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Commission on Macroeconomics and HealthTwo of the working groups of the Commission on Macroeconomics and Health(CMH) were concerned with aspects of health inequities – Working Group 1 onhealth, economic growth and poverty reduction and Working Group 5 on improvinghealth outcomes of the poor.An adaptation of a Commission working paper by Adam Wagstaff of the WorldBank appeared in a recent issue of the Bulletin of the World Health Organization(Wagstaff, 2002: see also Recommended Reading section). In his conclusions,Wagstaff highlights three points.• There is a considerable knowledge base on the extent of health inequalitiesbetween poor and non-poor in developing countries, including a “reasonableamount” about inequalities in health determinants.• Too little is known about the relative importance of inequalities in thedeterminants of health and health service utilization.• Too little is known about the impact of programmes and policies on healthsector inequalities.ConclusionsIn summary, the last five years have seen a considerable increase in the amount ofresearch being done about the problem of health inequities. Two particular pointscan be noted.• Unfair differences between groups can be better understood when the focus(or “variable”) of the difference is clarified. Examples are: socioeconomicdifferences; geographical differences (e.g. rural versus periurban, ordifferences among populations living in defined geographical areas, such asdistricts or provinces); gender; race.• A useful distinction can be made between health status inequities and healthsystem inequities. Health system inequities can include differences in theactual provision of health care or in the costs (and funding) of care — bothdirect and indirect – and in the accessibility of use of care.While more is known, there still are major gaps (as noted in Wagstaff's paper above),in both the production and the use of knowledge about health inequities. TheRecommended Reading list below provides more detail about the current state ofresearch into health inequities.This summary of the current state of health inequities research raises some advocacyand leadership challenges for the health research community to consider.Health Research for Policy,Action and Practice10Module I, Unit I
Tools and resourcesListed below are some examples of available tools related to the issue of healthinequities.1. Compendium of multicountry studies on equity, poverty and healthThis document was prepared in 1999 by Dana Carr, Davidson Gwatkin and DiannaFragueiro of the World Bank's Population, Health and Nutrition (PHN) department.The compendium introduces 14 multicountry programmes, and provides summaryand contact information for each of them. In a second section, tables display countryby-countrylists of studies produced and in progress under the auspices of eachprogramme. For further information, contact Dana Carr at dcarr@worldbank.org.2. Country profiles on “socio-economic differences in health, nutrition andpopulation”The HNP/Poverty Thematic Group of the World Bank has produced a series of shortpublications on the health, nutrition and population status and access to relatedservices of most low-income countries, by quintile. These data are displayed by totalpopulation, gender and place of residence (rural/urban). The information is availablethrough the World Bank's web site: http://www.worldbank.org/hnp (accessed August2004).3. Equity gaugeThis is a tool for tracking gaps in health status at national or subnational levels, firstdeveloped and tested in South Africa. Several different versions of this tool are nowbeing used in an increasing number of countries. Along with technical quality,important features of the use of equity gauges include involvement of key healthsystem stakeholders, community ownership and adaptation to ensure that decisionmakingis facilitated. Experience using equity gauges was shared at a meeting inSouth Africa in August 2000. The papers and proceedings of the meeting can be foundat the following web site: http://www.hst.org.za.4. Benchmarks of fairness for health care reformLed by Normal Daniels, a professor of philosophy at Tufts University, United Statesof America, this “policy tool” has been applied to aspects of the health care reformprocess in several developing countries. There are nine benchmarks. For example,Benchmarks 2-4 address different aspects of access to medical services. Benchmark 5concerns equity in financing. For more information, the following publications arerecommended:Caplan RL, Light DW, Daniels N (1999). Benchmarks of fairness: a moral frameworkfor assessing equity. International Journal of Health Services, 29:853-869.Daniels N, Light DW, Caplan R (1996). Benchmarks of fairness for health carereform. New York, Oxford University Press.5. World Bank Poverty Reduction Group. User’s guide to poverty and socialimpact analysis of policy reform (draft for comments). Available athttp://www.worldbank.org/poverty.Health Research for Policy,Action and Practice11Module I, Unit I
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