Unit 1 Session 3



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Introduction

In the previous session we looked at social inequality as the root cause of many of the inequalities that exist in health. We saw that improving the conditions in which people live and work can positively affect their health and ability to resist infection. In this session we will discuss the health status of populations in developed and underdeveloped countries today and how it is linked to the level of equality or inequality that exists.



Session contents

1 Learning outcomes of this session



    2 Readings and references

    3 Equity and health

    4 Case study 1: United States of America

    5 Case study 2: South Africa

    6 Case study 3: Cuba

    7 Case study 4: Haiti



8 Session summary

Timing of this session
There are two readings in this session and four tasks. It should take you about three hours to complete.


1 LEARNING OUTCOMES OF THIS SESSION





By the end of this session, you should be able to:

Public health outcomes:

  • Explain the connection between social inequality and health status.

  • Explain how a more equitable distribution of resources impacts on the health status of a population.

  • Identify key factors that are important in attaining improvement in health.

Academic outcomes:

  • Identify main arguments and supporting ideas.

  • Interpret diagrams.

  • Make notes while you read.






2 READINGS AND REFERENCES




    You will be referred to the following reading in this session.




Author/s

Reference details

Werner, D. & Sanders, D.

(1997). Chapter 14 - A look at the situation today: Equity as a determinant of Health Questioning the Solution: The Politics of Primary Health Care and Child Survival. (Health Wrights): 109 [SETWORK]

Milne, S.

(2010). Haiti's suffering is a result of calculated impoverishment. From guardian.co.uk, Wednesday 20 January 2010



REFERENCES:

  • CSDH. (2008). Closing the gap in a generation: health equity through action on the social determinants of health. Final Report of the Commission on Social Determinants of Health. Geneva, World Health Organization: 2.



3 EQUITY AND HEALTH


The final report from the Commission on Social Determinants of Health (CSDH) states:
Our children have dramatically different life chances depending on where they were born. In Japan or Sweden they can expect to live more than 80 years; in Brazil, 72 years; India, 63 years; and in one of several African countries, fewer than 50 years. And within countries, the differences in life chances are dramatic and are seen worldwide. The poorest of the poor have high levels of illness and premature mortality. But poor health is not confined to those worst off. In countries at all levels of income, health and illness follow a social gradient: the lower the socioeconomic position, the worse the health.”
It does not have to be this way and it is not right that it should be like this. Where systematic differences in health are judged to be avoidable by reasonable action they are, quite simply, unfair. It is this that we label health inequity. Putting right these inequities – the huge and remediable differences in health between and within countries – is a matter of social justice.”

(CSDH, WHO, 2008.)
Put simply, health equality can be narrowly defined as the equal (the same) access of all people to resources and services; and the allocation of equal expenditure on health care to different groups. Equity, on the other hand, is about the fair and just distribution of these resources and services, which might give priority to those who have been unfairly disadvantaged in the past (e.g. because of class, race and gender inequalities). In other words, equity is concerned with the corrective actions taken to ensure that the health needs of people are met in the fairest way possible. Equity is one of the most important factors in achieving the health of a population. This applies to high-income, middle-income and low-income countries.



TASK 1 - Describe the contrasting wealth of different countries and their health status


READING

Werner, D. & Sanders, D. (1997). Chapter 14 - A look at the situation today: Equity as a determinant of Health Questioning the Solution: The Politics of Primary Health Care and Child Survival. (Health Wrights): 109


1. Preview the above chapter. Read the title, headings, sub-headings, and skim the diagrams and graphs. What do you think you will read about?


2. Now read the introduction on page 109. While you read, make notes about the contrasting wealth of four countries in 1995 (in Gross National Income (GNI) and the health status of their children (in U5MR). Say how the country would be classified in terms of its income, i.e. low, middle, high. Use a table similar to the one below. There is one example for you.


Country

GNI

U5MR

Income classification

Vietnam, China and Sri Lanka

US$600.00 or less

Under 50 (fewer than 50 out of
1 000 children die before age 5)


Low income








































































Remember that in Unit 1, Study Session 2, you read that there are different ways to measure the development of a country. One way is to calculate the Gross National Income (GNI) of the country. (GNI used to be called GDP (Gross Domestic Product). These measurements are traditionally given in US dollars. GNI is calculated by adding the total value of all the goods and services produced by all the citizens of a country in a year. When this is divided by the total population, we arrive at the average GNI per capita in the country. You can read more about this in Unit 1 Study Session 2.


3. What can you conclude from the above table about wealth and the relative health of children in different countries?
4. What is a better measure of health status than GNI per capita? Why?
5. Use your own words to explain what equality and equity mean. Give an example from your own experience of inequality and inequity.



