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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
Access to healthdistricts with a population of over 200 000. This increasewas well over twice as large as that experienced in twocomparable districts that continued to provide standardgovernment services.✜ Distribution of insectide-treated bednets through measlesimmunizations campaigns in Ghana and Zambia. InGhana, the Red Cross and the Government HealthServices raised, from nearly 3% to nearly 60%, the rateof treated bednet use among children in the poorest 20%of people in one of the country’s Northernmost Ghana.A similar but larger programme in Zambia producedsimilar results.The RPP investigators concluded that the numerousexperiences like these that they found showed that theunimpressive equity performance of more typical programmesdid not have to be accepted as inevitable. Rather, much betterperformance is possible. But the investigators also noted thewide range of strategies that had proven successful againstdifferent settings, as illustrated by the very different nature ofthe three illustrations given above. This led them to warnagainst any belief in any single approach or small set ofapproaches that can be expected to work best in any setting.Rather, they advocated study of the entire range of promisingapproaches available, and experimentation to determinewhich among them is likely to work best in a particular setting.Protection against impoverishment: theAffordability Ladder Program of the LiverpoolFaculty of Medicine 6While the initiative described above dealt with helping peoplewho are currently poor, the Affordability Ladder Program(ALPS) focuses on preventing people from becoming poor inthe future. In so doing, it is working on a set of issues that hasattracted increasing interest in recent years as health systemsin developing countries have evolved in ways widely believedto increase the vulnerability of households to the economicconsequences of ill-health.The root of this evolution lies in the transition from statedirectedto market-led economies during the 1980s and1990s – most spectacularly in China and the countries ofthe former Soviet Union, but in many other parts of the worldas well.This shift brought a significant change in outlook to thehealth sector, where strategies had typically been dominatedby the aspiration to provide government-delivered services atno charge to the entire population; and thinking about healthservice delivery came increasingly to be dominated by thinkingabout mixed public-private systems, and about governmentsystems that more closely resembled private ones.Since this shift usually involved increased patient paymentsfor health services, it has given rise to concern that theservices might end up impoverishing people as well asimproving their health. Thus, the impoverishing impact ofillness in general, and of patient payments for health servicesin particular, began attracting the attention of both policymakersand researchers. They have been particularlyconcerned with two related issues: first, determination of howserious the problem is, and what its causes are; and second,identification of solutions to that problem.While by no means the only research project to deal withthese issues, ALPS is the largest known single organizedinitiative in this area. It is a network of researchers in countries(China, India, Sri Lanka, South Africa, Sweden, Tanzania,Uganda and Vietnam) coordinated by the Liverpool Faculty ofMedicine and funded by the Rockefeller Foundation. Thenetwork members are working on a wide range of issueswithin a common framework. The framework starts with aperceived health problem, and tracks how people respond toit through use or non-use of various types of care, with aparticular focus on how these choices are affected by theburden of financial payments and on what the resultinghealth, social, and economic consequences might be.The programme results available thus far have concernedprimarily the first of the two issues referred to above: that is,the dimensions and causes of the problem 7 . Of particularrelevance are the findings of a recent programme-initiatedpaper summarizing the available evidence on the economicconsequences of illness and paying for health care in low- andmiddle-income countries 8 .The findings suggest that that a focus on the impoverishingimpact of payments for health services provides only a partialview of illness’s consequences in low-income settings. For onething, the financial impact on households of payments forhealth care appear considerably smaller than the income lostfrom illness-induced inability to work. While the amount ofwork on this point is rather limited, the ALPS authors citestudies suggesting that the income lost from ill-health is on theorder of 2 to 3.6 times as large as the amount paid forservices. A second issue that the authors note concernsdecisions not to use health services because of their cost. Insuch cases, the cost of services to households or individualsmay have no financial impact, but it can obviously have majorconsequences for health status.Notwithstanding these important caveats, however, theauthors’ review of over 60 empirical studies leads to a clearconclusion that “there is growing evidence that somehouseholds (even middle-income ones) slide in to povertywhen faced with health care payments, especially whencombined with the loss of income due to ill-health”. They alsosuggest that illness-related costs diminish the likelihood thatalready-poor families will be able to move out of poverty 9 . ❏Davidson R Gwatkin serves as an advisor on health and poverty tothe World Bank, UNICEF and other agencies. From 2000 to 2003,he was the World Bank’s Principal Health and Poverty Specialist.Before joining the Bank, Davidson R Gwatkin had directed theInternational Health Policy Programs, a cooperative effort betweentwo American foundations, the World Bank, and the World HealthOrganization to strengthen health policy research capacity in Africaand Asia. He had previously been with the Ford Foundation in NewDelhi, New York, and Lagos; and with the Overseas DevelopmentCouncil in Washington, DC.026 ✜ Global Forum Update on Research for Health Volume 4
