Health and Poverty
Investment in basic health services
in developing countries is only a fraction of what is
needed. Low-income countries are spending only $21 per
capita per year for all forms of health care, much of
it directed to expensive curative services to the detriment
of basic health prevention and care. The WHO/World Bank
Commission on Macro-economics and Health (35)
estimated that an additional $30 billion per year is
needed. The poorest countries either have more urgent
priorities, such as debt servicing and repayment, defense
or industrial development, or lack the financing altogether.
HEALTH SECTOR REFORM IN BRAZIL
health system, established in 1988, has a basic care
package that includes family planning, reproductive health and
STI/HIV prevention and treatment.
Since the 1994 International Conference on Population and
Development and the 1995 Fourth World Conference on
Women the unified health system has undergone reform,
including additional financing for health care and rapid decentralization.
As a result, reproductive health care is increasingly
being integrated with municipalities' primary health services.
BEMFAM, the International Planned Parenthood Federation
affiliate in Brazil, contracts with municipalities in 14 of Brazil's
27 states to assist with sexual and reproductive health
Adolescent reproductive health programmes, however,
have not fared so well. According to a recent study of adolescent
reproductive health in São Paulo, structural adjustment
policies and health sector reform have left more young people
uninsured, cut public spending on health, reduced numbers of
health care personnel and created shortages of medical supplies.
All these have held up implementation of high-quality
health services for adolescents.
THE PURPOSE OF HEALTH SECTOR REFORM
According to UNAIDS, "Prolonging
life and reducing morbidity are not the only purpose
of health care systems, and of health care reform. Producing
health care procedures, 'interventions', is not its
only output. Health care reform has to aim at more than
good health status. As soon as one accepts that people,
not health care systems, produce health, then one realizes
that relief from suffering, irrespective of health outcomes,
and autonomy, the capacity of people to maintain their
health on their own, become equally important purposes
of the health care system.
HEALTH SECTOR REFORM These constraints have forced the
health sector to seek more effective use of available resources; to
improve the accountability of providers and regulators; to create
additional revenue from fees for service and other charges,
and to find ways to guarantee resource flows. These initiatives
are referred to as "health sector reform".
Putting the health sector on a solid financial footing can also
improve the efficiency and quality of overall health services and
promote equity in health care. In their five-year review of the
ICPD Programme of Action, governments recognized that countries
must include reproductive health in health sector reform.
"Governments, in collaboration with civil society,
including nongovernmental organizations, donors and
the United Nations system, should: (a) Give high priority
to reproductive and sexual health in the broader context
of health sector reform, including strengthening basic
health systems, from which people living in poverty
in particular can benefit…." (36)
MAKING REPRODUCTIVE HEALTH A
PRIORITY There is no guarantee that countries will
make reproductive health a priority under reform, particularly
in decentralized systems. However, essential health
service packages usually include some reproductive health
components, including safe motherhood, family planning
and action against sexually transmitted infections including
According to WHO, Colombia's health
sector reform, which includes reproductive health, "has
led to more financial resources for health care, an
emphasis on more efficient use of resources, decreased
donor dependence, broad-based support for health promotion
and preventive care, and special attention to underserved
groups. All of these sector-wide trends have had positive
impacts on the delivery of reproductive health services
Zambia began one of Africa's most ambitious health sector
reforms in the early 1990s. The reformed and decentralized
health system includes an essential health package with
components of reproductive health (maternal and child
health, family planning, and prevention and treatment
of STIs and HIV/AIDS), action against malaria and tuberculosis,
and attention to water and sanitation. Adolescent reproductive
health, action against gender violence, and prevention
of abortion are embedded in the package (39).
These reforms have not been fully implemented, in part
because of the lack of resources to support the package
of services and drugs.
Special care is needed under health
sector reform to protect supply chains. In Ghana, health
reform has neither harmed nor helped contraceptive supply,
in part because the contraceptive logistics system is
a separate element, and donors supply the commodities
(40). In Kenya,
the good performance of a similar contraceptive logistics
system gave the ministry of health some ideas for reforming
its logistics system for essential drugs (41).
