Shining the Spotlight on Inequality in the Health Sector, Abdo S Yazbeck
It would be very hard to find anybody working on the health sector in developed or developing countries that would be surprised that the poor and socially vulnerable suffer more from illnesses and die earlier than the better off. Nobody was really surprised when the World Bank (Gwatkin and others) began producing country reports in 1999/2000 that showed the poor with much higher rates of infant mortality, malnutrition, and fertility. The poor, after all, have so many strikes against them that should contribute to bad health outcomes. They tend to have lower levels of education, live in environments that contribute to communicable diseases, and in far too many countries have limited access to enough calories to sustain themselves. The World Bank recently published an update of these country reports which includes data from 56 low and middle income countries and shows the gap between the rich and poor to be large in every one of the regions where data is available (Figure 1.2 on page 6 of the book Reaching the Poor shows the data for under-five mortality rates, but data exists also for nutrition and fertility outcomes).
This expected outcome inequality is largely due to factors outside the health (medical) sector; therefore, it would be logical to expect that the health sector should become part of the solution by earmarking a larger share of resources to address the needs of the poor than it does for the better off. However, it is in this specific area where the country reports revealed the most damning facts on inequalities in the health sector: health spending, even public spending, tends to be pro-rich. The gaps in coverage between the rich and poor in low and middle income countries are large and persistent even when the spending is on the most basic (or primary) health services (see figure 1.3 on page 7 of Reaching the Poor).
The mere fact that this data has now been available for the last seven years has already changed the dialogue on inequality in health. Gone are the days when we could simply say that investing in health was investing in the poor. The overwhelming evidence put forward by Gwatkin et. al has exposed this assumption as naive. The global discussion on inequality has started to change from thinking of poor versus rich countries to understanding that inequalities within countries are probably even more important, given that 70 percent of the world’s poor live in middle income countries like China and India. Yet another important result of this research is that demand has started to grow both for understanding the causes of in-county inequalities in health and health services use and for documenting and learning from attempts at reversing inequality. And finally, the publication of these numbers has changed the way data is collected in the health sector by adding a distributional dimension to household survey data collection previously confined to rural/urban and gender differences, and this new dimension has started to impact how monitoring and evaluation efforts are run.
The dissemination of large volumes of country specific data on health and health service use inequalities has started a fundamental change in how health sector thinking is being approached in developing countries and by development agencies, but this is only the beginning. It will take much more dissemination and advocacy to complete this change and the recent updating of this critical work will help. The new data series includes more countries (56 low and middle income countries), more variables (120 health outcomes, health services, and determining factors), and newer data. Faced with overwhelming evidence, it is going to be difficult for the world to continue turning their backs on the needs of the poor.