Improving the Health
of the World’s Poorest People
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Health and the World’s
Poorest People
• More than 1 billion people live on less than
US$1 per day
• Health services and modern medicines are
out of reach
• Millions of people die from preventable,
curable diseases
• Poverty is both a cause and an outcome of
disease
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Health for All by the Year 2000?
• WHO led a global Health for All effort in the
1970s
• Representatives from 130 governments signed a
declaration in 1978, agreeing that:
• “Inequality in the health status of people,
particularly between developed and developing
countries as well as within countries, is politically,
socially, and economically unacceptable.”
• Despite this effort, disparities persist
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Poor-Rich Health Divide
•
•
•
•
Between Poor and Rich Countries
Within Countries
Explaining Health Disparities
Approaches for Improving the Health of the
Poor
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Health Divide Between
Poor and Rich Countries
Life Expectancy at Birth, 1995-2000
Years
64.6
74.8
65.4
48.7
World
More Developed
Regions
Least Developed
Countries
Other Less
Developed
Countries
Notes: More developed regions, according to the UN Population Division, include Australia, New Zealand, Europe, North America, and
Japan. Less developed regions include Africa, Asia (excluding Japan), and Latin America and the Caribbean; 49 countries within these
regions are classified as least developed.
Source: United Nations (UN) Population Division, World Population Prospects: The 2002 Revision—Highlights, accessed online at
www.un.org/esa/population/publications/wpp2002/WPP2002-HIGHLIGHTSrev1.PDF on June 17, 2003.
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Health Divide Between
Poor and Rich Countries
• Poor countries assume heavier burden of
disease
• Developing countries disproportionately
affected by many preventable and treatable
diseases: HIV/AIDS, malaria, TB,
malnutrition, maternal conditions, and
childhood diseases (according to WHO)
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Health Spending Per Capita,
by Country Income Level, 1997
$1,907
$11
$23
Least
developed
countries
Other lowincome
countries
$93
$241
LowerUpper-middle- High-income
middle-income
income
countries
countries
countries
Notes: As of 1998, other low-income countries are classified as having a per capita GNP less than US$760. Lower-middle-income countries
are classified as having a per capita GNP between US$761 and US$3030. Upper-middle-income countries are classified as having a per
capita GNP between US$3031 and US$9360. High-income countries are classified as having a per capita GNP greater than US$9360.
Source: WHO, Macroeconomics and Health: Investing in Health for Economic Development (2001): 56.
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Poor-Rich Health Divide
Within Countries
• Health disparities are also immense within
countries
• Inequalities in health risk; care-seeking
behavior, diagnosis, and treatment; and
incidence of disease, disability, and death
• Poor fare worse than others on various
health outcomes, including childhood
mortality and nutritional status
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Under-5 Mortality Rate
(deaths per 1000 live births, by age 5)
Poorest Quintile
Richest Quintile
192
164
140
92
155
109
72
Zambia 2001-2002 Bangladesh 19992000
64
Haiti 2000
Cambodia 2000
Source: D. Gwatkin et al., Initial Country-Level Information About Socioeconomic Differences in Health, Nutrition, and Population,
Volumes I and II (November 2003).
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Women Receiving
Delivery Assistance
Poorest Quintile
Richest Quintile
Percent
98
94
77
45
31
20
20
4
Uganda 2000-2001
Nepal 2001
Egypt 2000
Peru 2000
Source: D. Gwatkin et al., Initial Country-Level Information About Socioeconomic Differences in Health, Nutrition, and Population,
Volumes I and II (November 2003).
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Explaining Health Disparities
• Household: financial resources, education,
health services, and nutrition
• Community: drinking water, housing,
transportation, family size, and age at
marriage
• Health system: access, quality, and
availability
• Government: policies and public spending
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Share of Public Health Spending
Received by Poor and Rich
Poorest Quintile
Richest Quintile
42
Percent
30
29
29
24
17
16
9
12
11
Jamaica 1989 Malaysia 1989
Egypt 1995
Vietnam 1992
Brazil 1985
Source: W.Hsiao and Y. Liu, “Health Care Financing: Assessing Its Relationship to Health Equity,” in Challenging Inequalities in Health:
From Ethics to Action, ed. T Evans et al. (2001): 271.
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What can be done?
Approaches for Benefiting the Poor
•
•
•
•
Socioeconomic approaches
Health-service approaches
Health-financing approaches
Approaches for measuring progress
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Socioeconomic Approaches
• Policies that are pro-growth and pro-poor
– Association of economic growth with
inequality
– Promotion of strong social policies for poor
along with pro-growth policies
• Investments in education
– Safer jobs, higher health literacy, and
preventive health care measures
– Avoid risky behaviors, demand quality services
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Health-Service Approaches
• Directing more health benefits toward the
poor through “targeting”
• Promoting primary and essential health care
– Investing in primary care
– Improving the quality of services
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Health-Service Approaches (Cont.)
• Developing public-private partnerships to
improve reach and responsiveness
• Mobilizing community resources
– Reorganizing health resources
– Training community-based health workers
– Involving traditional healers
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Health-Financing Approaches
• Inequity in financing: poor are
disadvantaged; pay out-of-pocket; face
large, unanticipated costs; and lack cash
reserves
• Strategies for greater financial protection:
risk-sharing or insurance plans, subsidized
or free hospital care, and community
financed health plans
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Approaches for
Measuring Progress
• Defining goals is challenging
• Economic growth is associated with greater
inequalities
• Need to differentiate between absolute and
relative success
• Look beyond national averages to address
disparities
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Conclusion
• Over 1 billion people do not have access to
basic health care
• Growing inequalities are leaving the poor at
a disadvantage
• Need for comprehensive pro-poor
approaches
• Public health interventions must focus on
the poor (not necessarily the majority)
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For More Information
Dara Carr, “Improving the Health of the
World’s Poorest People,” Health Bulletin 1
(Washington, DC: Population Reference
Bureau, 2004).
Available online at www.prb.org
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