Braveman, B (2002b).
Powerpoint presentation

Sen, A. (1990). "More
than 100 million women
are missing." New York
Review of Books
(12/20/90): 61-66.

There are wide health inequalities within countries, as well as between countries. Comparisons made between countries, are comparisons of the average levels in each country. Within each country, differences between rich and poor, between men and women, and between dominant and marginalized ethnic groups, all lead to differences in health and longevity.

Generally, people with high incomes fare much better than the average. Almost universally, people with very low incomes fare much worse than the average. ‘Across societies there is an association between the degree of social inequality and the rate of disease and death: higher inequality results in higher disease and premature death’ (Wermuth 2000: 65-6). Why does high inequality lead to higher rates of death and disease? Firstly, high inequality leads to a larger proportion of the population living in relative poverty. These people may be unable to purchase health care. Secondly, high inequality, for example in Brazil and South Africa, is associated with government neglect of public health measures, and particularly neglect of the health of the poor.

Braveman (2002 a) provides some examples of health inequalities within countries:

There is very little information about inequalities within countries; governments rarely collect data of this sort. As a result, it is difficult to draw global maps showing how within country health inequalities change over time. Instead of global maps, this page contains graphs which illustrate preliminary findings from data covering a sample of 44 countries of the Third World. The data below comes from the ‘country health and poverty report’ project of the World Bank. It is based on data collected in household surveys covering 5,000 to 10,000 households in each country (Gwatkin 2002: 12).

Rich poor differences in Under Five Mortality

The proportion of children dying before the age of five (under Five Mortality Rate) is one important measure of health inequalities that has been collected for different income groups in a number of non-industrialized countries. The graph below shows Under Five Mortality rates for rich and poor in 44 non-industrialized countries.

The graph is sorted by child mortality in low income groups, with the highest child mortality to the left. The mortality rate of the poorest quintile (20%) of the population in each country is shown in red, while that of the richest quintile is shown in purple. The blue, jagged line indicates the ratio of child mortality for the poor and the rich (poor/rich). This latter line indicates that some countries, including Bolivia, Turkey, and Peru, have very large differences between the health of rich and poor children. This graph suggests that inequality demands particular attention in Bolivia, Turkey, Peru, the Dominican Republic and several other countries.

Gender differences in health: 100 million women are missing

There are significant inequalities in access to health care by gender. There is a growing literature about the high death rate of female children in some parts of the world. Amartya Sen (1990) has suggested that inequality in access to health care may be the main cause of the death of 100 million women in South Asia, China, and North Africa.

Inverse Care law: the poor become ill while the rich receive health care

Intracountry health inequalities are partly shaped by an inverse care law which suggests that ‘the availability of good medical care tends to vary inversely with the need for it in the population served’ (Hart 1971, cited in Gwatkin 2001). In other words, health care services are used disproportionately by those with high incomes, while the poor have greater need and much less access.

The graph (from Castro-Leal et al (2000); quoted in Gwatkin 2001), shows that the primary beneficiaries of government health expenditures are the richest. This is true not only in the case of total health care expenditure, but also for primary health care, which is intended to provide basic services for the poor.

Davidson Gwatkin comments ‘It is tempting to believe that a focus on poor countries is sufficient to assure that the majority of a program’s benefits will reach the people who need them most. Unfortunately, such is not the case…the power of the inverse care law…makes it highly likely that, in the absence of special efforts on behalf of the disadvantaged, the majority of benefits of health initiatives will flow to [the] better off.’

References

Braveman, P. (2002a). "Measuring Health Equity Within Countries: The Challenge of Limited Information." MSJAMA 288(October 2, 2002): 1650.

Braveman, B (2002b). Powerpoint presentation

Castro-Leal, F., J. Dayton, et al. (2000). Public spending on health care in Africa. Bulletin of the World Health Organization 78(1): 70.

Gwatkin, D. R. (2001). Overcoming the inverse care law: designing health programs to serve disadvantaged population groups in developing countries, Ms, World Bank.

Gwatkin, D. R. (2002). Reducing health inequalities in developing countries. Oxford Textbook of Public Health.

Sen, A. (1990). "More than 100 million women are missing." New York Review of Books (12/20/90): 61-66.