Some of Adam Wagstsaff's colleagues and research collaborators submitted short reflections about the different ways Adam made a difference through his amazing research output to health equity and health systems as well as a leader and mentor. The Guest Editors of this Special Issue selected a set of six essays related to dimensions of Adam's contributions.The first contribution highlights his role early on in his career, prior to joining the World Bank, in defining and expanding an important field of research on equity in health ("Adam and Equity," by Eddy van Doorslaer and Owen O'Donnell). The second contribution focuses on Adam's early work on equity and health within the World Bank and his leadership on important initiatives that have had impact far beyond the World Bank ("Adam and Health Equity at the World Bank," by Davidson Gwatkin and Abdo Yazbeck). The next contribution focuses on Adam's deep dive into providing support, through research, for country-specific programs and reforms, with a special focus on some countries in East Asia ("Adam and Country Health System Research," by Magnus Lindelow, Caryn Bredenkamp, Winnie Yip, and Sarah Bales). The next contribution highlights Adam's many ways of contributing to the International Health Economics Association, from the impressive technical contributions to leadership and organizational reform ("Adam and iHEA," by Diane McIntyre). The next to last contribution focuses on Adam's long-term leadership in the research group at the World Bank and the long-lasting influence on integrating the research produced into World Bank operations and creating an environment that rewarded producing evidence for action ("Adam the Research Manager," by Deon Filmer and Damien de Walque). The last contribution pulls on the thread found in many of the earlier ones, mentorship with honesty, directness, caring, commitment, and equity ("Adam the Mentor," by Agnes Couffinhal, Caryn Bredenkamp, and Reem Hafez).

This chapter provides a review of current thinking about health inequalities in developing countries and how to reduce them. The chapter initially discusses the relationship between three related indicators that describe distributional aspects of health status: The health of the poor, health inequality and health inequity. A concern for the health of poor flows from a broader concern for disadvantaged population groups. The definition of poverty may concern 'absolute poverty', with poverty defined in terms of a given level of income or consumption which is equally relevant for people wherever they may be. The concept of 'relative poverty' is more country-specific and attempts to define the poverty line in terms of relevance for a specific society. An alternative approach is to focus more on reducing inequalities, both in general and with respect to health in particular. Such a focus has traditionally occupied a particularly important place in thinking about international health issues and it is rare for a prominent international health statement not to give significant weight to inequality reduction. Poverty and inequality are both primarily empirical concepts. Equity, by contrast, is a normative concept, closely associated with the concept of social justice. One of the most widely cited definitions of health inequity is that it 'refers to differences in health which… are considered unfair and unjust'. At present, the greatest amount of attention in the overall economic development field is being paid to reducing absolute poverty, rather than to lessening relative poverty or decreasing inequality or inequity. This orientation is reflected most prominently in Millennium Development Goals (MDGs), a set of objectives that currently guide the strategy of most international and bilateral donor agencies. The second section of the chapter summarizes what is known about the dimensions and magnitude of health inequalities. The discussion focuses first on differences in life-expectancy and under-5 mortality between countries, and then describes variations in the distribution of health status and health service use within countries. The third section of the chapter presents a summary of current thought about how best to reduce inequalities and improve the health of the poor. This focuses on two, complementary issues. One is on reducing the social and economic inequalities that underlie the health inequalities described. The second is on reaching the poor more effectively with health and related services that are relevant to the principal health conditions from which they suffer. The chapter closes with a brief conclusion.This is a review of current thinking about health inequalities in developing countries and how to reduce them. It is in three parts. The first is a discussion of the concept of health inequalities, and of the similarities and differences between other distributional concepts in current use. The second summarizes what is known about the dimensions and magnitude of health inequalities. The third presents a comparable summary of current thought about how best to reduce inequalities and improve the health of the poor. The review closes with a brief conclusion.

