Whitehead M, Dahlgren G, Gilson L.Developing the policy response to inequities in Health: aglobal perspective. ill;.- Challenging inequities in health care:from ethics to action. New Y ork:Oxford University Press;2001:309-322

.vi

M~~~

~

A G loba

MARGARET WHITEHEAD, GORAN DAHLGREN I AND LUCY GILSON

II

A ccumulating evidence across the globe demon-

strates that social inequities in health are wide-

spread-in countries of the South as well as the.North. The country analyses in this book have provided~ ample illustrations of this fact. In some cases, the health! differences within countries have widened across

decades marked out by worsening macroeconomicconditions and increasing socioeconomic crises. At thesame time, economic growth in various countries hasnot necessarily distributed the benefits across all sec-tions of the population. Overall gains in a population'shealth frequently mask significant and worseninghealth outcomes for some population groups.

We believe that addressing health inequities is oneof the major challenges for policies that aim to pro-mote and sustain population health. The underlying

t premise of this chapter is that something can and mustf be done about inequities in health. The ~vidence that~ the choice of development policy, for example, makesI a significant difference to the heath status of the pop-

ulation as a whole and that differentials in h~th vary.over time and across countries with different policy en-

vironments yields the important message that mac-roeconomic and social policies do matter (Radcliffe1978; Caldwell 1986; Dreze and Sen 1989; Sen 1995;

Dahlgren 1993, 1996; Cornia 1996). In essence, ourcontention is that it is possible to challenge health in-equities with purposeful public policy. Such a challengeis long overdue.

Building a robust and appropriate policy response tohealth inequities requires action across a broad spec-trum of areas: first, establishing values; next, describ-ing and analyzing causes; then, tackling the root causesof inequities; and [mally, reducing the negative conse-quences of being in poor health. This chapter worksthrough these four key elements in turn, drawinglessons from the various analyses pr~sented in thisbook. A particular effort is made to focus on the prac-tical approaches that address these unacceptable dis-parities in health. The chapter concludes with some re-flections on the opportunities now opening up for amore concerted global response to this major challenge.

Element I: Establishing Shared Values

Any planned response to the gross and pervasive in-equities in health must acknowledge right from the startthat action involves ethical and political choices-andtherefore has to be based on a firm foundation of shared

309

Inequities in Health:

310 CONCLUSION~

values within a society. Developing value-driven policyaction is, however, particularly challenging in the cur-rent global context. Economic, social, and health poli-cies have increasingly sacrificed ethical concerns in therace to contain costs and in the pursuit of "efficiency"(Gilson 1998, 2000). Therefore, an essential first stepis to demonstrate the injustice and unfairness of pre-sent economic and social arrangements while makingexplicit the values on which proposed action is based.A start can be made by

Setting equity objectives and targets for policySubjecting existing and proposed developments to healthequity impact assessment

be reached through many different routes. The molikely of these routes will disproportionately impro~tinfant h~alth in. the upper. and mid?le. income grOUps~thereby mcreasmg poor-nch gaps m infant mortalityMost concerning is the possibility that the target couldbe achieved wi~o~t improving the infant mortality forthe poorest qumtiIe of the population. It is arguedtherefore, that the IDTs for health should incorporat~equity objectives to ensure improving health among thepoor (Gwatkin 2000).

The symbolic "Target One" of the WHO EuropeanRegion's Health for All strategy (first set in 1985, towhich all 50 countries in Europe signed up) has donemuch to focus attention on the equity issues: "By theyear 2000, the differences in health status betweencountries and between groups within countries shouldbe reduced by at least 25%, by improving the level ofhealth of disadvantaged nations and groups" (WHO1985). Adoption of this symbolic target spurred im-portant developments in the conceptualization, mea-surement, and articulation of pragmatic equity policies(Dahlgren and Whitehead 1992; Kunst and Macken-bach 1995; Gunning-Schepers 1989).

After years of lobbying from the public health com-munity in the United Kingdom, the latest national

,

health strategy for England has at last acknowledgedthe centrality of equity for promoting population healthand has set one of its two key aims as "to improve thehealth of the worst off in society and to narrow thehealth gap" (U.K. Department of Health 1999). In ad-dition, all local statutory agencies are now required toset local targets for reducing health inequalities and tospecify plans to meet those targets. Similarly, in Janu-ary 2000, the u.S. Department of Health and HumanServices released national health goals for the decadeto 2010, with one of the two overarching goals for theUnited States being to eliminate health disparities be-tween different segments of the population, includingthose related to gender, race, education, income, dis-ability, rural location, and sexual orientation (U.S. De-partment of Health and Human Services 2000).

The uptake of symbolic targets has not been limitedto Northern countries. Triggered by the grossly unjustpolicies that prevailed under the apartheid regime inSouth Africa, for example, symbolic equity goals arenow at the heart of social policy development in thatcountry. The government's White Paper, The Trans-formation of the Health System, states that the overallvision for the health sector includes playing a part inpromoting equity within society as a whole by devel-oping a single, unified health system (Republic of SouthAfrica 1997). In addition, the country's new constitu-tion includes a Bill of Rights that encompasses socio-

Setting Health Equity Objectives

Establishing a consensus on societal values for policymay seem a daunting task, but it is worth remember-ing that through international agreements many coun-tries have already committed themselves to health andhealth care policies with common equity objectives.Several international documents, including the seminal1948 United Nations Declaration of Human Rights andthe 1977 World Health Organization (WHO) HealthFor All Policy, state that social inequalities should bereduced and that access to good quality health servicesshould be increased and provided according to need.Likewise, the International Conference on Populationand Development 1994 in Cairo and the Fourth WorldConference on Women 1995 in Beijing catalyzed globalsolidarity in gender equity in health and other socialspheres.

Equity objectives tend to be of two types: symbolic,their main purpose being to inspire and motivate; andpractical or action targets, to help monitor progress to-ward equity and to improve accountability in the useof resources (Whitehead et al. 1998). The two typesare mutually supportive in shaping policy action. Suchtargets are instrumental at global, regional, and na-tionallevels.

At a global level, the Organization for Economic Co-operation and Development called upon its Develop-ment Assistance Committee to establish InternationalDevelopment Targets (IDTs) that articulate economicand social goals to be achieved by all countries by theyear 2015. The economic target aims at reducing theproportion of people living in extreme poverty by 50%.Of concern, the health targets are general and there-fore lack an equity focus. As Gwatkin (2000) demon-strates, achieving the overall goal of reducing infantmortality by two-thirds in each developing country can

,Policy

Response to Inequities in Health 311

Protests against welfare cuts in Ohio, the United States.Source: Piet van Lier/lmpact Visuals/Picture Quest.

Setting equity objectives is only the fIrst step in es-tablishing shared values. There is often a gap betweenstated objectives and how the policies are implementedon the ground. Both the implementation and outcomesof policy therefore need to be monitored and judgedagainst the original equity objectives. At the heart ofthe monitoring issue is the defInition of effectiveness,defmed in our analysis as the degree to which the ef-fort expended, or the action taken, achieves the desiredresult or objective (Slee et al. 1996). In other words,effectiveness must be related to overall objectives. Con-sequently, if the equity dimension is explicit, then thecentral focus is on how to achieve this politically de-termined objective in the most cost-effective way. Thiscontrasts with the more common approach, which setsequity in conflict-or as a trade-off-with efficiency.

economic rights such as to health care. Likewise, thecommitment to gender equity enshrined in theBangladeshi Constitution has legitimized a groundswellof activities advancing the status and well being ofwomen, thereby challenging pervasive cultural nonns.Politically, the potential power of such explicit objec-tives should not be underestimated..These representuseful tools in the attempts to establish the legitimacyof work toward health equity.

