Social inequalities in health within countries: not only an issue for affluent nations

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Abstract

While interest in social disparities in health within affluent nations has been growing, discussion of equity in health with regard to low- and middle-income countries has generally focused on north–south and between-country differences, rather than on gaps between social groups within the countries where most of the world's population lives. 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. The Primary Health Care strategy is at least as relevant today as it was two decades ago; but equity needs to move from being largely implicit to becoming an explicit component of the strategy, and progress toward greater equity must be carefully monitored in countries of all per capita income levels. Particularly in the context of an increasingly globalized world, improvements in health for privileged groups should suggest what could, with political will, be possible for all.

Section snippets

Background: wide and widening health inequalities within low- and middle- as well as high-income countries

Over the past decade, there has been a growing body of research and commentary on socioeconomic inequalities in health in western Europe and the United States (Bartley, Blane, & Montgomery, 1997; Braveman, Oliva, Reiter, & Egerter, 1989; Braveman, Egerter, & Marchi, 1999; Gilson, 1998; Kaplan, Pamuk, Lynch, Cohen, & Balfour, 1996; Kennedy, Kawachi, & Prothrow-Stith, 1996; Krieger, Williams, & Moss, 1996; Kunst & Mackenbach, 1994; Lynch, Everson, Kaplan, Salonen, & Salonen, 1998; Mackenbach &

What is equity in health?

Equity is an ethical concept that is as challenging to define precisely as its near-synonym social justice, which may mean different things to different people in different societies at different times. Inequity refers not to all inequalities, but to those inequalities that are considered unfair and avoidable (Whitehead, 1990). Equity implies that need rather than privilege be considered in the allocation of resources; as with equity and fairness, it is difficult to define need in precise terms

Why care about equity—in general or in health in particular?

Evidence is accumulating in industrialized countries of a relationship between the magnitude of socioeconomic inequalities and poor health that cannot be explained by differences in absolute levels of income or poverty (Lynch et al., 1998; Kaplan et al., 1996; Kawachi & Kennedy, 1997; Kennedy et al., 1996; Kennedy, Kawachi, Glass, & Prothrow-Stith, 1998; Smith, 1996; Wilkinson (1992a), Wilkinson (1992b), Wilkinson (1996), Wilkinson (1997). Some researchers have raised methodologic concerns

Global pressures are making it difficult for countries of every income level to achieve greater equity in health

In the face of powerful global economic, social, and political trends, many countries are finding it difficult to implement and sustain equity-promoting policies in sectors with major influences on health. Recent UNDP Human Development Reports have noted widening income inequalities in many countries, including Argentina, Bolivia, Brazil, Peru, Venezuela, Bangladesh, Thailand, Bulgaria, the Czech Republic, the Baltic States, Australia, the United Kingdom, and the United States of America (

Conclusion: the need for international and national organizations to focus explicitly on equity in health and its basic determinants, within as well as between countries

International agencies could play an important role in supporting research and action on social inequalities in health that is relevant to the needs of low- and middle-income countries. For example, international agencies can encourage and support national researchers from low- and middle-income countries to apply their talents to work in this area, and can support exchange among researchers from different countries as well as efforts to translate research into policy. Research methods and

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    1

    Formerly, Director, Division of Analysis, Research, and Assessment, World Health Organization, Geneva, Switzerland.

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