HEALTH EQUITY

Despite dramatic improvements in medicine and medical knowledge, which have led to improvements in health and subsequent reductions in mortality around the world, much still remains to be achieved especially in reducing disparities in health outcomes among population subgroups, both among and within countries (Gwatkin 2002). The burden of disease and poverty is highest among the poorest segments of populations. For instance, Wagstaff (2000) in a cross-country comparative analysis showed that people in the lower strata of the income divide have poorer health outcomes than those in the higher income bracket. Other studies have demonstrated similar results (Hobcraft, McDonald and Rutstein 1984; Cleland ,Becigo and Fegan 1992; United Nations 1985). Indeed, there is a synergistic link between poverty and health; ill-health undermines the capacity of individuals to harness their energies to the fullest in order to produce food and other essentials for survival while, poverty exacerbate the effects of ill-health by making individuals more vulnerable to disease infection.

Thus, with the increasing deterioration in health infrastructure and resources and economic performance in most countries of the developing world particularly in Africa and Asia, the effects of poverty are having an unprecedented toll in widening the gap among the health status of populations in the developing world. Apart from increasing the risk of ill-health and vulnerability of populations, poverty also has implications for the delivery of effective health care such because of “…reduced demand for services, lack of continuity or compliance in medical treatment, and increased transmission of infectious diseases” (WHO 1998).

Although concern about health inequalities and the distributional aspects of health have a long history (Gwatkin 2002), renewed efforts in addressing these concerns, particularly in the late 1990s have been gingered because of international consensus that there is an ever increasing widening gap between the health of the rich and the poor. As a result, there is now the need for a health model that will protect and improve the health status of the poorest and most vulnerable populations within and among countries of developing world.

In line with its mission to “harness the collective potential of community-based longitudinal demographic surveillance initiatives in resource constrained countries to provide a better and empirical understanding of health and social issues, with the ultimate aim of applying these to understand and help alleviate the most severe health and social challenges of the poor and deprived, the INDEPTH network is developing a health equity platform to among others;

1. Provide an avenue for continuous monitoring of health and socio-demographic outcomes and the distribution of health infrastructure and or, resources among and within population groups in INDEPTH member sites.
2. Encourage and support sites involved in the network to develop core indicators to collect data that would allow for the measurement of health and wellbeing of populations within the member sites.
3. Map out strategies for intervention to alleviate the health effects of poverty on ill health among and within population groups in Africa. 

To achieve this, the network will develop core indicators that could be integrated into the DSS platforms at the various sites. Each site will, nonetheless, have the leverage to add specific indicators that would answer certain questions pertaining to the site or the region to which the site is located. Ultimately, it is hoped that the core indicators would allow for cross-site and cross-country comparison of sites on the key health and social issues that would be investigated. The site specific modules would then allow each of the sites to monitor specific health problems that are peculiar to the area, but which are nonetheless important and would not necessarily be included in the core protocol. It is hoped that with the core indicators integrated in the DSS platforms, the INDEPTH network will be in position to demonstrate trends in health equity across sites/countries and therefore enable the network to map out strategies that would be beneficial in helping to solve some of the common health and poverty related problems confronting member countries of the network.

In pursuance of the objectives of the INDEPTH health equity platform objectives, we would take into consideration the United Nations Millennium Development Goals (MDGs), which among others aim at:

• Eradicating extreme poverty and hunger
• Achieving universal primary education
• Promoting gender equality and empower women
• Reducing child mortality
• Improving maternal health
• Combating HIV/AIDS, malaria, and other diseases

As a first step in this endeavour, sites were encouraged and supported to utilize existing socioeconomic and health status data in their sites to try to answer some of the basic health related questions of interest to the network. A report of this initial effort was submitted to the Rockefeller Foundation who supported this project. This initial exercise demonstrated the potential of socioeconomic and health outcome data for evaluating and answering questions related to health equity, which clearly formed the basis or motivation for the network to develop a platform that would enable the various sites to collect detailed data prospectively that in order to allow for cross-site and cross-country longitudinal analysis of health equity within the community of the indepth network.

As part of the effort to move the health equity research agenda forward, the network is organizing a meeting in early January 2003, involving representatives from the various indepth member sites as well as world renounced specialists in the field of health equity who will serve as resource persons to start the process of dialoguing and creating the platform for the take off of the health equity agenda. In preparation for this meeting, the network has started the process of developing the core indicators drawing on the experiences of the World Bank, the United Nations and the World Health Organizations, as well as other demographic and health research organizations or institutions. This instrument will be discussed during the workshop and refined further based inputs from the participants and the resource personnel. By the end of the January 2003 workshop, the network hopes to have achieved the following outcomes:

1. Develop a prototype protocol for understanding health equity. This protocol would indicate the core indicators as would have been agreed upon by the participants. Site- or region-specific modules would also be discussed, especially in cases where a subset of sites from the same geographic and ecological zone agree to have a regional module.
2. Discuss strategies for developing a wealth indicator, which will form the main basis for measuring health equity or inequality, as the case may be.
3. Agreed upon a timetable for implementing the health equity studies and the possible outcomes of interest.
4. Come out with an outline of a draft of monograph on health equity in the developing world. Sites would be invited to contribute chapters to the monograph, in addition to chapters that would focus on cross-site or level country analysis. 

In relation to point 2 above, several methods have already been proposed, but each of them has its own strengths and weaknesses. The various methods for developing the wealth index would be discussed in order to come out with an acceptable index agreeable to all.

 References

• Gwatkin, R. D. 2002. “Reducing Health Inequalities in Developing Countries,” forthcoming in Oxford Textbook of Public Health, forth edition.
• Hobcraft J.N, J.W McDonald and S.O Rutstein (1984). “Socio-economic factors in  infant and child mortality: a cross national comparison”, Population Studies, 38:193
• Cleland, J, G. Becigo and G. Fegan (1992), “Socioeconomic inequalities in childhood mortality: the 1970s to the 1980s”, Health Transition Review, vol. 2.
•  Cleland, J.G and J. K. van Ginneken (1988). “Maternal Education and Child Survival in Developing Countries: the search for pathways of influence”,  Social Science and Medicine, 27(12)1357-1368
•  United Nations (1985). Socioeconomic Differentials in child Mortality in eveloping countries, ST/ESA/SER. A/97, New York.
•  WHO. 1998. Poverty and health: who lives, who dies, who cares, policy paper no. 28, Division of intensive Cooperation with Countries in Greatest need.
•  WHO. 2002. Improving Health Outcomes of the Poor, report of working group 5 of the commission macroeconomics and health.