More practical, action-oriented targets have recentlybeen announced for Sweden (SOU 1999), focused ontackling the wider detenninants of inequities in health,such as income disparities, poverty, marginalization,and poor working environment. For example, for thestated strategy of strengthening the social cohesion andsolidarity of Swedish society by the year 2010, the fol-lowing targets have been set (SOU 1999):

Making Health Equity Impact Assessments

The emphasis on underlying values and recognition ofthe wider determinants of health inequities carries withit an obligation (or the imperative) to undertake heathequity impact assessments. Policies and programmes ina wide range of sectors must be subjected to such as-sessments so that "unhealthy policies" can be identifiedand "healthier" ones developed. The focus of the as-sessment process should be the impact of policies onthe health and circumstances of the most vulnerable

.Income disparities should not increase beyond the presentlevel of a GINI of 0.25. .

.Prevalence of poverty (EU defmition) should be reducedto less than 4%.

.Long-term dependence on social welfare should be reducedto under 1 % and homelessness should be reduced to un-der 0.05%.

.Political marginalization should be reduced through in-creasing voting rates in deprived suburban areas.

.Suicide rates should be reduced by 25% from present levelof 21 per 100,000.

312 CONCLUSION

environment, and gender concerns-for the prospec-tive analysis of economic and development policies.

Element ll: Assessing and Analyzingthe Health Divide

'"sections of society relative to other population groups.The field of environmental impact assessment is in-structive with regard to its emphasis on prospectivelyidentifying negative impact on ecosystems (VanclayandBronstein 1995).

Similarly, the idea of "gender mainstreaming" thatemerged from the U.N. World Conferences on Womenprovides important insights into and experience withthe application of equity lenses (Standing 1999). A par-allel means of assessing health impact (Birley 1995; Bir-ley et al. 1998; Lehto and Ritsatakis 1999), and morespecifically health equity impact, must be defmed andaccepted as standard practice (Acheson et al. 1998;Scott-Samuel 1998; Whitehead et al. 2000).

One example of a health impact assessment thattakes equity into consideration was carried out on theEuropean Union's Common Agricultural Policy-a ma-jor policy with a budget of about 40 billion ECU a year(roughly equivalent to US$40 billion), aimed at regu-lating food and agricul~ral production in 15 countriesin Europe (Dahlgren et al. 1997). This study concludedthat the regulations governing the growing and distri-bu~on of fruits and vegetables, for example, created afmancial barrier for low-income consumers to afford anutritious diet. Even more striking was the fact thatcultivation and production of tobacco-primarily forexport to developing countries-was heavily subsidizedby scarce public funds (see also chapter 4). Agri-cultural policies such as these are seen as a significantobstacle to improved health, in particular among dis-advantaged groups. It was clear from the analysis, how-ever, that there were practical possibilities for chang-ing the regulations to make the policy more healthenhancing (Dahlgren et al. 1997).

In the current context of rapid globalization, with itsattendant propensity to generate disparities, there is arich agenda of issues that urgently need analysisthrough an equity lens. For example, the effect of globalecological changes on human health (such as climatechanges, depletion of resources including food stocks,environmental damage arising from increased eco-nomic activity; see chapter 4) are a ripe subject forhealth equity impact assessment. Furthermore, theWorld Trade Organization's recent negotiations couldhave profound implications for the ability of states tomaintain equitable health, education, and social services(Price et al. 1999). This development re-emphasizes theneed to assess prospectively and retrospectively boththe positive and negative effects on health of variouspolicies, interventions, and actions.

This is not an argument for stand-alone health eq-uity impact assessments, but rather a call for an equity-oriented lens-encompassing, among others, health,

Describing Inequities in HealthAnother key element in any strategy to tackle health in-equity is to assess the size and nature of the problem.In this respect we start with the following assertions-fIrst, that health measures based on population aver-ages are not reliable guides to what may be happeningto the healili of different groups in society; and second,it is always possible (and necessary) to make some as-sessment of the health divide. What is surprising is thatsuch analysis is still not yet routine practice. Many na-tional databases are analyzed 1;>y averages only, undif-ferentiated by gender, area, ethnicity or socioeconomiccharacteristics. Differentiation by social groupingsshould be as natural as the current universal practiceof describing the health status of different age groups.

Even if data-poor countries are limited to basic de-scriptions from the available statistics or from morequalitative assessments, these can still be valuable inproviding policy-relevant information on the equity sit-uation in a country (see chapter 12 on Tanzania andchapter 15 on Kenya).. Regional differences, for exam-ple, may be gleaned from health care statistics and hos-pital records and backed up by population-based sur-veys to inform resource allocation (as in Mexico; sefchapter 19). In sub-Saharan Africa, where reliabledata on health are most scarce, a resourceful group-comprising over 20 computer-connected, district de-mographic surveillance sites-is compiling the besthealth data for populations that are otherwise invisibleand neglected. Recent analyses have disaggregatedDemographic and Health Survey (DHS) data, often.the most reliable population health data in data-poorcountries, into income quintiles derived from a house-hold asset index. This analysis has highlighted dramaticsocioeconomic gradients in health across about 50 ofthe poorest countries in the world using a data sourcenot originally designed for this purpose (Pande andGwatkin 1999). Analyses by gender should be possiblein nearly all cases and are essential to equity studies.Some countries may be able to go further in analyzinghealth data by ethnic group or by socioeconomic char-acteristics, such as education and income, while thedata-rich countries will be able to add to these de-scriptions with more sophisticated measures.

It is also important to analyze the prevalence of notonly health and disease in different population groupS

Policy Response to lIiequities in Health..but also differentials in exposure to health hazards, inbehavioral risk factors, in opportunities and barriers toadopting a healthier lifestyle or to gaining access to es-sential goods and services, and in the costs and bene-fits of macroeconomic policies. To do so, monitoringmust be improved and socioeconomic variables mustbe added to health information systems. Conversely,more health information could be added to routine so-cioeconomic data collection. Chapter 5 on measure-ment issues outlines a set of principles and indicatorsthat inform the analysis of health differentials withinsocieties.

313the differences in health between different occupationalgroups in the country. Policies specifically designed to re-duce inequities in health in Sweden, therefore, may needto focus more strongly on improving the work environ-ment, while a general health promotion policy may focuson other determinants of health (Dahlgren 1997). In Chile,although cardiovascular disease is the leading cause ofdeath, road traffic accidents actually prove to account formuch of the disparity in longevity between the least andmost educated (see chapter 10).

.The possible synergy between risk factors needs to be con-sidered, in particular when analyzing social inequities inhealth, as risks to health tend to accumulate in sections ofthe population already experiencing disadvantage. The ef-fect of a certain risk factor might therefore be different de-pending on the social position of an individual. The frame-work presented in chapter 2 provides the methodology fordistinguishing empirically between differential exposureand differential vulnerability in particular circumstances.This methodology is employed in the Anglo-Swedish casein chapter 17, in which the two countries provide an il-lustration of a "natural experiment," offering the opportu-nity of carrying out comparative analysis of the differentpolicies in the two countries to help make a more robusthealth impact assessment.

