Global Health ChallengesSocial Analysis 76: Lecture 5

Averages Do Not Tell the Whole StoryAverages Do Not Tell the Whole Story

Defining and Quantifying Inequalities in HealthDefining and Quantifying Inequalities in Health

Health Inequalities Correlated with IncomeHealth Inequalities Correlated with Income

Reducing Inequalities Through Health or Other Reducing Inequalities Through Health or Other Sectors?Sectors?

Three Examples Three Examples

Child mortality for rich and poor in developing Child mortality for rich and poor in developing countriescountries

Life expectancy across counties in the US Life expectancy across counties in the US

Social class differences in the UKSocial class differences in the UK

Child Mortality: gap between rich and poor

Poorest Quintile

Richest Quintile

0

50

100

150

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350

un

der-

five m

ort

ali

ty r

ate

55

60

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1961

1963

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1999e0

at

bir

th

males females

Trend for US overall life expectancy at birth, 1961-2000Trend for US overall life expectancy at birth, 1961-2000

County life expectancy, males 1999

78.8 to 80.476.9 to 78.8

to 76.973.1 to 7571.2 to 73.169.3 to 71.267.4 to 69.365.5 to 67.463.6 to 65.561.7 to 63.6

75.075.0

Trends in life expectancy at birth for the eight best and eight worst counties, males

55

60

65

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75

80

85

1980 1985 1990 1995 2000

Year

Lif

e e

xp

ec

tan

cy

at

bir

th

I. Professional etc. occupations I. Professional etc. occupations

II. Managerial and Technical occupations II. Managerial and Technical occupations

III. Skilled occupations III. Skilled occupations

IV. Partly-skilled occupations IV. Partly-skilled occupations

V. Unskilled occupations V. Unskilled occupations

Social Class Designation Based on OccupationSocial Class Designation Based on Occupation in the UK in the UK

Age-standardized death rate, adult males, England and Wales, 1911-1991

0

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1,000

1,200

1,400

1910 1920 1930 1940 1950 1960 1970 1980 1990

pe

r 1

00

,00

0

I II III

IV V

Based on ONS UK Health Inequalities Decennial SupplementBased on ONS UK Health Inequalities Decennial Supplement

Why Are There Inequalities in Health?

Why Are There Inequalities in Health,even in a country like the United

Kingdom with nearly 100% financial and physical access to healthcare?

Averages Do Not Tell the Whole StoryAverages Do Not Tell the Whole Story

Defining and Quantifying Inequalities in HealthDefining and Quantifying Inequalities in Health

Health Inequalities Correlated with IncomeHealth Inequalities Correlated with Income

Reducing Inequalities Through Health or Other Reducing Inequalities Through Health or Other Sectors?Sectors?

Social Analysis 76 Distribution of Social Analysis 76 Distribution of

Healthy Life ExpectancyHealthy Life Expectancy

Inequalities vs. InequitiesInequalities vs. Inequities

The term The term inequalityinequality simply refers to a quantity that is simply refers to a quantity that is unequal across individuals or groups of individuals. unequal across individuals or groups of individuals.

InequityInequity invokes the concept of unjust inequalities. invokes the concept of unjust inequalities.

1. Inequalities in healthy life expectancy due to living without clean water?

2. Inequalities in healthy life expectancy due to tobacco consumption?

3. Inequalities due to extreme sports?

Inequities?

Total health inequalityTotal health inequality = =

Between Group InequalityBetween Group Inequality + +

Within Group InequalityWithin Group Inequality

What Should We Measure?What Should We Measure?

“Inequality in the US has been increasing.”

Relative and Absolute Inequalities

Distribution of child mortality

0.00

0.05

0.10

0.15

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0.35

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0.45

0.00

0.05

0.10

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0.20

0.25

0.30

0.35

0.40

0.45

0.50

0 20 40 60 80 100Child mortality

% p

op

ula

tio

n

AB

C

Averages Do Not Tell the Whole StoryAverages Do Not Tell the Whole Story

Defining and Quantifying Inequalities in HealthDefining and Quantifying Inequalities in Health

Health Inequalities Correlated with IncomeHealth Inequalities Correlated with Income

Reducing Inequalities Through Health or Other Reducing Inequalities Through Health or Other Sectors?Sectors?

Health and income at the national, community, and household level are highly correlated.

Dual causality: poverty causes poor health and poor health causes poverty.

Poverty to poor health has been the focus of social epidemiology for a century.

More recently, recognize that health may be a key determinant of income growth.

Income and Health Relationship

Source: Author’s calculations based on World Development Indicators 2003 (life expectancy and Penn World Table (GDP.) Note: Circles have diameter proportional to population size.

The Millennium Preston Curve

The World Health ChartThe World Health Chart

www.gapminder.orgwww.gapminder.org

Averages Do Not Tell the Whole StoryAverages Do Not Tell the Whole Story

Defining and Quantifying Inequalities in HealthDefining and Quantifying Inequalities in Health

Health Inequalities Correlated with IncomeHealth Inequalities Correlated with Income

Reducing Inequalities Through Health or Other Reducing Inequalities Through Health or Other Sectors?Sectors?

Strategies to Reduce Health InequalitiesStrategies to Reduce Health Inequalities

Major debate on the balance of intervention in Major debate on the balance of intervention in sectors other than health such as improving sectors other than health such as improving educational opportunities or income distribution educational opportunities or income distribution versus the role of public health and medical care.versus the role of public health and medical care.

Often the rich benefit from health system technologies more than the poor – this is true both for prevention and cure.

Important agenda is to understand why interventions that might reduce health inequalities often do not reach the poor.

Reducing Health Inequalities Through Health Systems

Coverage of glasses/contacts, Mexico 2005/6 by state

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20%

40%

60%

80%

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Crude Coverage

Effective Coverage

0%

20%

40%

60%

80%

100%

1 2 3 4 5

Quintile of Wealth

Co

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ite

Eff

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Maternal andChild Health

OtherInterventions

All Interventions

Intervention coverage by wealth quintile, Mexico 2005/6

What Determines Effective Coverage of What Determines Effective Coverage of Interventions?Interventions?

• Price of health care• Perceived need and knowledge• Geographic proximity of providers - travel time• Cultural and social acceptability of intervention -

responsiveness of health systems• Availability of necessary technology and

resources• Technical quality of providers • Choice of an intervention• Adherence Quality of Quality of

providersproviders

Demand for Demand for health carehealth care