Health systems
Reducing health inequalities in developing countries
Looking at ways of analysing and addressing inequalities in the provision of health services in poor countries
Authors:
D. R. Gwatkin
Publisher:
World Bank, 2002
What does current thinking tell us about trends in health inequalities and methods for reducing such inequalities? This is the central question addressed by D. Gwatkin of the World Bank in an article that draws on a variety of worldwide studies on health inequalities in developing countries.
Gwatkin’s article, which makes up a chapter of a book on public health, is divided into four sections. The first provides a brief history of recent trends in concern about health inequalities. The second is a discussion of the concept of health inequalities, while the third summarises what is known about the dimensions and magnitudes of such inequalities. The fourth section presents a comparable summary of current thought about how best to reduce inequalities.
The key findings, taken from a number of recent studies, are as follows:
- A child born to parents who make up the poorest 20 percent of a sampled developing country is roughly twice as likely to die in infancy than is a child born in the richest 20 percent. A recent study by the World Health Organisation using different research methods suggests that the figure may be much higher.
- Intracountry socio-economic inequalities in infant and child mortality are smaller in sub-Saharan African than in Latin America or Asia.
- A study assessing access to health services in 7 African countries found that on average the richest 20 percent of the population received well over twice as much financial benefits as the poorest 20 percent from overall government health service expenditures. In the case of 7 Latin American countries assessed, the results are the reverse, with greater benefits accruing to the poor.
- When data are compared between countries, differences in infant mortality rates between richest and poorest countries are found to decline over time in absolute terms, but rise in relative terms. For life expectancy, country comparisons show a decrease in inequality in both absolute and relative terms.
It is now commonly agreed that improvements in public health are not determined solely by improvements in health services. A broader approach is needed that influences development policy more generally and includes interventions in other sectors such as water and sanitation, and conflict resolution. Approaches for tackling inequality in health provision that are proposed in this article are as follows:
- Targeting – this refers to a set of techniques used to increase the percentage of benefits from a particular intervention that flows to the poor. Target groups may be based on individuals, geographic areas or specific diseases.
- Participatory approaches to health service planning and delivery - these may take three forms: identification of the poor through participatory poverty assessments; determining what the poor want in the way of health services and what they think of the services they currently receive; and an increased reliance on non-governmental organisations rather than government agencies to deliver health and other services.
- Protecting the poor from the financial consequences of illness – mechanisms to protect against severe illness include the development of risk-pooling or insurance plans and subsidised or free secondary medical care for income-earning adults.
- Establishing health objectives in distributional terms – this approach encourages alternative ways of stating goals and objectives for the health sector, using poverty or distributional terms rather than social averages.