~

iff

I

Element ill: Tackling Root Causes

Once the health divide in a country has been describedand the causes analyzed, the most critical element of astrategy to promote health equity is to identify pointsof entry for action on root causes. The maindetermi-nants of health in general can be thought of as layersof influence (Fig. 1). Individuals have age, sex, and con-stitutional characteristics that influence their health(largely fIXed), but surrounding ~em are irilluencesthat are modifiable by policy. First, there are personal,behavioral factors such as smoking habits, sexual be-havior, and physical activity. Second, individuals in-teract with peers and their immediate community andcome under social and community irilluences, factorsrepresented in the next layer. The wider influences ona person's ability to maintain health (in the third layer)include their living and working conditions, food sup-plies, and access to essential goods and services. Fi-nally, as an overarching mediator of population health,there are the economic, cultural and environmentalconditions prevailing in society as a whole. Figure 1emphasizes interactions: Individual lifestyles are em-bedded in social and community networks, and in liv-ing and working conditions, which in turn are relatedto the wider cultural and socioeconomic environment.

Drawing on this general model, below we focus onpolicy options for those determinants that playa par-

Analyzing Causes andUnderstanding Pathways

Many of the causes of inequities in health are social inorigin. Considering the magnitude ,of the problem froma human development and well-being point of view, itis striking how little systematic research has been doneon the social causes of ill health. Furthermore, it isequally striking that the now emerging literature on thesocial determinants of health has been predominantlyconcentrated in the North. Diderichsen's model (seechapter 2) outlines a valuable framework for under-standing how health inequities are generated and main-tained in a society. This model provides both a theo-retical and a practical tool for analyzing which caus'esare important for a particular country, at differentpoints in the pathways from social position to disease/disability, and looking both upstream and downstream.

Starting at the "upstream" end of the pathways, withsocial context and social position and their relation-ships to health, it is possible to consider the impact ofmacroeconomic and social policies on life chances andultimately on health status for different groups in thepopulation. Equally, searching "downstream" is alsonecessary in order to trace the physiological. mecha-nisms by which specific risk factors or risk conditionsactually generate/cause different diseases or poorerhealth. Not to be forgotten is the imperative of mov-ing back "upstream" to understand how the sick anddisabled are dealt with differentially by health and so-cial systems. Above all, the accumulating evidence onthe social origins of inequities in health highlights theneed to tackle the root causes of poor health, not justthe symptoms. In this respect, it should be recogniZedthat

.Detenninants of inequities may be different from determi-nants of aggregate health. For example, in modem-daySweden, while poor physical working conditions play onlya minor role as an influence on the health status of thepopulation as a whole, they explama large proportion of

314 CONCLUSION

Figure 1 A conceptual model of the main determinants of health-

layers of influence

.0\101 lifestyle f:

I ~~~~ ~

~ ~.

/'/

/'/

/ /'/\/

'\

/I

\\

"t)"c.!.2"5u." ~,,'j.)

\ Age, sex, and personal constitution

Source: Adopted From Dahlgren and Whitehead 1991.

ticularly major role in generating inequities in healthin developing countries, although most are just as rel-evant to the situation in developed nations. Country-specific analyses are always necessary to take the as-sessment further, but some general lessons can begleaned from the Global Health Equity Initiative(GHEI) studies and others about the most effective pol-icy options to tackle root causes (Whitehead 1995;Dahlgren 1997).

Promoting Healthy Macropolicies I

The overarching macroeconomic., cultural, and envi-ronmental conditions prevailing in a country are ofparamount importance in the pathways to inequities inhealth in developing countries. They are therefore keypolicy entry points in the promotion of health equity. I

First., in relation to macroeconomic policies, it needsto be acknowledged that absolute poverty is still themajor risk factor for poor health and premature deathglobally. The pathways leading from poverty to poor. :health include inadequate nutrition and lack of access I

Ito other prerequisites for health, such a decent hous-ing, sanitation, and clean water. In addition, the evi-dence on the psychosocial effects of relative poverty, Ior social inequality, on ill health is also mounting. Wide ill

income inequalities, for example, are associated withindicators of social breakdown and more threatening, Istressful environments. Large and increasing income in- Iequities may have a negative effect on health conditions i

for the whole population, not just the poorest, as theeconomic divide promotes social segregation, threatenscommunity values, and thus creates a culture that gen-erates, rather than prevents, violence (Kawachi andKennedy 1997; Lomas 1998; Kawachi et al. 1999).

Consequently, as discussed above, a health equity im-pact analysis should inform the articulation of macro-economic policy. When this is done, it becomes clearthat some of the "unhealthy" economic policies are onesbased on the widespread view that economic growthshould/must occur at any cost, disregarding any ad-verse impacts on sections of the population. There isnow a wealth of experience from around the world onthe adverse health effects of macroeconomic policiesfocused primarily on growth, as eloquently elaboratedin the provocatively titled book Dying for Growth (Kimet al. 2000). In this respect, a number of the case stud-ies in this volume-on Russia, Chile, and China-bearwitness to these adverse effects.

In Russia, the 1992 liberalization of prices and thetermination of state subsidies in many sectors of theeconomy cqincided with an ~cute crisis in the economy.During this period, liberal monetary and macroecO-nomic measures were not accompanied by compen-satory social policies, with disastrous results for thehealth and welfare of the population, especially thepoorer, less educated groups (see chapter 11). Chileand China are both countries that have gone throughmajor economic, political, and demographic transitionsover the past 20 years, and both have experienced sub-

315

around where the poorer sections of the population liveor work (McLaren et al. 1999). This situation can bea side effect of unhealthy economic policies in whichthe pursuit of financial profits is given priority over thehealth of employees and local residents. Recognition ofthis fact has led in recent years to a growing Environ-mental Justice movement, advocating policies that re-dress these excess exposures to environmental hazards.

Improving Living and Working Conditions

The classic public health endeavors to improve livingand working conditions and access to essential services,such as education and health care, still have a vital roleto play in promoting health equity. Groups experienc-ing social and material disadvantages are often the onesexposed to the most health-damaging environments.This is painfully obvious in relation to the living con-ditions experienced in shanty-towns in poo'r countries,as well as segregated poor urban areas in richer ones.In Mexico, roughly 58% of the indigenous people lackrunning water and 88% have no sewage facilities. Pro-vision of this basic infrastructure is a prerequisite toreducing the disproportionate burden of diarrheal andother communicable diseases in this group (see chap-ter 19). Even in a wealthy country like the UnitedStates, evidence on the determinants of poor healthpoint to inadequate access of substantial sections of thepopulation to healthy living and working conditionsand to essential services, such as an adequate social se-curity system and health care coverage (see chapter 9).

One of the starkest illustrations of the pathways lead-ing from inequitable housing and work policies to dis-advantages in many spheres of life, including health, isgiven in chapter 14, where the apartheid system inSouth AfriCa had severe consequences for the nonwhitemajority. This resulted in large sections of the popula-tion living in poverty, in squalor, and without the ba-sic prerequisites for good health. South Africa is nowtrying to deal with this legacy of apartheid by imple-menting policies with explicit equity objectives.

Policy Response to Ineq),lities in Health~

stantial economic growth, but with widening incomeinequalities and debates, at least in Chile, about the ex-tent to which the poorer sections of the population havebenefited from the economic growth. Although popu-lation health on average has improved in both coun-tries, the transition has also been accompanied by in-creasing inequities in health.

