A breakthrough in measuring inequalities in health has shattered myths about the effectiveness of health systems in helping the poor. The resulting evidence on outcome inequality is overwhelming. Children from poor families from over 50 low- and middle-income countries suffer malnutrition and die at much higher rates than children from better-off families. Fertility rates for poor women far outpace those of better-off women. The most jarring finding, however, is not that the poor suffer more, but that health systems, even when publicly financed, are much more likely to serve the better-off than the poor and, by doing so, increase inequalities in health, nutrition, and fertility outcomes. There is hope, though. In this ocean of inequality, islands of success exist and critical lessons can and should be learned from them. 'Attacking Inequality in the Health Sector' distills the operational knowledge relevant to attacking health sector inequality and uses available empirical evidence to answer two critcal questions: Why is there persistent inequality in health care? What can be done about it? Using 14 evaluated, proven successes and an exhaustive literature review, this book serves as a practical 'how to' manual for defining, understanding, and effectively addressing the problems of inequality in health service use. It will be of particular interest to policy makers, advocates in civil society, and development agencies that are committed to improving health service use by the poor and socially vulnerable.

While women in developing countries continue to die in large numbers in child birth, Population and Reproductive Health specialists and advocates around the world are struggling to keep the policy agenda focused on the rights and needs of poor women. The 1994 Cairo Conference and Program of Action changed how we do business, and opened many doors, but the agenda is not complete and has stalled in a number of ways. At the country level, governments and donors are making difficult choices about how and where to allocate scarce human and financial resources. Funding approaches have moved away from the implementation of narrowly directed health programs to a broader approach of health system development and reform. At the same time, countries are also centering their development agenda on the broad goal of poverty reduction. This volume addresses a large knowledge and capacity gap in the Reproductive Health community and provides tools for key actors to empower faster positive change. It is a synopsis of the materials developed for WBI's learning program on Achieving the Millennium Development Goals: Poverty Reduction, Reproductive Health and Health Sector Reform. The volume brings together knowledge about epidemiology, demography, economics, and trends in global financial assistance. The volume also introduces practical tools such as benefit incidence analysis, costing, and stakeholder analysis to strengthen the evidence base for policy and to address the political economy factors for reform.

This volume presents eleven case studies that document how well or poorly health, nutrition, and population programs have reached disadvantaged groups in the countries of Africa, Asia, and Latin America where they were undertaken. The studies were commissioned by the Reaching the Poor Program, undertaken by the Word Bank in cooperation with the Bill and Melinda Gates Foundation and the Dutch and Swedish governments, in an effort to find better ways of ensuring that health, nutrition, and population programs benefit the neediest. These case studies, reinforced by other material gathered by the Reaching the Poor Program, indicate clearly that health programs do not have to be inequitable. Although most health, nutrition, and population services achieve much lower coverage among disadvantaged groups than among the better-off, many significant and instructive exceptions exist. These show that the poor can be reached much more effectively than at present and point to potentially promising strategies for doing so.

Resume : L'Afrique est sur le bord d'un lancement potentiel de croissance economique soutenue. Cette ascension peut etre acceleree par un dividende demographique du aux changements dans la structure par age de la population. Les baisses de la mortalite infantile, suivies par la baisse de la fecondite, produisent une generation.

Africa is poised on the edge of a potential takeoff to sustained economic growth. This takeoff can be abetted by a demographic dividend from the changes in population age structure. Declines in child mortality, followed by declines in fertility, produce a 'bulge' generation and a large number of working age people, giving a boost to the economy. In the short run lower fertility leads to lower youth dependency rates and greater female labor force participation outside the home. Smaller family sizes also mean more resources to invest in the health and education per child boosting worker productivity. In the long run increased life spans from health improvements mean that this large, high-earning cohort will also want to save for retirement, creating higher savings and investments, leading to further productivity gains. Two things are required for the demographic dividend to generate an African economic takeoff. The first is to speed up the fertility decline that is currently slow or stalled in many countries. The second is economic policies that take advantage of the opportunity offered by demography. While demographic change can produce more, and high quality, workers, this potential workforce needs to be productively employed if Africa is to reap the dividend. However, once underway, the relationship between demographic change and human development works in both directions, creating a virtuous cycle that can accelerate fertility decline, social development, and economic growth. Empirical evidence points to three key factors for speeding the fertility transition: child health, female education, and women's empowerment, particularly through access to family planning. Harnessing the dividend requires job creation for the large youth cohorts entering working age, and encouraging foreign investment until domestic savings and investment increase. The appropriate mix of policies in each country depends on their stage of the demographic transition.