Background Global health equity strategists have previously focused much on differences across countries. At first glance, the global health gap appears to result primarily from disparities between the developing and developed regions. We examine how much of this disparity could be attributed to within-country disparities in developing nations. Methods We used data from Demographic and Health Surveys conducted between 1995 and 2010 in 67 developing countries. Using a population attributable risk approach, we computed the proportion of global under-five mortality gap and the absolute number of under-five deaths that would be reduced if the under-five mortality rate in each of these 67 countries was lowered to the level of the top 10% economic group in each country. As a sensitivity check, we also conducted comparable calculations using top 5% and the top 20% economic group. Results In 2007, approximately 6.6 million under-five deaths were observed in the 67 countries used in the analysis. This could be reduced to only 600,000 deaths if these countries had the same under-five mortality rate as developed countries. If the under-five mortality rate was lowered to the rate among the top 10% economic group in each of these countries, under-five deaths would be reduced to 3.7 million. This corresponds to a 48% reduction in the global mortality gap and 2.9 million under-five deaths averted. Using cutoff points of top 5% and top 20% economic groups showed reduction of 37% and 56% respectively in the global mortality gap. With these cutoff points, respectively 2.3 and 3.4 million under-five deaths would be averted. Conclusion Under-five mortality disparities within developing countries account for roughly half of the global gap between developed and developing countries. Thus, within-country inequities deserve as much consideration as do inequalities between the world’s developing and developed regions.

Many low- and middle-income countries continue to search for better ways of financing their health systems. Common to many of these systems are problems of inadequate resource mobilisation, as well as inefficient and inequitable use of existing resources. The poor and other vulnerable groups who need healthcare the most are also the most affected by these shortcomings. In particular, these groups have a high reliance on user fees and other out-of-pocket expenditures on health which are both impoverishing and provide a financial barrier to care. It is within this context, and in light of recent policy initiatives on user fee removal, that a debate on the role of user fees in health financing systems has recently returned. This paper provides some reflections on the recent user fees debate, drawing from the evidence presented and subsequent discussions at a recent UNICEF consultation on user fees in the health sector, and relates the debate to the wider issue of access to adequate healthcare. It is argued that, from the wealth of evidence on user fees and other health system reforms, a broad consensus is emerging. First, user fees are an important barrier to accessing health services, especially for poor people. They also negatively impact on adherence to long-term expensive treatments. However, this is offset to some extent by potentially positive impacts on quality. Secondly, user fees are not the only barrier that the poor face. As well as other cost barriers, a number of quality, information and cultural barriers must also be overcome before the poor can access adequate health services. Thirdly, initial evidence on fee abolition in Uganda suggests that this policy has improved access to outpatient services for the poor. For this to be sustainable and effective in reaching the poor, fee removal needs to be part of a broader package of reforms that includes increased budgets to offset lost fee revenue (as was the case in Uganda). Fourthly, implementation matters: if fees are to be abolished, this needs clear communication with a broad stakeholder buy-in, careful monitoring to ensure that official fees are not replaced by informal fees, and appropriate management of the alternative financing mechanisms that are replacing user fees. Fifthly, context is crucial. For instance, immediate fee removal in Cambodia would be inappropriate, given that fees replaced irregular and often high informal fees. In this context, equity funds and eventual expansion of health insurance are perhaps more viable policy options. Conversely, in countries where user fees have had significant adverse effects on access and generated only limited benefits, fee abolition is probably a more attractive policy option. Removing user fees has the potential to improve access to health services, especially for the poor, but it is not appropriate in all contexts. Analysis should move on from broad evaluations of user fees towards exploring how best to dismantle the multiple barriers to access in specific contexts.

