In 2000, the United Nations General Assembly adopted the Millennium Development Goals — a series of objectives meant to improve health and well-being among residents of developing countries by 2015. As a part of this process, U.N. member nations set targets for reducing hunger, child and maternal mortality, and the incidence of major diseases such as HIV and malaria.

According to a 2014 U.N. report, countries have made substantial progress towards some of these goals — for example, public health interventions prevented 3.3 million malaria-related deaths between 2000 and 2012; saved the lives of 6.6 million people with HIV from 1995 to 2012; and nearly halved the child mortality rate over the period 1990-2012. The report warns, however, that countries are unlikely to achieve some of the Millennium Development Goals by 2015 and that even if they are achieved, the global burden of disease and hardship is still unacceptably high — for example, 162 million young children suffered from chronic malnutrition in 2012.

Even if health improves globally or for a country’s population, this does not mean improvements reach those who need it most. The World Health Organization defines health equity as the “absence of avoidable or remediable differences among groups of people, whether those groups are defined socially, economically, demographically or geographically.” As socially disadvantaged groups typically experience the poorest health, a health-equity framework holds that they should benefit the most from public health interventions. If the wealthiest or most privileged groups benefit disproportionately, that can have the effect of increasing rather than decreasing the level of health inequality in a society.

A 2014 World Bank Research Observer study, “Progress on Global Health Goals: Are the Poor Being Left Behind?” looks at progress on the health-related Millennium Development Goals through a health-equity lens. The researchers — Adam Wagstaff and Caryn Brendenkamp, based at the World Bank, and Leander R. Buisman of Erasmus University Rotterdam in the Netherlands — assess whether health improvements among developing countries have been “pro-poor” (primarily benefiting residents in the bottom 40% of the national wealth distribution and therefore increasing health equality) or “pro-rich” (disproportionately benefiting those in the top 60% and thus decreasing health equality). The study covers 60 countries over the period 1990-2011, using data from surveys by the U.S. Agency for International Development and the United Nations Children’s Fund.

The study’s findings include:

• As a whole, a majority of the developing countries experienced improvements on most health indicators. The prevalence of childhood stunting fell in 66% of the countries, childhood malnutrition (underweight) decreased in 80% of countries and access to prenatal care increased in 88%.
• In more than half of the nations, however, there was no increase in the rate of contraception access. Further, “for every indicator, there are several countries that have gone backwards. For some indicators, the fraction of such countries is quite high: one-quarter for immunization and one-fifth and one-third for underweight and stunting.”
• At a global level, access to programs meant to improve health increased faster among the poor than for the relatively wealthy. There was evidence that access to condoms, malaria nets and immunizations were pro-poor.
• Despite increased equality in access to public health programs, the relatively wealthy still had 20% higher odds of sleeping under malaria nets, 50% higher odds of being immunized and 270% higher odds of having their children delivered by a skilled birthing attendant compared to those who were poor.
• Pro-poor improvements in public health access do not, in many cases, translate into pro-poor improvements in health outcomes and thus decreased levels of health equality. For example, HIV prevalence decreased faster among the wealthy than among the poor, while changes in malnutrition and childhood mortality were neither pro-poor nor pro-rich, on average. “Though the poorest 40% may have experienced a larger percentage increase in, for example, antenatal visits, they have not observed the same improvement in the survival prospects of their babies,” the researchers note, and theorize that the quality of health care may play a role.
• There was evidence of geographic variation in health inequalities. For most of Asia and the Americas, improvements in access to prenatal care and skilled birthing attendants were pro-poor. Progress on childhood malnutrition (underweight) has been pro-rich for much of Asia. African improvements in childhood mortality have generally been pro-rich.

“Our first finding — that in most countries the poor have not been left behind by the [Millennium Development Goals] — will be reassuring to donors, international development and technical agencies, national governments, NGOs, program implementers and health care professionals,” the researchers conclude. “However, our other two findings — that relative inequalities have grown in a sizable minority of countries, especially on health status indicators, and that despite reductions in most countries, inequalities are still appreciable — will be a cause for concern.”

Related research: A 2013 report in The Lancet, “Global Health 2035: A World Converging Within a Generation,” examines the economic benefits of improving global health, while the United Nations Development Programme’s 2014 report charts both the major gains of many poorer countries as well as the huge challenges that remain. In a 2006 article in PLoS Medicine, “Structural Violence and Clinical Medicine,” lead author Dr. Paul E. Farmer and colleagues provide insights into the deeper factors that explain why many types of health inequality persist.

Keywords: Asia, poverty, health, global south, developing world, malnutrition, children