Combining health and social protection measures to reach the ultra ...

Introduction
Research contributions to
improving equitable access to
health in developing countries
Article by Stephen A Matlin
Everywhere in the world, issues of equitable access are
fundamental to improving the health of all the people 1 .
Limitations of access to information, to services for
prevention and treatment, or to good quality health-related
products are among the many factors that create gradients in
health status within and between societies.
High levels of malnutrition, maternal and child mortality
and infections with HIV/AIDS, TB, malaria and a number of
pathogenic tropical parasites in some developing countries
have attracted much attention and led to the establishment of
the Millennium Development Goals 2 to reduce some of the
starkest health gradients between countries. But these do not
address the broader health conditions that affect people
throughout the world, including a host of noncommunicable
diseases that are becoming increasingly prevalent in low- and
middle-income countries 3 , nor the wide range of factors and
determinants that act as pre-conditions for people to achieve
and maintain good health.
Historically, some groups have experienced long-standing
discrimination in access to health including, among others:
women, people with disabilities, indigenous peoples, poor
people, people in low-income countries, rural populations,
slum dwellers, elderly people, children, adolescent and young
people, people of low social class or caste and people
stigmatized by specific conditions such as HIV/AIDS.
Given the wide range of health determinants and
conditions that are at play, the spectrum of research required
to address the complex range of factors associated with
inequities in access is necessarily very broad. Research can
help to identify and address barriers to access of all types
(including economic, geographical, institutional, political,
socio-cultural and technological barriers) and can help to
identify, test and validate measures to improve equity of
access for all. The range of people who need to be engaged
Given the wide range of health determinants and
conditions that are at play, the spectrum of research
required to address the complex range of factors
associated with inequities in access is necessarily
very broad
in such research is also extensive – encompassing not just
physical, biological, social and behavioural scientists located
in academic research institutions but also health workers,
nongovernmental organizations (NGOs), communities, civil
society groups and individuals, including representatives of
groups on whom the research is focused.
This article considers a diverse array of factors associated
with inequities in access to the means to achieve better
health in developing countries and summarizes some of the
ways in which research is, or could be, playing a role in
removing barriers and biases.
Access to the preconditions for health
It is increasingly appreciated 4 that a broad array of nonbiological
factors act as determinants of health, including
those of economic, environmental, political and social origins
(Figure 1). Improving health, especially for some of the
poorest and most marginalized in society, will require giving
much greater attention to these “causes of the causes” of illhealth,
with effort needing to be concentrated on securing the
human rights on which many of these determinants depend.
Research to examine these wider determinants of health, to
understand the causal relationships and to demonstrate ways
in which they can be used to improve health status and
health equity is scarce and there is a need to begin by
establishing the scope of the research agenda, mapping the
human and financial resources already available and setting
priorities for where and how the most urgent gaps are to be
filled. The research agenda on determinants of health must
include studies of the extent to which human rights are
recognized and upheld, given that health and human rights
are inextricably connected.
Among the broad range of determinants, social factors have
received most attention recently, particularly through the
establishment of a series of Knowledge Networks by the WHO
Commission on Social Determinants of Health (CSDH) 5 . The
CSDH, created in 2005 to draw attention to pragmatic ways
of creating better social conditions for health, aims to promote
models and practices that effectively address underlying
social inequities, human rights and the broad social
determinants of health; to support countries in placing health
as a shared goal to which many government departments and
sectors of society contribute; and to help build a sustainable
Global Forum Update on Research for Health Volume 4 ✜ 011