OBJETIVO: Descrever o efeito das iniquidades sociais sobre a nutricao e saude de criancas de paises de renda baixa e media. METODOS: Foram revisadas informacoes disponiveis sobre disparidades socioeconomicas intra-paises, relativas a uso de servicos de saude, estado nutricional, morbidade e mortalidade. Adotou-se um modelo conceitual com cinco categorias hierarquicas na producao de iniquidades: contexto e posicao socioeconomica, diferencas na exposicao, na vulnerabilidade, nos desfechos de saude e nas consequencias. Em pesquisa realizada na base PubMed, no periodo de 1990-2007 foram encontrados 244 artigos relacionados ao tema. Foram tambem analisados os resultados de cerca de 100 inqueritos de âmbito nacional recentes, incluindo Pesquisas Nacionais de Demografia e Saude e Inqueritos por Conglomerados de Multiplos Indicadores, do Fundo das Nacoes Unidas para a Infância. RESULTADOS: Criancas de familias pobres, em comparacao com aquelas de familias mais ricas, sao mais suscetiveis a exposicao a agentes patogenicos; uma vez expostas, tem um risco aumentado de adoecer, devido a sua menor resistencia e menor cobertura de medidas preventivas. Uma vez que se tornam doentes, tem menor acesso a servicos de saude, a qualidade dos servicos que logram utilizar tende a ser inferior, com menor acesso a tratamentos medicos que garantam sua sobrevivencia. Como consequencia, criancas de familias mais pobres apresentam maiores taxas de mortalidade e maior risco de serem subnutridas. CONCLUSOES: Exceto obesidade infantil e praticas inadequadas de aleitamento materno, todas as outras condicoes adversas analisadas tiveram maior prevalencia entre as criancas de familias menos favorecidas. A documentacao cuidadosa dos multiplos niveis de determinantes das iniquidades socioeconomicas em saude infantil e essencial para o entendimento da natureza do problema, e para o estabelecimento de intervencoes que possam reduzir estas diferencas.

OBJETIVO: Describir el efecto de las iniquidades sociales sobre la nutricion y salud de ninos de paises de renta baja y media. METODOS: Fueron revisadas informaciones disponibles sobre disparidades socioeconomicas intra-paises, relativas al uso de servicios de salud, estado nutricional, morbilidad y mortalidad. Se adopto un modelo conceptual con cinco categorias jerarquicas en la produccion de inequidades: contexto y posicion socioeconomica, diferencias en la exposicion, en la vulnerabilidad, en los hechos de salud y en las consecuencias. En investigacion realizada en la base PubMed, en el periodo de 1990-2007 fueron encontrados 244 articulos relacionados al tema. Fueron tambien analizados los resultados de cerca de 100 pesquisas de ambito nacional recientes, incluyendo Pesquisas Nacionales de Demografia y Salud y Pesquisas por Conglomerados de Multiples Indicadores, del Fondo de las Naciones Unidas para la Infancia. RESULTADOS: Ninos de familias pobres, en comparacion con aquellas de familias mas ricas, son mas susceptibles a la exposicion a agentes patogenicos; una vez expuestas, tienen un riesgo aumentado de enfermar, debido a su menor resistencia y menor cobertura de medidas preventivas. Una vez que se toman enfermos, tienen menor acceso a servicios de salud, la calidad de los servicios que logran utilizar tiende a ser inferior, con menor acceso a tratamientos medicos que garanticen su sobrevivencia. Como consecuencia, ninos de familias mas pobres presentan mayores tasas de mortalidad y mayor riesgo de ser subnutridas. CONCLUSIONES: Excepto obesidad infantil y practicas inadecuadas de amamantamiento, todas las otras condiciones adversas analizadas tuvieron mayor prevalencia entre los ninos de familias menos favorecidas. La documentacion cuidadosa de los multiples niveles de determinantes de las inequidades socioeconomicas en salud infantil es esencial para el entendimiento de la naturaleza del problema, y para el establecimiento de intervenciones que puedan reducir estas diferencias.

