Inequities and global development frameworks

KRISHNA HART: In the previous objective, we examined inequities principally on the basis of income or other indicators of poverty, such as education, that are distributed widely throughout the population. However, the pattern of distribution can vary. And the figure in this slide demonstrates three common patterns. These patterns include marginal exclusion, which is the blue line, where there is much lower coverage in the poorest quintile; incremental linear patterns, such as the orange line, where we see equal increases in each quintile from poorest to richest; and mass deprivation, or the purple line, where there is low coverage in all quintiles except the richest.

Inequities can also be distributed geographically, both between countries and within countries, for example, between different subnational administrative divisions such as provinces and districts. These differences in the distribution of inequities require different approaches or strategies. The strategies range along a continuum between universal strategies, which target the whole population, and strategies targeted towards specific population groups or geographic areas, or a combination of these. The diagrams illustrate three common approaches. Type A countries, where there are four deprived quintiles, indicating widespread deprivation and only the wealthiest spared. Interventions in type A countries should address mass deprivation and target the whole population.

Type C countries, on the other hand, where deprivation is confined to the poorest one or two quintiles, are appropriate for a targeted approach, where resources are directed only at the most, most disadvantaged. While type B countries, which show a more incremental pattern of inequality, and each quintile has progressively higher levels of coverage or health than the previous, are more appropriate for a combination of population-wide or universal approaches and targeted interventions. The Global Development Framework has adopted a much more explicit focus on addressing inequities in its latest version. This shift can be seen in the Sustainable Development Goals, or SDGs, and their targets.

In contrast to the focus on poverty and developing countries in the MDGs, the SDGs are integrated, indivisible, and global in nature. They are applicable to all countries and are about addressing the needs of the poor or otherwise disadvantaged wherever they live. The SDGs are unprecedented in scope and significance. In comparison, the MDGs were about a limited set of human development targets and focused on poor countries. The SDGs cover a broader range of economic, environmental, and social targets, with a strong focus on equity. While each goal has a focus, including equity around inclusion, vulnerable groups, there’s also a specific goal and target on reducing inequities, SDG number 10.

Health comprises one of the 17 goals of the SDGs and has an expanded focus compared to the MDGs that includes the unfinished MDG agenda and new SDG targets and means of implementation. Universal health coverage is the underpinning target and the key means of implementation to achieve the other targets. However, to address the other targets will require a combination of universal and targeted approaches. If we consider the three key objectives of health systems, we can describe how health systems can address inequities as part of each objective. Financial protection is largely addressed through efforts to achieve UHC and ensure an equitable distribution of costs among the population.

Responsiveness involves sensitivity to and responding to the needs of the disadvantaged and vulnerable groups in the population, implying a more targeted approach. In particular, this involves specific services or modifications to services and facilities to allow access to and respond to the needs of the disabled or to populations displaced by emergencies or disaster. Improving health requires a combination of universal programs, together with targeted programs addressing specific populations or areas. Health will also benefit from addressing the other SDG targets, which will reduce inequities in the socioeconomic determinants that underlie many of the inequities in health.

The more integrated and comprehensive approach of the SDGs can also provide opportunities for synergies and cooperation among programs and avoid the tendency to vertical approaches, which emerged in addressing the MDGs. Addressing inequalities may improve coverage faster and be more cost-effective than ignoring inequalities. A study by Carrera and colleagues published in The Lancet modelled the impacts on health outcomes and relative costs of an equity-focused and a mainstream approach. The modelling was conducted on data from 15 countries, including African countries, Asian countries. The paper found that equity-focused investments tended to result in greater improvements in deprived compared to nondeprived groups and to have higher costs.

However, depending on the extent of deprived groups, an equal investment of $1 million in an equity-focused approach, the blue bar, resulted in more under five deaths and stunting averted, particularly in countries with widespread deprivation, compared to mainstream approaches, the red bar. The universal and equity-focused approach that underlies the SDGs has also been translated and adopted in key RMNCH global policies. For example, the 2015 UN Global Strategy for Women’s, Children’s and Adolescents’ Health, reflects an every woman, every child approach. It continues many of the themes of the 2010 strategy, such as country leadership, accountability, integration of interventions, and stronger health systems.

But it is broader, more ambitious, and more focused on equity and expands the scope to include adolescents, humanitarian fragile settings, and focusing on the health equity gap.