FEEDBACK


Country

GNI per capita 1995

U5MR 1995

Income classification

Vietnam, China and Sri Lanka

US$600.00 or less

Under 50

Low income

Libya, South Africa, Brazil, Botswana and Iran

US$2000

56 or more

Lower middle income

Gabon

$4450

154

Upper middle income

Jamaica

$1340

13

Lower middle income

Hong Kong

$13 340

7

High income

Singapore

$14 210

6

High income

US

$22 240

10

High income

3. From the above table we can conclude that the contrasting wealth of these countries does not reflect the relative health of their children. You will see later in this session that in rich countries like United States of America, there is little correlation between GNI per capita and life expectancy (one of the indicators of development). For example, USA has a GNI of more than $45,890 and a life expectancy of 78 years, while Cuba has a GNI of less than $10 000 and a life expectancy of 78 years.

4. How income is truly distributed amongst the population is a better indicator of health status than GNI per capita, as GNI per capital wrongly assumes that each person gets an equal share of the country’s wealth. However there are income disparities within a country, which is a factor that contributes to the relative ill-health of the poorest. You know from Unit 1, Study Session 2 that economic classifications on their own are not sufficient to explain the health levels of a country. The UNDP, for example, ranks countries on a Human Development Index (HDI). Three basic indicators are used to measure average achievements of a country towards human development:


  • A long and healthy life: Measured by life expectancy at birth

  • Access to knowledge: Measured by the adult literacy rate and the combined gross enrolment ratio in education

  • A decent standard of living: Measured by GNI per capita in purchasing power parity (PPP) in US dollars.

The Human Poverty Index (HPI) is used to measures the extent of poverty in a country using the following indicators:



  • The likelihood of death at a relatively early age (Infant mortality rate and Under 5 mortality rate)

  • A lack of basic education, measured by the percentage of adults who are illiterate

  • The lack of access to a decent standard of living.

5. Your explanations and examples will differ, but should include the following points:



    • Equality is about everyone having equal or the same access to services no matter what level need they have.

    • Equity is about fair access and distribution based on need.

In the rest of this session you will read about and compare the health status of four different countries to see what lessons we can learn about achieving health equity:



  • United States of America (USA) which is classified as a developed, high-income country

  • South Africa (SA) which was classified as a low-middle income country, but was reclassified as an upper-middle-income country in 1995. However, today South Africa still has aspects of development alongside underdevelopment.

  • Cuba which is classified as a middle-income underdeveloped country

  • Haiti which is classified as a low-income underdeveloped country.


4 CASE STUDY 1: UNITED STATES OF AMERICA


Although the United States (US) is classified as a developed, high-income country, Health, United States, 2008, identifies major disparities in health and health care in the US by socio-economic status, race, ethnicity, and insurance status. Many aspects of the health of the nation have improved, but the health of some income, racial and ethnic groups has improved less than others; and for some groups, the gap has widened. The figures in the reading in Task 2 are for 1995. So read the reading together with the information box below, which provides you with updated data.



TASK 2 – Identify factors that account for substandard health levels in the United States


READING

Werner, D. & Sanders, D. (1997). Chapter 14 - A look at the situation today: Equity as a determinant of Health. In Questioning the Solution: The Politics of Primary Health Care and Child Survival. (Health Wrights): 109 – 113.







  1. While you read the case study about the United States (pages 109 – 113) and the Information Box below, identify ten factors that could account for the substandard health levels in the US as compared to other countries.




  1. What are the root causes of health inequalities in the US?





Purchasing Power Parity (PPP):

Gross National Income (GNI) is converted to international dollars using purchasing power parity (PPP) rates. An international dollar has the same purchasing power as the US dollar has in the United States.





Information box

According to World Development Indicators database, World Bank (2009):




  • In 2008 the US had the highest GDP ranking in the world at $14 204 322

  • GNI per capita (Purchasing Power Parity (PPP) international $): 45,890 

  • Health care spending is approximately 16% of the GDP

  • The U5MR: 8

  • Life expectancy at birth (years): 78 (this lags 42nd in the world)

  • Total expenditure on health per capita (international $ (2006): 6,714

  • Immunisation, measles (% of children ages 12-23 months): 93%

  • Primary completion rate, total (% of relevant age group): 96%

  • Health care facilities are largely privately owned and people cover their own health care expenses, mainly through contributions to health insurance. However, at least 15% of the population is completely uninsured and a substantial additional number are underinsured. According to a 2009 Harvard study published in the American Journal of Public Health inequalities in health care are often caused by income disparities that result in lack of health insurance. According to this study more than 44,800 deaths annually in the US were due to Americans lacking health insurance.

  • In 2000, the World Health Organisation ranked the US health care system as 37th in overall performance and 72nd by overall level of health (among 191 member nations included in the study).