Children under 5 years of age are especially susceptible to the effects of socioeconomic inequities, due to their dependence on others to ensure their health status. This review relies on the framework developed by the Priority Public Health Conditions Knowledge Network of the Commission on Social Determinants of Health (see Chapter 1). The main data sources included over 100 national surveys and a systematic review of the post-1990 literature on child morbidity, mortality, nutrition and services utilization in low- and middle-income countries.Poor children and their mothers lag systematically behind the better-off in terms of mortality, morbidity and undernutrition. Such inequities in health outcomes result from the fact that poor children, relative to those from better-off families, are more likely to be exposed to disease-causing agents; once they are exposed, they are more vulnerable due to lower resistance and low coverage with preventive interventions; and once they acquire a disease that requires medical treatment, they are less likely to have access to services, the quality of these services is likely to be lower, and life-saving treatments are less readily available. There were very few exceptions to this pattern child obesity and inadequate breastfeeding practices were the only conditions more often reported among the rich than the poor.Health services play a major role in the generation of inequities. This is due both to inaction lack of proactive measures to address the health needs of the poor and to pro-rich bias such as geographical accessibility of services and user fees. Evaluations of the equity impact of health programmes and interventions are scarce. Nevertheless, those available show that innovative approaches can effectively promote equity through, for example, prioritizing diseases of the poor; taking the pattern of inequity into account; deploying or improving services where the poor live; employing appropriate delivery channels; removing financial barriers; and monitoring implementation, coverage and impact with an equity lens.Tackling inequities requires the involvement of various programmes and stakeholders, both within and outside the health sector, that can help address social determinants. This review shows that there are many intervention entry-points, providing room for different sectors to contribute. Actors involved in any given approach need to realize that their efforts constitute only part of the solution, and they must support the work of those promoting complementary approaches. Finally, there is a need for a general oversight function to ensure that all relevant issues are considered.In light of the mandate of the World Health Organization (WHO), this review was purposefully biased towards health sector interventions. Policy-makers, planners and health workers should be aware that the way in which they plan and implement preventive and curative interventions often contributes to further increasing inequities. Mainstreaming equity considerations in the health sector is essential for ensuring that those involved become part of the solution, rather than part of the problem.

OBJECTIVETo describe the effects of social inequities on the health and nutrition of children in low and middle income countries.METHODSWe reviewed existing data on socioeconomic disparities within-countries relative to the use of services, nutritional status, morbidity, and mortality. A conceptual framework including five major hierarchical categories affecting inequities was adopted: socioeconomic context and position, differential exposure, differential vulnerability, differential health outcomes, and differential consequences. The search of the PubMed database since 1990 identified 244 articles related to the theme. Results were also analyzed from almost 100 recent national surveys, including Demographic Health Surveys and the UNICEF Multiple Indicator Cluster Surveys.RESULTSChildren from poor families are more likely, relative to those from better-off families, to be exposed to pathogenic agents; once they are exposed, they are more likely to become ill because of their lower resistance and lower coverage with preventive interventions. Once they become ill, they are less likely to have access to health services and the quality of these services is likely to be lower, with less access to life-saving treatments. As a consequence, children from poor family have higher mortality rates and are more likely to be undernourished.CONCLUSIONSExcept for child obesity and inadequate breastfeeding practices, all the other adverse conditions analyzed were more prevalent in children from less well-off families. Careful documentation of the multiple levels of determination of socioeconomic inequities in child health is essential for understanding the nature of this problem and for establishing interventions that can reduce these differences.

