Imagine you are a poor person who contracts TB in a remote village in the Himalayas. Poor people in remote villages experience many risk factors including crowding and use of wood burning stoves, which increases susceptibility to TB. (1) The village is a two-day walk and a one-day bus ride from Katmandu, where the TB hospital is. That is where individuals who contract TB are referred to go. The government has a policy that they will only give 30 days’ worth of drug at the time, which is based on good intentions to reduce risk of non-adherence and drug resistance, but it also means you will have to come back every month. You wait in line, which they told you can take days. It’s been two weeks. Who is taking care of your family while you are away? How will you get food while you are away for so long? What if someone of higher rank gets in line, and you have to let them go before you?
Health programs need to be designed to deal with the obstacles to access that poor people confront.
In particular, the fact that poor children die at a much higher rate than other children indicates the depth of inequality and unfairness that is a key feature of the global health situation. Poverty-targeted measures are necessary in order to make the needed improvements in global health equity.
An infant born in the poorest income quintile in Egypt is more than twice as likely to die as her counterpart in the wealthiest income quintile. (2) We see this same disparity in numerous other developing countries such as Ghana, Honduras, Indonesia, Jordan, and the Maldives, just to name a few. (2) In India and Kenya, infants born in the poorest income quintile are more than three times as likely to die as infants in the wealthiest income quintile, and in Kyrgyzstan, the difference in mortality between infants born to poor and wealthy families is eight-fold. (2)
Health systems in countries with large wealth disparities are often inequitable, providing more and higher quality services to the well-off, who need them less, than to the poor, who are unable to obtain them. In the absence of a concerted effort to ensure that health systems reach disadvantaged groups more effectively, such inequities are likely to continue. (3)
Women in the lowest wealth quintile in developing countries are 13 times less likely to have a facility-based birth, and almost 12 times less likely to receive antenatal care, than women in the top wealth quintile. (4) This means more than 95% of the poorest women in the poorest countries do not receive any medical care or assistance during their entire childbirth process.
The health services enjoyed by the top economic quintile represent a level of coverage that cannot be rejected as infeasible in the local context – given that 20% of the country’s population is already there. Improvements in health for privileged groups should suggest what could, with political will, be possible for all. (5)
When health aid provides resources to people who can afford health care on their own, it may not make much of a difference, since if the aid did not provide the care the beneficiaries would often just purchase it on their own. Whereas when global health aid provides health care to people who otherwise would have to go without it, it can make a life-or-death difference.
Walson, Judd. “Interaction Between Nutrition and Infection.” NUTR 420, 19 October 2018, University of Washington. Lecture.
Gwatkin, Davidson R., Abbas Bhuiya, and Cesar G. Victora. "Making health systems more equitable." The Lancet 364.9441 (2004): 1273-1280. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(04)17145-6/fulltext
Amouzou, Agbessi et al. “How well does LiST capture mortality by wealth quintile? A comparison of measured versus modelled mortality rates among children under-five in Bangladesh.” International journal of epidemiology vol. 39 Suppl 1,Suppl 1 (2010): i186-92. doi:10.1093/ije/dyq034. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2845873/
Clermont, Adrienne. “The impact of eliminating within-country inequality in health coverage on maternal and child mortality: a Lives Saved Tool analysis.” BMC public health vol. 17,Suppl 4 734. 7 Nov. 2017, doi:10.1186/s12889-017-4737-2.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5688502/