Davidson R. Gwatkin

Universal health coverage: friend or foe of health equity?

Once again, calls for universality are being heard from health advocates and planners. Last time around, such calls were for achieving the health-for-all goal at the 1978 Alma-Ata conference. Now they are re-emerging, as more limited but nonetheless stirring appeals to seek universal coverage or access in a wide range of health-related areas such as HIV/AIDS, reproductive health, health insurance, and free health services, particularly for women and children. Refl ecting such interest, universal coverage will fi gure as the organising theme of a large WHO research meeting on Nov 16–19. This quest for universal coverage is often advocated as a way of improving health equity. If fully achieved, it would clearly do so. Everyone—rich and poor, men and women, ethnic or religious majorities and minorities—would enjoy full equal access to the services concerned. Such an achievement would obviate both the stigma thought to accompany use of services designed specifi cally for people who are poor, and the possibility that such services might be of low quality. But beware—universal coverage is much more diffi cult to achieve than to advocate. And people who are poor could well gain little until the fi nal stages of the transition from advocacy to achievement, if that coverage were to display a trickle-down pattern of spread marked by increases fi rst in better-off groups and only later in poorer ones. Should the resulting rise in inequality endure for an extended time—or worse, become permanent as a drive for universal coverage falls short of fully realising its goal—the result would be to reduce rather than enhance health equity. Unfortunately, an increasing volume of empirical evidence suggests that the trickle-down pattern occurs often enough to constitute the norm. In Brazil, for example, it appears to predominate; and the Brazilian experience has given rise to an inverse equity hypothesis, which holds that new health programmes “initially reach those of higher socioeconomic status and only later aff ect the poor”. Several subsequent studies suggested that the hypothesis has widespread validity. For example, in its 2005 World Health Report, WHO cited several country examples in arguing that increases in average coverage typically display movement from a situation of mass deprivation (low coverage among all but the highest socioeconomic groups) toward marginal exclusion (high coverage among all groups but the lowest). This message was repeated in the 2008 World Health Report, which presented additional country illustrations and included a discussion of options for dealing with the issue. The same year, the Countdown 2008 Equity Analysis Group presented a still fuller set of country data suggesting that the pattern is pervasive. To this needs to be added the experience of previous eff orts to reach universal coverage, which warns against anticipating easy or rapid attainment. For example, universal health insurance coverage took a century or more to achieve in much of western Europe. And while progress toward the health-for-all aspirations of the Alma-Ata conference of 30 years ago has been impressive in many respects, universal coverage remains to be attained in most parts of the developing world—even for the basic services that fi gure so centrally in primary health care for which the conference became known. Because of considerations like these, there is little reason to expect that working to reach universal coverage will lead to improvements in health equity. In fact, the quest for universal coverage could have the opposite eff ect, by serving as a rationale for overlooking people who are poor in the rush to raise overall coverage, in anticipation of even larger gains for them on the attainment of an ultimate goal that subsequently proves to be unattainable. However, a quest for universal coverage does not have to bypass disadvantaged groups. To illustrate Published Online November 16, 2010 DOI:10.1016/S01406736(10)62058-2

Trends in health inequalities in developing countries

This is a review of current professional thinking about health inequalities in developing countries and how to reduce them. It is in four parts. The first provides a brief history of recent trends in concern about health inequalities and related issues. The second is a discussion of the concept of health inequalities, and of the similarities and differences between other distributional measures in current use. The third summarizes what is known about the dimensions and magnitude of health inequalities. The fourth presents a comparable summary of current thought about how best to reduce inequalities. The review closes with a brief conclusion.

Where is the gap?: the contribution of disparities within developing countries to global inequalities in under-five mortality

BackgroundGlobal health equity strategists have previously focused much on differences across countries. At first glance, the global health gap appears to result primarily from disparities between the developing and developed regions. We examine how much of this disparity could be attributed to within-country disparities in developing nations.MethodsWe used data from Demographic and Health Surveys conducted between 1995 and 2010 in 67 developing countries. Using a population attributable risk approach, we computed the proportion of global under-five mortality gap and the absolute number of under-five deaths that would be reduced if the under-five mortality rate in each of these 67 countries was lowered to the level of the top 10% economic group in each country. As a sensitivity check, we also conducted comparable calculations using top 5% and the top 20% economic group.ResultsIn 2007, approximately 6.6 million under-five deaths were observed in the 67 countries used in the analysis. This could be reduced to only 600,000 deaths if these countries had the same under-five mortality rate as developed countries. If the under-five mortality rate was lowered to the rate among the top 10% economic group in each of these countries, under-five deaths would be reduced to 3.7 million. This corresponds to a 48% reduction in the global mortality gap and 2.9 million under-five deaths averted. Using cutoff points of top 5% and top 20% economic groups showed reduction of 37% and 56% respectively in the global mortality gap. With these cutoff points, respectively 2.3 and 3.4 million under-five deaths would be averted.ConclusionUnder-five mortality disparities within developing countries account for roughly half of the global gap between developed and developing countries. Thus, within-country inequities deserve as much consideration as do inequalities between the world’s developing and developed regions.

Metrics matter: the case of assessing the importance of non-communicable diseases for the poor

As the saying goes, ‘bad publicity is better than no publicity.’ So I was gratified to see in IJE such a prominent, even if highly critical, reference to a piece that two colleagues and I did nearly 15 years ago and that I’d thought long forgotten. In our piece my colleagues and I had questioned, on equity grounds, the then-incipient shift in emphasis from communicable to non-communicable diseases (NCDs) in global health policy. Using 1990 data from the 1996 World Health Organization (WHO) global burden of disease (GBD) study, we had estimated that communicable illnesses were still responsible for a majority of the disease burden in the poorest quintile of the world’s population. But in the richest quintile, the situation was the reverse: NCDs were overwhelmingly dominant. This finding had led us to advocate a continuing focus on communicable diseases because of their central importance to the health of the global poor, a group of especially high priority in the 2015 Millennium Development Goals that were then being formulated. To move toward NCDs, we argued, would result in increased attention for a set of conditions far more relevant to the world’s better-off. Not surprisingly, perhaps, NCD advocates did not find this argument very compelling. Nor did any of the four commentatorson a similar argument for India advanced by S.V. Subramanian and colleagues in the article featured in this current IJE collection of papers on equity and the pattern of disease. In that article, Subramanian et al. challenge the argument that the distribution of cardiovascular diseases and risk factors has shifted so that they have become more prevalent in lowthan in high-income groups. The many problems they find with this argument lead them to consider a shift away from communicable diseases toward cardiovascular issues to be premature, or ‘jumping the gun’ as they put it. Among the several arguments advanced by the commentators disagreeing with this conclusion, two stand out. The first is that Subramanian et al. have simply misread the available literature, and that the burden of disease from NCDs is in fact higher among the poor. The second is that, even if they did not misread, NCDs now constitute an adequately important (and growing) minority of the disease burden in even the poorest population groups to justify significant attention.

Where next for family planning

This article discusses the comeback of family planning after years of controversy over certain family planning programs throughout the world. It states that to take advantage of the opportunity to re-emerge family planning it will require a major reorientation of the design of family planning programs--away from a focus on the couples who are easiest to reach toward couples who are poor and excluded and who most need and want family planning services.