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ORIGINAL ARTICLE
Open Access

Improved Reproductive Health Equity Between the Poor and the Rich: An Analysis of Trends in 46 Low- and Middle-Income Countries

John Ross
Global Health: Science and Practice September 2015, 3(3):419-445; https://doi.org/10.9745/GHSP-D-15-00124
John Ross
aDemographic consultant.
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  • For correspondence: rosshome8@frontiernet.net
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Figures & Tables

Figures

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  • FIGURE 1
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    FIGURE 1

    Contraceptive Prevalence Rates at Initial and Latest Surveys,a by Wealth Quintile, 46 Low- and Middle-Income Countries

    a Survey years varied by country, ranging from 1990 in the initial surveys to 2013 in the latest surveys.

  • FIGURE 2
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    FIGURE 2

    Gap (in Percentage Points) Between Richest and Poorest Quintiles in the Contraceptive Prevalence Rate, and Gap Reduction From Initial to Latest Survey,a 46 Low- and Middle-Income Countries

    a Survey years varied by country, ranging from 1990 in the initial surveys to 2013 in the latest surveys.

  • APPENDIX FIGURE 3
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    APPENDIX FIGURE 3

    Quintile Membership by Rural and Urban Residence: Illustrative Example From Indonesia, 2012

Tables

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    TABLE 1 Countries and Survey Years Included in the Analysis
    Region/CountryInitial Survey YearLatest Survey YearRegion/CountryInitial Survey YearLatest Survey Year
    sub‐Saharan AfricaNorth Africa/West Asia
    Benin19962006Armenia20002010
    Burkina Faso1998‐992010Egypt19952008
    Cameroon19912011Jordan19902009
    Chad1996‐972004Morocco19922003‐04
    Côte d'Ivoire19942011‐12Central Asia
    Eritrea19952002Kazakhstan19951999
    Ethiopia20002011South & Southeast Asia
    Gabon20002012Bangladesh1993‐942011
    Ghana19932008Cambodia20002010
    Guinea19992005India1992‐932005‐06
    Kenya19932008‐09Indonesia19972012
    Lesotho20042009Nepal19962011
    Madagascar19972008Pakistan1990‐912012‐13
    Malawi19922010Philippines19932008
    Mali1995‐962006Viet Nam19972002
    Mozambique19972011Latin America & Caribbean
    Namibia19922006‐07Bolivia19942008
    Niger19982006Colombia19902010
    Nigeria19902008Dominican Republic19962007
    Rwanda19922010Guatemala19951998‐99
    Senegal19972010‐11Haiti1994‐952012
    Tanzania19962010Honduras2005‐062011‐12
    Uganda19952011Nicaragua19982001
    Zambia19962007Peru1991‐922012
    Zimbabwe19942010‐11
    • View popup
    TABLE 2 Two Types of Changesa in Quintile Gaps for Contraceptive Use, Illustrative Examples From Ethiopia and Eritrea
    Ethiopia: Rising GapsEritrea: Declining Gaps
    Gap at Initial SurveyGap at Latest SurveyGap ChangeGap at Initial SurveyGap at Latest SurveyGap Change
    CPR
    Poor3.513.39.82.51.7−0.8
    Rich28.351.823.525.520.4−5.1
    Gap24.838.513.723.018.7−4.3
    mCPR
    Poor2.713.010.30.31.41.1
    Rich22.948.225.318.917.9−1.0
    Gap20.235.215.018.616.5−2.1
    • ↵a​ The rising CPR and mCPR gaps in Ethiopia are a reflection of larger gains among the rich than among the poor. On the other hand, in Eritrea the CPR and mCPR fell among both quintiles but more so in the wealthiest quintile, resulting in shrinking gaps.