Conversely, the "healthy" economic policies are thosethat contribute to alleviating poverty and that reduceincome inequalities. There is evidence, for example,that it is possible for development strategies to be "pro-growth and pro-poor" by which macroeconomic poli-cies support social policies that deliver services such asprimary education and preventive health care, whichboth have greatest benefit for the poor and high socialrates of return (Tanzi 1998). This highlights anotherimportant element of macroeconomic policies-theirimpact on health inequities through their prescriptionson public sector expenditures. Dreze and Sen (1989)emphasize the real potential for a strategy of "support-led security," rooted in direct public support for edu-cation, health care, and food, to tackle deprivation evenat low levels of income and economic growth.

Second, the overall cultural environment can be im-proved by pro-equity public policy. The position ofwomen in society or of ethnic minorities, for example,can be greatly influenced by purposeful national action.Countries such as Bangladesh and the Indian State ofKerala, for example, as detailed in chapter 13, havedemonstrated this with their dynamic policies of in-creasing the literacy rate, particularly female literacy,and improving the empowerment and human rights ofwomen, enshrining those rights in the constitution andin law. The role of education in achieving and sustain-ing greater equity in health is paramount. There arelifelong and intergenerational health benefits arising!from the promotion of universal education (Caldwell1986; see also chapter 8). Furthermore, education m&yact as a buffer against the adverse health effects asso-ciated with increasing economic inequality (see chap-ters 10 and 11).

Third, hazard control policies in the physical envi-ronment are critical at both national and internationallevels. A poignant example comes from Vietnam, wherethe ;country's health system has to deal with the long-tenD environmental, social, economic, and health prob-

Ilems created by the aftermath of weapons of war, suchas Agent Orange. The issue of industrialized countries"exporting" or dumping their toxic waste on the de-veloping world is another example of an environmen-tal cause of injustice. Even within countries, it is no-ticeable that environmental hazards and degradationare not distributed evenly, but tend to be clustered

Buil~g Social Cohesionand Mutual Support

Some commentators believe tf1at the most health-dam-=--aging effects of social inequality are those that excludepeople from taking part in society, denying them seIf-respect and dignity (Wilkinson 1996; Sen 1999). Thenegative health effects of social exclusion are increas-ingly recognized-the exclusion and powerlessness thatcomes with lack of money, lack of education, and lackof influence.

~i\

f~

I.~i$i..itfI.lI'i

i

~

316 CONCLUSION

Masai women's co-op meeting, Kenya.Source: Neil Cooper/Panos.

women in poor rural villages meeting together to poolfunds. These funds are then used to provide loans ataffordable interest rates to members of their group toset up small businesses and stimulate employment op-portunities in the community. The scheme is controlledand run by the women themselves-an important as-pect of the strategy for improving not only the women'seconomic position but also their status within the pre-vailing culture. The chapter provides compelling evi-dence of a health equity dividend.

Creating Supportive Environmen~ forBehavioral Changes

The pathways linking socioeconomic position to health-damaging behavior highlight the need to take into ac-count the structural barriers to healthier lifestyles andthe creation of supportive environments. The researchevidence clearly indicates the importance of structurallydetermined lifestyles, rather than freely chosen life-styles, among less privileged socioeconomic groups. Inshort, the evidence reinforces the need for combiningstructural changes related to economic, living, andworking conditions with health education efforts whentrying to influence lifestyle factors such as smoking, useof violence, alcohol intake, diet, and sexual behaviors.Furthermore, general policies for health promotion anddisease prevention need to be based on the reality ex-

The challenge is to open up opportunities for every-one in the population, not just for the people who havethe loudest voice, at the same time building up condi-tions in society that offer greater mutual support (Drezeand Sen 1989; Gilson 2000). Policy options at this levelinclude building inclusive social welfare systems (inwhich everyone contributes and everyone benefits); im-plementing initiatives to strengthen, and to make it eas-ier for people to participate in, the democratic process;designing facilities to encourage meeting and social in-teraction in communities; and promoting schemes thatenable people to work collectively on their identifiedpriorities for health. These options must give explicitweight to the most disenfranchised, including ethnicand racial minorities, women, and the poor.

The Bangladesh country analysis in chapter 16 pro-vides an example of action on several levels, includingstrengthening mutual support in communities to pro-mote the rights and status of the poorest women in thatsociety. Development policies in one region in partic-ular, Matlab, have emphasized complementary im-provements in access to health care, combined withstrategies to reduce poverty and increase the status ofwomen. Among these strategies, participatory micro-credit schemes linked to employment for women havebeen vigorously promoted. together with the provisionof more places in schools for the daughters of poorfamilies. The microcredit schemes involve groups of

Policy Response to Inequities in Health.317

Young girls smoking in Bali, Indonesia.Source: Culver Pictures/Picture Quest.

perienced by socioeconomically less privileged groupsrather than on that of the middle classes (Townsend1987; Townsend et al. 1993). Tobacco control policieswill be of the utmost importance for population healthin many developing countries in the coming decade, asthe growing opportunities to market tobacco productsare aggressively exploited by the major producers in in-

.-.countries. Once again, it is the poorest, and the health of the poor within those coun-

tries, that will suffer the most from this trade. Policies.--be needed at allievels.-from global to local, and

legal and fiscal to community development andsupport-to regulate this threat to health

transport industry is organized, the long hours and em-ployment conditions of drivers, the lack of safer alter-natives for low-income passengers, and the role ofbribery in the feeble enforcement of road safety laws.The study points to the futility of exacting massive fineson individual drivers. Such action is likely only to ex-acerbate the problem in the absence of a more com-prehensive attempt to address the social and economiccontext underlying poor driver behavior and trafficaccidents. .

The Tanzanian country analysis in chapter 12 also il-lustrates insights from taking into account the lives andlivelihoods of vulnerable adolescents rather than thestandard approach of scrutinizing their sexual behav-ior in isolation. It reveals that those who are not inschool may face immediate physical health hazards,such as dangerous work environments, unsanitary liv-ing conditions, and poor access to food and essentialhealth care. For many there are additional emotionaland social health hazards as they attempt to survive inlonely and unprotected circumstances, separated fromtheir families. Their sexual. behavior (and related mor-bidity and mortality), the study argues, has to be seenin the light of these interwoven economic, social, andcultural factors if effective policy responses are to beformulated.

Another example of the type of policy action rele--,.- discussion of behavioral factors is provided

Kenyan analysis of road traffic accidents in chap-ter 15. The study demonstrates that taking a broad per-

--" in developing policy action is important evep

the determinants appear to be behavioral. Seeingreckless behavior of the drivers of matatus (i.e.,

minibuses) as the major determinant of roadaccidents previously led policy proposals to afocus on modifYing the individual behavior ofThe current study, however, revealed the com-

linkages between driver behavior and the way the

~

CONCLUSION318

Element IV: Building EquitableHealth Care Systems

A critical dimension of social and economic policies forhealth equity (not mentioned thus far) is, of course, thehealth care system. There are important welfare issuesconcerned with improving the quality of life of peoplewho are already sick. The issue of how to amelioratetheir ill health and reduce the socioeconomic conse-quences of illness is a concern in all societies. Thefourth element of a policy response is therefore con-cerned with building more equitable health systems,with the dual purpose of removing barriers to accessto good quality health care while at the same time pre-venting the health care system itself from contributingto poverty and other adverse consequences.

care when resources are scarce (see chapter 13) and againStethnic minorities is also an important issue. Amartya Senhas highlighted a further issue related to "cultural access"concerned with differing perceptions of ill health: an ac-ceptance of one's lot among people experiencing disad-vantage, when there is no scientific reason for acceptingsuch poor health from conditions that could be preVentedor at least ameliorated by good quality health care (Sen1999).

