Trends in health inequalities in developing countries
Authors: Davidson R Gwatkin
Journal: The Lancet Global Health (2017)

As a result of several studies, a coherent view of reproductive, newborn, maternal, and child health inequalities has begun to emerge.1Wagstaff A Bredenkamp C Buisman LR Progress on global health goals: are the poor being left behind?.World Bank Research Observer. 2014; 29: 137-162Crossref Scopus (36) Google Scholar, 2Bendavid E Changes in child mortality over time across the wealth gradient in less-developed countries.Pediatrics. 2014; 134: e1551-e1559Crossref PubMed Scopus (25) Google Scholar, 3Alkenbrack S Chaitkin M Zeng W Couture T Sharma S Did equity of reproductive and maternal health service coverage increase during the MDG era? An analysis of trends and determinants across 74 low- and middle-income countries.PLoS One. 2015; 10: e134905Crossref Scopus (31) Google Scholar, 4Victora CG Barros AJD Axelson H et al.How changes in coverage affect equity in maternal and child health interventions in 35 Countdown to 2015 countries: an analysis of national surveys.Lancet. 2012; 380: 1149-1156Summary Full Text Full Text PDF PubMed Scopus (176) Google Scholar, 5Ross J Improved reproductive health equity between the poor and the rich: an analysis of trends in 46 low- and middle-income countries.Glob Health Sci Pract. 2015; 3: 419-445Crossref PubMed Scopus (19) Google Scholar, 6Restrepo-Méndez MC Barros AJD Wong KLM et al.Inequalities in full immunization coverage: trends in low- and middle-income countries.Bull World Health Organ. 2016; 94: 794-805BCrossref PubMed Scopus (95) Google Scholar, 7WHOState of Inequality: childhood Immunization. World Health Organization, Geneva2016Google Scholar Overall, and in most countries, inequalities have been decreasing. However, inequalities have been growing in a small but substantial proportion of countries, and in many of these countries, a decline in health status and health-service coverage among poor populations is part of the cause. In The Lancet Global Health, Cesar Victora8Victora CG Barros AJD França GVA da Silva ICM Carvajal-Velez L Amouzou A The contribution of poor and rural populations to national trends in reproductive, maternal, newborn, and child health coverage: analyses of cross-sectional surveys from 64 countries.Lancet Glob Health. 2017; (published online Feb 23.)http://dx.doi.org/10.1016/S2214-109X(17)30077-3Summary Full Text Full Text PDF PubMed Scopus (40) Google Scholar and colleagues present the findings of the latest study of these trends. The focus of the Article is inequalities in service coverage—as measured by a composite reproductive, maternal, newborn, and child health service indicator—in developing countries as a whole and in economically defined country sets. The main finding of this research is that coverage inequalities have been decreasing in the past 20 years because of faster progress within poor populations and rural populations. Victora and colleagues do not discuss variations in individual-country experiences, and neither do they assess differentials in health status. But these factors have been investigated in other studies, such as that by Wagstaff and colleagues,1Wagstaff A Bredenkamp C Buisman LR Progress on global health goals: are the poor being left behind?.World Bank Research Observer. 2014; 29: 137-162Crossref Scopus (36) Google Scholar who showed that, between 1990 and 2011, overall health-service coverage increased and coverage inequalities fell on average and in most countries (findings similar to those of Victora and colleagues). But the outcomes of Wagstaff and colleagues' more detailed investigations are much less reassuring: in 28% of countries, coverage inequalities have risen, and in 24%, coverage among the poorest 40% of the population has decreased.1Wagstaff A Bredenkamp C Buisman LR Progress on global health goals: are the poor being left behind?.World Bank Research Observer. 2014; 29: 137-162Crossref Scopus (36) Google Scholar Trends for health status were also less encouraging than those for service coverage—health-status inequalities have increased in 42% of countries, and health status among the poorest 40% of the population declined in about a quarter of the countries.1Wagstaff A Bredenkamp C Buisman LR Progress on global health goals: are the poor being left behind?.World Bank Research Observer. 2014; 29: 137-162Crossref Scopus (36) Google Scholar A similar picture emerges from several other studies that have been done in the past few years. The only study of child mortality, for which trends are especially difficult to assess because of the large sample sizes required, was done by Eran Bendavid,2Bendavid E Changes in child mortality over time across the wealth gradient in less-developed countries.Pediatrics. 2014; 134: e1551-e1559Crossref PubMed Scopus (25) Google Scholar who reported faster declines in child mortality among poor populations than among wealthier populations overall and in 61 of the 85 countries he studied between 2002 and 2012. The remaining studies focused on health-service coverage. Two covered several types of reproductive, maternal, newborn, and child health interventions: Sarah Alkenbrack and colleagues3Alkenbrack S Chaitkin M Zeng W Couture T Sharma S Did equity of reproductive and maternal health service coverage increase during the MDG era? An analysis of trends and determinants across 74 low- and middle-income countries.PLoS One. 2015; 10: e134905Crossref Scopus (31) Google Scholar reported overall inequality declines for the four intervention types that they examined, and Victora and colleagues4Victora CG Barros AJD Axelson H et al.How changes in coverage affect equity in maternal and child health interventions in 35 Countdown to 2015 countries: an analysis of national surveys.Lancet. 2012; 380: 1149-1156Summary Full Text Full Text PDF PubMed Scopus (176) Google Scholar noted a similar trend for the several interventions that they studied. Others have focused on specific types of reproductive, maternal, newborn, and child health intervention. For example, John Ross5Ross J Improved reproductive health equity between the poor and the rich: an analysis of trends in 46 low- and middle-income countries.Glob Health Sci Pract. 2015; 3: 419-445Crossref PubMed Scopus (19) Google Scholar showed that the poor–rich disparity in terms of contraceptive prevalence fell overall and in three-quarters of 46 countries followed. Similarly, two multicountry investigations6Restrepo-Méndez MC Barros AJD Wong KLM et al.Inequalities in full immunization coverage: trends in low- and middle-income countries.Bull World Health Organ. 2016; 94: 794-805BCrossref PubMed Scopus (95) Google Scholar, 7WHOState of Inequality: childhood Immunization. World Health Organization, Geneva2016Google Scholar of changes in immunisation inequalities showed overall reductions but wide intercountry variations. The findings of all these studies are remarkably similar. To some degree, such similarity is unsurprising, because all the investigators used the same—and only—sources of suitable information: household survey data from the well known Demographic and Health Survey and Multiple Indicator Cluster Survey programmes. But in other respects, the approaches taken vary substantially—for example, the investigators look at many different health indicators, use many different definitions of inequality, and measure change in many different ways. The similarity of results despite such difference in approach makes the results mutually reinforcing and produces an unusually distinct picture of a glass that is clearly more than half full, but still well over a quarter empty. I have no conflicts of interest. The contribution of poor and rural populations to national trends in reproductive, maternal, newborn, and child health coverage: analyses of cross-sectional surveys from 64 countriesNational coverage gains were accelerated by important increases among poor and rural mothers and children. Despite progress, important inequalities persist, and need to be addressed to achieve the Sustainable Development Goals. Full-Text PDF Open Access