    • View popup
    TABLE 3 List of Countries According to Type of Change in the CPR Gap and CPR Decrease or Increase Between Surveys, Q1 (Poorest) Compared With Q5 (Richest)
    Increasing CPR GapDecreasing CPR GapTOTAL
    Both rates fell0Q1 fell; Q5 fell more: 22
    Eritrea
    Senegal
    Both rates roseQ1 rose; Q5 rose more: 7Q1 rose; Q5 rose less: 2633
    EthiopiaBangladeshKenya
    GuatemalaBoliviaLesotho
    MozambiqueCambodiaMadagascar
    NigeriaColombiaMalawi
    RwandaCôte d'IvoireMorocco
    TanzaniaDominican Rep.Namibia
    UgandaEgyptNepal
    GuineaNicaragua
    HaitiPakistan
    HondurasPeru
    IndiaPhilippines
    JordanZambia
    KazakhstanZimbabwe
    MixedQ1 fell; Q5 rose: 5Q1 rose; Q5 fell: 611
    ArmeniaGabon
    BeninGhana
    Burkina FasoIndonesia
    CameroonMali
    ChadNiger
    Viet Nam
    TOTAL123446
    • View popup
    TABLE 4 Initial and Latest Gaps (in Percentage Points) Between Richest and Poorest Quintiles and Gap Changes Between Initial and Latest Survey, for the Contraceptive Prevalence Rate (CPR) and Modern Contraceptive Prevalence Rate (mCPR), 46 Low- and Middle-Income Countries
    CPRmCPR
    Country, Latest Survey YearGap at Initial SurveyGap at Latest SurveyGap ChangeGap at Initial SurveyGap at Latest SurveyGap Change
    sub-Saharan Africa
    Benin, 200617.025.9−8.97.710.8−3.1
    Burkina Faso, 201016.730.0−13.314.326.5−12.2
    Cameroon, 201131.238.3−7.111.823.3−11.5
    Chad, 20046.610.3−3.74.77.3−2.6
    Côte d'Ivoire, 2011–1224.516.38.211.412.2−0.8
    Eritrea, 200223.018.74.318.616.52.1
    Ethiopia, 201124.838.5−13.720.235.2−15.0
    Gabon, 201223.114.98.212.610.02.6
    Ghana, 200822.417.25.213.79.04.7
    Guinea, 200513.411.81.68.210.0−1.8
    Kenya, 2008–0937.034.62.434.831.03.8
    Lesotho, 200936.931.65.337.832.35.5
    Madagascar, 2008–0939.937.42.521.518.82.7
    Malawi, 201015.914.31.613.313.5−0.2
    Mali, 200619.215.43.814.813.61.2
    Mozambique, 201116.827.4−10.616.026.6−10.6
    Namibia, 2006–0748.639.29.451.538.812.7
    Niger, 200618.910.08.917.313.53.8
    Nigeria, 200818.931.8−12.911.719.8−8.1
    Rwanda, 20108.814.0−5.26.311.1−4.8
    Senegal, 2010–1120.619.70.922.618.54.1
    Tanzania, 201026.327.7−1.424.018.55.5
    Uganda, 201122.331.5−9.223.726.4−2.7
    Zambia, 200720.513.76.825.917.78.2
    Zimbabwe, 2010–1119.510.39.224.611.213.4
    Mean22.923.2−0.318.818.9−0.1
    North Africa/West Asia
    Armenia, 2010−2.49.2−11.613.716.3−2.6
    Egypt, 200830.710.020.729.210.418.8
    Jordan, 200930.011.818.222.812.610.2
    Morocco, 2003–0440.411.628.830.45.425.0
    Mean24.710.714.024.011.212.9
    Central Asia
    Kazakhstan, 199912.84.58.35.86.2−0.4
    South & Southeast Asia
    Bangladesh, 201113.3−0.714.08.2−1.810.0
    Cambodia, 201023.110.812.312.9−3.816.7
    India, 2005–0629.725.34.425.723.42.3
    Indonesia, 201213.75.18.610.72.48.3
    Nepal, 201131.419.212.229.213.315.9
    Pakistan, 2012–1330.225.05.222.013.58.5
    Philippines, 200817.49.28.215.77.28.5
    Viet Nam, 200216.93.213.78.5−6.314.8
    Mean22.012.19.816.66.010.6
    Latin America & Caribbean
    Bolivia, 200845.724.621.139.923.916.0
    Colombia, 201030.94.526.427.46.421.0
    Dominican Rep., 200713.85.68.212.52.89.7
    Guatemala, 1998–9960.164.5−4.451.754.3−2.6
    Haiti, 201223.61.322.316.0−2.218.2
    Honduras, 2011–1220.08.811.223.512.311.2
    Nicaragua, 200127.022.05.024.020.83.2
    Peru, 201236.51.035.537.817.620.2
    Mean32.216.515.729.117.012.1
    Overall Mean24.318.65.720.415.45.0
    • View popup
    TABLE 5 Initial and Latest Levels of Contraceptive Use, by Region, for the Poorest Quintile
    RegionInitial CPR LevelCPR RiseLatest CPR LevelRatio, Latest/InitialInitial mCPR LevelmCPR RiseLatest mCPR LevelRatio, Latest/Initiala
    Overall
     Mean20.612.332.91.913.812.726.53.5
     Median14.610.631.81.75.510.324.32.6
    sub-Saharan Africa
     Mean9.57.617.12.04.69.614.24.2
     Median8.04.513.32.02.16.311.63.9
    North Africa/West Asia
     Mean34.021.155.12.019.221.240.32.1
     Median27.427.154.52.016.722.644.02.1
    Central Asia
     Kazakhstan52.810.963.71.243.85.148.91.1
    South & Southeast Asia
     Mean31.716.047.71.725.713.539.21.8
     Median28.313.243.71.520.310.635.41.6
    Latin America & Caribbean
     Mean33.619.152.81.924.118.242.33.8
     Median38.918.853.71.824.118.245.12.4
    • Abbreviations: CPR, contraceptive prevalence rate; mCPR, modern contraceptive prevalence rate.

