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

Access to healthimperative for actions on the determinants of health and thatinforms both policy and effective, equitable interventions onthose determinants” 3 . Thus far, nine networks have beenestablished, each with 12 or more individual memberssupported by a coordinating “hub”. The locations of eight wereselected through open competition; they deal with earlychildhood development, globalization, health systems, urbansettings, measurement and evidence, women and genderequity, social exclusion, employment conditions. The ninthnetwork, on priority public health conditions, is housed atWHO.Since these networks have yet to complete their work, thefull syntheses of knowledge in their particular areas that canbe expected from them are not yet available. However, a senseof the general orientation that they are likely to take is availablefrom the earlier work of Commission Chairman MichaelMarmot and his colleagues, which has centrally shaped theCommission’s orientation.At the heart of this work is the idea of a “social gradient” inhealth, whereby health outcomes become worse as onedescends the socioeconomic ladder. This means that not onlydo the poor have worse health than the rich, but the middleclasses have worse health than the more rich as well. Whilethis is itself far from startling, the idea incorporates two otherpoints that are much less intuitively obvious and that greatlyincrease its significance. One is the finding that thesegradients exist not just in poor countries, but also in better-offones where living conditions among even the lowest groupsstudied are far above any meaningful absolute poverty line.From this, it is pretty clear that there are causes of ill-healththat lie well outside the nexus of poor nutrition, inadequateeducation, unfavourable environmental surroundings, and thelike that is normally blamed for particularly high rates of illnessand death among the poor. The second is the identification ofpsychological factors – degree of control over one’s workenvironment, for example – that appear to be responsible forthese high rates, and the delineation of the biological channelsthrough which such psychological and other factors work.Such findings lead towards an emphasis on social andeconomic policies, more than on health services, as the mostpromising approaches to the reduction of socioeconomichealth inequalities. One of the several examples that could becited involves unemployment, which has been shown to affecthealth not only through loss of income, but also through theanxiety that it causes. Government moves to smooth thebusiness cycle, and to ensure reasonable unemploymentbenefits illustrate ways of countering ill-health and the othereffects of this factor. Another illustration concerns transport,where government policies focusing on cycling, walking, andthe use of public transport can promote health by providingexercise, reducing fatal accidents, increasing social contact,and reducing air pollution 4 .Thus far, most work on the social gradients of health hasdealt with Northern, developed countries, particularly inEurope. If the Commission is successful, the same approachwill be applied increasingly to health equity research andpolicy development in middle- and lower-income countriesover the years ahead.Health service use among the poor and thebetter-off: the World Bank’s reaching thepoor program 5The World Bank’s recently-completed Reaching the PoorProgram (RPP) was initiated in order to find ways of dealingwith a disturbing finding from earlier Bank-sponsoredresearch: that basic health services intended for andtraditionally believed to be reaching the poor were in fact notdoing so. For example, full immunization coverage amongchildren in the poorest 20% of a country’s population wastypically only one half to two thirds what it was amongchildren in the best-off 20%; a pregnant woman in that poorgroup was only about one third as likely to be attended at thetime of delivery by an adequately trained medical person as awoman in the highest group.Like that earlier research, the RPP focused primarily oneconomic inequalities, taking advantage of a recent findingthat a household’s assets could serve as a reasonable indicatorof its overall economic status. This meant that researchers nolonger had to rely on data about income or consumption,which are both notoriously difficult to collect, in order to assesshouseholds’ economic status. Rather, they could useinformation on such things as sources of water, availability ofelectricity, and possessions (watches, radios, etc.) that takesonly limited time to collect, and that is already being routinelycollected through many health surveys.The RPP investigators commissioned approximately 20studies – and collected findings from as many other studies asthey could identify – that incorporated this approach to themeasurement of economic status and sought to determine thedistribution of service use across the economic groups thusidentified. The interest was the rate of service coverage in thepoorest population group, and the proportion of total servicesbenefits going to that group. (This latter dimension – themeasurement of the proportion of total service benefitsaccruing the poor – represented an application of an approachfrom the public finance field called “benefit incidence”; andone of the RPP’s purposes was to call the attention of thepublic health community to that technique.)The outcome was the identification of numerous healthprojects that “swam against the tide” by achieving highcoverage among the poor, and/or delivering to the poor adisproportionately high percentage of benefits (i.e. apercentage of benefits higher than the share of the populationrepresented by the disadvantaged group in question).Illustrative examples of such projects included:✜ Mexico’s “Progresa/Oportunidades” Programme that paysrather than charges poor families for clinic and schoolattendance. The programme serves over 20 millionpeople, and almost 60% of the people served belong tothe poorest 20% of Mexico’s population.✜ Cambodia’s experiment in contracting with nongovernmentalorganizations to operate governmental ruralprimary health services, under contracts calling forattainment of specified coverage levels among the poor.During the four years of the project, the coverage amongthe poorest 20% of the population by eight basic servicesrose from an average of below 15% to over 40% in twoGlobal Forum Update on Research for Health Volume 4 ✜ 025