Skip main navigation

Hurry, only 9 days left to get one year of Unlimited learning for £249.99 £174.99. New subscribers only. T&Cs apply

Find out more

The state of inequality

To move towards equitable health outcomes, we need to know where the inequities are and who is disadvantaged.
A female staff member sits with pen in hand, checking names off a list at a data collection centre.
© Nossal institute for Global Health at the University of Melbourne

We know that a conscious effort is needed to address inequities to see further progress in health outcomes.

A recognised shortcoming of the Millennium Development Goals was the failure to target equitable distribution of benefits while focusing on raising national averages for improved health. But to move towards equitable health outcomes, we need to know:

  • where are the inequities?
  • which population groups are disadvantaged?
  • which health interventions see the largest gaps between the disadvantaged and advantaged groups?

This information is critical to design appropriate policies to address health equity.

So, let’s see what the World Health Organization found in their 2015 report State of Inequality: Reproductive, maternal, newborn and child health.

In recent years, many countries have succeeded in reducing overall within-country health inequalities, but women, infants and children remain disadvantaged (especially the poorest, the least educated and rural residents) with significant inequalities persisting in most reproductive, maternal, newborn and child health (RMNCH) indicators.

The proportion of births attended by skilled health personnel differed by up to 80 percentage points between the richest and poorest. Antenatal care coverage also differed widely between rich and poor, as well as between the most and the least educated.

But it’s not all bad news, and some indicators have seen more equitable progress. The under-five mortality rate decreased more rapidly in the poorest than in the richest subgroups. Immunisation indicators showed particular gains in the disadvantaged subgroups. Demand for family planning showed substantial progress in narrowing education-related inequality.

These changes have not happened automatically, but because health programs that aim to increase vaccination rates or raise the level of antenatal care visits, for example, have targeted those population groups where the problem has been the greatest, often the poorer and more remote communities.

They were able to do this because they had information on who was missing out on these health services and therefore who to target. Health information systems that are equity oriented will have tools to collect, analyse and report data about health inequalities. Collecting good data and monitoring inequality is an important issue while considering equity, because accurate reporting of inequalities reveals the different experiences of rural and urban residents, the poor and the rich, the educated and the non-educated, and females and males. Building capacity for health inequality monitoring requires developing, strengthening and/or expanding equity-oriented health information systems at the national level. Monitoring inequality demonstrates how progress in national averages is realised by population subgroups, which encourages planners to establish goals that specify a reduction in inequality, and leads to policies and practices that promote health outcomes in disadvantaged subgroups.

Take a careful look at the graph below from the WHO report mentioned above (you can download a larger version in the “Downloads” section at the bottom of this page). This shows the level of coverage of RMNCH services in various low and middle income countries (the coloured circles) broken down by the common equity markers of economic status, education and rurality. Out of these three markers, which one has the lowest average coverage of RMNCH interventions among its most disadvantaged group?

Image source: Fig 4.14 on page 46 of World Health Organization, 2015. State of Inequality: Reproductive Maternal Newborn and Child Health: Interactive Visualization of Health Data. World Health Organization.

While it might be a little complicated, looking at data that shows different equity markers together might help policy makers and programmers see where they might be able to make a difference. While improving services in rural areas continues to be a persistent challenge, this graph shows that the biggest disadvantage is having no education, which can be addressed, but not by the health sector alone. And this brings us to another important concept in the health systems strengthening discussion, which is the importance of intersectoral or multisectoral action. Different sectors (in this case, the education sector) can play a large role in addressing inequities in health outcomes, but in health program planning, multi-sectoral involvement is a rarity.

Do you think we can strengthen health systems and address inequities without multi-sectoral involvement? Reflect on this question as we go through this week.

If you’re interested in further exploring trends, visit the World Health Organization Global Health Observatory which provides an equity country interactive visual.

World health organization, 2015, State of inequality: Reproductive, maternal, newborn and child health, viewed 24 June 2019, <>
World health organization, 2019, Millennium Development Goals (MDGs), viewed 24 June 2019, <>
© Nossal institute for Global Health at the University of Melbourne
This article is from the free online

Health Systems Strengthening

Created by
FutureLearn - Learning For Life

Reach your personal and professional goals

Unlock access to hundreds of expert online courses and degrees from top universities and educators to gain accredited qualifications and professional CV-building certificates.

Join over 18 million learners to launch, switch or build upon your career, all at your own pace, across a wide range of topic areas.

Start Learning now