    • ↵a​ These ratios average the 46 individual country ratios. They do not reconcile with the average starting and ending levels in the same row since those smooth out the overall numerators and denominators of the ratios. It is preferable to use the 46 individual country ratios.

    • View popup
    TABLE 6 Correlations (r Values) for Relation of Family Planning Program Efforts to Gap Changes Between Richest and Poorest Quintiles and to Contraceptive Use by the Poorest, 46 Low- and Middle-Income Countries
    Gap Change
    CPRmCPRCPR for Poorest QuintilemCPR for Poorest Quintile
    sub-Saharan Africa (N=25 Countries)
    Total Effort Score
     20090.580.490.430.43
     2004(0.04)0.120.130.21
     19990.260.390.360.42
     19940.380.450.430.44
     Mean0.300.360.340.38
    Access Score
     20090.550.520.600.61
     20040.090.250.240.29
     19990.340.490.380.41
     19940.190.390.420.43
     Mean0.290.410.410.44
    All Other Countries (N=21 Countries)
    Total Effort Score
     20090.250.410.320.47
     20040.190.290.290.50
     19990.200.220.280.36
     1994(0.02)—0.280.38
     Mean0.160.230.290.43
    Access
     20090.320.350.440.53
     20040.050.010.450.56
     19990.320.090.400.26
     1994(0.11)(0.25)0.220.23
     Mean0.150.050.380.40
    • View popup
    TABLE 7 Gaps Between the Poorest and Richest Quintiles (Poor Minus Rich) at Initial and Latest Surveya and Gap Changes, by Reproductive Health Indicator, 46 Low- and Middle-Income Countries
    Reproductive Health IndicatorGap at Initial SurveyGap at Latest SurveyGap Reduction% Improvement
    % with no antenatal care30.719.611.136.1
    % not told of pregnancy complications27.920.97.025.1
    % not receiving iron or syrup31.724.37.423.2
    % not receiving tetanus21.914.87.132.3
    % not delivering in health facility48.349.1(0.7)(1.6)
    % lacking skilled attendant at birth51.446.84.68.9
    % with distance problem52.635.517.132.5
    Perinatal mortality14.49.64.833.1
    Infant mortality rate37.124.213.034.9
    Under-5 mortality rate66.846.820.030.0
    Total fertility rate2.92.90.030.9
    Wanted fertility rate2.11.90.28.8
    Want to limit childbearing(7.1)(2.5)4.664.4
    Ideal no. of children1.381.280.107.4
    Ideal no. of children at ages 20–241.171.020.1412.0
    Unmet need for family planning7.97.80.11.4
    Unmet need for limiting3.73.60.25.1
    Unmet need for spacing4.14.2(0.1)(1.4)
    • ↵a​ Survey years varied by country, ranging from 1990 in the initial surveys to 2013 in the latest surveys.

