Inequity in access to the determinants of health

The determinants that are critical for health outcomes include clean air, water, sanitation, shelter and nutrition. Household air pollution causes 50% of lower respiratory tract infections which is responsible for 15% of deaths in children. Inadequate water and sanitation are responsible for more than half of the disease burden due to diarrhoea, which is responsible for 10% of under-five mortality, while environmental interventions could halve the disease burden due to malaria.15

These social determinants of health (SDH) are core human rights, enshrined in the Universal Declaration of Human rights and the United Nations Convention on the Rights of the Child (UNCRC).16 The indicators, which will be used in the Sustainable Development Goal era,17 include these and all children in all countries should have immediate access. Access to these determinants is unequal, the poorest children being far more likely to be deprived despite some improvement in coverage over recent decades.18

Inequity in child health services

Inequity in child health services is a major determinant of child health inequity. The majority of conditions responsible for mortality and morbidity among children in LMICs are preventable and treatable but limited access and affordability continue to deny poor children essential treatment. Lack of medical insurance in some HICs also excludes many poor children from access to essential treatment. Figure 1 shows inequity by wealth index for interventions of proven efficacy in 54 LMICs.19

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Figure 1

Mean coverage for each wealth quintile for interventions in 52 countdown countries. Source: Barros et al.19 (Reproduced with permission from Elsevier (License number 4593591509657).)

Early child development: a critical determinant for equity

Most health and social inequities originate in the earliest periods of life and even before, since transmission of a significant proportion of inequities is intergenerational.20 The earliest periods of life are crucial for the development of most systems and organs and primarily for the brain, thus establishing the biological foundations for lifelong functioning.21 In the earliest years there is a window of both vulnerability and opportunity that is the most important along the entire life span.

The development of neural networks and the entire brain architecture is shaped by the early environment: the thickness of brain cortex and the size of important underlying functional hubs such as the hippocampus are associated with family income, parental education, parenting styles and adverse life experiences.22 23 Child development is influenced by a range of factors from socioeconomic background to the psychosocial and physical environment including family income, parental stress, maternal education, breast feeding and nutrition, parent–child interactions and parental skills, day care attendance and environmental exposure.24 From very early in life, and particularly since conception and up to the third year, risk and protective factors combine to determine different trajectories in child development, ranging from very delayed to optimal, which will continue to produce their effects throughout the life course.24

The pervasive effect of social and economic inequity on society

High levels of social and economic inequity act as a social stressor, disturbing the social cohesion and damaging the social fabric, so important for a healthy society.25–27 For example, parental stress increases the risk of unfavourable neonatal outcomes, maltreatment and later behavioural and mental problems.28 29 Greater equity makes most difference to the least well off but also produces benefits for the well off, by facilitating the sense of balance and control in life and increasing the generalised trust,25 30 ultimately benefitting the whole society.

Strengthening individuals and communities

In LMICs, evidence-based interventions aimed at addressing maternal and child undernutrition, a major determinant of inequity, can be delivered through community engagement and pro-poor delivery strategies that reach poor segments of the population at greatest risk.33 34 These include—periconceptional folic acid supplementation or fortification, maternal and infant balanced energy protein supplementation, micronutrient supplementation in pregnancy, promotion of breast feeding, appropriate complementary feeding, vitamin A and preventive zinc supplementation in children 6–59 months of age, clinical management of acute malnutrition. Interventions aimed at enhancing horizontal social interactions, particularly those targeting women’s groups practising participatory learning and action, have a strong evidence-base in low resource settings.35

Effective interventions in LMICs and HICs to promote early child development should include direct learning experiences to children and families, target younger and disadvantaged children, be long-term, high quality and high intensity, and integrated with family support, health, nutrition, educational services, welfare and finance sectors.33 36 Universal access to early promotion and assessment of child development since birth are key to equitable outcomes. Early education programmes enhance early childhood development among disadvantaged children and impact health and well-being across the life course in both HICs and LMICs.37–39

The ‘Three Generation Approach’ is designed to break the cycle of intergenerational disadvantage.20 This approach emphasises childhood, adolescence and young adulthood as critical period during which the health, social/welfare and education sectors must work together in optimising (1) young people’s capacities for education, employment, productivity; (2) preconception health; (3) reproductive life course planning and (4) parenting capacities.