  • Health disparities in US are well documented in ethnic minorities such as African Americans, Native Americans, Asian Americans and Hispanics. When compared to whites, these minority groups have higher incidence of chronic diseases, higher mortality, and poorer health outcomes. A 2001 study found large racial differences exist in healthy life expectancy at lower levels of education.

  • In 2007 the official poverty rate was 12.5%. 37.3 million people lived in poverty, with the majority being Black, Hispanic and Asian. The poverty rate for children under 18 years was 18%. (From: Income, Poverty, and Health Insurance Coverage in the United States: 2007 (US Census Bureau).





FEEDBACK

1. You could have included any of the following points:



  • There is growing inequality in access to health care and essential services.

  • There is growing inequity, poverty and hunger.

  • The government’s policies were unsympathetic towards the poor.

  • The government of the day rolled back welfare benefits and social services including health care and food subsidies.

  • The income between rich and poor widened.

  • The number of Americans living below the poverty line increased.

  • The number of Americans with no health insurance rose.

  • There were cutbacks on welfare, prevention and protective programmes for high risk children.

  • Diminishing public assistance and services for poor urban communities resulted in the rapid spread of diseases.

  • Racism and xenophobia have contributed to poor health which manifests in hate crimes, physical violence, social violence, as well as discriminatory legislation in some states.

  • Use of alcohol and illicit drugs has increased, as has the rate of unplanned pregnancies, sexually transmitted diseases, as well as social, emotional and other health problems.

2. The root causes of health inequalities within the US are disparities in socio-economic status, race and ethnicity. The gap between rich and poor is widening and poverty and poor health persist. Compare the case study of the US with that of South Africa, a country with a history of inequality and inequity.




5 CASE STUDY 2: SOUTH AFRICA


South Africa had its first democratic elections in 1994. In 1995 it was reclassified as an upper-middle-income country (its former classification was as a low-middle income country). South Africa has a history of wide-ranging discrimination in every aspect of life, based on race, income and gender inequalities. Major inequities still exist, with huge variations in health status between communities. The poorest (black population) carry the brunt of the disease burden which includes an HIV/AIDS epidemic, a TB epidemic, chronic illness, mental health disorders, injury and violence, as well as maternal, neonatal and child mortality. The majority of people still live in extreme poverty and have limited access to quality health care services.
According to the WHO World Health Statistics, 2008 (figures are for 2006, unless indicated):

  • Total population in South Africa: 48,282,000

  • Gross national Income per capita (PPP international $): 8,900

  • Life expectancy at birth: males 50 years; females 53 years. The HIV and TB epidemics have contributed significantly to these figures - South Africa carries 17% of the world’s HIV/AIDS cases (although it only has 0.7% of the world’s population) and 5% of the world’s TB cases.

  • Each year almost 75 000 children die – 23,000 in their first 4 weeks of life. The most common causes of child death are neonatal (over 30%) and HIV/AIDS.

  • The maternal mortality ratio (per 100 000 live births) has ranged from 180 to 270 between 2005 and 2007.

  • 12% of children under the age of 5 years old are underweight.

  • Healthy life expectancy at birth (2003): males 43 years; females 45 years.

  • Probability of dying under five (per 1 000 live births): 69 (see Figure 1 below).

  • Probability of dying between 15 and 60 years (per 1 000 of the population): males 598; females 531.

  • Total expenditure on health per capita (Intl $): 869.

  • Total expenditure on health as % of GDP: 8.6.

  • There are 4.9 physicians, nurses, and midwives per 1 000 people (2004). (WHO standard = 2.5) However most are situated in the urban areas; and 79% work in the private sector. Thus, poor people living in rural areas have access to very few health professionals.

Source: World Health Statistics 2008


Figure 1: U5MR: Estimated trend in South Africa (1980 – 2004)

, 1980-2004

Source: i) WHO mortality database ii) World Health Statistics 2006


Although social class is generally the most significant determinant of inequality in most countries, in South Africa in the past, the policy of apartheid served to fuse social class with race, so that class and race have become synonymous. Therefore, a poor person is generally black, and a rich person white. In time, social class will become the more dominant factor.

Although social change is gradually taking place in South Africa, there are still huge disparities between rich and poor, and black and white people. In fact, South Africa remains one of the most unequal nations in the world with regard to income distribution. In 1995, the poverty gap was estimated to be R18-million – this is the amount of wealth that would have needed to be redistributed to bring the living conditions of all South Africans at least up to the poverty line (from President Mandela’s report to the UN World Summit on Social Development). In September 2009, Haroom Bhorat, an economics professor at the University of Cape Town (UCT) told a briefing at Parliament that South Africa was now, “the most unequal society in the world” with a significant increase in income inequality. (Business Report September 28th 2009 http://www.busrep.co.za/index.php?fArticleId=5181018).


