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Gender and Public health
Dr Stephen T. Odonkor
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Key Concepts (1)
The biological differences between women and men, boys and girls, are limited to the differences in their sexual and reproductive organs and functions.
Sex is unchanging and universal. Gender is contextual and variable.
Key Concepts (2)
GENDER has been defined and constructed in different cultures and at different periods of history.
Social norms and expectations of what women and men should be and should do, and about their roles and rights change according to generation, culture and even family
Key Concepts (3)
GENDER
Socially defined roles
Change over time
Influenced by education, income level, religion…
Are different among women and men
SEX
Biological characteristics with which women and men are born
Do not vary
Are not influenced by economic or social factors
Are the same for men and women
Key Concepts (4)
Gender refers to the socially defined roles and responsibilities of men, women and boys and girls. Male and female gender roles are learned from families and communities and vary by culture and generation
Gender equality means the absence of discrimination, on the basis of a person’s sex, in opportunities, in the allocation of resources or benefits or in access to services
Gender equity means fairness and justice in the distribution of benefits and responsibilities between women and men and often requires women-specific projects and programmes to end existing inequities
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Global Magnitude
70% of the world’s 7.7 billion people living in poverty are women
Women represent two thirds of the world’s non-literate people
In most developing countries, boys enrolment in school exceeds that of girls
Approximately two thirds of the children of school age who do not or can not go to school are girls
Globally, violence against women causes more deaths and disability among women aged 15 to 44 than do cancer, malaria, traffic accidents or war
Over 4 million girls are at risk each year of female genital mutilation
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Women and girls are disproportionately vulnerable to HIV/AIDS, with inequality between men and women fuelling its spread
Many countries continue to discriminate against women in law. Worldwide, women hold only 12% of parliamentary seats
Gender in the context of health
Gender Inequality in relation to health
Lower status/social value in the household
Cultural factors such as lack of female health provider
Being excluded from decision making on health actions and expenditure
Lower literacy rates and reduced access to information
High opportunity costs of women’s labour time –distance, waiting time etc.
Social division of labour (women-informal care provider)
Susceptibility and Treatment to infectious diseases-Malaria & Tb. High
Public health issues like violence, alcoholism, smoking and life style related problems
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Gender-Perspective
Gender equality is an issue of development effectiveness, not just a matter of political correctness or kindness to women.
(World Bank 2002)
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Gender and Women Health
In many societies, women systematically fail to achieve or fail to use some basic human rights.
Most of the time, women’s health status and problems related to affect:
morbidity
disability
mortality
DISCRIMINATION ALL THROUGH THE LIFE OF WOMEN
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CHILDHOOD
Sex selective abortion
Female mutilation
Nutrition problems
Neglect
Cannot benefit from the services
ADOLESENT/ADULT
Unwanted pregnancies, STDs
Sexuel harassment/abuse
Turnpike sex
Smoking and substanve abuse
OLDERS
Increase in morbidity /problems on quality of life
Violence
Social pressure
Increase in morbidity
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Female Genital Mutilation (FGM)
An estimated 100 to 140 million girls and women worldwide are currently living with the consequences of FGM.
Each year 2 million girls at risk!
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Female genital mutilation (FGM) includes procedures that intentionally alter or injure female genital organs for non-medical reasons.
An estimated 100 to 140 million girls and women worldwide are currently living with the consequences of FGM.
In Africa, about three million girls are at risk for FGM annually.
The procedure has no health benefits for girls and women.
Procedures can cause severe bleeding and problems urinating, and later, potential childbirth complications and newborn deaths.
It is mostly carried out on young girls sometime between infancy and age 15 years.
FGM is internationally recognized as a violation of the human rights of girls and women.
FGM / Problems
Obstetric
Menstruel
Phychological
Urinary
Other problems..
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Violence and Women
World scale: Today one of every 3 women are subjected to different forms of violence.
(Heise, Ellsberg, Gottemoeller, 1999).
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“…any distinction, exclusion or restriction made on the basis of sex which has the effect or purpose of impairing or nullifying the recognition, enjoyment or exercise by women, irrespective of their marital status, on a basis of equality of men and women, of human rights and fundamental freedoms in the political, economic, social, cultural, civil or any other field.”
(UN, CEDAW-1994)
Discrimination against women
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Sexually Transmitted Disease
Young women know very little information on STDs and because of the fear of being branded as sexual active they hardly try to learn information.
Woman equipping less power as a decision maker has resulted with late diagnosis and treatment.
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Sex trade/tourism..
4 million people in sex abuse traffic is estimated in the world.
