Elsevier

The Lancet

Volume 356, Issue 9235, 23 September 2000, Pages 1093-1098
The Lancet

Public Health
Explaining trends in inequities: evidence from Brazilian child health studies

https://doi.org/10.1016/S0140-6736(00)02741-0Get rights and content

Summary

There is considerable international concern that child-health inequities seem to be getting worse between and within richer and poorer countries. The “inverse equity hypothesis” is proposed to explain how such health inequities may get worse, remain the same, or improve over time. We postulate that as new public-health interventions and programmes initially reach those of higher socioeconomic status and only later affect the poor, there are early increases in inequity ratios for coverage, morbidity, and mortality indicators. Inequities only improve later when the rich have achieved new minimum achievable levels for morbidity and mortality and the poor gain greater access to the interventions. The hypothesis was examined using three epidemiological data sets for time trends in child-health inequities within Brazil. Time trends for inequity ratios for morbidity and mortality, which were consistent with the hypothesis, showed both improvements and deterioration over time, despite the indicators showing absolute improvements in health status between rich and poor.

Section snippets

Inequities and public health

Although health status has been improving for most countries, wide inequities persist both between and within countries.1, 2, 3, 4, 5, 6 In more-developed countries evidence suggests that such inequities commonly show an increase despite an improvement in the overall health status of the whole population. However, there is also some evidence to show that reductions in inequities can also be achieved, at least in more-developed countries.7 Inequities are particularly severe in the Americas,

The inverse equity hypothesis

How can we explain epidemiological trends that show that inequities between rich and poor commonly become worse before showing signs of improving? Figure 1 proposes time trends for hypothetical outcome indicators, such as disease incidence or mortality, in the richest and poorest subgroups in the general population, and presents the corresponding inequity ratios obtained by dividing the level of the outcome in the poor by that in the rich.

At 1 year the initial inequity in the outcome has a rate

Inequities in infant and child mortality

Information on time trends for IMR and child (1–4 years) mortality rates (IMR) in American countries is based on a Pan-American Health Organization document on mortality trends and initial levels.11 This document showed that both rates had decreased substantially since the 1960s. For this study we estimated inequities in mortality between countries by identifying which country had the median level of infant and child mortality in the Americas, and then dividing these national rates by those for

Inequities in Ceará, northeastern Brazil

Evidence that public-health interventions or packages can help in reducing inequities between rich and poor was also sought for the State of Ceará, in the poor northeastern area of Brazil. Early in the 1980s the IMR was above 100 per 1000 and malnutrition was very common. In 1986 the new State government requested UNICEF support to help improve child health and a statewide survey of child health and nutrition was commissioned. More than 4500 childen younger than 3-years old were surveyed by

Inequities in Pelotas, Southern Brazil

Good epidemiological evidence from cohort studies done in the city of Pelotas in 1982 and 1993 suggest that inequities can be reduced by public-health programmes. Pelotas is in a relatively developed area in southern Brazil. During 1982 more than 6000 births were studied and this cohort—who are now adolescents—are still being followed up.17 In 1993 another similar birth cohort of 5000 newborn babies was studied.18 Both studies were population based and had high follow-up rates. There was a

Conclusion

The studies from Ceará and Pelotas suggest that the “inverse equity hypothesis”, a corollary of the “inverse care law” applied to public health, provides a reasonable explanation of several observations. The hypothesis suggests that good quality public health programmes for improving child health are more available and being utilised by those families who need them least. The hypothesis also predicts that new interventions will tend to increase inequity since they will initially reach those who

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