Inequalities in Health in Developing Countries: Swimming Against the Tide?

Without wishing to incriminate them in any way, I should like to thank Rohini Pande and Abdo Yazbeck for allowing me to cite data from their India study, to Abbas Bhuiya for providing me with supplementary data and clarification on his Bangladesh study, to Naoko Watanabe for help with the benefit-incidence calculations for China, to Deon Filmer for several useful discussions on the data used in the crosscountry comparisons, and to Nga Nguyen, Eddy van Doorslaer and Naoko Watanabe for allowing me to cite data from our papers on Vietnam. The findings, interpretations, and conclusions expressed in this paper are entirely those of the author(s) and do not necessarily represent the views of the World Bank, its Executive Directors, or the countries they represent. Working papers describe research in progress by the author(s) and are published to elicit comments and to further debate. Abstract Health inequalities have recently started to receive a good deal of attention in the developing world. But how large are they? And how large are the differences across countries? Recent data from a 42-country study shows large but varying inequalities across countries. It explores the reasons for these intercountry differences and concludes that large inequalities in health are not apparently associated with high income inequalities, or with low shares of health spending financed publicly. They are, however, associated with higher per capita incomes. Evidence from trends in health inequalities—in both the developing and developed world—supports the notion that health inequalities rise with rising per capita incomes. The association between health and inequality and per capita income is probably due in part to technological change going hand-in-hand with economic growth, coupled with a tendency for the better-off to assimilate new technology ahead of the poor. Given that increased health inequality associated with rising per capita incomes is a bad thing and increased average health levels associated with rising incomes are a good thing, the paper outlines a way of quantifying the trade-off between health inequalities and health levels. The paper also suggests that successful anti-inequality policies can be devised, but that their success cannot be established simply by looking at " headline " health inequality figures, since these reflect the effects of differences and changes in other variables, including per capita income. Four approaches that can shed light on the impacts on health inequalities of anti-inequality policies include crosscountry comparative studies, country-based before-and-after studies with controls, benefit-incidence …