The revenue / year of organized criminal organizations is 7 billion dollars
500,000 women and children for the sex trade is estimated to infiltrate into European Union countries as at 1995.
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WOMEN’S HEALTH
Why do sex differences in mortality and morbidity continue to exist?
How do socioeconomic position, race, and other dimensions of social status interact with gender to produce variations in gender inequity and its health consequences?
How do socially constructed gender roles and differential opportunities shape men’s and women’s lives and turn affect their health?
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WOMEN’S HEALTH …
Improved living conditions, better public health and sanitation, better nutrition, and improved medical care and services have benefited both men and women
Mortality rates have fallen and life expectancy has consistently increased for both men and women
Health gains have been greater for women
WOMEN’S HEALTH TRENDS
Current lower mortality for women is a relatively recent occurrence
The present patterns of longer life expectancy for women emerged at the end of the nineteenth century and only in developed countries
Before then, women suffered from excess mortality, attributable to a comparatively harsher life for women and factors such as frequent pregnancies and poor maternal care
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WOMEN’S HEALTH TRENDS …
The lives of women in these countries continue to be harsher, due to factors such as:
feudal cultural practices
excessive violence
lack of control by women over their bodies and reproduction
frequent pregnancies
poor nutrition
poor obstetric care (UN, 1995)
WOMEN’S HEALTH – A PARADOX?
Women on average live longer than men, but they also report more illness than men
Women are more likely than men to be hospitalized
The causes for hospitalization are different for males and females
Differences in morbidity and mortality patterns between men and women are evident in other areas
WOMEN’S HEALTH – A PARADOX? …
For example, men are more likely than women to commit suicides, women are twice more likely as men to be depressed and their depression last longer
Women are more likely than men to report conditions such as allergies, headaches etc
While conditions such as arthritis as a cause of activity limitation are frequently reported by women, men report conditions such as heart, back, and limb problems as causing activity limitation
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WOMEN’S HEALTH – A PARADOX? …
Women are more likely than men:
To visit health professionals
Make more frequent visits
Use emergency health services
Have recent check-ups
Use more antidepressant drugs than men – consistent with their higher levels of depression
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WOMEN’S HEALTH – A PARADOX? …
“Women get sicker, but men die quicker” sums up the morbidity and mortality patterns of men and women in developed countries
How can this paradox be explained?
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“Women get sicker, but men die quicker”: Explaining gender differences in health
Artefact explanation
Genetic causation
Social causation
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Artefact explanation
Some researchers argue that the differences between men and women are an “artefact,” rather then real
Their main argument is that while women’s health status is not any worse than men’s, women are more likely:
to take notice of their symptoms
are inclined to see a physician
seek treatment
are more willing to respond to health surveys (Miles, 1991)
Biological and genetic explanation
Biological and genetic differences (sex chromosomes and hormones) have also been used to explain morbidity and mortality differences between men and women
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Biological and genetic explanation …
Statistics that are often used to show female “superiority” refer to differences in male and female conception, fetal mortality, stillbirths, and infant mortality rates
It is also argued that females, due to their biological and genetic constitution, reproductive anatomy, and physiology, may be endowed with resistance to certain diseases.
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Social causation explanation
Social and economic inequalities and socially constructed gender roles have important consequences for men’s and women’s lives and produce variations in health and illness patterns
Social and economic inequalities produce differential opportunities and life chances; social roles and related activities expose men and women to different health risks
The focus here is on the social production of health and illness
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Social causation explanation …
Social and economic inequality produce negative health outcomes and poor health status for women
Also it is argued that male socialization and lifestyles expose men to riskier, aggressive, and dangerous behaviour,
For instance, men have higher mortality due to motor vehicle accidents
Men are also more likely to indulge in excessive smoking, drinking, and substance abuse, with negative health consequences
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Social causation explanation …
On the other hand, it is pointed out that the often demanding and contradictory social roles of women produce negative health outcomes
For instance, domestic work responsibility and a caring role in the family, combined with the increasing participation of women in the paid work force, may contribute to elevated stress levels among women
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Explaining Gender Differences – Theoretical Perspectives
Two theoretical perspectives are advanced to explain gender differences in psychological health:
differential exposure theory
differential vulnerability theory
Both theories attribute gender differences in psychological well-being to the social organization of men’s and women’s lives.
The former emphasizes the extent to which men and women are exposed to particular stressors, whereas the latter focuses on men’s and women’s responses to those stressors (Rieker & Bird, 2000, p, 102).
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Differential exposure theory
According to this, women experience hardships and stressors to a greater extent than do men because of their disadvantaged position relative to men in the work force and the inequitable division of work in the household
Married women in particular experience work overload due to work outside home and at home
This overload produce higher psychological distress
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Differential vulnerability theory
This theory argues that, the effects of particular stressors differ for men and women for a variety of reasons.
