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These root causes have to be tackled through intersectoral and cross-government action. The basis Chapter 2 The central place of for this is the set of reforms that health equity in PHC 24 aim at moving towards universal Moving towards universal coverage 25 coverage, i. Deeply life in rural Canada prompted Matthew Anderson unequal opportunities for health combined with — to launch a tax-based health insur- endemic inequalities in health care provision ance scheme that eventually led to countrywide lead to pervasive inequities in health outcomes 3.
Unfortunately, equally shocking lose-lose is causing increasing intolerance of the whole situations abound today across the world. More spectrum of unnecessary, avoidable and unfair than 30 years after the clarion call of Alma-Ata differences in health4.
They stem from inequitable method for fi nancing health-care ser- social stratification and political inequalities vices: out-of-pocket payments by the sick or their that lie outside the boundaries of the health sys- families at the point of service. For 5. Income and social status matter, as do the people in low- and middle-income countries, over neighbourhoods where people live, their employ- half of all health-care expenditure is through out- ment conditions and factors, such as personal of-pocket payments.
This deprives many families behaviour, race and stress 5. Health inequities of needed care because they cannot afford it. Also, also fi nd their roots in the way health systems more than million people around the world exclude people, such as inequities in availability, are pushed into poverty each year because of access, quality and burden of payment, and even catastrophic health-care expenditures 2.
There is in the way clinical practice is conducted6. Left to a wealth of evidence demonstrating that fi nancial their own devices, health systems do not move protection is better, and catastrophic expenditure towards greater equity. Most health services — less frequent, in those countries in which there hospitals in particular, but also fi rst-level care is more pre-payment for health care and less — are consistently inequitable providing more out-of-pocket payment.
Conversely, catastrophic and higher quality services to the well-off than expenditure is more frequent when health care to the poor, who are in greater need7,8,9, Dif- has to be paid for out-of-pocket at the point of ferences in vulnerability and exposure combine service Figure 2.
These 5 interventions reach well beyond the traditional realm of health-service policies, relying on the mobilization of stakeholders and constituencies outside the health sector They include 0 Q reduction of social stratification, e.
Advancing and sustaining universal coverage adequate pay, using labour intensive growth the same: pooling pre-paid contributions col- strategies, promoting equal opportunities for lected on the basis of ability to pay, and using women and making free education available, these funds to ensure that services are available, etc.
Universal cover- developing social networks at community level, age is not, by itself, sufficient to ensure health introducing social inclusion policies and poli- for all and health equity — inequalities persist in cies that protect mothers while working or countries with universal or near-universal cover- studying, offering cash benefits or transfers, age — but it provides the necessary foundation 9.
Indeed, in countries against exposure to health hazards, e. As with from unfair dismissal from their jobs. There is now wide- which they have little influence. Yet, they do spread consensus that providing such coverage is have a responsibility to address health inequal- simply part of the package of core obligations that ity.
In itself, this is a political achievement exacerbate or mitigate health inequalities and that shapes the modernization of society. The question, therefore, is not the 20th century. The opportunity now exists for if, but how health leaders can more effectively low- and middle-income countries to implement pursue strategies that will build greater equity comparable approaches. Costa Rica, Mexico, in the provision of health services. Other countries are weighing sim- coverage: universal access to the full range of ilar options The technical challenge of moving personal and non-personal health services they towards universal coverage is to expand coverage need, with social health protection.
Whether the in three ways Figure 2. Public expenditure The third dimension, the height of coverage, Extend to uninsured on health i. Expanding the breadth of coverage context of disengagement of the state and dwin- is a complex process of progressive expansion dling public resources for health.
Most undertook and merging of coverage models Box 2. Dur- these measures without anticipating the extent ing this process, care must be taken to ensure of the damage they would do.
In many settings, safety nets for the poorest and most vulnerable dramatic declines in service use ensued, par- until they also are covered. It may take years to ticularly among vulnerable groups 20, while the cover the entire population but, as recent experi- frequency of catastrophic expenditure increased.
Particularly in these countries, however, it is crucial to move towards pre-payment systems from a very early stage and to resist the temptation to rely on user fees. Coordinate funding sources. In order to organize universal coverage, it is necessary to consider all sources of funding in a country: public, private, external and domestic. In low-income countries, it is particularly important that international funding be channelled through nascent pre-payment and pooling schemes and institutions rather than through project or programme funding.
