From Global to Local: Inequalities in Health and Healthcare

This is the year that time runs out on the Millennium Development Goals (MDGs). Established following a United Nations summit in 2000, countries around the world committed to eight goals – including halving extreme poverty, stopping the spread of HIV/AIDS and reducing child mortality (United Nations 2015). While some questioned the process for establishing and monitoring the goals, the MDGs have galvanized and focused efforts from governments, civil society and other partners over the past 15 years. There have been some remarkable achievements during this period. Globally, the number of people living in extreme poverty is down by more than half since 1990, the year against which MDG targets were benchmarked. So is under-five mortality, which dropped from an estimated 90 to 43 deaths per 1,000 live births. And maternal mortality and new HIV infections have fallen by 45 and 40 per cent, respectively. There were similar reductions in the prevalence of tuberculosis and mortality from the disease. That said, progress towards the 21 MDG targets is uneven and not all milestones set for 2015 will be achieved. Large gaps exist between countries and within them. For example, children under five in the poorest households in developing regions are almost twice as likely to die as those in the richest, although this gap seems to be narrowing in at least some countries. However, the United Nations notes that progress in some other areas – such as measles vacci-nation – has stalled since 2010. Their report highlights the fact that many of the 21.6 million infants who did not receive the measles vaccine in 2013 were “from the poorest and most marginalized communities, residing in especially hard-to-reach areas” (United Nations 2015). Similar patterns of health and disease are seen around the world; Canada is no exception. For instance, there is a 10-year gap in life expectancy at birth among provinces and territories (Statistics Canada 2013). Rates of arthritis, diabetes, hypertension, injuries and other diseases also differ among jurisdictions. Zooming in to the health region level, variations are even wider (Greenberg and Normandin 2011; Statistics Canada 2015). This “postcode lottery” represents the sobering reality that driving a few hours makes the difference between health status that is among the best in the world and one that reflects average life chances from half a century or more ago. In this issue of the journal, Sara Allin, Jeremy Veillard, Li Wang and Michel Grignon study regional variations to understand how we can improve the efficiency with which the health system translates its resources into improved outcomes. There are no simple answers – but neither is this a simple problem. Their research highlights a combination of population, behavioural and managerial factors that help to explain variations in efficiency. Other papers bring new perspectives to bear on equally challenging questions. The most personal explores the views of individuals designated as alternative level of care in Atlantic Canada and those of their families. Other authors examine system-level issues that have personal consequences for those they affect, such as generic drug pricing, the reimbursement of medications for rare diseases and the choice/implications of services from different types of maternity care providers. Whatever areas of health policy you focus on, I hope that you will find food for thought, for study and for action in the journal's pages.

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