies and insti­tu­tions, and between those with resources and those without.

Urban areas con­sist­ently benefited, not only because of infra­struc­ture, but because of their prox­im­ity to power and decision-making. These dynam­ics shaped how resources were dis­trib­uted. Donor fund­ing, while vital, often rein­forced these pat­terns – for example, draw­ing health­care work­ers and invest­ment into fun­ded pro­grammes and loc­a­tions, leav­ing other areas com­par­at­ively under­served.

Too often, the voices of com­munit­ies them­selves were absent from decisions about the ser­vices inten­ded to sup­port them.

Hav­ing returned to work in Scot­land, I’m struck by how famil­iar the pat­tern between health, place and power feels.

Inequal­it­ies remain stark; men in Leven­mouth live on aver­age 10 years less than men in north-east Fife. These are not mar­ginal dif­fer­ences; they are struc­tural.

And yet, pub­lic under­stand­ing of health still often defaults to indi­vidual beha­viour. Of course, our life­style mat­ters – whether we drink too much, smoke, etcetera – but it is only part of the story.

Focus­ing solely on beha­viour risks obscur­ing the con­di­tions in which those beha­viours occur.

Health is very much shaped by place: by whether you live in warm, secure hous­ing; by whether you have a stable income; by whether your envir­on­ment makes healthy choices easy or dif­fi­cult.

Recent debates on obesity in Scot­land have reflec­ted this, with calls to move bey­ond med­ical solu­tions and instead reshape the envir­on­ments that drive unhealthy out­comes.

But place itself is shaped by power. Decisions about where invest­ment is dir­ec­ted, how ser­vices are designed, and which pri­or­it­ies are advanced all influ­ence the dis­tri­bu­tion of health.

Some com­munit­ies are bet­ter posi­tioned to influ­ence these decisions than oth­ers. This uneven dis­tri­bu­tion of influ­ence con­trib­utes dir­ectly to unequal out­comes.

Scot­land has long recog­nised the need for a “pre­vent­at­ive shift” to address these chal­lenges. Pre­ven­tion is often under­stood as earlier inter­ven­tion – identi­fy­ing risks sooner and act­ing before prob­lems escal­ate.

But in its fullest sense, pre­ven­tion is about something more fun­da­mental: chan­ging the dis­tri­bu­tion of power and resources that pro­duce ill health in the first place.

Des­pite con­sist­ent rhet­oric, pro­gress has been lim­ited. Strategies, frame­works and reforms have repeatedly emphas­ised pre­ven­tion and tack­ling inequal­it­ies, yet out­comes have been slow to change. This reflects a more dif­fi­cult real­ity: without shift­ing power, efforts to reduce inequal­it­ies will con­tinue to struggle.

A more sub­stant­ive shift in power would involve strength­en­ing com­munity influ­ence in decision-mak­ing.

The most effect­ive pub­lic health inter­ven­tions – whether in Kin­shasa or Kirk­c­aldy – are those that are designed with com­munit­ies, not imposed upon them. This requires genu­ine par­ti­cip­a­tion, not con­sulta­tion as an after­thought.

Second, it would mean using the full range of policy levers bey­ond health.

Hous­ing, employ­ment, edu­ca­tion, trans­port and the envir­on­ment are not peri­pheral to health – they are cent­ral. The Pop­u­la­tion Health Frame­work rightly recog­nises this, but deliv­ery requires align­ment across gov­ern­ment, not just ambi­tion.

Third, it requires being hon­est about trade-offs and redis­tri­bu­tion. Address­ing inequal­it­ies will require shift­ing invest­ment upstream, even when pres­sures down­stream are acute. But it also means apply­ing uni­ver­sal policies with a scale and intens­ity pro­por­tion­ate to need. We all know that people’s start­ing points are unequal, but it requires polit­ical cour­age to act­ively level the play­ing field.

There is reason for optim­ism. Scot­land has a strong policy archi­tec­ture, a clear com­mit­ment to pre­ven­tion, and grow­ing recog­ni­tion of the import­ance of social determ­in­ants of health. But pro­gress will depend on whether we are will­ing to go fur­ther, to address not just place, but power too.

Health inequal­it­ies are not inev­it­able. They are shaped by decisions about resources, pri­or­it­ies and whose voices are heard.

Improv­ing health there­fore requires more than reform­ing ser­vices; it requires a shift in how power is under­stood and exer­cised across the sys­tem. Until that shift hap­pens, the gap in health out­comes between com­munit­ies will remain – not because it can­not be closed, but because the con­di­tions that sus­tain it have yet to be fully addressed.

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Dr Rishma Maini is a qualified Consultant in Public Health Medicine with over 15 years of experience across domestic and international public health. She currently holds a joint role with Public Health Scotland and NHS Fife and works closely with the Scottish Prevention Hub at Edinburgh Futures Institute. She has been a key strategic leader within the Hub, helping to shape the development of the Common Data Platform for Scotland and championing the use of data, evidence and cross-sector collaboration to support prevention-focused policy, practice and system change.