For instance, men and women may attach different meanings and significance to paid work and family roles because of different normative expectations about work and family responsibilities
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Differential vulnerability theory …
Sociocultural beliefs and normative expectations may affect men’s and women’s self evaluations as parents and spouses.
Women are more likely than men to experience role conflict and to see their work and family roles as competing rather than integral, and thus they experience more guilt and stress than men
That the consequences of housework and employment differ for men and women and produce different health outcomes
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Differential vulnerability theory …
Patterns of health and illness have everything to do with women’s lives, work, employment opportunities, life experience, and social and economic circumstances.
However, it should be noted that social, economic, and other disadvantages do not accrue to all women equally (Macintyre, Hunt, & Sweeting, 1996).
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Differential vulnerability theory …
Women are not a homogeneous group, but, rather, are diversified and stratified by class, race, and ethnicity.
The social patterning of health and disease are also differentially experienced by various subgroups.
For instance …
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Differential vulnerability theory …
Racial minority women often experience ill health because of unhealthy work environments and harsher working conditions in areas such as farm labour, textiles and sewing, and domestic work
Health status inequalities and the social patterning of disease between diverse groups of women are supported by research findings from other countries
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Differential vulnerability theory …
Racial minority women are doubly disadvantaged
Social and economic differentiation and heterogeneity among women produce subgroup differences in health effects and health outcomes.
Health inequality monitoring: with a special focus on low- and middle-income countries
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What is monitoring?
Monitoring is repeatedly answering a given study question over time
It helps to determine the impact of policies, programmes and practices, and to indicate whether change is needed
Handbook on Health Inequality Monitoring
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The study question usually pertains to the measurement of a condition that a policy seeks to impact.
Monitoring has the ability to track policy outcomes over time and provides a means of evaluating the need for policy change.
Once a policy has been changed, subsequent monitoring is necessary to evaluate the outcomes of the new policy, and thus monitoring should be an iterative and cyclical process that operates continuously.
Monitoring alone cannot typically explain the cause of troublesome trends; rather, monitoring may be thought of as a warning system. Monitoring activities can both inform and direct research in a given area.
Applied to the area of health, monitoring picks up trends in health and allows policy-makers to target further research in those areas to determine the root cause of problems.
On-going monitoring may identify subpopulations that are experiencing adverse trends in health.
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What is involved in health monitoring?
Handbook on Health Inequality Monitoring
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Health monitoring is the process of tracking the health of a population and the health system that serves that population. In general, health monitoring is a cyclical process, as shown in this figure:
The process begins by identifying health indicators that are relevant to the study question at hand.
The second step involves obtaining data about those health indicators from one or more data sources.
Data are then analysed to generate information, evidence and knowledge. Depending on the study question, the process of analysing health data can be as simple as creating overall summary statistics about the population’s health, or it can involve more complex statistical analyses.
Following analysis, it is essential to report and disseminate the results so that they can be used to inform policy. The goal should be to ensure that the results of the monitoring process are communicated effectively, and can be used to inform policies, programmes and practice.
Based on monitoring results, changes may be implemented that will impact and improve the health of the population. In order to monitor the effects of these changes, more data must be collected that describe the on-going health of the population; thus, the cycle of monitoring is continuous.
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Select relevant health indicators
Obtain data
Analyse data
Report results
Implement changes
Inequity versus inequality
Health inequity: unjust differences in health between persons of different social groups; a normative concept
Health inequality: observable health differences between subgroups within a population; can be measured and monitored
Handbook on Health Inequality Monitoring
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An explanation of health inequality monitoring begins with the concept of health inequity. Health inequities can be linked to forms of disadvantage such as poverty, discrimination and lack of access to services or goods.
Monitoring health inequalities serves as an indirect means of evaluating health inequity.
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Equity-based interventions
Equity-based interventions seek to improve health outcomes in subgroups that are disadvantaged, while improving the overall situation
Targeting expansions in health services specifically towards the most disadvantaged may be more successful and cost effective than using limited resources to create across-the-board increases in services where they are not required by all
For example, nutritional supplementation for children
Interventions that do not have an equity focus may inadvertently exacerbate inequalities, even when national averages indicate overall improvements
For example, media campaigns and workplace smoking bans have shown evidence of increasing inequalities
EXTRA INFORMATION
Handbook on Health Inequality Monitoring
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What is health inequality monitoring?
