Measuring Total Health Inequality: Adding Individual Variation to Group-Level Differences

Studies have revealed large variations in average health status across social, economic, and other groups. No study exists on the distribution of the risk of ill-health across individuals, either within groups or across all people in a society, and as such a crucial piece of total health inequality has been overlooked. Some of the reason for this neglect has been that the risk of death, which forms the basis for most measures, is impossible to observe directly and difficult to estimate.

The study develops a measure of total health inequality – encompassing all inequalities among people in a society, including variation between and within groups – by adapting a beta-binomial regression model. The model is applied to children under age two in 50 low- and middle-income countries. The method has been adopted by the World Health Organization and is being implemented in surveys around the world; preliminary estimates have appeared in the World Health Report.

Results: Countries with similar average child mortality differ considerably in total health inequality. Liberia and Mozambique have the largest inequalities in child survival, while Colombia, the Philippines and Kazakhstan have the lowest levels among the countries measured.


Social Inequalities In Health Within Countries: Not Only an Issue for Affluent Nations

This paper aims to articulate a rationale for focusing on within- as well as between-country health disparities in nations of all per capita income levels, and to suggest relevant reference material, particularly for developing country researchers. Routine health information can obscure large inter-group disparities within a country. While appropriately disaggregated routine information is lacking, evidence from special studies reveals significant and in many cases widening disparities in health among more and less privileged social groups within low- and middle- as well as high income countries; avoidable disparities are observed not only across socioeconomic groups but also by gender, ethnicity, and other markers of underlying social disadvantage. Globally, economic inequalities are widening and,where relevant information is available, generally accompanied by widening or stagnant health inequalities. . Related global economic trends, including pressures to cut social spending and compete in global markets, are making it especially difficult for lower-income countries to implement and sustain equitable policies. For all of these reasons, explicit concerns about equity in health and its determinants need to be placed higher on the policy and research agendas of both international and national organizations in low-, middle-, and high-income countries. International agencies can strengthen or undermine national efforts to achieve greater equity.

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Inequalities In Health Care Use and Expenditures: Empirical Data from Eight Developing Countries and Countries In Transition.

This paper summarizes eight country studies of inequality in the health sector. The analysis uses household data to examine the distribution of service use and health expenditures. Each study divides the population into income quintiles, estimated using consumption expenditures. The studies measure inequality in the use of and spending on health services. Richer groups are bound to have a higher probability of obtaining care when sick , are more likely to be seen by a doctor, and have a higher probability of reviving medicines when they are all ill , than the poorer groups . The richer also spend more in absolute terms on care. In several instances, there are unexpected findings. There is no consistent pattern in the use of private providers. Richer households do not devote a consistently higher percentage of their consumption expenditures to health care. The analyses indicate that intuition concerning inequalities could result in misguided decisions .It would thus be worthwhile to measure inequality to inform policy making. Additional research could be performed using common methodology for the collection of data and applying more sophisticated analytical techniques. These analyses could be used to measure the impact of health policy changes in inequality.


Inequality of Child Mortality Among Ethnic Groups in Sub-Saharan Africa.

Accounts by journalists of war in several countries of sub-Saharan Africa in the 1990s have raised concern that ethnic cleavages and overlapping religious and racial affiliations may widen inequalities in health and survival among ethnic groups throughout the region, particularly among children. Paradoxically, there has been no systematic examination of ethnic inequality in child survival chances across countries in the region. This paper uses survey data collected in the 1990s in 11 countries ( Central African Republic , Cote d Ivoire , Ghana, Kenya , Mali , Namibia , Niger , Rwanda , Senegal , Uganda and Zambia) to examine whether ethnic inequality in child mortality has been present and spreading in sub-Saharan Africa since 1980s. The focus was on one or two groups in each country which may have experienced distinct child health ans survival chances , compared to the rest of the national population as a result of their geographical location .


Mapping Global Health Inequalities: Challenges and Opportunities

Health inequalities both between and within countries persist, for almost all diseases and health problems. Between countries, both average life expectancy and child mortality have improved more in the richest countries than the poorest (Marmot 2007). Within countries, progress on redressing health inequalities is uneven, and data are not always available over time. Analysis of 22 countries with available data found that only five of 22 countries reduced health inequalities in childhood mortality across income from 1995 to 2000. Health inequalities are differences in health across population groups defined by socioeconomic, demographic, or geographic factors. These factors can be summarized using the acronym PROGRESS: Place of residence (urban/rural), Race/ethnicity, Occupation, Gender, Religion, Education, Socioeconomic status, and Social capita.


