Equity and gender

Gwatkin's paper provides an excellent historical review of the developments in thinking and research with regard to health inequalities and the health of the poor. More importantly, the paper provides a thought-provoking analysis of the impact of those developments on policy and its implications for health inequalities and the health of the poor. I agree entirely with Gwatkin's conclusion that there has been a puzzling disconnection between policy discourse and the setting of health policy objectives and that this disconnection has severely limited the impact of health policies and programmes in reducing health inequalities or solving the health problems of the poor. The central thesis of Gwatkin's paper is that health goals based on societal averages without an effort to incorporate distributional differences in health conditions across the socioeconomic classes do very little to meet the needs of the poor. I would like to add that the setting of health targets based on societal averages also masks gender differentials and thereby fails to deal with the gender-based health inequities that take a great toll on the health of women. In India, for example, using under-five-year-old mortality rates in aggregate form as an indicator of health status would mask the fact that the deaths of girls in this age group exceed those of boys by nearly 330 000 annually (1). Although Gwatkin acknowledges gender inequalities in health status when discussing the dimensions of inequality that matter most, he restricts his recommendation for disaggregated goals to the socioeconomic dimension. It could be argued that because women constitute about 70% of the world's poorest people, disaggregation by socioeconomic status and the pursuit of health goals that specifically target the poor would automatically include the needs of women. But just as Gwatkin argues that using a pro-poor target, such as reducing under-five-year-old mortality by one-third, may not result in any appreciable improvements in the conditions of the poorest, it could be argued that a target to improve the health status of the poor without explicit goals to improve women's health may likewise run the risk of completely missing the health needs of the most vulnerable and the poorest of the poor -- women. Poor women suffer the interactive consequences of two of society's most persistent and damaging inequities, poverty and gender. If the goal of health policy is to reduce health inequalities, it is imperative to set explicit goals for improvements in women's health. Meeting gender-based health goals, however, will only be possible with an approach that addresses the gender-specific sociocultural and economic factors that increase women's vulnerability to illness and infection and restrict their access to health care information and services. For example, women's use of health services has been found to be impeded by sociocultural norms that restrict their mobility or limit their participation in household decision-making (2). Research on human immunodeficiency virus/acquired immunodeficiency syndrome has also shown that economic dependence and income insecurity act as significant constraints for women who want to adopt preventive practices such as the use of a condom, if these go against the wishes of their male partners (3). …