Health inequality monitoring describes the differences and changes in health indicators in subgroups of a population
Special considerations:
the need for two different types of intersecting data: health indicator and equity stratifier data
the use of statistical measurements of inequality
the challenges of reporting on different health indicators by different dimensions of inequality
Handbook on Health Inequality Monitoring
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The process of monitoring social inequalities in health follows the same cycle as any type of health monitoring, although there are some aspects that are unique to health inequality monitoring:
the need for two different types of intersecting data.
The health indicators chosen for use in health inequality monitoring should be reasonably likely to reflect unfair differences between groups that could be corrected by changes to policies, programmes or practices.
While health monitoring only needs to consider data related to health indicators, health inequality monitoring requires an additional intersecting stream of data related to a dimension of inequality (for example, wealth, education, region or sex). This is sometimes referred to as an equity stratifier.
(b) the statistical measurement of inequality, and
(c) the challenge of reporting on different health indicators by different dimensions of inequality in a way that is clear and concise.
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Why conduct health inequality monitoring?
To provide information for policies, programmes and practices to reduce health inequity
To evaluate the progress of health interventions
To show a more-complete representation of population health than the national average
Indicates the situation in population subgroups
Disadvantaged subgroups may impede improvements in national figures
Handbook on Health Inequality Monitoring
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The reduction of inequity is a common goal, from ethical and practical standpoints.
If certain population subgroups continue to be underserved by the health system and suffer a disproportionate burden of morbidity, this endangers the well-being of a society at large and, in some situations, even holds back health progress for the most advantaged.
Ignoring health inequality can present a variety of challenges. If only national averages of health indicators are monitored, they may not provide a complete representation of the changes in the health of a population.
The national average of an indicator could remain constant over time, while certain population subgroups experience improvements in health and other population subgroups see their health deteriorating; it may even be possible to have improving national averages of health indicators while within-country inequality increases.
Disadvantaged population subgroups can also hold back a country’s national figures as outliers that affect national averages.
Donors and the international community look for progress in national health indicators (and increasingly to health inequality explicitly) to make decisions in funding. Addressing health inequalities and improving these figures can thus lead to a better national health system for all, not only those currently disadvantaged.
Equity monitoring is important for health interventions, whether or not targets are equity-specific
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Total health inequality versus social inequality in health
Total inequality: the overall distribution of health
Consider only health indicator variables (no equity stratifiers)
Social inequality: health inequalities between social groups
Indicate situations of inequity, where differences between social groups are unjust or unfair
The emphasis of this lecture series
EXTRA INFORMATION
Handbook on Health Inequality Monitoring
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Those who study health inequality should consider a fundamental decision of whether they wish to measure the overall distribution of health (total inequality) or inequalities between social groups (social inequality).
Measures of total inequality consider only health indicator variables, and involve calculations such as standard deviation and variance.
Measures of social inequalities require at least two intersecting variables related to health indicators and equity stratifiers.
Both are valid and important approaches that contribute to a comprehensive understanding of health inequality in societies.
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Making comparisons on a global level
Within-country inequality exists between subgroups within a country, based on disaggregated data and summary measures of inequality
For example, comparing the difference between infant mortality rates among urban and rural subgroups
Cross-country inequality shows variability between countries based on national averages
For example, comparing countries on the basis of national infant mortality rates
Cross-country comparisons of within-country inequality are possible
For example, countries may be compared based on the level of rural–urban inequality in infant mortality rate within each country
EXTRA INFORMATION
Handbook on Health Inequality Monitoring
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This lecture series and the Handbook on Health Inequality Monitoring focus on within-country inequality.
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How can health inequality monitoring lead to implementing change?
Agenda-setting
Health inequality monitoring offers quantitative evidence for policy makers
Analytic data serve as an important basis for identifying where inequalities exist and how they change over time
Other factors to consider: contextual factors, political and popular support, funding, feasibility, timing, cost effectiveness, normative issues, etc.
Handbook on Health Inequality Monitoring
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Although a particular area may be identified as a priority based on the results of health inequality measures, improvements in the area are only likely to be realized if the environment for change is favourable.
For example, a programme that improves the health of only a small subgroup of a population may not be justified if an alternative programme could impact the health of a greater segment of the population for the same resource cost. These types of decisions may call into question normative issues of what is important and acceptable for a society.
Developing strategies to tackle health inequalities often begins by considering what has already been done in other environments, and whether previous successes are likely to be replicable in a new environment. This step should involve a systematic consideration of evidence to gather information about previous approaches to address a given problem. Experts in the area may be consulted to offer suggestions and recommendations. After learning what has been done by others, decision-makers can begin to consider what might work in their situation. The more thorough the understanding of the situation at hand, the more appropriate a response can be developed.