OBJECTIVE: To describe the effects of social inequities on the health and nutrition of children in low and middle income countries. METHODS: We reviewed existing data on socioeconomic disparities within-countries relative to the use of services, nutritional status, morbidity, and mortality. A conceptual framework including five major hierarchical categories affecting inequities was adopted: socioeconomic context and position, differential exposure, differential vulnerability, differential health outcomes, and differential consequences. The search of the PubMed database since 1990 identified 244 articles related to the theme. Results were also analyzed from almost 100 recent national surveys, including Demographic Health Surveys and the UNICEF Multiple Indicator Cluster Surveys. RESULTS: Children from poor families are more likely, relative to those from better-off families, to be exposed to pathogenic agents; once they are exposed, they are more likely to become ill because of their lower resistance and lower coverage with preventive interventions. Once they become ill, they are less likely to have access to health services and the quality of these services is likely to be lower, with less access to life-saving treatments. As a consequence, children from poor family have higher mortality rates and are more likely to be undernourished. CONCLUSIONS: Except for child obesity and inadequate breastfeeding practices, all the other adverse conditions analyzed were more prevalent in children from less well-off families. Careful documentation of the multiple levels of determination of socioeconomic inequities in child health is essential for understanding the nature of this problem and for establishing interventions that can reduce these differences.OBJETIVO: Describir el efecto de las iniquidades sociales sobre la nutrición y salud de niños de países de renta baja y media. MÉTODOS: Fueron revisadas informaciones disponibles sobre disparidades socioeconómicas intra-países, relativas al uso de servicios de salud, estado nutricional, morbilidad y mortalidad. Se adoptó un modelo conceptual con cinco categorías jerárquicas en la producción de inequidades: contexto y posición socioeconómica, diferencias en la exposición, en la vulnerabilidad, en los hechos de salud y en las consecuencias. En investigación realizada en la base PubMed, en el período de 1990-2007 fueron encontrados 244 artículos relacionados al tema. Fueron también analizados los resultados de cerca de 100 pesquisas de ámbito nacional recientes, incluyendo Pesquisas Nacionales de Demografía y Salud y Pesquisas por Conglomerados de Múltiples Indicadores, del Fondo de las Naciones Unidas para la Infancia. RESULTADOS: Niños de familias pobres, en comparación con aquellas de familias más ricas, son más susceptibles a la exposición a agentes patogénicos; una vez expuestas, tienen un riesgo aumentado de enfermar, debido a su menor resistencia y menor cobertura de medidas preventivas. Una vez que se toman enfermos, tienen menor acceso a servicios de salud, la calidad de los servicios que logran utilizar tiende a ser inferior, con menor acceso a tratamientos médicos que garanticen su sobrevivencia. Como consecuencia, niños de familias más pobres presentan mayores tasas de mortalidad y mayor riesgo de ser subnutridas. CONCLUSIONES: Excepto obesidad infantil y prácticas inadecuadas de amamantamiento, todas las otras condiciones adversas analizadas tuvieron mayor prevalencia entre los niños de familias menos favorecidas. La documentación cuidadosa de los múltiples niveles de determinantes de las inequidades socioeconómicas en salud infantil es esencial para el entendimiento de la naturaleza del problema, y para el establecimiento de intervenciones que puedan reducir estas diferencias.OBJETIVO: Descrever o efeito das iniqüidades sociais sobre a nutrição e saúde de crianças de países de renda baixa e média. MÉTODOS: Foram revisadas informações disponíveis sobre disparidades socioeconômicas intra-países, relativas a uso de serviços de saúde, estado nutricional, morbidade e mortalidade. Adotou-se um modelo conceitual com cinco categorias hierárquicas na produção de iniqüidades: contexto e posição socioeconômica, diferenças na exposição, na vulnerabilidade, nos desfechos de saúde e nas conseqüências. Em pesquisa realizada na base PubMed, no período de 1990-2007 foram encontrados 244 artigos relacionados ao tema. Foram também analisados os resultados de cerca de 100 inquéritos de âmbito nacional recentes, incluindo Pesquisas Nacionais de Demografia e Saúde e Inquéritos por Conglomerados de Múltiplos Indicadores, do Fundo das Nações Unidas para a Infância. RESULTADOS: Crianças de famílias pobres, em comparação com aquelas de famílias mais ricas, são mais suscetíveis à exposição a agentes patogênicos; uma vez expostas, têm um risco aumentado de adoecer, devido à sua menor resistência e menor cobertura de medidas preventivas. Uma vez que se tornam doentes, têm menor acesso a serviços de saúde, a qualidade dos serviços que logram utilizar tende a ser inferior, com menor acesso a tratamentos médicos que garantam sua sobrevivência. Como conseqüência, crianças de famílias mais pobres apresentam maiores taxas de mortalidade e maior risco de serem subnutridas. CONCLUSÕES: Exceto obesidade infantil e práticas inadequadas de aleitamento materno, todas as outras condições adversas analisadas tiveram maior prevalência entre as crianças de famílias menos favorecidas. A documentação cuidadosa dos múltiplos níveis de determinantes das iniqüidades socioeconômicas em saúde infantil é essencial para o entendimento da natureza do problema, e para o estabelecimento de intervenções que possam reduzir estas diferenças.