All three aspects are vividly illustrated in relation togender inequities in access to care in the developingworld, where women use health services less than men(WHO 1995). Due to a deadly combination of fman-cial, geographical, and cultural barriers, women's ac-cess to high quality health care is compromised, oftencosting them their lives, particularly around the timeof labor and delivery (WHO 1998a; Thaddeus andMaine 1994; see also chapter 13).

Building an Equity-Oriented Health System

To address issues of access and impoverishment, thereare many factors to consider, including

.How to mobilize fInancial resources in order to improveaccess

.How to alloCate those resources equitably in relation toneed

.How to monitor the use of available resources to ensurethat they are being deployed to meet the stated equity ob-

jectives.

Mobilizing financial resourcesThe costs of health care services are paid for by the cit-izens of a country via taxes, social health insurance,community-based insurance schemes, private health in-surance, and/or direct user fees. Foreign aid can alsoprovide health care fmancing in low-income countries.The mix of these different sources determines to a greatextent how the fmancial burden for health care costsis shared between different age and social groups, aswell as how available resources can be utilized. Thechoice of financing options should be guided by the fol-

lowing equity principles:.The mobilization of fmancial resources should be based on

contributions from the population as a whole and shouldbe progressive, that is, according to ability to pay

.Financial protection should be optiniized by pooling risksamong the largest number of people to avoid impoverish-ment due to high medical expenses.

Despite these clear principles there is no global blue-print for an equitable and sustainable financial system.This is due in part to the multiple stakeholders involvedin health care financing, the dynamics of the public-

Impoverishment and Barriers to Access

The fact that ill health often leads to impoverishmentis of major concern. Moreover, the very fact that peo-ple experiencing social and economic disadvantage tendto be sicker raises fundamental issues for the organi-zation of health systems. It means, for example, thattheir need for health care services is greater and wouldrequire more resources per capita to meet that need.Despite overwhelming evidence of greater need, a com-mon fmding is that health services are sparser and ofpoorer quality in areas serving populations experienc-ing disadvantage and access is more difficult-the so-called inverse care law (Tudor Hart 1971). A wide lit-erature proves the tenaciousness of this maxim,showing repeatedly that the lower the level of income,the larger the gap between health needs and utilizationof health services (Makinen et al. 2000; Castor-leal etal. 1999). There are several dimensions of access towhich the inverse care law can be seen to apply:

.Financial access: User charges are often prohibitive. Highuser fees not only reduce access and utilization of healthservices but also force people to bypass medical personnelwhen in need of drugs. Furthermore, economic growth isnot enough to increase access to health services. In fact,recent experience in Asia indicates the opposite trend, thatis, rapid economic growth tends to generate or spur in-creasing inequities in access.

.Geographical or physical access: There may be uneven dis-tribution between urban and rural areas, most acute in apredominantly agrarian society, or concentration of the sys-tem on providing tertiary services that reach relatively fewwhile primary care services that would benefit many are

neglected..Cultural access: Negative attitudes of health workers to

poor people often discourage poor people from using theservices. Discrimination against girls and women for health

PolicyR~onse

to Inequities in Health

319

(

Vigilance in Monitoring andProtecting Equity

The need to maintain equitable health systems has be-come more pressing since the early 1980s, as manycountries have had to face both economic recessionand rising unemployment, pushing more people intopoverty and ill health (Whitehead 1992). This situationis made worse by cost-containment measures (or bud-get cuts) in health systems inre~ponse to the economicclimate and the introduction of market-oriented healthsector reforms (Gilson 1998; Whitehead 1994; Dahl-gren 1994b). For many countries, though, the pressingtask is to maintain the access that has been achievedin the face of mounting forces working against this aim(Dahlgren 1994a; Gilson et al. 1995). It is particularlyimportant to develop tools and approaches for moni-toring and protecting equity in such circumstances.

One equity-monitoring approach is provided by the"benchmarks of fairness" concept. This originated inthe context of the U.S. health care reform efforts of1993 as a means of making explicit in a systematic way

Ii-

private mix characterized primarily by increased pri-vate sector and reduced public sector presence, and the

pervasive trecnds toward decentralization of health sys-tems. Nonetheless, using the principles outlined above,a set of policy lessons can be draWn from experiencesgained in high- as well as in low-income countries:

.Taxes, including payroll taxes and subsidized communityhealth insurance schemes, constitute the fundamental ba-sis of an equitable fmancial system for health.

.Any shift, at a given level of services, from tax to, for ex-ample, direct user fees increases the burden of payment oneconomically less privileged groups, reduces access, andmay generate a serious poverty trap.

.Private, for-profit health insurance schemes, direct userfees for public health services, and direct fees to privatefor-profit schemes produce substantial, and over time usu-ally increasing, inequities in terms of fmancing, access, andfinancial security.

The Vietnamese case study in chapter 20 illustrateshow one country has been struggling with such majorrmancing issues and the complexities behind some ofthe decisions that have to be made when there is so lit-tle room for maneuvering. In such circumstances, how-ever, the importance of analyzing the health sector re-forms from an equity perspective is greater than ever.

Allocating financial resources according to needA key equity principle is that resources should be al-

locat~ according to need, regardless of ability to pay..In practice, this can be promoted by devising more eq-uitable resource allocation mechanisms for commis-sioninghealth care, with need for care assessed not onlybased on size and age structure of the population butalso according to disease burden and socioeconomiccharacteristics.

.The allocation of available resources between different ar-eas should be based on an assessment of need for healthservices, for example, as related to the age, disease burden,and socioeconomic structure of the population.

.The allocation of available resources for health within aspecific area should be determined by perceived as well asby professionally defined need for health services, regard-less of age, sex, ethnic background, and ability to pay.

Above all, this requires taking into account the iden-tified social gradients in mortality and morbidity thatexist and that indicate differential levels of need ill dif- !

ferent places and for different groups of people. InBritain and Sweden, for example, funds from generaltaxation are allocated on a geographic basis to official

Ihealth authorities to cover the health care needs of theresidents in each administrative area. Both countries

Ihave selected lack of employment and living alone asimportant indicators of increased need for health care

resources. Sweden has added indicators of housingtenure (Diderichsen et a1. 1997), while Britain hastaken into account the proportion of households withsingle parents, as well as direct health indicators (Carr-Hill et a1. 1 994) .

South Mrica provides an example of the potentialfor and problems associated with trying to develop al-location formulas adjusted for need in a data-scarce sys-; tern (Doherty and van Den Heever 1998), Similar is-

sues arise for other countries introducing reforms inwhich the function of commissioning services is sepa-rated from the provision of care or in which there isdecentralization of budgets and control to local areas,The Chinese country analysis in chapter 7, for exam-ple., highlights a particular problem of resource alloca-tion in this respect. Administrative areas that were rel-atively well-off used to be able to subsidize moredisadvantaged areas, but this is no longer the case fol-lowing health sector reform in the country because ofdecentralization. In the poorer regions, where the taxbase is smaller, there is now less money for health ser-vices and these services are at risk of serious decline,while the services in the more affluent areas are in aposition to expand and improve. Unless mechanismscan be devised to cross-subsidize, the inequities arebound to increase still'further, Similar problems ariseunder user-fee systems where revenues collected at thepoint of provision cannot be used to improve serviceselsewhere (Russell and Gilson 1997).

