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Disease Control Priorities Project
 
http://www.dcp2.org/features/12

Disparities in Health: Inequities Create Great Risks for Poor, Adolescents, and Women in Developing Countries

August 18, 2006  

By Barbara Crossette

Whatever the cause of inequality, the resulting inequities in terms of health can mean living in a physically weakened state, perhaps from birth. People around the world are unable to find affordable care, even when the need is urgent, and struggle to survive the host of environmental and epidemiological threats that surround the disadvantaged, from unsafe drinking water and poor sanitation to an absence of basic health services or lax enforcement of simple road safety rules. In an era of vicious civil wars, moreover, the most vulnerable civilians are the most numerous casualties.

“No process of setting priorities and designing strategies for improving health can ignore the pervasive large inequities,” says Priorities in Health, a companion book to the Disease Control Priorities in Developing Countries, 2nd edition (DCP2). Patterns of inequity can be seen at three levels, it adds: “large disparities in health status, differential access to and use of health care services, and disproportionate exposure to health risks.”

If DCP2, that enormous compendium of medical expertise, is missing a chapter devoted solely to the inequities of health care in many nations – the gaps between rich and poor, urban and rural, men and women, young and old, ethnic majorities and minorities, to name a few – there is a very good reason. It is because concerns about equity in health care run through the entire book; it is an underlying theme of nearly every chapter. No longer is it possible to pretend that disadvantage can be marginalized when assessing or reforming health systems, or set aside for later consideration. Inequity is intrinsic.

The Stark Rich-Poor Division
When DCP2 was launched in Beijing in April 2006, China’s Vice Minister of Health, She Jing, pointed to what she called an “irrational distribution of resources” in health care regionally in her country. She mentioned that, among other indicators, 75 percent of the population had no medical insurance of any kind, while at the same time medical costs were soaring and some infectious diseases were reappearing.

The rich-poor division is the most obvious of inequities, not only globally among nations but now also within countries. As Dr. Anne Mills, professor of health economics and policy at the London School of Hygiene and Tropical Medicine, told reporters in Beijing, governments in some rapidly developing nations are not keeping pace in health care improvements as their economies boom, causing gaps in health and living standards to widen.

The rich everywhere find ways to get access to sophisticated medical equipment and expertise. The poor, especially in the most underdeveloped countries, cannot even get basic medications. Of 1,233 new drugs marketed in the last quarter of the 20th century, only 13 were for treating tropical diseases. This is not entirely a result of wealthy over-developed countries ignoring the needs of poor under-developed countries. In India, a country with a large pharmaceutical industry, 65 percent of the population cannot obtain essential drugs, according to the experts of DCP2. In sub-Saharan Africa, that figure is 47 percent. Much of the inaccessibility is due to a large and growing gap between the rich and the poor.

Latin Americans are acutely aware of this disturbing trend, most of all Brazil, with the largest rich-poor gaps in the region. Worldwide, says DCP2, the richest 20 percent of the global population now has 150 times the income of the poorest 20 percent. In 1960 the ratio was 30 to 1.

In that context the rapid expansion of private medicine (frequently not adequately regulated) in many developing countries with newly affluent groups, coupled with reductions in subsidies for public health care, often create unbearable burdens and deterrents for poor would-be patients. Preventive care is usually the first to be abandoned. Self-medicating with over-the-counter drugs or reliance on cheap alternative medicines or even faith healing grows more, not less, common.

Poverty often combines with geography – rural villages without public transportation or even roads – to deny people health care. But poverty and isolation, alone or together, can be mitigated to a significant extent, as some poor nations have proved. Smart policy decisions, good social programs, strong nongovernmental organizations (NGOs) and often religious bodies matter. In particular, effective NGOs, including some faith-based community groups, have successfully worked around negative cultural or religious factors as, for example, in some Muslim societies, where women may sicken and die because they cannot consult male doctors.

Women Less Likely to Seek or Get Care
The experts note in DCP2 that biology (sex) and social and cultural conditions (gender) may combine to make women less likely to seek or get medical care. But, they say, “The main characteristic of gender-based conditions is that they have no biological referent and can, therefore, be prevented by means of behavioral change.” These attitudinal changes may require effective legislation and law enforcement as well as educating the public to see and correct inequities.

