Health Inequities:
The Relationship Between
Poverty and Health
Thibaut Williams
Dr. Sukumar Sarker
USAID/Bangladesh
Global Health Inequities
• Nearly 1,000 women die each day from
preventable causes
– 99 percent of these deaths occur in the developing
world
• 80 percent of child deaths occur in SubSaharan Africa and South Asia
• In most countries these gaps are widening
Health Inequities within Countries
• Poorest quintile (20%) of women in
developing countries are 2-3 times less likely
to have access to maternal health services
than those in the wealthiest quintile
• In Peru, MMR is 6x higher in the poorest
quintile than in the wealthiest quintile
• Health inequities are larger in countries with:
– Overall lower levels of health care
– Higher rates of poverty
– Weaker governance
Inequity vs. Inequality
• Health Inequality refers to differences in
health status or access
• Health Inequities refer to systematic, unjust
inequalities
• In Narrowing the Gap to Meet the Goals,
UNICEF states that an equity-focus child
survival and development approach is the
most cost-effective and practical way of
meeting the MDGs
Other Factors Affecting Health Inequity
• Demographics
– Age
– Parity
– Educational status
• Place of Residence
– Urban
– Rual
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Ethnicity
Caste
Age
Stigmatized Groups (e.g., female sex workers)
Inequities by Types of Service
• Inequities disproportionately affect maternal
health services
– More costly and require more specialized care
than other basic primary health services
– Tanzania: avg distance traveled for basic medical
care is 7-8km vs 28km for delivery services
– Normal deliveries can account up to 26% of
annual income for poor women, while severe
complications consume on average 90-138%
Health Inequities in Bangladesh
Inequities in Maternal Health Services in Bangladesh
• The poorest 20% of
women are:
– Nearly 3x less likely to
have received ANC
– Nearly 6x less likely to
have a skilled attendant
at birth
• The poorest 20% of
children are:
– >2x to be stunted (HFA)
– >2x to be underweight
(WFA)
– nearly 3x less likely to
be fed correctly (6-23
months)
Source: BDHS 2011
The Pathway from Poverty to Poor Health – the
Supply Side
• Inequitable financial and human resource
allocations
• Inadequate infrastructure (e.g., health
facilities, roads, bridges)
• Poorer quality of care
• Less outreach services
• Poorer care giving behaviors to less educated
and less wealthy clients
The Pathway from Poverty to Poor Health –
the Demand Side
• Financial barriers
– Cost of services
– Informal fees
– Indirect costs (e.g.,
transportation,
time lost)
• Cultural beliefs and practices
• Gender imbalances
• Differences in education
The Pathway from Poverty to Poor Health – Contextual
Factors
• Poor generally lack access to:
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Safe water
Sanitation
Adequate housing
Education
Adequate quality & quantity of food
• Environmental pollution
• Poor infrastructure
• Unsafe living conditions (e.g., violence, road
accidents
How to Target the Poor
• Individual/Household targeting
– Means testing (e.g., income, consumption)
– Proxy means testing (e.g., asset ownership)
– Community-based/Participatory targeting
• Categorical Targeting
– Demographics (e.g., sex, age, parity)
– Geographical
• Self-Targeting
Challenges in Targeting
• Trade-off between costs/benefits of targeting
• Data either unavailable, of poor quality,
insufficiently disaggregated, or underreported
• Errors of inclusion (i.e., leakage) and
exclusion
• “Paradox of Targeting”
• Stigma
• Large informal sector or poor population
How to Better Serve the Poor - I
• Health financing approaches (e.g., social
insurance, removing user fees, sliding scale
fee structures, conditional cash transfers,
subsidies, vouchers/waivers for particular
services)
• Allocations of financial, human and
material resources prioritizing low
performing areas/groups
• Task-shifting/sharing to increase access for
poor groups
How to Better Serve the Poor - II
• Infrastructural improvements (e.g., health
facilities, roads, maternity waiting homes)
• Expanded outreach services (e.g.,
satellite/mobile clinics, community-based
health workers)
• Addressing the social determinants of
health (e.g., gender, education, economic
strengthening)
How to Better Serve the Poor-III
• Health system strengthening (e.g., quality
improvement, improved governance, attitudes of care
givers)
• Increased community participation to increase
access/acceptance and improve cost-effectiveness
• Use of technology to reduce access barriers for
information and services
• Public-private partnerships to introduce new
technology, to improve quality and options of care
What are we doing in Bangladesh?