"",;r~::f;.;~c..

CONCLUSION320

climate for policy change, and some new approacheshold promise for the fu~re: It is important to recog-nize the two-way traffic ill Ideas and strategies: fromglobal to local and from local to global. On the Onehand, policy developments in other countries Or agen-cies can be valuable in raising awareness and stirringpolitical response closer to home. On the other handgreater understanding of how inequities in health com~about, gleaned from experiences gained locally, canprovide some of the most powerful ammunition forglobal advocacy. Most importantly, perhaps, is therecognition that equity in health is a common challengeto all societies and thus requires an integrated global

response.

the ethical dimensions and trade-offs inherent in thehealth care system (Daniels et al. 1996). In the U.S.context, benchmarks queried the following equity di-mensions of health care reform proposals: the provi-sion of universal access to services; the comprehen-siveness of services; uniformity of benefits; equitablefInancing by ability to pay; value for money (clinicaland fmancial efficiency); public accountability; and de-gree of consumer choice. Interestingly, efficiency wasone of the criteria under a broad enquiry into equity.Since this application in the U.S. context, the "bench-marks of fairness" idea has been initiated in several de-veloping countries, including Thailand, Pakistan, Mex-ico, and Colombia.

In such settings, new benchmarks have been addedas different social determinants of health are high-lighted in these diverse contexts. The range of bench-marks discussed in Pakistan, for example, includesbenchmarks for iIitersectoral public health; fmancialbarriers to equitable access; nonfmancial barriers to ac-cess (including gender); comprehensiveness of benefitsand tiering; equitable financing; effectiveness, effi-ciency, and quality of health care; administrative effi-ciency; democratic accountability; and, finally, patientand provider autonomy (Khan 1999). In addition toprovoking debate about health care systems within par-ticular countries, the benchmarks have potential to bedeveloped into a useful mechanism for comparing therelative equity of different countries' health systems(Daniels et al. 1996; Khan 1999).

South Africa provides a further example of an ex-plicit equity-monitoring approach. As detailed in chap-ter 14, the paucity and nature of the available data mustbe addressed within efforts to allow the impact of newprograms on the apartheid legacy of inequity to bemon-itored (Bloom and McIntyre 1998). One monitoringsystem that is being developed within South Africa isthe "equity gauge." This approach engages legislatorsat national and subnationallevels in monitoring the im-pact of government policy actions on the health system(Ntuli et al. 1999). The "gauge" monitors equity inhealth and health care and feeds this information intoparliamentary and legislative processes related to healthpolicy and resource allocation.

Strategies for a Global Response

Taking Advantage of CurrentExperience and Opportunities in

Developing Policy .ActionKnowledge

about research and policy gained from de-velopments around the world could be used much moresystematically to gain entry into national debates, al-though there is always a need to be, sensitive to timeand context in a particular country when drawinglessons from elsewhere. First, much more could bemade of the power of comparison in spurring nationalaction. For example, researchers and public health ad-vocates in Europe have been successful in raising andmaintaining awareness of health equity issues amongnational policy makers through a diversity of ap-proaches,--ranging from a careful consensus buildingapproach in the Netherlands, to a more confrontationalstrategy in the United Kingdom, and to a stance builton arguments of social justice in Sweden (Whitehead1998). Despite this diversity, what has been most strik-ing about the European developments is the reinforc-ing effect of events in one country on the situation inthe others. Progress in one country has been used tostimulate or legitimize work toward health equity inothers. The fact that the Dutch government set up aprestigious national program of research on inequitiesin health, for example, helped to persuade other gov-ernments to follow suit. The Dutch initiative itself hadin part been triggered by the interest stimulated by theBritish Black Report, which also set off a spate of in-vestigations around the world, with countries produc-ing their own "Black Reports" on the extent of in-equities in health in their society.

The time has come to marshal these experiences.learning from the mistakes as well as the successes. tostrengthen the impact of existing efforts. A more crit-ical challenge, however, in keeping with the themes of

Over and above specific policy actions, what could andshould a more concerted global effort to redress in-equities in health entail in the immediate future? Anumber of strategies have been effective at creating a

321Policy Response to Inequities in Health~

this volume, is to extend the burgeoning interest in r uity worldwide. The types of practical initiatives thathealth inequities to developing countries. Encouraging need to be taken includein this regard are the emergence of global efforts ailned En! . th h Ith .ty I..

Thi..argIng e ea equi po ICY commumty. s can

at the reduction of poverty broadly defmed. The World be ach'eved by b ' ld ' g 0 stre gthe ' tw ks f, ' , ..I UI m r n rung ne or 0 re-

B~ s explicIt focus on the poor-as exemplified m searchers and advocates, Examples of existing networkstheIr World D~elopment Report 2 000/200 I-the i that could be expanded, apart from the Global Health Eq-G-8-supported HIghly Indebted Poor Country (HIPC) i uity Initiative, include Southern Mrica's Equinet and theinitiative for debt relief, and the civil society-led I International Society for Equity in Health, as well as theprotests for greater transparency of global trade and various human rights networks, Sh~ning the equity fo-economic policies are enhancing prospects for con- cus of existing research networks such as the Global Fo-certed action toward distributive justice.. rum for Health Research would be valuable, as would

Second, collective setting of international standards, building supportive links between established n~twork:'targets, and resolutions can improve the political. cli- s~ch as the EU N~twork of Researchers E.v~lua.ting Poh-

t .thin tri' .d.. tu t I I d Cles and Interventions to Reduce Inequalities m Healthma e WI coun es proVl mg lffipe S 0 oca a-,

f~ h I . h . I b (Mackenbach and Droomers 1999) and emergIng networks~ocacy e lortS 0: even ~ pmg to s ape n~tiona Pu. -in the South.

lIc heal:h strategIes. In this respect, the settIng of equIty. Building greater capacity to monitor and analyze policiestargets m the WHO (1998b) renewal of Health For All from an equity perspective. More collaborative workin 1998 should not be underestimated as a future lever should be encouraged to focus minds on refming methodsfor change. The UN Conference on Population and and tools for monitoring and analysis, particularly for useDevelopment, Cairo, 1994, continues to aid the re- in low-income and data-poor settings. The South Africancasting of population policies in terms of health, em-: Equity Gauge, for example, is being adapted to monitorpowerment, and rights of women in many developing i health ~ystem ~h~nges in other countries. Research andcountries (Sen et al. 1994), As mentioned earlier, it is pr~fesSlonal tramm~must be, supported to, devel~p ~e new

articularly ilnportant to place equity- or distribution- skills and perspectives requIred. Innovative thinking andp " .. kin pump-priming support is required to investigate the press-sensItive targets on the mternational agenda (Gwat '. d ' th ff t f I b I ' t ' thmg Issues surroun mg. e e ec s 0 go a lza Ion on e