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How can health inequality monitoring lead to implementing change?
Involving key stakeholders
The process of implementing change should involve a diverse group of stakeholders, as appropriate for the health topic
Key stakeholders may include representatives from government, civil society, professional bodies, donor organizations, communities and any other interested group
For example, the World Health Organization’s Commission on Social Determinants of Health is a multisectoral effort to tackle the “causes of causes”
Health inequality issues should be framed as broad problems
Intersectoral approaches help to drive multifaceted solutions and a wide base of support
Handbook on Health Inequality Monitoring
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Involving stakeholders promotes the success and longevity of policies, programmes and practices.
Consulting with stakeholders helps to ensure a high degree of acceptability and “buy-in” across sectors
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Recommendations for promoting equity within the health sector
Recognize that the health sector is part of the problem
Prioritize diseases of the poor
Deploy or improve services where the poor live
Employ appropriate delivery channels
Reduce financial barriers to health care
Set goals and monitor progress through an equity lens
EXTRA INFORMATION
Source: Based on unpublished work by Cesar G Victora, Fernando C Barros, Robert W Scherpbier, Abdelmajid Tibouti and Davidson Gwatkin.
Handbook on Health Inequality Monitoring
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Recognize that the health sector is part of the problem. Health services do not, on their own, gravitate towards equity. Both public and private services contribute to generating inequalities in health if they are more accessible to the better off.
Prioritize diseases of the poor. When choosing which interventions to implement an essential starting point is to match them closely to the local epidemiological profile of conditions affecting the poor. This requires assessing the burden of disease and allocating resources accordingly.
Deploy or improve services where the poor live. Because health services tend to be more accessible to the urban and better-off populations, there is a natural tendency for new interventions to reach them first. Several recent examples show, however, that this logic can be subverted. Rather than introducing new interventions or programmes initially in the capital and nearby districts, countries can prioritize remote areas where mortality and malnutrition are usually highest.
Employ appropriate delivery channels. The same intervention may be delivered through more than one channel. For example, micronutrients or nutritional counselling may be delivered to mothers and children who spontaneously attend facilities, through outreach sessions in communities, or on a door-to-door basis. Either facility-based or community health workers may be used. Equity considerations are fundamental in choosing the most appropriate delivery channel for reaching the poorest families, who often live far away from the facilities and require community or household delivery strategies.
Reduce financial barriers to health care. Out-of-pocket payments are the principal means of financing health care in most of Africa and Asia. However, this often places extra burden on the sick, who are most likely to be poor, children or elderly. Such user fees would probably not have been instituted had equity considerations been prioritized on the health agenda. Countries adopting a universal health system without any type of user fees, such as Brazil, have lowered levels of inequities in access to first-level health facilities.
Set goals and monitor progress through an equity lens. Progress towards equity depends on the continuous cycle of health inequality monitoring. Each component of the cycle can be strengthened and improved to match the goals of health equity.
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How are the social determinants of health related to health inequality monitoring?
Health inequalities tend to stem from social inequalities
Equity stratifiers typically reflect social conditions
Actions to lessen the impact of the social determinants of health promote equity, and thus reduce health inequalities
Three principles of action to achieve health equity:
1. Improve the conditions of daily life (the circumstances in which people are born, grow, live, work and age)
2. Tackle the inequitable distribution of power, money and resources – the structural drivers of the conditions of daily life – at global, national and local levels
3. Raise public awareness about the social determinants of health– measure the problem, evaluate action, expand the knowledge base and develop a workforce that is trained in the social determinants of health
Source: Based on the Final report of the Commission on Social Determinants of Health, World Health Organization, 2008.
Handbook on Health Inequality Monitoring
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Equity stratifiers (dimensions of inequality) used in health inequality monitoring typically reflect social conditions, such as level of wealth or education, place of residence and gender. A description of social determinants of health encompasses all aspects of living conditions across all life stages, including the health system and wider environment; they are largely shaped by the distribution of resources and power at global, national and local levels.
Monitoring health inequalities reveals differences in how social groups experience health; it does not explain the drivers that cause and perpetuate inequality
To distinguish, the social determinants of health are often pinpointed as the cause of health inequalities.
The movement to garner support to address social determinants of health is inextricably linked to reducing health inequality and achieving health equity. Health inequality monitoring contributes to this end by providing data, direction and evidence.
Extra reading: Commission on Social Determinants of Health. 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, 2008.
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Health inequality monitoring: with a special focus on low- and middle-income countries Full text available online: http://apps.who.int/iris/bitstream/10665/85345/1/9789241548632_eng.pdf
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