Health and Poverty
Health gaps between rich and poor
are generally wider in poorer countries than richer
ones, but this does not have to be so. Countries that
design their health systems to promote equality can
show a narrow range of difference, regardless of income.
Viet Nam has reduced the differences between richest
and poorest on most health measures (including those
related to reproductive health) to less than two to
This applies to rich countries as well as poor ones. In the
United States, the country that spends the most on health care per
capita in the world, inequalities in access to health care are higher
than in other industrialized states. These disparities mean that
overall health performance is worse; for example, infant and child
mortality in the United States is higher than in most European
INFANT MORTALITY AND WEALTH
A study of infant mortality and reproductive health
indicators in 44 developing countries (16)
reveals very wide differences between regions, and between
rich and poor within countries. National averages tell
only part of the story: child survival and reproductive
health are matters of internal equity as well as overall
wealth or poverty. Child survival and child health are
tied to income levels, between and within nations. Child
mortality levels in some poor communities in the United
States, for example, rival those in Panama (17).
Poor infants and children are more
likely to die than children in better-off families.
In some countries, for example, the under-5 mortality
rate of the poorest 20 per cent of the population is
more than four times that of the richest 20 per cent
44 developing countries, the average infant mortality
rate in the poorest families is twice as high as in
the richest families. The goal of halving infant mortality
could be reached in several regions by bringing national
averages down to the levels of the richest 20 per cent.
But in some regions it will be more difficult. In sub-Saharan
Africa and South Asia, which have the highest infant mortality,
the gap between the richest and the poorest is smaller, and
even among the richest 20 per cent infant deaths are higher than
the average in other regions.
Health risks to infants and children
are worse in poor families with many children. Larger
families are more common among the poor and the children
in them are less likely to receive even basic preventive
health care (19).
If the children become ill, they are less likely to
be treated. If the sick child is a girl, her risks can
be even higher.
Figure 4: Infant mortality differentials
Average deaths per 1,000 live births, richest fifth to poorest fifth of population, by region
Click here to enlarge image
SAFE MOTHERHOOD In any country,
poor women are far more likely than rich women to die
in childbirth. Rates of maternal mortality show a greater
disparity between rich and poor nations than any of
the other commonly used public health indicators, including
infant mortality rates. Maternal mortality is a function
of access to resources and access to care: women who
become pregnant in developing countries face a risk
of maternal death 80 to 600 times higher than women
in developed counties (20).
A woman's lifetime risk of dying due to maternal causes
(pregnancy, delivery and related complication) is:
- in Africa, one in 19;
- in Asia, one in 132;
- in Latin America, one in 188;
- in more-developed countries, only one in 2,976 (21).
A mother's death is more than a
personal tragedy. It can have severe consequences, not
only for her family, but also for the community and
the economy. When mothers die, their young children
are also more likely to die (22).
Approximately 500,000 women die each year from maternal
causes, and many times that number suffer illnesses and injuries
associated with pregnancy and childbirth.
Ninety-nine per cent of these deaths
occur in developing countries (23).
These maternal mortality differences reflect both higher
risk and the larger number of births in developing countries.
Unwanted fertility, leading to the
birth of unplanned and unwanted children, is higher
in poorer settings and among the poorest of the poor.
There is less information on maternal morbidity (24)
but the differentials are likely to be similar, since
the causes-lack of information, access, community and
family support, finance, transport and provider quality
(25) -are broadly
the same as those that produce unwanted children.
There are also wide differences within countries. The outcomes
of pregnancy depend on the health and age of the mother, her
nutritional status, her prior pregnancy history and the spacing
between her previous births, as well as her available resources,
her education and her access to information and services.
Protecting the health of mother and baby requires:
good antenatal care;
- skilled attendants;
- a safe place to give birth;
- access to emergency obstetric care.
Most maternal deaths could be prevented. Complications of
pregnancy and childbirth are a leading cause of death and disability
for women aged 15-49 in most developing countries. Better
care in childbirth and more access to it would substantially reduce
Poorer women do not have access to the more costly services
before or during delivery. Access to and use of maternal services
still tend to be more affected by wealth than either contraceptive
use or completed fertility (see figures below), perhaps because of
the relatively high fees for attendants or hospitals.
