Inequity and Unwanted Fertility in Developing Countries
Shah, Iqbal H., Chandra-Mouli, Venkatraman, Bulletin of the World Health Organization
The persistence of inequities in health, with poor and other disadvantaged population groups bearing a disproportionately high burden of ill-health, remains a public health, ethical and human rights challenge. (1) The WHO Constitution enshrines equity thus: "The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition." Addressing inequities in health has been a central concern of development aid and government policies. The Millennium Development Goals (MDGs) have further galvanized efforts to eliminate poverty and to reduce inequities. There has been a quantum increase in the published literature on health inequities, and "pro-poor" programmes have been initiated to redress them. Yet consensus is lacking on many aspects of inequity--its conceptual and operational definitions, its classification criteria and ways to alleviate it.
Most professionals accept that inequities are "differences which are unnecessary and avoidable, but in addition are considered unfair and unjust". (2) However, some argue that it is impossible to formulate irrefutable criteria by which health inequities can be recognized. (3) Moreover, they assert, what is viewed as unjust or unfair may depend on subjective values, political ideologies or normative considerations. (3) Others say "pro-poor" policies oversimplify the problem by focusing only on income disparities, thus ignoring more intricate structural factors which underlie the inequity dynamics in a given context. (4) The evidence from six countries (Cambodia, the Dominican Republic, Ethiopia, Ghana, Kenya and Tajikistan) indicates that differences in health outcomes by ethnic group, educational attainment and region were more pronounced than the differences caused by wealth, the factor which work on inequity generally addresses. (4)
Against this backdrop, Gillespie et al. (5) examine through an equity lens the prevailing differences by wealth quintile in total fertility, unwanted fertility, use of modern contraceptives and access to family planning services in developing countries. More specifically, they consider whether unwanted fertility among the poor compared with wealthier population segments is a case of an inequality (that is, a difference that has no moral implications) or an inequity. Using data from Demographic and Health Surveys in 41 developing countries, the authors conclude that for reproduction and family planning interventions, the equity concept needs to be "applied more cautiously than in the case with health". They further state that this equity analysis is useful in countries where poor segments have high actual and unwanted fertility, low contraceptive use and limited access to family planning information or services.
By extending the equity analysis to fertility and modern contraceptive use by wealth quintile, Gillespie et al. have broadened the discourse on inequities. …