Equity
The broad historical perspective on human health is reassuring in many ways. The overarching trends are positive, with unprecedented gains, widespread advances, and converging health status. However, these positive trends mask the uneven progress that has left large numbers of people behind and at a disadvantage. No process of setting priorities and designing strategies for improving health can ignore the pervasive large inequities. As DCP2 (chapter 1, p. 5) observes, "In far too many countries health conditions remain unacceptably—and unnecessarily—poor. This factor is a source of grief and misery, and it is a sharp brake on economic growth and poverty reduction."
". . . half of British growth during the Industrial Revolution could be attributed to improved nourishment . . ."
Given today's tools and resources, health conditions could be reasonable everywhere, but for far too many people "reasonable" health conditions are not the norm. Children born in low-income countries have much smaller chances of leading a long life with good health than those born in higher-income countries. Women generally lead longer lives than men, but their lives tend to be marked by poorer health (DCP2, chapter 10). Where societies deny women rights of inheritance, political voice, legal standing, or education, those women suffer from more diseases and injuries and have less access to treatment and services. Other socially marginalized groups, whether large groups like indigenous populations, rural dwellers, and migrant workers or smaller groups like sex workers and street children, suffer from similar excessive disease burdens.
"Women generally lead longer lives than men, but their lives tend to be marked by poorer health . . ."
Equity is a major subtext throughout DCP2.3 Each disease-specific chapter notes the distribution of the disease burden and identifies where this burden is concentrated, whether in particular regions or populations. Discussions of interventions assess their effectiveness relative to different age, gender, cultural, and social groupings, and analyses of delivery mechanisms address the barriers to accessing appropriate and timely health care as those barriers vary across population groups. As the authors of the chapter on integrated management of childhood illness (IMCI) observe, "The challenge of improving equity is not unique to IMCI or to child survival; it affects virtually every intervention and delivery strategy. Unless equity considerations become a key part of policy making and of monitoring outcomes, interventions may widen instead of narrow inequity gaps" (DCP2, chapter 63, p. 1189, emphasis added).
Health inequities, many of which are plainly visible, can be documented when researchers disaggregate analyses by the relevant divisions in society, for example, age, gender, income, ethnicity, or region. The resulting patterns of inequity can be seen at three different levels: large disparities in health status, differential access to and use of health care services, and disproportionate exposure to health risks.
Patterns of Inequity in Health Status
"During 1990-2002, the mortality rate for children under five remained stagnant or increased in 27 countries."
The reassuring picture painted by rising global averages obscures substantial disparities in health among different regions of the world and different income brackets, genders, and age groups. A child born in Ethiopia today, for example, has a 20 percent chance of dying before the age of five compared with a less than 1 percent chance for a child born in North America or Western Europe. During 1990-2002, the mortality rate for children under five remained stagnant or increased in 27 countries. A woman's risk of death in childbirth is less than 20 per 100,000 births in high-income countries, but the average exceeds 900 per 100,000 births in the lowest-income countries. Progress on reducing maternal mortality has slowed, and has even reversed, in some countries, and thus the gap is widening.
"The excess disease burden for women is not exclusively a result of diseases related to maternal conditions, . . ."
The excess disease burden for women is not exclusively a result of diseases related to maternal conditions, but includes a higher incidence of illnesses that derive from inequitable gender roles; for example, in Sub-Saharan Africa, teenage girls are 5 to 16 times more likely to be infected with HIV than teenage boys. In China, India, and other parts of South Asia, neglect of female children, gender-selective abortions, violence, and other causes of excess mortality mar the lives of women, leading to the haunting estimates of millions of women who are therefore missing from population counts.
In many of the former Soviet republics, life expectancy declined among men in the 1990s because of a rise in alcoholism and social dislocation and the deterioration of basic health infrastructure. By far the worst calamity of recent years has hit Sub-Saharan Africa, where HIV/AIDS is reducing average life expectancy and increasing mortality from opportunistic infections, TB, malaria, and malnutrition.
