Transcript Global inequalities in health

Global inequalities in health:
Are they relevant to an Atlas of
Global Inequality?
Paula Braveman, MD, MPH
Professor of Family and Community
Medicine, UCSF
March 1, 2002
Health inequalities between countries
80
70
60
50
40
30
20
10
0
Life Expectancy 1994
Japan
Sierra Leone
1600
1400
1200
1000
800
600
400
200
0
Maternal Mortality 1990
Norway
Guinea
Health inequalities between
countries
• A child born in a developing
country of Africa, Asia, or Latin
America is roughly 10 times more
likely to die before reaching age
five than a child born in Europe or
North America
And inequalities within countries
• Wide inequalities in health not
only between but also within
countries
• Between-country gaps have
received more attention
• Routine health data can obscure
large gaps within countries
Health disparities within
countries: by SES
• Venezuela (1994): poor municipalities had
infant mortality rates 3 times those of nonpoor municipalities
• UK: widening gap in life expectancy
between social classes
• Indonesia (1990): 12% of public spending
for health care went to poorest 20% of
people
Smoking is more common among
less educated men in India
Smoking Prevalence (%)
(Chennai)
70
60
50
40
30
20
10
0
Illiterate
<6 yrs
6-12 yrs
Source: Gajalakshmi, CK et al. Patterns of Tobacco Use and Health
Consequences, Background Paper for “Curbing the Epidemic: Governments and
the Economics of Tobacco Control, World Bank, 1999.
>12 yrs
The “Inverse Care Law”
• Rich consume more hospital and public health
care than the poor (Hart 1971)
• Immunization coverage strongly correlated with
wealth (Gwatkin et al. 1999)
• Poor with illness don’t access care: 2x more likely
to self treat; 10x more likely to do nothing (Uganda,
HH Survey, 1994/5)
• Poor that access health care risk impoverishment
(Liu and Hsiao, 1997; WB, Voices of the Poor)
Distribution of Health Care Resources, Mexico 1990-96
by municipalities’ level of deprivation
%
Rate per 10,000 population
20
100
80
15
60
10
40
5
20
0
0
Very low
Low
Medium
High
Physicians
Beds
Hospital deliveries
Very high
Health status of poor versus non-poor
in selected countries, 1990
Country
Aggregate
Malaysia
Ecuador
Chile
China
Kenya
India
Percentage
of
population
in absolute
poverty a
6
8
15
22
50
53
Probability of dying
per 1000 (females)
Between
Between
birth - 5
ages 15 - 59
Prevalence
of
tuberculosis
Poor:non-poor
ratio
Poor:non-poor
ratio
Poor:non-poor
ratio
4.8
15.0
4.9
8.3
6.6
3.8
4.3
4.3
5.1
4.4
12.3
11.0
3.8
3.7
2.6
3.2
1.8
8.0
3.8
2.6
2.5
Adapted from Table 2.1, The World Health Report, World Health Organization, 1999.
a
Poverty is defined as income per capita of less than or equal to $1 per day, expressed in
dollars adjusted for purchasing power.
Health inequalities within
countries: by race/ethnicity
• Kenya: likelihood of a child dying before
age 2 varied by ethnicity (7.4% vs 19.7%
• USA: African-American infant mortality
is twice that for European-Americans
• Guatemala: malnutrition 40% higher
among indigenous children
Health inequalities within
countries: by gender
• India (1987): girls nearly twice as likely to
die by age 2 as boys, probably due to family
behavior
• India, Bangladesh, & Pakistan (UN 1989):
death of one of six girls was due to neglect
and discrimination
• Large differences in immunization and
nutritional status of girls vs boys
Why we need to monitor health
inequalities in countries
• None of these gaps would be revealed by
routine data
• Most countries are facing pressures making
it increasingly difficult to implement and
sustain equitable policies
– government down-sizing
– privatization
– competing in global markets
Health and wealth
• Widening economic inequalities
everywhere
• Strong evidence that health and
wealth are connected
• Yet no routine monitoring of how
widening gaps in wealth may
impact health
• Equity in health needs to be higher
on the agendas of governments and
national and international
organizations
• Capability for ongoing monitoring
of equity in health must be
developed everywhere
Health vs. health care
• Health = physical and mental well-being
(disease, mortality, functional status, quality
of life, risks)
• Social determinants of health
– conditions in households, neighborhoods, and
workplaces
– health care (use of health services, resource
allocation, financing, quality)
– policies affecting any of the above
Challenges in monitoring health
inequalities in countries
• Lack of data on both health and social factors
• Simplicity, timeliness, sustainability
• Universal problems, but particularly in lowerincome countries
• Lack of trained personnel for data collection,
analysis, reporting
• Lack of clarity about what to monitor
Lack of data in poorer countries
– under-registration of births and deaths,
particularly for marginalized groups
– unreliable cause-of-death information
– registration by occurrence vs residence
– no socioeconomic data in vital records
– reliance on data from clinical sites
– no information on mental health, quality of
life, functional status, adult health
The Equity Gauge Initiative
• 12 teams in 11 countries
• Burkina Faso, Kenya, South Africa,
Uganda, Zimbabwe
• Bangladesh, China, Thailand
• Chile, Ecuador
• monitoring different aspects of health equity
+ advocacy + capacity-building
Importance of monitoring
inequalities in health
• Ill-health is both a consequence and a
cause of poverty
• Human rights
• In most societies, less tolerance for
disparities in health than in wealth
• Could increase pressure to address
social and economic inequalities