Inequalities in child health: Who is reaching the absolute poor?

1. Inequalities in child health:Who is reaching the absolute poor? Emmanuela Gakidou, Margaret Hogan, Christopher JL Murray, Angelica Sousa, Ajay Tandon, Cecilia Vidal Workshop on Inequalities in Financing and Health Mexico City, April 22, 2004 Harvard Center for Basic Research in the Social Sciences Harvard University Initiative for Global Health

2. Data Sources • Inequalities analysis requires data on outcomes and outputs of the health system and rich information on socio-economic status • Economic status: Perhaps most important SES variable, but least measured in health surveys • Best suited data sources for health inequalities analyses: • Demographic and Health Surveys (112 surveys in 65 countries) • World Health Surveys (71 surveys in 71 countries) Harvard Center for Basic Research in the Social Sciences Harvard University Initiative for Global Health

3. Socio-demographic Age & sex Economic status Education Place of residence Race / Ethnicity Household size Health Child mortality Immunizations Birth attendance Antenatal care Information available in DHS Harvard Center for Basic Research in the Social Sciences Harvard University Initiative for Global Health

4. Economic status estimation • Use all available indicators including consumer and non-traded goods. All must be normal goods. • ownership of radio, television, car, motorbike, phone; material of floor, wall, roof; type of water and sanitation facilities; electricity • Estimate permanent income on the same scale across all countries • Divide “global” population into quintiles Cross-country comparable estimates of health status of the poor Harvard Center for Basic Research in the Social Sciences Harvard University Initiative for Global Health

5. Results from the DHS • Trends over time for Bolivia, Egypt, Indonesia and Zimbabwe • under-2 mortality • DTP3 immunization • skilled birth attendance Harvard Center for Basic Research in the Social Sciences Harvard University Initiative for Global Health

6. Trends in under 2 mortality by income quintile Harvard Center for Basic Research in the Social Sciences Harvard University Initiative for Global Health

7. Trends in DTP3 by income quintile Harvard Center for Basic Research in the Social Sciences Harvard University Initiative for Global Health

8. Trends in skilled birth attendance by income quintile Harvard Center for Basic Research in the Social Sciences Harvard University Initiative for Global Health

9. Within-quintile inequalities • How do the poor compare across countries? • How much worse off are the rural poor? Harvard Center for Basic Research in the Social Sciences Harvard University Initiative for Global Health

10. Within quintile inequalities across countries Harvard Center for Basic Research in the Social Sciences Harvard University Initiative for Global Health

11. Skilled birth attendance by quintile in Urban and Rural Populations: 4 regions Harvard Center for Basic Research in the Social Sciences Harvard University Initiative for Global Health

12. Conclusions • Health status of absolute poor varies substantially across countries • Some countries are more effective at reaching the absolute poor • Simple interventions are easier to deliver to the absolute poor; the more complex the intervention the greater the gradient • Poverty may not be the most important social determinant in all settings Harvard Center for Basic Research in the Social Sciences Harvard University Initiative for Global Health