Bhorat said South Africa's Gini coefficient index stood at 0.679. This figure was drawn from figures collated by Bhorat using Statistics SA's income and expenditure survey. The figures are based on household income in the 2005/06 year. However, according to presidential policy adviser Joel Netshitenzhe, the figure may not necessarily be accurate because state benefits targeted at the poor - and particularly the unemployed - of free basic water and electricity, access to health care and the social welfare grants which now go to over 13 million of the poorest of the poor may not be adequately reflected in the GINI coefficient.


GINI coefficient index:

This shows the level of income inequality. A value of 1 reflects complete inequality; while a value of 0 reflects complete equality. A GINI coefficient above 0.5 is unacceptably high.



The extracts below come from the publication, Development Indicators 2009 (Presidency of the Republic of South Africa)

Development indicators 2009


  • The real annual mean per capita analysis…shows an improvement in the incomes of the poorest rising from R783 in 1993 to R1041in 2008 (in 2008 Rand). At the same time, however, the income of the richest 10% of the population increased at a faster rate. When the percentage income of the richest and poorest quintiles are compared, the deep structural nature of poverty in South Africa is clear. This structural nature of poverty has a racial underpinning. It seems also that that the lowest rate of improvement is in the middle income ranges.

  • The percentage of households with access to water infrastructure above or equal to the Reconstruction and Development Programme (RDP) standard increased from 61.7% in 1994 to 91.8% in March 2009.

  • As of March 2009, more than 10 million households (77%) had access to sanitation compared to about 5 million (50%) in 1994. Further, government has moved closer to attaining its objective of eradicating the bucket system in formally established settlements. In 1994, 609 675 households used the bucket system, in March 2009 only 9 044 households were using the bucket system. The target date for universal access to sanitation is 2014.

  • The estimate number of households with access to electricity has increased from 4.5 million (50.9%) in 1994 to 9.1 million (73%) in 2008.



(Source: Development Indicators 2009, www.thepresidency.gov.za)
Since 1994, the South African Government has made strides to address the fragmentation and gross inequalities in health infrastructure and health services. In this regard several pieces of legislation have been passed since 1994. The Health Act (Act No 63 of 1977) outlined the priority programmes that needed to be focused on e.g. HIV and AIDS, tuberculosis, maternal health, child health, nutrition, improvement of access to public health facilities and health care, increasing access to medicines, provision of free primary health care for pregnant women and children under the age of six, improvement of childhood nutrition and the management of communicable diseases.

TASK 3 – Identify commonalities
1. What would you say is the root cause of health inequalities in both the US and South Africa?

FEEDBACK

1. The main cause of the disparities in health levels in both the US and South Africa are socio-economic inequalities, racial inequalities (ethnic for US), and gender inequalities in South Africa. The gap between rich and poor in both countries is widening, and poverty and poor health persist. Both countries have not acted sufficiently on the social determinants of health within their countries.


6 CASE STUDY 3: CUBA


We will now turn back to the underdeveloped countries of the Americas. This time we will compare Cuba, which the World Health Organization (WHO) praised in 1989 as, ‘a model for the world’, with its neighbour, Haiti, which ranks last in the western hemisphere in terms of health care spending.
There are very few statistics on the health and well-being of the Cuban people prior to the 1959 Cuban revolution, which ended Cuba’s status as a US neo-colony. In 1989, former Cuban President Fidel Castro made available the following statistics for the neo-colonial period (i.e. prior to the 1959 revolution):


  • Infant mortality rate exceeded 60 deaths per 1 000 live births




  • Twelve mothers died during delivery for every 10 000 births




  • There were 6 000 doctors in the entire country, almost all of whom were in the capital city




  • Life expectancy was below 60 years of age




  • Public health services were nonexistent in the countryside, where more than half the population lived




  • There were marked inequalities in health care, for example only 8% of the rural population had access to health care.

In October 1960 the United States imposed a commercial, economic and financial embargo on Cuba, which is officially still in operation. The embargo resulted in an overall worsening of disease and infant mortality rates. However the Cuban government began to rebuild the health care system and its reform is an ongoing process.


Cuban Government policy focused on achieving equity throughout Cuban society by ensuring universal access to free social services, including health. According to the WHO, “a basic level of food intake and provision of essential goods are assured, with differential treatment for vulnerable groups.” The Cuban Constitution guarantees and promotes the right of all citizens to health protection and care, and provides free medical, dental and hospital care. The State assumes complete responsibility for the national health care system and there are no private hospitals.
Figure 2 from the World Health Organisation shows the IMR in Cuba from 1980 to 2006.
Figure 2: U5MR: Estimated trend and MDG goal Cuba, 1980-2004



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