    • Note: Data in the last 2 columns were calculated with more decimals than shown and can reflect rounding.

    • View popup
    APPENDIX 1 Contraceptive Prevalence Rate (CPR), CPR Changes, Quintile Gaps, and Changes in Quintile Gaps Between Initial and Latest Survey, 46 Low- and Middle-Income Countries
    Lowest QuintileHighest Quintile
    Country, Survey YearCPRCPR RiseCPRCPR RiseQuintile GapGap Change
    sub-Saharan Africa
    Benin 20067.7−1.533.67.425.9−8.9
    Benin 19969.226.217.0
    Burkina Faso 20107.4−0.637.412.730.0−23.6
    Burkina Faso 1998–998.024.716.7
    Cameroon 20112.9−1.941.25.238.3−7.1
    Cameroon 19914.836.031.2
    Chad 20040.0−3.510.30.210.3−3.7
    Chad 1996–973.510.16.6
    Côte d'Ivoire 2011–1211.78.028.0−0.216.38.2
    Côte d'Ivoire 19943.728.224.5
    Eritrea 20021.7−0.820.4−5.118.74.3
    Eritrea 19952.525.523.0
    Ethiopia 201113.39.851.823.538.5−13.7
    Ethiopia 20003.528.324.8
    Gabon 201221.32.536.2−5.714.98.2
    Gabon 200018.841.923.1
    Ghana 200814.22.431.4−2.817.25.2
    Ghana 199311.834.222.4
    Guinea 20055.33.617.12.011.81.6
    Guinea 19991.715.113.4
    Kenya 2008–0920.15.454.73.034.62.4
    Kenya 199314.751.737.0
    Lesotho 200930.112.561.77.231.65.3
    Lesotho 200417.654.536.9
    Madagascar 2008–0919.914.157.311.637.42.5
    Madagascar 19975.845.739.9
    Malawi 201038.729.353.027.714.31.6
    Malawi 19929.425.315.9
    Mali 20063.72.419.1−1.415.43.8
    Mali 1995–961.320.519.2
    Mozambique 20112.91.630.312.227.4−10.6
    Mozambique 19971.318.116.8
    Namibia 2006–0731.922.471.113.039.29.4
    Namibia 19929.558.148.6
    Niger 200610.97.320.9−1.610.08.9
    Niger 19983.622.518.9
    Nigeria 20083.22.335.015.231.8−12.9
    Nigeria 19900.919.818.9
    Rwanda 201043.123.657.128.814.0−5.2
    Rwanda 199219.528.38.8
    Senegal 2010–114.8−1.824.5−2.719.70.9
    Senegal 19976.627.220.6
    Tanzania 201022.912.850.614.227.7−1.4
    Tanzania 199610.136.426.3
    Uganda 201114.74.546.213.731.5−9.2
    Uganda 199510.232.522.3
    Zambia 200740.520.554.213.713.76.8
    Zambia 199620.040.520.5
    Zimbabwe 2010–1154.314.264.65.010.39.2
    Zimbabwe 199440.159.619.5
    MEAN CHANGES7.67.9−0.3
    North Africa/West Asia
    Armenia 201053.2−8.462.43.29.2−11.6
    Armenia 200061.659.2−2.4
    Egypt 200855.425.065.44.310.020.7
    Egypt 199530.461.130.7
    Jordan 200953.529.165.310.911.818.2
    Jordan 199024.454.430.0
    Morocco 2003–0458.338.669.99.811.628.8
    Morocco 199219.760.140.4
    MEAN CHANGES21.17.114.0
    Central Asia
    Kazakhstan 199963.710.968.22.64.58.3
    Kazakhstan 199552.865.612.8
    South & Southeast Asia
    Bangladesh 201161.521.160.87.1−0.714.0
    Bangladesh 1993–9440.453.713.3
    Cambodia 201045.230.856.018.510.812.3
    Cambodia 200014.437.523.1
    India 2005–0642.214.167.59.725.34.4
    India 1992–9328.157.829.7
    Indonesia 201256.27.961.3−0.75.18.6
    Indonesia 199748.362.013.7
    Nepal 201140.422.759.610.519.212.2
    Nepal 199617.749.131.4
    Pakistan 2012–1320.819.245.814.025.05.2
    Pakistan 1990–911.631.830.2
    Philippines 200840.812.350.04.19.28.2
    Philippines 199328.545.917.4
    Viet Nam 200274.310.277.5−3.53.213.7