Improving living and working conditions and promoting healthy macroeconomic policies

In LMICs women’s empowerment, agriculture, food systems, education, employment, social protection and safety nets are essential to ensure adequate levels of nutrition in child populations.33 A living wage and healthcare system financing providing prepayment system (funded either through progressive income tax or universal social insurance) are essential to protect against catastrophic out-of-pocket health spending.40

Investment in early education for disadvantaged children from birth to age 5 helps reduce the achievement gap, reduce the need for special education, increase the likelihood of healthier lifestyles, lower the crime rate and reduce overall social costs.37 40 Policies that provide early childhood educational resources to the most disadvantaged children produce greater social and economic equity.41

To achieve child health equity, access to effective healthcare services is essential. Universal health coverage (UHC) means all people receiving the health services they need, including health promotion, illness prevention (such as vaccinations), and treatment, rehabilitation and palliative care of sufficient quality to be effective while ensuring that the service user is not exposed to financial hardship.39

An estimated 400 million people do not receive healthcare consistent with this definition. Policy approaches differ across LMICs40: some, such as Costa Rica, Brazil and Cuba, have succeeded in ensuring affordable and effective UHC despite relatively limited resources. Case studies in Africa, Asia and Latin America of reaching the poor with health, nutrition and population programme show that better performance in reaching the poor is both needed and feasible.34 Poor and marginalised people face barriers in access to, affordability of, and use of health interventions and services36 42 43 which, if not addressed, will lead to increasing inequity (see box 1).

Investments that increase access to high-impact health and nutrition interventions by poor groups have saved almost twice as many lives as equivalent investments in non-poor groups.32 The key practical, high-impact and low-cost health interventions include insecticide-treated nets to prevent malaria; oral rehydration salts to treat diarrhoea; early immunisation against vaccine-preventable diseases; primary and community-based health services such as skilled birth attendants to reduce complications during labour and delivery; early initiation of breast feeding continuing for the first 6 months of life; and care-seeking by parents of young children to treat illness. Community-based interventions are more equally distributed than those delivered in health facilities.19

National and international economic and social policies are important determinants of inequities. National income (Gross Domestic Product/capita) is an important determinant of child survival44 and, along with the level of governance, it determines how well a country can provide for their citizens with the essential social determinants of health (SDH).45 Stopping leaks from government revenue, including tax avoidance by domestic companies, multinational companies and wealthy residents and tax incentives which do not promote economic growth, is essential if LMICs are to retain resources necessary to reduce poverty.46 International and local action to end wars, use of scarce resources to buy armaments47 and debt repayment, all of which are promoted by HICs, can contribute to ending these drains on essential government revenue.

Growth alone without pro-poor policies may improve child survival overall but increase inequity.45 Pro-poor policies introduced by governments reduce inequity in child health in LMICs. Conditional Cash Transfer programmes have been shown to have wide-ranging positive effects.48–54 There is also evidence of short-term to medium-term impact on poor households with evidence of reduction in inequity in uptake of preventive child health services including immunisation55 and, in the longer term, sustained improvement in education and achievement among poor boys stretching into early adulthood.56

HICs, which adopt social and economic policies that reduce child poverty rates, reduce income and wealth inequalities and protect families and children from risk,57 have reduced levels of child health inequities.

For governments

1. Recognise child poverty is detrimental to health and well-being across the life course and act to reduce child poverty rates.

2. Continue with or urgently enact policies designed to reduce inequities in child health and development in line with WHO recommendations.1

3. Commit to implementing Sustainable Development Goals (SDG) Poverty targets including:

   1. Diminishing poverty by 50% by 2030.

   2. Implementing appropriate social protection systems for the poor.

   3. Ensuring equal access to economic resources.

   4. Mobilising resources for the poor.

4. Recognise that health inequity violates children’s rights under the UNCRC and ensure the rights of all children are fully protected.

5. Ensure the basic determinants of health such as adequate nutrition, education, clean water and sanitation are available to all children.

Using a simple schema proposed by The College of Family Physicians of Canada,58 paediatricians and professionals working with children can act at three levels:

1. Micro—in practice: At the individual level, clinicians can regularly assess to what extent children and their families are exposed to poverty and intervene where appropriate. Paediatricians can ensure their clinical services are accessible and acceptable to all children and families, especially marginalised populations. To address complex problems among vulnerable groups, flexibility of appointment times and duration is essential. Multidisciplinary and team-based models of care with access to social welfare services are necessary for marginalised populations.

2. Meso—in communities: Paediatricians can collect and use data on their local population’s health and well-being; promote undergraduate and postgraduate experiential learning on the SDH; and engage in advocacy at a community level.

3. Macro—national and international: Paediatricians can form advocacy groups or networks to take a stance on poverty and its impact on children. Advocacy efforts should be directed at all levels of government and international organisations, such as the International Monetary Fund which has significant influence on domestic policy space. Paediatricians can engage with their own and other medical, healthcare and social service organisations to provide organisational advocacy to work on improving the SDH and use the framework and targets of the SDGs to prioritise their advocacy.

For national and international paediatric and child health professional organisations

1. Ensure their members and constituent bodies are aware of the impact of inequities on the health and well-being of children and across the life course.

2. Include global child health inequities in their national programmes and curricula for medical students and paediatricians in training.

3. Publish policy statements relevant to their country or regional setting highlighting the impact of inequities on child health and well-being.

4. Advocate for evidence-based pro-equity interventions with policy makers at national, regional or global level using a child rights perspective.

5. Promote and institute data collection and policy focused research to monitor inequity in child populations and study social policy responses and interventions that promote equity in child health and well-being.

6. Participate in global partnerships based on SDG targets and advocate, through these partnerships, for child health equity using a child health perspective.