Routing funds in this way has two purposes. Combine schemes to build towards full coverage. Many countries with limited resources and administrative capacity have experi- mented with a multitude of voluntary insurance schemes: community, cooperative, employer-based and other private schemes, as a way to foster pre-payment and pooling in preparation for the move towards more comprehensive national systems Such schemes are no substitute for universal coverage although they can become building blocks of the universal system Realizing universal coverage means coordinating or combining these schemes progressively into a coherent whole that ensures coverage to all population groups15 and builds bridges with broader social protection programmes Advancing and sustaining universal coverage Box 2.
This has been one of the key strategies in improving the effectiveness of health systems and the equitable distribution of resources. It is supposed to make priority setting, rationing of care, and trade-offs between breadth and depth of coverage explicit. In most cases, their scope has been limited to maternal and child health care, and to health problems considered as global health priorities. Q It should specify what should be provided at primary and secondary levels.
Q The implementation of the package should be costed so that political decision-makers are aware of what will not be included if health care remains under-funded. This has resulted risk that people will incur catastrophic expenses in substantial increases in the use of services, when they are sick. Finally, it provides the means especially by the poor In Uganda, for example, to re-invest in the availability, range and quality service use increased suddenly and dramatically of services.
Challenges in moving Pre-payment and pooling institutionalizes solidarity between the rich and the less well-off, towards universal coverage All universal coverage reforms have to fi nd com- and between the healthy and the sick.
It lifts bar- promises between the speed with which they riers to the uptake of services and reduces the increase coverage and the breadth, depth and height of coverage. However, the way countries devise their strategies and focus their reforms Figure 2. In some countries, a very large part of the pop- 30 ulation lives in extremely deprived areas, with an absent or dysfunctional health-care infra- 20 structure.
Ensuring access to quality care in these vices are grossly inadequate or fragmented, the settings entails grappling with the diseconomies basic health-care infrastructure needs to be built of scale connected with small, scattered popula- or rebuilt, often from the ground up.
These areas tions; logistical constraints on referral; difficulties are always severely resource-constrained and linked to limited infrastructure and communica- frequently affected by confl icts or complex emer- tions capacities; and, in some cases, more specific gencies, while the scale of under-servicing, also technical complications, such as maintaining in other sectors, engenders logistical difficulties patient records for nomadic groups.
A different challenge is extending coverage in Health planners in these settings face a funda- settings where inequalities do not result from the mental strategic dilemma: whether to prioritize a lack of available health infrastructure, but from massive scale-up of a limited set of interventions the way health care is organized, regulated and, to the entire population or a progressive roll-out above all, paid for by official or under-the-counter of more comprehensive primary-care systems on user charges.
These are situations where under- a district-by-district basis. Such pat- number of priority programmes is rolled out terns of exclusion occur in countries such as simultaneously to all the inhabitants in the Colombia, Nicaragua and Turkey Figure 2. It deprived areas. This allows for task shifting to is particularly striking in the many urban areas low-skilled personnel, lay workers and volunteers of low- and middle-income countries where a and, consequently, rapid extension of coverage.
It is still central to what the global community Figure 2. Births attended by medically est countries 28, and quite a number of countries trained personnel percentage , by income group27 have chosen this option over the last 30 years. Nevertheless, skill limitations reinforce 20 the focus on a limited number of effective but simple interventions. Scaling up a limited number of interventions 0 Quintille 1 Quintille 2 Quintille 3 Quintille 4 Quintille 5 has the advantage of rapidly covering the entire lowest highest population and focusing resources on what is known to be cost effective.
Advancing and sustaining universal coverage when people experience health problems, they want them to be dealt with, whether or not they Box 2.
They offer tion as a long-term investment, allocation of resources to rural and patients an appealing alternative, but one that is under-privileged areas, and prioritizing ambulatory care over hospitaliza- tion. A network of district teams to manage and oversee almost often exploitative and harmful. Compared with village-based rural health centres was established. These centres are a situation of utter lack of health action, there staffed by a team that includes a general practitioner, midwife, nurse and is an indisputable benefit in scaling up even a several health technicians.