Socioeconomic Inequalities in Infant and Child Mortality among Urban and Rural Areas in Sub-Saharan Africa

Studies on urban-rural mortality differentials in Sub-Saharan Africa show that overall mortality, and infant and child mortality in particular, is generally lower in urbanthan in rural areas. Various factors account for this, including the high concentration of salaried workers (who generally have higher incomes) in urban centers, better education in urban areas, the concentration of public infrastructure in urban areas that provides sanitation services, including water supply, household waste and excreta removal and disinfection, and hospital infrastructure, with health conditions that are more favorable in urban than in rural areas.

This paper discusses the factors likely to explain the observed urban-rural differences in infant and child mortality in Sub-Saharan Africa. The paper addresses five points: the first two discusses the factors likely to be associated with excess urban mortality; the third assesses recent trends in infant and child mortality in a few selected countries in Sub-Saharan Africa; the fourth point deals with the determinants of infant and child mortality, with emphasis on the role of urban-rural residence as a differentiating factor. The last point provides the most salient results and a few recommendations


Determinants of Social Inequalities in Child Mortality in Mozambique: What Do We Know? What Could Be Done?

Health inequalities are no longer an issue only for developed countries. In recent years there is agreement that all countries present health inequalities regardless of their level of wealth. In low-income countries and especially in sub-Saharan Africa where the majority of the poor people live as well as their children, research on child health inequalities is still scarce. This review of evidence suggests that if Mozambique is to achieve the millennium development goals (MDGs) by 2015 further research on important determinants of disparities in child mortality is urgently needed

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Child health inequities in developing countries: differences across urban and rural areas

This study documents and compares the magnitude of inequities in child malnutrition across urban and rural areas, and investigates the extent to which within-urban disparities in child malnutrition are accounted for by the characteristics of communities, households and individuals.

The study finds that across countries in sub-Saharan Africa, though socioeconomic inequalities in stunting do exist in both urban and rural areas, they are significantly larger in urban areas. Intra-urban differences in child malnutrition are larger than overall urban-rural differentials in child malnutrition, and there seem to be no visible relationships between within-urban inequities in child health on the one hand, and urban population growth, urban malnutrition, or overall rural-urban differentials in malnutrition, on the other. Finally, maternal and father’s education, community socio economic status and other measurable covariates at the mother and child levels only explain a slight part of the within-urban differences in child malnutrition.

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An Individual-Level Approach To Health Inequality: Child Survival In 50 Countries.

Background: Reducing health inequalities is an important part of the agenda of health policymakers globally. Studies of health inequalities have revealed large variations in average health status across social, economic, and other groups. However, no studies have been conducted on the distribution of the risk of ill-health across individuals.

Methods: We use an extended beta-binomial model to estimate the distribution the risk of death in children under the age of two in the 50 developing countries where data from a Demographic and Health Survey are available. Inequality in these distributions is measured by the WHO health inequality index.

Findings: At the same level of average child mortality, inequality in the risk of death across children can vary considerably across countries. Representing the entire distribution of risk with an inequality measure involves normative choices that we delineate and formalise with quantitative measures. The results are not very sensitive to the choice of measure. Liberia, Mozambique and the Central African Republic have the largest inequalities in child survival, while Colombia, the Philippines and Kazakhstan have the lowest among the 50 countries measured. Interpretation: Inequality estimates should be routinely reported alongside average levels of health, as they reveal important information about the distribution of health in populations. Measuring inequality with individual level data, rather than quantifying differences in average levels of health across social groups, enables meaningful comparisons of inequality across countries and analyses of the determinants of inequality. This approach should be extended to the measurement of inequalities in healthy life expectancy.


Economic development in Africa: Structural Transformation and Sustainable Development in Africa

This report examines how African countries can promote structural transformation without jeopardizing the objective of environmental sustainability, paying particular attention to how the relative decoupling of resource use and environmental impact from economic growth could contribute to the transformation process. Furthermore, the Report presents stylized facts on resource use and efficiency in Africa, which are crucial for understanding the nature and scale of the sustainable development challenges facing the region. Finally, the Report provides a strategic framework for sustainable structural transformation and identifies policies that could be adopted to promote it in Africa.


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