2000~. ..determinants of health and inequalities. Beaglehole andThird, much can be achIeved by taking advantage of Bonita (2000) have gone a step further and proposed a

windows of opportunity that unexpectedly arise. The worldwide cooperative research program that would be theglobal wave of democratization represents one such I public health equivalent of the human genome project.phenomenon. As Amartya Sen points out, "the absence. Encouraging global advocacy. There are multiple oppor-of democracy is in itself an inequality-in this case of I tunities for synergistic action by statutory organizations,political rights and powers." The strengths of democ- multilateral funders, and charitable foundations. Follow-racy-participation, civil rights, and liberties-are tied ing the example of the :World I:Iealth Organization's Worldto a society's ability to stem inequality, provide secu- Health Repo'! 1999, mterna,tiona! report~ on .h~alth andrity and protection for all citizens, and prevent major de~elopment Issues could be Identified while ~tlll m prepa-

t tr h h f . (S 1999 187) D .t ration and encouraged to have a substantive focus onca as op es suc as amme en : .espl e h al h ' s ff h Id be d t ..

ti e t equIty. trong e orts s ou ma e 0 mJec a

formldabl~ obstacles m the aftermath .of apa~eId m I consideration for equity into current policy debates, aSouth ~nca, the advent of ~~mocratic electIons. has I prominent instance being health sector reform proposalsresulted m an upsurge of polItical and popular will to 1 in low-income countries (Gilson 1998; Whitehead andbuild a fairer society. Similarly, transitions from states I Dahlgren 1991), Other pressing global developments re-

of conflict and insecurity to peace and responsible gov- quiring an equity lens include the effects of moving to-ernance provide a solid foundation and fresh hope for! ward ever more deregulated market economies and theredressing long-standing inequities. I World Trade Organization agreements that recently trig-

I gered such a violent reaction in Seattle and Washington

(Price et al. 1999),

Taking action on all these frontiers requires re-spected international. leadership, as Chen andBerlinguer emphasize in chapter 4. They call for theWorld Health Organization' to assume that role oncemore, becoming "the worlq conscience of health."Certainly, we must launch a more concerted effort-beyond the well-meaning, but thus far largely haphaz-

Developing the Capacity forMonitoring and Advocacy

Awareness of health equity as an international issue hasreached the point where sufficient momentum has builtup to stimulate the types of collaborative action thatare necessary to monitor and advocate for health eq-

CONCLUSION322

ard, development of advocacy in this field. In a time ofgrowth and promise, yawning health divides must notbe tolerated. With a "world conscience" plaYing a lead-ership role, it is up to a constellation of governments,ministries of health, regional organizations, non-governmental organizations, researchers, advocacygroups, and individuals to stem the tide of wideninginequities in health. We must collectively seize this un-precedented opportunity for global equity in health.

References

Dahlgren G., Nordgren P., Whitehead M. (eds). 1997. Health Im-pact Assessment of the European Union Common Agricultur 1Policy. Stockholm: Sweden's National Institute of Public Healt~

Daniels N., Light D., Kaplan R. 1996. Benchm.arks.of Fairness fo~Health Care Reform. New York: Oxford Umverslty Press.

Diderichsen F., Varde E., Whitehead M. 1997b. Resource allocationto health authorities: the quest for an equitable formula in Britainand Sweden. British Medical Journal 315:875-878.

Doherty J., van Den Heever A. 1998. A needs-based, weighted-cap-itation formula in support of equity and primary health Care: aSouth African case study. In: Barer M.L., Getzen T.E., StoddartG.L. (eds) , Health, Health Care and Health Economics: Per.spectives on Distribution. London: Wiley. pp. 271-294.

Dreze J., Sen A. 1989. Hunger and Public Action. Oxford: Claren-don Press.

Gilson L. 1998. In defence and pursuit of equity. Social Science andMedicine 47(12):1891-1896.

Gilson L. 2000. Re-addressing equity: the importance of ethicalprocesses. In: Mills A. (ed), Reforming Health Sectors. London:Kegan Paul (In press).

Gilson L., Buse K., Russell S. 1995. The political economY of COstrecovery: towards equitable healthfirnmcing policy .Journal of In-ternational Development 7(3):369-401.

Gunning-Schepers L. 1989. How to put equity in health on the p0-litical agenda. Health Promotion 4:149-150.

Gwatkin D. 2000. Health inequalities and the health of the poor.Bulletin of the World Health Organization 78( 1 ):3-17.

Kawachi I., KennedyB. 1997. Health and social cohesion: why Careabout income inequality? British Medical Journal 314:1037-1040.

Kawachi I., Kennedy B., Wilkinson R. 1999. Crime: social disorga-nization and relative deprivation. Social Science and Medicine48:719-731.

Khan K.S. 1999. Benchmarks of Fairness in Health Care: Report ofa Karachi Workshop. Karachi, India, April 1-5, 1999.

Kim J.Y.; Millen J.V., Irwin A., Gershman J. (eds). 2000. Dying forGrowth. Monroe, ME: Common Courage Press.

Kunst A., Mackenbach J. 1995. Measuring Socioeconomic Inequal-ities in Health. Copenhagen: World Health Organization.

Laflamme L. 1998. Social Inequality in Injury Risks. Report 98/33.Stockholm: Sweden's National Institute of Public Health.

Lehto J., Ritsatakis A. 1999. Health Impact Assessment as a Toolfor Intersectoral Health Policy. Brussels: European Center forHealth Policy/WHO Regional Office for Europe.

Lomas J. 1998. Social capital and health: implications for publichealth and epidemiology. Social Science and Medicine 47:1181-1188.

Mackenbach J., Droomers M. (eds). 1999. Interventions and Poli-cies to Reduce Socioeconomic Inequalities in Health. Proceed-ings of the third workshop of the European Network on Inter-ventions and Policies to Reduce Socioeconomic Inequalities inHealth, Rotterdam, November 19-20, 1998. Rotterdam: ErasmusUniversity .

Makinen M., Water H., Rauch M., Aimagambetova N., Bitran R.,Gilson L., Mcintyre D., Pannarunothia S., Orieto A.L., Ubilla G.,Ram S. 2000. Inequalities in health care use and expenditures:empirical data .from eight developing countries and countries intransition. Bulletin of the World Health Organization 78(1):55-65.

Mclaren D., Cottray 0., Taylor M., Pipes S., Bullock S. 1999. TheGeographic Relation Between Household Income and pollutingFactors. London: Friends of the Earth.

Acheson D., Barker D., Chambers J., Graham H., Mannot M., White-head M. 1998. The Report of the Independent Inquiry into In-equalities in Health. London: The Stationery Office.

Beaglehole R., Bonita R. 2000. Reinvigorating public health. Lancet356:787-788.

Birley M. 1995. The Health Impact Assessment of Development Pro-jects. London: Her Majesty's Stationery Office.

Birley M., Boland A., Davies L., Edwards R.T., Glanville H., 1sonE., Millstone E., Osborn D., Scott-Samuel A., Treweek J. 1998.Health and Environmental Impact Assessment: An Integrated Ap-proach. London: Earthscan/British Medical Association.

Bloom G., McIntyre D. 1998. Towards equity in health in an un-equal society. Social Science and Medicine 47: 1529-1538.

Caldwell J. 1986. Routes to low mortality in poor countries. Popu-lation and Development Review 12:171-220.

Carr-Hill R.,Sheldon T., Smith P., Martin S., Peacock S., HardmanG. 1994. Allocating resources to health authorities: developmentof methods for small area analysis and use of inpatient services.British Medical Journal 309:1046-1049.

Castor-leal F., Dayton J., Demery L., Mehra K. 1999. Public healthspending on health care in Africa: do the poor benefit? WorldBank Research Observer 14(1):49-72.

