1. Global inequalities in health: Are they relevant to an Atlas of Global Inequality? Paula Braveman, MD, MPH Professor of Family and Community Medicine, UCSF March 1, 2002

2. Health inequalities between countries

3. A child born in a developing country of Africa, Asia, or Latin America is roughly 10 times more likely to die before reaching age five than a child born in Europe or North America

4. And inequalities within countries Wide inequalities in health not only between but also within countries Between-country gaps have received more attention Routine health data can obscure large gaps within countries

5. Health disparities within countries: by SES Venezuela (1994): poor municipalities had infant mortality rates 3 times those of non- poor municipalities UK: widening gap in life expectancy between social classes Indonesia (1990): 12% of public spending for health care went to poorest 20% of people

6. Smoking is more common among less educated men in India (Chennai) Source: Gajalakshmi, CK et al. Patterns of Tobacco Use and Health Consequences, Background Paper for “Curbing the Epidemic: Governments and the Economics of Tobacco Control, World Bank, 1999.

7. The “Inverse Care Law” Rich consume more hospital and public health care than the poor ( Hart 1971 ) Immunization coverage strongly correlated with wealth ( Gwatkin et al. 1999 ) Poor with illness don’t access care: 2x more likely to self treat; 10x more likely to do nothing ( Uganda, HH Survey, 1994/5 ) Poor that access health care risk impoverishment ( Liu and Hsiao, 1997; WB, Voices of the Poor)

8. Physicians Beds Hospital deliveries Distribution of Health Care Resources, Mexico 1990-96 by municipalities’ level of deprivation Rate per 10,000 population Very lowLowMediumHighVery high 0 5 10 15 20 0 40 60 80 100 %

9. Health status of poor versus non-poor in selected countries, 1990

10. Health inequalities within countries: by race/ethnicity Kenya: likelihood of a child dying before age 2 varied by ethnicity (7.4% vs 19.7% USA: African-American infant mortality is twice that for European-Americans Guatemala: malnutrition 40% higher among indigenous children

11. Health inequalities within countries: by gender India (1987): girls nearly twice as likely to die by age 2 as boys, probably due to family behavior India, Bangladesh, & Pakistan (UN 1989): death of one of six girls was due to neglect and discrimination Large differences in immunization and nutritional status of girls vs boys

12. Why we need to monitor health inequalities in countries None of these gaps would be revealed by routine data Most countries are facing pressures making it increasingly difficult to implement and sustain equitable policies –government down-sizing –privatization –competing in global markets

13. Health and wealth Widening economic inequalities everywhere Strong evidence that health and wealth are connected Yet no routine monitoring of how widening gaps in wealth may impact health

14. Equity in health needs to be higher on the agendas of governments and national and international organizations Capability for ongoing monitoring of equity in health must be developed everywhere

15. Health vs. health care Health = physical and mental well-being (disease, mortality, functional status, quality of life, risks) Social determinants of health –conditions in households, neighborhoods, and workplaces –health care (use of health services, resource allocation, financing, quality) –policies affecting any of the above

16. Challenges in monitoring health inequalities in countries Lack of data on both health and social factors Simplicity, timeliness, sustainability Universal problems, but particularly in lower- income countries Lack of trained personnel for data collection, analysis, reporting Lack of clarity about what to monitor

17. Lack of data in poorer countries –under-registration of births and deaths, particularly for marginalized groups –unreliable cause-of-death information –registration by occurrence vs residence –no socioeconomic data in vital records –reliance on data from clinical sites –no information on mental health, quality of life, functional status, adult health

18. The Equity Gauge Initiative 12 teams in 11 countries Burkina Faso, Kenya, South Africa, Uganda, Zimbabwe Bangladesh, China, Thailand Chile, Ecuador monitoring different aspects of health equity + advocacy + capacity-building

19. Importance of monitoring inequalities in health Ill-health is both a consequence and a cause of poverty Human rights In most societies, less tolerance for disparities in health than in wealth Could increase pressure to address social and economic inequalities