Equity in access to and coverage of services needed for real progress

Inequities in health are ‘differences in health that are not only unnecessary and avoidable, but in addition unfair and unjust,’ as Margaret Whitehead defined in 1990[1]. These inequitable health outcomes which manifest themselves in particular groups of people often result from inequitable access to and coverage of health services. Women and children in many societies are vulnerable to such health inequities. 

Poverty, place of residence (rural/urban), low educational levels, gender, occupation, and religion or socio-cultural status can be factors that deny good health to a person. Such inequities in maternal, newborn and child health (MNCH) care have existed for years and are still widespread. As said in The Millennium Development Goals Report 2010, - “Maternal health is one of the areas in which the gap between rich and poor is most conspicuous.”

The recent report from Countdown to 2015 shows that the overall improvements in MNCH services in several countries mask the deep inequities across countries and within them. Coverage rates were lowest among women and children from the poorest families and women with low levels of education.  The disparities between rich and poor are particularly wide for skilled/facility-based health services that those provided at the community level through outreach programs.  For example, women in the richest households are 1.7 times more likely to consult a skilled worker at least once before birth than the poorest women; contraceptive use is four times higher among women who have a secondary education than among those with no education.

Facility-based childbirth and health care is being promoted in all developing countries.  However women’s access to and use of facility based care is inequitable. For example in many developing countries, more women from poorer families than those from a better economic status prefer to deliver at home.  This could be due to reasons such as costs of such care, distance to a health facility, perceptions about its quality, etc., which discourage many poor families from using facilities. A recent publication - India’s Janani Suraksha Yojana, a conditional cash transfer program to increase births in health facilities: an impact evaluation - found that despite having achieved its objective to a great extent, the cash transfer program which targeted poor women, did not reach the poorest of them (who perhaps have the greatest need) at the highest rate.

All this gets reflected in terms of health outcomes as well. Child mortality, for instance, is higher amongst poorer families even in countries which have overall low child mortality rates. A report - Inequalities in child survival: looking at wealth and other socio-economic disparities in developing countries (PDF), which compared inequalities in child mortality between Bangladesh and India, shows that Bangladesh improved child mortality rates due to its wide coverage of interventions. Coverage and child survival in India, however, was inequitable despite the overall improvements.