In remote rural areas, these health houses are staffed by Behvarz it an attractive option. However, upgrading often multi-purpose health workers who are selected by the community, proves more difficult than initially envisaged 30 receive between 12 and 18 months training and are then recruited by and, in the meantime, valuable time, resources the Government.
The district teams provide training based on problem- and credibility are lost which might have allowed solving, as well as ongoing supervision and support. Over the years, the PHC network has grown infrastructure.
Rural health service support. Such a response obviously includes the utilization rates are now the same as in urban areas. The progressive priority interventions, but integrated in a com- roll-out of this system has helped to reduce the urban-rural gap in child mortality Figure 2.
The extension platform is the primary-care centre: a profession- Figure 2. The limiting factors for a progressive roll-out 0 of primary-care networks are the lack of a sta- ble cadre of mid-level staff with the leadership qualities to organize health districts and with the ability to maintain, over the years, the constant adequately, a blend of response to need and effort required to build sustainable results for the demand, and participation of the population and entire population.
Where the roll-out has been key actors has made it possible to build robust conducted as an administrative exercise, it has primary-care networks, even in very difficult and led to disappointment: many health districts exist resource-constrained settings of confl ict, and in name only. But where impatience and pres- post-confl ict environments Box 2.
However, of external health funding, in addition to popula- for all the convergence, trying to balance speed tion size. Supplements are paid to districts with and sustainability is a real political dilemma In Chile, budgets are allocated on a choice, people willingly opt for progressive roll- capitation basis but, as part of the PHC reforms, out, making community health centres — whose these were adjusted using municipal human infrastructure is owned and personnel employed development indices and a factor to reflect the by the local community — the basis of functional isolation of underserved areas.
Quality and sustainabil- persed populations is often a daunting logisti- ity are important, particularly since nowadays cal challenge, some countries have dealt with the multitude of varied and dynamic governmen- it by developing creative approaches. Devising tal, not-for-profit and for-profit private providers mechanisms to share innovative experiences and of various kinds are in dire need of alignment.
Nevertheless, there is curative health-care services, but also reinforcing no getting away from the need for massive and promotive strategies and cross-sectoral action on sustained investment to expand and maintain the determinants of health and health equity.
The fi rst concerns Extending health-care networks to under- collaboration in organizing infrastructure that served areas depends on public initiative and maximizes scales of efficiency. An isolated com- incentives. One way to accelerate the extension munity may be unable to afford key inputs to of coverage is to adjust budget allocation for- expand coverage, which includes infrastructure, mulae or contract specifications to reflect the technologies and human resources particularly extra efforts required to contact hard-to-reach the training of personnel.
However, when com- populations. Several countries have taken steps in munities join forces, they can secure such inputs this direction. In January , for example, the at manageable costs Depending on the setting, this five mortality as a proxy for disease burden and strategic focus may include transportation, radio poverty level, while adjusting for the differential communications, and other information and com- costs of providing health services in rural and munications technologies.
It has a health centres and the district hospital took care of more than network of health centres, a referral hospital and a district man- 1 disease episodes in 20 years, immunized more than agement team where community participation has been fostered infants, provided midwifery care to 70 women and for years through local committees.
Rutshuru has experienced carried out 8 surgical procedures. This shows that, even in severe stress over the years, testing the robustness of the district disastrous circumstances, a robust district health system can health system. Over the last 30 years, the economy of the country has gone These results were achieved with modest means. Out-of-pocket into a sharp decline.
This was compounded by an interruption of over- ally nil during most of these 20 years. The continuity of the work seas development aid in the early s. This complex of disasters severely affected the and maintain a critical mass of dedicated human resources, and working conditions of health professionals and access to health limited but constant nongovernmental support, which provided a services for the people living in the district.
The from this experience. With no 30 national health profession- more than 70 nurses and als. Local health services 20 three medical doctors at have a consider able a time, and in the midst 10 potential for coping with of war and havoc, the 0 crises Finally, the fi nancing In urban and periurban contexts, health services of health care for dispersed populations poses are physically within reach of the poor and other specific challenges, which often require larger vulnerable populations.