In Bangladesh, male-female inequality once outranked even the inequities of wealth and geography, said Mushtaque Chowdhury, deputy executive director of BRAC, the country’s leading independent NGO, with more than 97,000 workers in the field. BRAC pioneered microcredit, supports health care for women and runs 45,000 schools, many in areas where girls had no chance of an education. “In enrollment at primary level, inequality has disappeared,” Chowdhury, a contributor to DCP2, said in an interview from Dhaka, where he is also the dean of BRAC’s newest venture, a school of public health at the organization’s own university.

Although Bangladesh, ranked among the least developed countries, still has plenty of problems to overcome, Chowdhury is confident that a recurrence of institutionalized gender discrimination is a worry of the past. NGOs, along with government affirmative action programs for girls, have reduced inequity through a holistic approach to improving family life. “Once you reach a certain level of consciousness, you can’t go back,” he said. Founded in 1972, BRAC sees its goal as “a just, enlightened, healthy and democratic Bangladesh.”

Children and Adolescents Still Ignored by Health Care System
In Chowdhury’s experience, better educated children, girls and boys, become adults who are more aware of the importance of good health. It is a message BRAC now takes to other countries, most recently Afghanistan. In developing nations, the health of children who live through infancy is often neglected by poor families suffering huge burdens simply trying to survive.

“Children under five account for an unnecessarily large share of the disease burden in many low- and middle-income regions,” DCP2 reports. It is now commonly known how relatively simple and inexpensive it is to prevent many of these childhood illnesses or physically debilitating long-term conditions such as malnutrition or diet deficiencies. Political will, health education outreach, and the involvement of both local civil society and outside help from UNICEF, Rotary International, and a host of NGOs and foundations can all play a part in prevention and cure of childhood illnesses, as the international campaign against polio has demonstrated.

But it is not only the youngest children who are being ignored, says Katherine Bond of the Rockefeller Foundation. Bond said in an exchange of emails that there are “two windows in the development process by which to intervene that have long-lasting effects on long-term health—infancy and adolescence.” But adolescents are largely out of the health system and need to be reached in other ways.

Bond, who is the foundation’s associate director for health equity, based in Bangkok, does not see enough work going on in testing approaches to adolescents or gathering information on effective interventions to influence adolescent behavior. “What is the evidence in terms of clusters of risk behaviors such as alcohol, smoking, accidents/injuries, unsafe sex, and are there efforts to address this cluster?” she asks.

An Urban Focus Also Helps Rural Areas
Among the millions of people, especially young men, who migrate from the countryside to cities in developing nations, there are many still in adolescence. They should be easier to reach in urban settings, where they form groups for company. In Ghana, the youth-led organization Young & Wise targets these clusters of young people with messages about safe sex to reduce HIV/AIDS, sexually transmitted infections, and unwanted pregnancy.

Urban areas may be where preventive health care at all levels should be primarily focused first -- despite the great concern about the inequities of life in the hinterlands, says Anthony R. Measham, an international health expert who is now a consultant at the World Bank. The dilemma, says Measham, co-managing editor of DCP2, “is that humanitarian instincts often run counter to cost-effectiveness.

“If you immunize the easiest to reach part of the population, not worry about the remote rural who are expensive to reach, you will improve the health of the remote rural at lower cost through herd immunity,” he wrote in an email. “This occurs in a number of diseases, especially the infectious ones. In general, DCP2 argues for going, first, where you have the biggest impact at the lowest cost.”

This argument may be controversial to those who would insist that both urban and rural populations need the attention of health services. But viewed from the grass roots up to policy level in the case of HIV/AIDS, for example, it is certainly true that the spread of the epidemic to poor rural villages of Nepal can be traced to the failure of cities like Mumbai to curb the infection in urban brothels, into which healthy young Nepali girls are often sold or lured.

Partnerships with Governments Yield Impressive Results
Finally, urban or rural, rich or poor, male or female, adult or adolescent, people everywhere can begin to reduce inequities – once they recognize them for what they are and how they affect a community’s health. Where government becomes a partner in the community effort by making officials more accountable to the population, gains can be impressive. It is not surprising, as DCP2 points out, that there is a correlation between “good governance” and better health and nutrition. Yet in too many nations, government doctors never show up for work.

Better training and pay for health care workers, and better equipment for health centers imply higher costs, but rewards are great in lives and productive work days saved. “Organizational reforms,” says DCP2, “must keep the goal of improved health outcomes, equity and responsiveness in sight.”





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