Page 3 and 4: Editorial Advisory Board:Luis Gabri
Page 5 and 6: Contents096 Child immunization: acc
Page 7 and 8: IntroductionResearch contributions
Page 9 and 10: IntroductionType IType IIType IIIPr
Page 11 and 12: Introductionmaking), takes account
Page 13: Access to healthStrengthening healt
Page 16 and 17: Access to healthTraining more healt
Page 20 and 21: Access to healthReferences1.Further
Page 22 and 23: Access to healthDeterminantsAvailab
Page 24 and 25: Access to healthThe authors are inv
Page 26 and 27: Access to healthCombining health an
Page 28 and 29: Access to health100%Availability of
Page 30 and 31: Access to healthhypothesis that an
Page 32 and 33: Access to healthMandatory clinical
Page 34 and 35: Access to healthWhile there are som
Page 36 and 37: Access to healthItemDefinition/Expl
Page 38 and 39: Access to healthReferences continue
Page 40 and 41: Access to healthintegrating individ
Page 42 and 43: Access to healthA social determinan
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Page 46 and 47: Access to healthMaking human rights
Page 48 and 49: Access to healthResources outsideth
Page 50 and 51: Access to healthReferences1.McCoy D
Page 52 and 53: Access to healthand financial burde
Page 54 and 55: Access to healthDiscrimination as a
Page 56 and 57: Access to health“Two months ago I
Page 60 and 61: Access to healthsocio-cultural and
Page 62 and 63: Access to healthIntergovernmental P
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InnovationTowards the development o
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InnovationMajor classificationMajor
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Innovation60% of enterprises5040302
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InnovationUsing the power ofintelle
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Innovationbe adapted - and harnesse
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InnovationFinancing of vaccine R&D-
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InnovationFinancing Ultimate Interm
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Innovationsome of this risk might b
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InnovationChild immunization:accele
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Innovationare revealing previously
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InnovationDeveloping countries % De
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Innovationcapacities. It is indeed
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InnovationSome plausible causes of
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Innovationwhere he was a programme
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Research resourcesResearch impact o
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Research resourcesBiotechnologists6
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Research resources1,61001,41,219080
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Research resourcesReferences1.The R
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Research resources✜ A group of nu
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Research resourcesReferences1.Inter
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Research resourcesThe threat of pan
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Research resourcesChanging environm
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Research resourcesPartnerships offe
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Research resourcesWe encourage othe
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Research resources181614No. of PPPs
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Research resources12010080604020Pro
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Research resourcesCapacity strength
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Research resourcestreatment is prov
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Research resourcesSmall scale busin
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Research resourcesthis process in a
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Research resourcesways. For instanc
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Decision-making148 Delivering evide
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Decision-makingChallenges in employ
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Decision-makingUsing evidence forpo
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Decision-makingdesire to publish. T
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Decision-makingsystems development.
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Decision-makingTowards evidence-inf
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Decision-making✜ develop a critic
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Decision-makingwas prior to 2001, a
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Decision-makingGlobal and regional
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Decision-makingHigh-incomeChildrenE
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Decision-makingLow- and middle-inco
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Decision-makingLow- and middle-inco
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Decision-makingthan a quarter of th
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Decision-makingThe potentials of in
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Decision-makingGenerally, any resea
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Decision-makingReferences1.Hawes H.
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