Background: Diarrhoea represents a major burden of childhood disease in countries with low and middle incomes. The need for targeting poorer socioeconomic groups has been forwarded as a priority in diarrhoea control. The aim of this study was to determine the role of socioeconomic inequalities in the control of childhood diarrhoea.

This series is produced by the Health, Nutrition, and Population (HNP) Family of the World Bank’s Human Development Network. The findings, interpretations, and conclusions expressed in this paper are entirely those of the authors and should not be attributed in any manner to the World Bank, to its affiliated organizations or to the members of its Board of Executive Directors or the countries they represent.

This series is produced by the Health, Nutrition, and Population (HNP) Family of the World Bank’s Human Development Network. The findings, interpretations, and conclusions expressed in this paper are entirely those of the authors and should not be attributed in any manner to the World Bank, to its affiliated organizations or to the members of its Board of Executive Directors or the countries they represent.

This case study was conducted to impart a thorough understanding of Catholic Relief Services (CRS) OVC program model in Kenya and to document lessons learned that could be applied to other OVC initiatives. This case study is based upon a program document review; program site visits including discussions with local staff volunteers beneficiaries and community members; as well as observations of program activities. The primary audience for this case study includes OVC program implementers in Kenya and elsewhere in Africa as well as relevant policy makers and funding agencies addressing OVC needs. The Kilifi OVC project of CRS was selected as a priority program for the evaluation. Program goals are to: increase the capacity of communities and families and orphans to respond to the needs of OVC; and increase the institutional capacity of local partners to deliver high quality and sustainable interventions. (excerpt)

This series is produced by the Health, Nutrition, and Population (HNP) Family of the World Bank’s Human Development Network. The findings, interpretations, and conclusions expressed in this paper are entirely those of the authors and should not be attributed in any manner to the World Bank, to its affiliated organizations or to the members of its Board of Executive Directors or the countries they represent.

This series is produced by the Health, Nutrition, and Population (HNP) Family of the World Bank’s Human Development Network. The findings, interpretations, and conclusions expressed in this paper are entirely those of the authors and should not be attributed in any manner to the World Bank, to its affiliated organizations or to the members of its Board of Executive Directors or the countries they represent.

This report on the Socio-economic differences in health, nutrition, and population in Philippines is one in a series that provides basic information about health, nutrition, and population (hnp) inequalities within fifty-six developing countries. The report's contents are intended to facilitate preparation of country analyses and the development of activities to benefit poor people. To this end, the report presents data about hnp status, service use, and related matters among individuals belonging to different socio-economic classes. The principal focus is on differences among groups of individuals defined in terms of the wealth or assets of the households where they reside. The report is organized in four principal parts. Part one constitutes the report's core, and consists of tables presenting quintile-specific data for each hnp indicator covered from the two most recent DHS surveys available at the time of the report's publication. Part two provides supplementary technical information designed to help readers understand the data presented in part one. Part three presents supporting tables that deal with three of the technical matters covered in part two: the size of the sample for each indicator covered; the standard error for each quintile-specific estimate in the total population; and the items used in constructing the wealth index, along with the weight assigned to each. An additional fourth part consists of three annexes, for readers interested in applying the approach used in the report or in learning more about the other reports in this series.