Bangladesh Experiences
Expanded Outreach Services / Community Participation
• Vaccination outreach (EPI sites, NID)
– Community offered premises (makeshift)
• Community IMCI (Diarrhea and ARI management)
– Community health workers
– Volunteers
• Satellite clinics for ANC, PNC, and FP services
• Community offered premises
– Support group
• Community clinics
– Clinic management group
– Support group
– Donated sites
Expanded Outreach Services / Community Participation
• Community based safe motherhood and newborn
care services (MaMoni project)
– Community action group (micro-planning at community level)
– Union coordination meeting (problem solving and ensuring
support)
• Fistula repair and rehabilitation (Fistula Care)
– Community awareness
– Community support for rehabilitation
Health Financing Approaches
• Demand side financing (DSF) for maternal health
• Reimbursement payment for permanent FP methods
• SSFP safety net for the poor
Infrastructural Improvements
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EmOC centers in Upazila Health Complex
Upgradation of Upazila Health Complexes
Upgradation of Union Family Welfare Centers
Community Clinic: New tier of static health centers
Urban primary health care centers (UPHCP)
Vaccine storage capacity (GAVI)
Increased capacity in district hospitals
Addition of tertiary level facilities (new medical
college hospitals and specialized hospitals)
Allocation of Financial Resources
• Subsidized contraceptives in private market (Social
marketing)
• Expanded DOTS services for TB (Global Fund)
• Community based management of MDR TB- support for
nutritional supplements
• Targeted HIV prevention interventions for the most at
risk population (female sex workers, MSMs and
Transgenders, IDUs, and PLHAs)
Inequity exists
• Vaccination coverage for all basic vaccines
– Lowest wealth quintile: 76.8%
– Highest wealth quintile: 93.5%
• Diarrhea and ARI management
– Treatment sough for ARI
• Lowest wealth quintile: 25%
• Highest wealth quintile: 60%
– Treatment sought for diarrhea
• Lowest wealth quintile: 9.5%
• Highest wealth quintile: 49.5%
Inequity exists
• Maternal Health services
– Received any ANC
• Lowest wealth quintile: 48%
• Highest wealth quintile: 93%
– Facility delivery
• Lowest wealth quintile: 10%
• Highest wealth quintile: 60%
– Delivery by trained provider
• Lowest wealth quintile: 12%
• Highest wealth quintile: 64%
Inequity exists
• Severe malnutrition (Weight for age)
– Lowest wealth quintile: 16.6%
– Highest wealth quintile: 4%
• Infant and young child feeding practices (4+ food
groups among all children 6-23 months)
– Lowest wealth quintile: 13%
– Highest wealth quintile: 37.6%
• Vitamin A supplementation
– Lowest wealth quintile: 55%
– Highest wealth quintile: 62%
Inequity exists
• Knowledge of AIDS
Women
Men
Lowest wealth quintile: 43%
Lowest wealth quintile: 71%
Highest wealth quintile: 93%
Highest wealth quintile: 99%
• Knowledge of HIV Prevention (Condom and Faithfulness)
Women
Men
Lowest wealth quintile: 21%
Lowest wealth quintile: 45%
Highest wealth quintile: 58%
Highest wealth quintile: 71%
How to reduce the existing gap?
What additional equity-focused approaches
we need to implement?
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Health systems strengthening?
Participatory planning?
Demand generation and BCC?
Financial support for utilization of services?