The presence of multiple per capita expenditure compared to more clus- health-care providers does not mean, however, tered populations. In countries whose territories that these groups are protected from diseases, include both high-density and low-density popu- nor that they can get quality care when they need lations, it is expected that dispersed populations it: the more privileged tend to get better access to will receive some subsidy of care.
After all, equity the best services, public and private, easily com- does not come without solidarity. In the urban and increasingly in the critical mass of primary-care centres that provide rural areas of many low- and middle-income an essential package of quality services free-of- countries — from India and Viet Nam to sub- charge, provides an important alternative to sub- Saharan Africa — much health care for the poor standard, exploitative commercial care.
Further- is provided by small-scale, largely unregulated more, peer pressure and consumer demand can and often unlicenced providers, both commer- help to create an environment in which regula- cial and not-for-profit. Often, they work along- tion of the commercial sector becomes possible. Vested interests avenues to follow, particularly where ministries make the promotion of universal coverage para- of health with budgetary constraints also have to doxically more difficult in these circumstances extend services to underserved rural areas.
Targeted interventions to These contexts often combine problems of fi nan- cial exploitation, bad quality and unsafe care, and complement universal coverage exclusion from needed services37,38,39,40,41,42,43,44, This towards universal coverage are, unfortunately, not may be for broader reasons of poverty, ethnic- sufficient to eliminate health inequities. Socially ity or gender, or because the resources of the determined health differences among population health system are not correctly targeted.
It may groups persist in high-income countries with be because there are no adequate systems to pro- robust, universal health-care and social-service tect people against catastrophic expenditure or systems, such as Finland and France11, Health from fi nancial exploitation by unscrupulous or inequalities do not just exist between the poor and insensitive providers. It may have to do with the the non-poor, but across the entire socioeconomic way people, rightly or wrongly, perceive health gradient.
There are circumstances where other services: lack of trust, the expectation of ill-treat- forms of exclusion are of prime concern, includ- ment or discrimination, uncertainty about the ing the exclusion of adolescents, ethnic groups, cost-of-care, or the anticipation that the cost will drug users and those affected by stigmatizing be unaffordable or catastrophic. Services may diseases In Australia, Canada and New Zea- also be untimely, ineffective, unresponsive or land, among others, health equity gaps between plain discriminatory, providing poorer patients Aboriginal and non-Aboriginal populations have with inferior treatment 48,49, As a result, health emerged as national political issues52,53, In the United States, for systems.
For a variety of reasons, pre-payment or public resources for their fund- some groups within these societies are either not ing.
Whether these networks are expanded by reached or insufficiently reached by opportunities contracting commercial or not-for-profit provid- for health or services and continue to experience ers, or by revitalizing dysfunctional public facili- health outcomes systematically inferior to those ties is not the critical issue. The point is to ensure of more advantaged groups.
Advancing and sustaining universal coverage Thus, it is necessary to embed universal cov- Latin America. A recent systematic review of six erage in wider social protection schemes and to such programmes suggests that conditional cash complement it with specially designed, targeted transfers can be effective in increasing the use of forms of outreach to vulnerable and excluded preventive services and improving nutritional and groups Established health-care networks often anthropometric outcomes, sometimes improving do not make all possible efforts to ensure that health status However, their overall effect on everyone in their target population has access health status remains less clear and so does their to the full range of health benefits they need, as comparative advantage over traditional, uncon- this requires extra efforts, such as home visits, ditional, income maintenance, through universal outreach services, specialized language and entitlements, social insurance or — less-effective cultural facilitation, evening consultations, etc.
These may, however, mitigate the effect of social Targeted measures are not substitutes for the stratification and inequalities in the uptake of long-term drive towards universal coverage. They services They may also offer the opportunity can be useful and necessary complements, but to construct comprehensive support packages to without simultaneous institutionalization of the foster social inclusion of historically marginal- fi nancing models and system structures that sup- ized populations, in collaboration with other gov- port universal coverage, targeted approaches are ernment sectors and with affected communities.
