Evidence suggests that the impressive health gains achieved over recent decades are unequally distributed and have largely failed to reach the poor and other marginalized or socially excluded groups.

Persistent and growing inequalities in health are increasingly evident, both between and within countries. For example, the poorest 20% of the global population are roughly 10 times more likely to die before the age of 14 than the richest 20%.

Poverty has multiple dimensions. These dimensions include not only low income, but also lack of access to services, resources and skills; vulnerability; insecurity; and voicelessness and powerlessness. Poverty and other forms of social exclusion—such as gender, race, ethnicity, age, place of residence, employment status, and sexual orientation—are strong determinants of health.

Evidence points to a two-way relationship between poverty or inequity and health. In the “vicious cycle”, poverty breeds ill-health, while ill-health causes more poverty. In the “virtuous cycle”, higher income is linked to good health, and good health is linked to higher income and welfare. These positive and negative links operate both at the individual and the societal level.

Although the poor (and other socially excluded groups) need health services more, they tend to use health services less. This phenomenon is known as the “inverse care law", which states that "the availability of good medical care tends to vary inversely with the need for it in the population served."

The poor and other excluded groups use health services less because they typically face multiple barriers to access to services, including:

• geographical barriers;
• financial barriers;
• sociocultural attitudes, such as those related to gender or ethnicity;
• lack of knowledge and awareness; and
• the poor quality or lack of responsiveness of the health system.

Effectively reducing health equities can ensure improved outcomes for public health programmes, while also promoting social justice and the human right to health.

Reducing health inequities requires a range of strategies, tailored to the needs of the specific situation, including:

• prioritizing underserved areas or populations and the health conditions that affect them the most, using targeted approaches where needed;
• investing in primary health care;
• redistributing health services and personnel equitably;
• reducing the out-of-pocket costs of seeking health care for the poor;
• improving information and communication to stimulate demand;
• improving health systems responsiveness;
• in monitoring and evaluation, collecting, analysing and using information that is disaggregated by socioeconomic position, sex, age, ethnicity/race, geographical location or other relevant indicators of social exclusion; and
• undertaking health equity-focused research and analysis to identify context-specific issues and their solutions.

WHO supports countries to build their capacities to design and implement health policies and programmes that enhance health equity and integrate pro-poor, gender-responsive, and human rights-based approaches.

Presentations

Equity in health (part 1) Poverty and Health: a framework for analysis and action (September 2008)

Equity in health (part 2) Gender and Health: a framework for analysis and action (September 2008)

Essential medicines, equity and human rights: a framework for analysis and action (November 2007)

100% CUP: poverty, gender and human rights issues (October 2006)

Poverty and gender issues in tobacco control (March 2004)

Equity and ARV access: Some issues for discussion (January 2003)

TB and Equity, Stakeholder meeting (January 2008)

Pro-poor health policies: a framework for analysis and action (November 2002)

PRSP in Cambodia: a case study (July 2002)

Food safety and poverty: some issues and approaches (November 2000)

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