    Viet Nam 199764.181.016.9
    MEAN CHANGES17.37.59.8
    Latin America & Caribbean
    Bolivia 200846.223.670.82.524.621.1
    Bolivia 199422.668.345.7
    Colombia 201075.529.080.02.64.526.4
    Colombia 199046.577.430.9
    Dominican Rep. 200767.512.773.14.55.68.2
    Dominican Rep. 199654.868.613.8
    Guatemala 1998–998.41.872.96.264.5−4.4
    Guatemala 19956.666.760.1
    Haiti 201231.724.133.01.81.322.3
    Haiti 1994–957.631.223.6
    Honduras 2011–1267.314.076.12.88.811.2
    Honduras 2005–0653.373.320.0
    Nicaragua 200152.510.374.55.322.05.0
    Nicaragua 199842.269.227.0
    Peru 201272.937.473.91.91.035.5
    Peru 1991–9235.572.036.5
    MEAN CHANGES19.13.515.7
    OVERALL MEAN CHANGES12.56.85.4
    • View popup
    APPENDIX 2 Modern Contraceptive Prevalence Rate (mCPR), mCPR Changes, Quintile Gaps, and Changes in Quintile Gaps Between Initial and Latest Survey, 46 Low- and Middle-Income Countries
    Lowest QuintileHighest Quintile
    Country, Survey YearmCPRmCPR RisemCPRmCPR RiseGapGap Change
    sub-Saharan Africa
    Benin 20062.41.113.24.210.8−3.1
    Benin 19961.39.07.7
    Burkina Faso 20107.16.333.617.226.5−10.9
    Burkina Faso 1998–990.816.415.6
    Cameroon 20112.41.725.713.223.3−11.5
    Cameroon 19910.712.511.8
    Chad 20040.0−0.17.32.57.3−2.6
    Chad 1996–970.14.84.7
    Côte d'Ivoire 2011–127.46.319.67.112.2−0.8
    Côte d'Ivoire 19941.112.511.4
    Eritrea 20021.41.117.9−1.016.52.1
    Eritrea 19950.318.918.6
    Ethiopia 201113.010.348.225.335.2−15.0
    Ethiopia 20002.722.920.2
    Gabon 201211.96.321.93.710.02.6
    Gabon 20005.618.212.6
    Ghana 200811.66.220.61.59.04.7
    Ghana 19935.419.113.7
    Guinea 20052.71.712.73.510.0−1.8
    Guinea 19991.09.28.2
    Kenya 2008–0916.96.647.92.831.03.8
    Kenya 199310.345.134.8
    Lesotho 200928.613.260.97.732.35.5
    Lesotho 200415.453.237.8
    Madagascar 2008–0917.615.336.412.618.82.7
    Madagascar 19972.323.821.5
    Malawi 201034.931.048.431.213.5−0.2
    Malawi 19923.917.213.3
    Mali 20062.82.316.41.113.61.2
    Mali 1995–960.515.314.8
    Mozambique 20112.92.029.512.626.6−10.6
    Mozambique 19970.916.916.0
    Namibia 2006–0729.624.268.411.538.812.7
    Namibia 19925.456.951.5
    Niger 20062.31.515.8−2.313.53.8
    Niger 19980.818.117.3
    Nigeria 20082.52.022.310.119.8−8.1
    Nigeria 19900.512.211.7
    Rwanda 201038.526.749.631.511.1−4.8
    Rwanda 199211.818.16.3
    Senegal 2010–114.43.422.9−0.718.54.1
    Senegal 19971.023.622.6
    Tanzania 201019.214.337.78.818.55.5
    Tanzania 19964.928.924.0
    Uganda 201112.710.639.113.326.4−2.7
    Uganda 19952.125.823.7
    Zambia 200730.625.248.317.017.78.2
    Zambia 19965.431.325.9
    Zimbabwe 2010–1152.421.263.67.811.213.4
    Zimbabwe 199431.255.824.6
    MEAN CHANGES9.69.7−0.1
    North Africa/West Asia
    Armenia 201021.45.937.78.516.3−2.6
    Armenia 200015.529.213.7
    Egypt 200851.923.762.34.910.418.8
    Egypt 199528.257.429.2
    Jordan 200936.621.549.211.312.610.2
    Jordan 199015.137.922.8
    Morocco 2003–0451.433.556.88.55.425.0
    Morocco 199217.948.330.4
    MEAN CHANGES21.28.312.9
    Central Asia
    Kazakhstan 199948.95.155.15.56.2−0.4