Such targeted measures may evaluation of methods to target the excluded is include subsidizing people — not services — to take scarce and marred by the limited number of up specific health services, for example, through documented experiences and a bias towards vouchers 60,61 for maternal care as in India and reporting preferentially on successful pilots If Yemen, for bednets as in the United Republic of anything defi nite can be said today, it is that the Tanzania 62,63, for contraceptive uptake by ado- strategies for reaching the unreached will have lescents 64 or care for the elderly uninsured as in to be multiple and contextualized, and that no the United States Conditional cash transfers, single targeting measure will suffice to correct where the beneficiary is not only enabled, but health inequalities effectively, certainly not in the compelled to take up services is another model, absence of a universal coverage policy.
Finally, the social protection programme also provides preferential access to pre-school programmes, adult literacy courses, employment programmes and preventive health visits for women and children. This social protection programme complements a multisectoral effort targeting all children aged 0—18 years Chile Crece Contigo — Chile Grows with You.
More debates70, The universal coverage reforms Q Health systems designed for universal access required to move towards greater equity demand are equitable — they are a necessary, but not the enduring commitment of the highest political a sufficient condition. Two levers may be especially Q In poor countries, everybody is equally poor important in accelerating action on health equity and equally unhealthy — all societies are and maintaining momentum over time.
The fi rst stratified. The reasons 2. Q It is equally important, for the same reasons, to identify and understand the determinants Increasing the visibility of of health inequality not only in general terms, health inequities but also within each specific national context.
With the economic optimism of the s and Health authorities must be informed of the s and the expansion of social insurance in extent to which current or planned health industrialized countries , poverty ceased being policies contribute to inequalities, so as to be a priority issue for many policy-makers.
It took able to correct them. Alma-Ata to put equity back on the political Q Progress with reforms designed to reduce agenda. The lack of systematic measurement and health inequalities, i. In recent years, as they unfold.
This has generated a wealth health science. Unless health information systems of documentary evidence on socioeconomic dif- collect data using standardized social stratifiers, ferentials in health outcomes and access to care. The to the centre of the health policy debate. Advancing and sustaining universal coverage have made a major difference in the awareness of policy-makers about health equity problems Box 2. There are also examples of Ghent, Belgium: how local authorities how domestic capacities and capabilities can be strengthened to better understand and manage can support intersectoral collaboration equity problems.
For example, Chile has recently between health and welfare embarked on integrating health sector informa- organizations76 tion systems in order to have more comprehen- sive information on determinants and to improve In , a regional government decree in Flanders, Belgium, the ability to disaggregate information according institutionalized the direct participation of local stakeholders to socioeconomic groups.
Indonesia has added and citizens in intersectoral collaboration on social rights. This health modules to household expenditure and now applies at the level of cities and villages in the region. In demographic surveys. However, this is more than a technical of the various organizations and sectors, for example, through challenge. They are also responsible for networking process to identify what constitutes a fair distri- between all the sectors with a view to improving coordination.
It relies on the development and are responsible for channelling them, if appropriate, to of institutional collaboration between multiple the province, region, federal state or the European Union for translation into relevant political decisions and legislation. The support of the admin- posals for better equity and solidarity. Creating space for civil society Participation of all stakeholders is particularly prominent in the health forum: it includes local hospitals, family physicians, participation and empowerment primary-care services, pharmacists, mental health facilities, Knowledge about health inequalities can only self-help groups, home care, health promotion agencies, be translated into political proposals if there is academia sector, psychiatric home care, and community organized social demand.
Demand from the com- health centres. Among the concrete realizations is the creation within countries, but also globally. The participating groups or those suffering from specific health organizations report that the creation of the sectoral forums, in conjunction with the organization of intersectoral coopera- conditions. Social participation in health action more technocratic and top-down approach to becomes a reality at the local level and, at times, assessing social inequalities and determining it is there that intersectoral action most effectively priorities for action.
However, these achieve- were partner-based entities whose mission was to ments should not mask the contributions that the improve the well-being of disadvantaged groups.
It has been used success- disadvantaged groups, showing that local govern- fully to foster dialogue with and among members ments can help reduce health inequities Advancing and sustaining universal coverage References 1. Houston S. Hutton G. Saskatchewan History, , —14 A look over the past 25 years at the shifting support for user fees in health and 2. London, Department for International , — Geneva, World July Tarimo E. Essential health service packages: uses, abuse and future directions.
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