GOOD ANTENATAL CARE The lower a woman's income, the
less likely she is to seek antenatal care, but restrictions on
women also reduce access. In 44 countries studied, more than three
quarters of pregnant women visit a doctor, nurse or midwife
at some point in their pregnancy. In South Asia and North Africa,
where women's mobility is more restricted, the figure is nearer
The gap between rich and poor families is greatest when
national averages are lowest. In South Asia the gap between the
richest and poorest groups results from particularly high levels
of care among the richest-even in relation to the next 20 per cent.
In North Africa, where the rich/poor gap is even greater, differences
between the wealth groups are more evenly distributed.
SKILLED BIRTH ATTENDANTS Poorer women are even less
likely to have skilled assistance at delivery than to seek antenatal
care. In Asian countries and sub-Saharan Africa they are half
as likely. In North Africa, however, women are more likely to give
birth with skilled assistance than to seek care during pregnancy.
Increases in antenatal care and
attended delivery as wealth increases are sharper than
for other basic health care services, such as oral rehydration
therapy or medical treatment for diarrhoea, medical
treatment for acute respiratory infections or immunization.
Attendance by a doctor is the most sensitive to income
A SAFE PLACE TO GIVE BIRTH Childbirth at home or in a
health facility is also strongly related to wealth. In the 44
countries studied, nearly 80 per cent of the poorest quintile have
their children at home. Nearly 80 per cent of births in the richest
families are at a health facility, as are most births in the two
richest quintiles. At each lower wealth group, the proportion of
home births increases.
FERTILITY AND CONTRACEPTIVE USE There is little difference
in fertility between income groups in countries with fertility
rates above six children per woman (for example, Nigeria, Mali,
Madagascar, Malawi, Niger, Zambia, Burkina Faso, Benin and
Uganda). The wealthiest tend to have fewer children than the
poorer, but total fertility is never as low as four.
In Latin American countries, where fertility ranges from about
3.5 to 5.1 children per woman, the differences by wealth group
are among the largest in the world. In six countries, the wealthiest
quintile has fertility rates below replacement (less than 2.1 children),
while the poorest have 2.5 to 3.5 more children per woman.
In intermediate-level fertility countries in Europe and Asia,
the wealthiest families are at or below replacement level fertility
and the poorest have more than twice as many children (4.6 in
Kyrgyz Republic). In the Asian countries reviewed (national fertility
between 2.3 and 4.9) not all the wealthy groups have reached
low fertility levels. In five, the wealthiest have reached fertility
levels at or below replacement while the poorest are higher
(between 3.1 in Viet Nam, and 6.5 in the Philippines). Other countries
are earlier in the transition. In Nepal only the wealthiest
had fewer than four children (2.9). In Pakistan only the wealthiest
had as few as four children, and all groups of poorer women had
between 4.9 and 5.1.
FAMILY PLANNING USE Differences in access, acceptance and
use of family planning accounts for most of the difference in the
fertility of rich and poor.
The higher the overall level of women's contraceptive use, the
lower the differential between women in the richest and poorest
groups. Once family planning use exceeds 40-45 per cent overall,
the differences between wealth groups narrows considerably, and
family planning becomes accepted as the norm.
In sub-Saharan African countries,
where contraceptive prevalence is only around 10 per
cent, the richest use family planning more than five
times as often as the poorest (27).
In Pakistan, the country with the lowest overall prevalence
in South Asia (9 per cent) the difference is 20 times.
In Nepal, with a prevalence of 26 per cent, the difference
is less than three times. Differences are large in the
Philippines, where contraceptive use is low; but in
Indonesia and Viet Nam, where contraceptive prevalence
is high, wealth differentials are relatively low. Several
European and Central Asian countries have reached overall
prevalence levels of family planning close to 50 per
cent, with lower differences between richer and poorer.
In Latin America, overall contraceptive prevalence rates are
high. In the lower-prevalence countries, internal wealth differentials
are greater. In high-prevalence countries, family planning
is widely accepted, and other factors contribute to a varied relationship
between wealth levels and prevalence. In North Africa,
the rich are twice as likely as the poor to use contraception.