Cornia G. 1996. Labor Market Shocks, Psychosocial Stress and theTransition's Mortality Crisis. Research in Progress 4. Helsinki:United Nations University, World Institute for Development Eco-nomics Research.

Dahlgren G. 1993. Economic analyses of health development. NUNews on Health Care in Developing Countries 7(2):4-7.

Dahlgren G. 1994a. The political economy ofhealth.fmancing strate-gies in Kenya. In: Chen L., Kleinman A., Ware N. (eds), Healthand Social Change in International Perspective. Boston: HarvardUniversity Press. pp. 453-470.

Dahlgren G. 1994b. Health Markets of the Future: Winners andLasers [in Swedish]. Stockholm: Natur och Kultur.

Dahlgren G. 1996. Sectoral approaches to poverty reduction: health.In: SIDA, Promoting Sustainable Livelihoods: A Report From theTask Force on PoveTty Reduction. Stockholm: Swedish interna-tional Development Agency.

Dahlgren G. 1997. Strategies for reducing social inequities inhealth-visions and reality. In: Ollila E., Koivusalo M., PartonenT. (eds), Equity in Health Through Public Policy. Helsinki:STAKES (National Research and Development Center for Healthand Welfare).

Dahlgren G., Whitehead M. 1991. Policies and Strategies to PromoteSocial Equity in Health. Stockholm: Institute for Futures Stud-ies.

Dahlgren G., Whitehead M. 1992. Policies and Strategies to PromoteEquity in Health. Copenhagen: World Health Organization.

323Policy Response to Inequitiesm Health*

Ntuli A., Khosa S., McCoyD. 1999. The Equity Gauge. Durban:Health Systems Trust.

Pande R., Gwatkin D. 1999. Country-level infonnation on poor-richdifferences with respect to health, nutrition and population. Pro-visional data. Washington, DC: World Bank.

Price D., Pollock A., Shaoul j. 1999. How the World Trade Orga-nization is shaping domestic policies in health care. Lancet 354: ,1889-1892. I

Radcliffe j. 1978, Social justice and the demographic transition: jlessons from India's Kerala State. International Journal of HealthServices 8:123-144.

Republic of South Africa. 1997. White Paper for the Transformationof the Health System in South Africa: Toward a National HealthSystem. Government Gazette 382 (17919): Notice 667.

Russell S., Gilson L. 1997. User fee policies to promote health ser-vice access for the poor: a wolf in sheep's clothing. InternationalJournal of Health Services 27(2):359-379.

Scott-Samuel A. 1998. Health impact assessment-theory into prac-tice. Journal of Epidemiology and Community Health 52:704- i705.

ISen A, 1995. Mortality as an indicator of economic success and fail-ure. Innocenti lnaugral Lecture, March 3, 1995, Instituto degli 'I'Innocenti, Florence.

Sen A. 1999. Development as Freedom. New York: Alfre<;i A. Knopf.Sen G., Gennain A., Chen L. (eds). 1994. Population Policies Re-

considered: Health, Empowerment, and Rights. Harvard Serieson Population and International Health. Boston: Harvard Uni-versity Press.

Slee V.N., Slee D.A., Schmidt H.J. 1996. Health Care T~rms. St.Paul, MN: Tringa Press.

SOU. 199,9, Equity in Health-The Second Step Towards NationalHealth Targets. Stockholm: National Public Health Commission!SOU 1999:137 [in Swedish].

Standing H. 1999. Frameworks for Understanding Gender Inequal-ities and Health Sector Reform: An Analysis and Review of Pol-icy Issues. Harvard Center for Population and Development Stud-Ies, Working Paper Series No. 99.06. Cambridge, MA: HarvardCenter for Population and Development Studies. I

Tanzi V. 1998. Macroeconomic adjustment with major structuralre- Ifonns: implications for employment and income distribution. In: ITanzi V., Chu K. (eds), Income Distribution and High Quality ,Growth. Cambridge, MA: MIT Press'

jThaddeus S., Maine D. (1994) Too far to walk: maternal mortalityin context. Social Science and Medicine 38:1091-1110. I

Townsend j. 1985. Cigarette tax, economic welfare and social class ipatterns of smoking. Applied Economics 19:335-365.

Townsend J., Roderick P., Cooper J. 1993. Cigarette smoking by so-cioeconomic group, sex and age: effects of price, income, andhealth publicity. British Medical Journal 309:923-927,

Tudor Hart J. 1971. The inverse care law. Lancet i:40S-412.

U.K. Department of Health. 1999. Saving Lives: Our HealthierNation. Command White Paper 4386. London: The StationeryOffice.

U.S. Department of Health and Human Services. 2000. Healthy Peo-ple 2010. Washington, DC: U.S. Department of Health and Hu-man Services.

Vanclay F., Bronstein D. (eds). 1995. Environmental and Social Im-pact Assessment. Chichester: John Wiley and Sons.

Whitehead M. 1992. The health divide. In: Townsend P., WhiteheadM., Davidson N. (eds), Inequalities in Health: The Black Reportand the Health Divide, 2nd ed.. London: Penguin. pp.. 214-450.

Whitehead M. 1994. Is it fair? Evaluating the equity implications ofthe NHS reforms. In: Robinson R., Le Grand J. (eds), Evaluat-ing the NHS Reforms. London: King's Fund. pp. 208-242.

Whitehead M. 1995. Tackling inequalities: a review of policy initia-tives. In: Benzeval M., Judge J., Whitehead M. (eds), Tackling In-equalities in Health: An Agenda for Action. London: King's Fund.

Whitehead M. 1998. The diffusion of ideas on inequalities in health:a European perspective. Milbank Quarterly 76:469-492.

Whitehead M., Burstrom B., DiderichsenF. 2000. Social policies andthe pathways to inequalities in health: a comparative analysis oflone mothers in Britain and Sweden. Social Science and Medi-cine SO:2SS:-270.

Whitehead M., Dahlgren G. 1991. What can be done about in-equalities in health? Lancet 338:1059-1063.

Whitehead M., Diderichsen F. 1997. International evidence on so-cial inequalities in health. In: Drever F., Whitehead M. (eds),Health Inequalities-Decennial Supplement. DS Series No. 15.Office for National Statistics. London: Her Majesty's StationeryOffice. pp. 44-68. .

Whitehead M., Scott-Samuel A., Dahlgren G. 1998. Setting targetsto address inequalities in health. Lancet 351:1279-1282.

Wilkinson R. 1996. Unhealthy Societies: The Afflictions of Inequal.ity. London: Routledge.

Wilkinson R., Kawachi I., Kennedy B. 1998. Mortality, the social en-viromnent, crime and violence. In: Bartley M., Blane D., SmithG.D. (eds), Sociology of Health Inequalities. Oxford: BlackwellPress.

World Bank. 1993. Investing in health. World Development Report1993. Oxford: Oxford University Press.

World Bank. 2000. World Development Report 2000/2001. Oxford:Oxford University Press.

World Health Organization (WHO). 1985. Targets for Health forAll. Copenhagen: WHO.

WHO. 1995. Women's Health: Improve Our Health, Improve theWorld. Geneva: WHO.

WHO. 1998a. Report of the Technical Consultation on Safe Moth-erhood, October 18-23, 1997, Sri Lanka. Geneva: WHO.

WHO. 1998b. Health for All in the 21st Century. Geneva: WHO.WHO. 1999. World Health Report 1999. Geneva: WHO.