    Kazakhstan 199543.849.65.8
    South & Southeast Asia
    Bangladesh 201152.918.451.18.4−1.810.0
    Bangladesh 1993–9434.542.78.2
    Cambodia 201035.222.731.46.0−3.816.7
    Cambodia 200012.525.412.9
    India 2005–0634.69.758.07.423.42.3
    India 1992–9324.950.625.7
    Indonesia 201253.06.855.4−1.52.48.3
    Indonesia 199746.256.910.7
    Nepal 201135.619.948.94.013.315.9
    Nepal 199615.744.929.2
    Pakistan 2012–1318.116.931.68.413.58.5
    Pakistan 1990–911.223.222.0
    Philippines 200825.910.233.11.77.28.5
    Philippines 199315.731.415.7
    Viet Nam 200257.910.951.6−3.9−6.314.8
    Viet Nam 199747.055.58.5
    MEAN CHANGES14.43.810.6
    Latin America & Caribbean
    Bolivia 200822.621.046.55.023.916.0
    Bolivia 19941.641.539.9
    Colombia 201068.530.874.99.86.421.0
    Colombia 199037.765.127.4
    Dominican Rep. 200766.515.369.35.62.89.7
    Dominican Rep. 199651.263.712.5
    Guatemala 1998–995.40.059.72.654.3−2.6
    Guatemala 19955.457.151.7
    Haiti 201229.724.827.56.6−2.218.2
    Haiti 1994–954.920.916.0
    Honduras 2011–1255.114.067.42.812.311.2
    Honduras 2005–0641.164.623.5
    Nicaragua 200150.210.071.06.820.83.2
    Nicaragua 199840.264.224.0
    Peru 201240.530.058.19.817.620.2
    Peru 1991–9210.548.337.8
    MEAN CHANGES18.26.112.1
    OVERALL MEAN CHANGES 12.9 7.8 5.0
    • View popup
    APPENDIX 3 Distribution of Survey Respondents by Quintile and Urban-Rural Residence
    Quintile
    Country, Survey Year12345
    Indonesia, 2012Total
    Urban6.413.621.026.432.7100
    Rural33.526.419.013.77.4100
    Urban16.034.052.565.881.5
    Rural84.066.047.534.218.5
    Total100.0100.0100.0100.0100.0
    Egypt, 2014Total
    Urban3.12.84.635.853.7100
    Rural30.030.229.210.60.0100
    Urban5.65.18.366.1100.0
    Rural94.494.991.733.90.0
    Total100.0100.0100.0100.0100.0
    Malawi, 2010Total
    Urban2.93.47.519.966.3100
    Rural23.323.122.320.011.3100
    Urban2.32.75.915.752.4
    Rural97.797.394.184.347.6
    Total100.0100.0100.0100.0100.0
    • Note: The first “Urban” and “Rural” rows under each country represent the percentage of the urban and rural population, respectively, falling under each wealth quintile. The second set of “Urban” and “Rural” rows under each country represent the percentage of respondents from each wealth quintile who live in urban or rural areas, respectively.

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Global Health: Science and Practice: 3 (3)
Global Health: Science and Practice
Vol. 3, No. 3
September 10, 2015
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Improved Reproductive Health Equity Between the Poor and the Rich: An Analysis of Trends in 46 Low- and Middle-Income Countries
John Ross
Global Health: Science and Practice Sep 2015, 3 (3) 419-445; DOI: 10.9745/GHSP-D-15-00124

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Improved Reproductive Health Equity Between the Poor and the Rich: An Analysis of Trends in 46 Low- and Middle-Income Countries
John Ross
Global Health: Science and Practice Sep 2015, 3 (3) 419-445; DOI: 10.9745/GHSP-D-15-00124
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