Large disparities in health can also be found within countries. Western China, for example, lags far behind China's wealthier coastal regions in its health profile, and indigenous populations in Latin American countries have shorter, less healthy lives than other segments of the population. Indeed, researchers regularly find that in most countries the poor live shorter, less healthy lives than the rich.
Patterns of Inequity in Health Care Provision
"Coverage levels for effective interventions to improve child survival are remarkably low in most developing countries."
Inequity is also evident from disparities in health care services, for instance:
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Coverage levels for effective interventions to improve child survival are remarkably low in most developing countries. A review of the 42 countries that account for 90 percent of global child deaths showed that only two out of nine key interventions reached more than half of all children.
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In 1999, skilled birth attendants assisted less than half the women giving birth in Sub-Saharan Africa.
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One-third of the world's population has no effective access to essential modern medicines or vaccines. Some 65 percent of people in India and 47 percent of those in Sub-Saharan Africa simply cannot obtain essential drugs when they need them.
". . . 65 percent of people in India and 47 percent . . . in Sub-Saharan Africa simply cannot obtain essential drugs . . ."
Many different barriers exclude people from getting appropriate health care. As noted in the DCP2 chapter on gender differentials (chapter 10), these barriers can be divided into those related to services, to clients, or to institutions and tend to affect women disproportionately as follows:
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Service factors include high costs of care and transportation, distances to services and the time needed to reach them, poor quality care, inappropriate care, negative staff attitudes, and cultural and linguistic differences.
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Client factors include social and cultural constraints on women's mobility and women's lower incomes and wealth, women's greater time burdens because of their socially assigned family roles, and women's limited information about their health needs and rights and about the availability of services.
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Institutional factors include men's control over decision making, health budgets, and facilities; local perceptions of illness; local treatment norms; and stigma and discrimination in health settings.
Although the particulars vary, other DCP2 chapters delineate a wide range of barriers that constrain access to care for infants, children, sex workers, and a number of other disadvantaged populations.
Patterns of Inequity in Exposure to Health Risks
"Many risks are associated with climatic and geographic conditions . . . relevant to malaria, river blindness, helminthic infections, and . . . tropical diseases."
Differences in health status are also the result of differential exposure to health risks. Many of these differences are associated with poverty and are discussed in a number of DCP2 chapters, including those on water and sanitation (chapter 41), neonatal care (chapter 27), malnourishment (chapter 28), and indoor air pollution from stoves (chapter 42). Many risks are associated with risky and physically demanding occupations (chapter 60). Still others are associated with climatic and geographic conditions, which are particularly relevant to malaria (chapter 21), river blindness (chapter 50), helminthic infections (chapter 24), and a wide range of tropical diseases (chapters 22 and 23).
Equity and Technical Progress
How did these inequities in health status, health care services, and exposure to risk arise? Many factors play a role, ranging from accidents of climate or geography to political repression and neglect. Yet despite ample debate about some aspects of the nature and origins of inequities in health, most experts tend to agree that health inequities have arisen largely from the uneven adoption and implementation of health interventions associated with technical progress; that is, they have arisen largely because cost-effective interventions have been applied in some places and not others or for privileged groups and not other groups.
". . . health inequities have arisen largely from the uneven adoption and implementation of health interventions associated with technical progress . . ."
Where the fruits of technical progress have not been available, people have been left behind, with some gaps growing ever deeper. For example, among 12 million childhood deaths analyzed in 1998, close to 4 million resulted from diseases for which effective vaccines are available. Cost-effective and relatively inexpensive interventions for many vaccine-preventable illnesses, diarrhea, pneumonia, TB, and malaria have resulted in a reduction of the disease burden from these diseases to as little as 0.3 percent of the total where such interventions have been applied. Where such interventions are not deployed, these preventable diseases account for 11.7 percent of the disease burden (table 1.2, figure 1.2).
[Figure
1.2]
[Table .]