ADOLESCENT CHILDBEARING The poorest women start their
childbearing earliest. In many developing countries, poor women
start bearing children between ages 15 and 19. Their higher levels
of pregnancy reflect early marriage, less ability to negotiate
delays in sex and reproduction, and less access to family planning.
Countries with low adolescent fertility overall have larger
differences in fertility between poorer and richer young people.
The exception is Latin America, with a relatively high overall level
of adolescent fertility and wide differences between the wealthiest
and poorest. The poorest families have extremely high rates of
childbearing among the young.
In Indonesia, the Philippines and Viet Nam, the poorest
adolescents are nearly seven times as likely to have children as
their better-off counterparts. In the Philippines, poor young
women are nearly 11 times as likely to have a child. In all three
countries, reductions in youthful fertility are systematically
related to increases in wealth.
In Egypt, adolescent fertility differences reflect wealth levels
in a regular way. In Morocco, adolescent fertility is much lower
in wealthier than in poorer families.
Countries in Europe and Central Asia do not show a regular
relation between wealth and adolescent fertility, indicating a
complex interaction among service access, ethnic variation and
regional differentials. The wealthiest subgroups still have the
lowest adolescent fertility, however.
Latin American countries show a large gap between the
poorest group (ranging from 105 to 234 births per thousand adolescent
women) and the three middle quintiles, and another large gap between these intermediate groups and the wealthiest (ranging
from 18 to 58). Only in Haiti, the poorest country in the region,
does a single large gap occur between the richest quintile and the
In some of the 22 countries reviewed
in sub-Saharan Africa, adolescent fertility decreases
with higher wealth (28).
Many others show a large difference between the wealthiest
group and the others but there are no systematic differences
among the poorer groups, probably because these are
all least-developed countries, and the wealthier are
well-to-do only in comparison with the poorest. Compared
to other regions, nearly everyone is very poor (29).
OVERVIEW OF DIFFERENCES BY WEALTH There are glaring differences
in infant mortality between poorer families and the better
off. The "reproductive health gap" between wealthier and poorer
is often at least as wide. The largest overall difference between
the poorest and wealthiest groups is in assisted delivery (an expensive
service), but the measure that most clearly sets one income
group off from the next is adolescent fertility. The teenage pregnancy
gap between richer and poorer is wider than the gap in both
trained birth attendance and infant mortality.
The use of family planning services depends less on cost than
on personal motivation and institutional commitment to providing
the service, so older age groups show smaller gaps between richer
and poorer. For the young, early marriage, social pressure and
reluctance to spend public money on protecting their reproductive
health increase the dangers of being both young and poor.
NON-WEALTH-BASED HEALTH DIFFERENTIALS Well-being and
wealth depend on more than income and bank balances. Physical
and social infrastructure, opportunities, resources, skills
and information all add or subtract, reinforced by complex social
processes of inclusion and exclusion. Geographical location is
important: rural areas provide lower levels of services, information
and opportunities than urban areas.
Some of the reproductive health
differentials reflect rural poverty, but differences
can be seen within both urban and rural areas (30).
Fewer rural residents reach the income levels seen in
cities, but the poorest have the worst services in both.
In India, for example, total and adolescent fertility
levels, contraceptive usage and immunization levels
are very similar across the wealth spectrum in rural
and urban areas. The poorest in rural areas are more
disadvantaged than their counterparts in cities-rural
families have less access to safe delivery services,
particularly if they involve highly trained personnel
or specialized facilities. In the richest groups, the
differences are minor (31).
Urban areas are growing rapidly,
and the majority of the world's poor will soon be urban
(32). In theory,
economies of scale and ease of access could increase
coverage, but there are already large inequities in
access to basic services within cities. On the other
hand, smaller cities, while better served than rural
areas, compare poorly to larger cities (33).
The relative disadvantage of medium-sized
cities in providing health quality and service is a
growing problem as a larger proportion of urban dwellers
comes to live in them (34).
Municipal and other local authorities have more responsibility
under the decentralization of public health administration,
an aspect of health reform, without the corresponding
resources or revenueraising authority. Local governments
will find it increasingly difficult to fill the gaps