PARTNERSHIPS Public-private partnerships can improve
access to services. Bolivia established a separate organization,
PROSALUD, as part of health sector reform in the mid-1980s.
Designed to improve equitable access to better-quality
and cost-efficient basic services, including reproductive
health, PROSALUD operates more efficiently than the
ministry of health, and has become a leader in health
care delivery (42).
In Bolivia and other Latin American
countries NGOs are strong advocates for reproductive
health and clients' rights to quality services within
health sector reform. "The involvement and empowerment
of clients, through civil, societal and actual con-
sumer inputs in health service design, delivery and
evaluation, is helping to make clients more aware and
more demanding of the services they receive." (43)
HIV/AIDS has a profound impact on
health sector reform and civil society mobilization,
particularly in Africa where governments were often
slow to react. Experience in Phayao Province, Thailand,
which has had the highest rate of reported AIDS cases
in the country, has shown that an effective response
to AIDS demands more than a health care package. It
calls for reorganizing the health system to provide
care, catalysing community action to promote behaviour
change, and integrating health concerns into the core
business of all sectors of society (44).
THE PURPOSE OF HEALTH SECTOR REFORM
AIDING THE POOREST IN PALESTINIAN
TERRITORY Poverty is a major
challenge in the Occupied Palestinian
Territory, with more than a third of the work
force unemployed and nearly half the population
living on less than $2 a day. Poverty
rates are highest among the rural population
and female-headed households.
Maternal mortality, estimated at 70-80
per 100,000 live births, reflects both gender
inequality and the poor state of health
services. Early marriage (median age
18 years) also contributes to rapid population
growth, making poverty alleviation
more difficult. Women lag far behind men
in educational achievement and labour
UNFPA is working to improve the
quality of life of the Palestinian people by
improving their reproductive health, through
interventions focused on women and youth.
Thirty-nine UNFPA-supported clinics in the
West Bank and Gaza provide family planning,
gynaecological care and counselling,
at locations selected to serve those who
would otherwise lack access to care.
Three model centres serve the most
underprivileged areas, including two
refugee camps, El-Bureij and Jabalyia. Here,
social, psychological and legal counselling
services are linked to reproductive health
service provision. The poorest clients are
exempt from payment for service, and are
also referred to charitable agencies that
offer subsidies for food and basic services.
The Fund also works with Palestinian
parliamentarians and ministry officials to
increase understanding of populationdevelopment
links and adopt policies that
more effectively address development concerns.
It played a catalytic role in creating a
committee of ministries and civil society
groups for intersectoral planning and coordinated
implementation of programmes
that support the poor.
EXPENDITURES, ACCESS AND QUALITY
Government health spending tends to favour the rich,
mostly because a disproportionate share goes to curative
care and hospitals, which are more frequently used by
the rich, rather than to services the poor rely on,
such as clinics (45).
A comparison of the public spending on health devoted
to different income quintiles in 12 countries from different
regions (46) illustrates
this inequity. In a majority of the countries, the richest
40 per cent receive a larger share of the total outlays
than the poorest 40 per cent. In only four countries,
all of them in South America, do the poorest and richest
40 per cent receive a comparable share of public resources.
In six African countries, "the highest
20 per cent of the population gets about one-and-one-half
times as large a benefit from government primary health
care programmes as the lowest 20 per cent."(47).
A study in India showed that around 32 per cent of the
benefit from public health services goes to the richest
population quintile, compared with around 10 per cent
to the poorest quintile (48).
The poor-rich inequalities are considerably larger in
India's poorest states and in rural as opposed to urban
areas. They are less marked in outpatient and primary
health care services than in hospital-based services,
but most government expenditures go to hospital care.
The exception is immunizations, which tend to be more
equally distributed across socio-economic groups. Some
countries show fewer disparities. In Viet Nam, for example,
the poorest receive nearly their proportional share
of reproductive health expenditures. Where the richer
capture more than their proportional share it is because
they go to hospitals or high-level clinics for services
such as contraception, which the poor obtain from more
Smaller gaps in service distribution between rich and poor do
not translate into equitable access to information and services.
The poor are still exposed to higher levels of risk more frequently
than the rich. If need rather than population size is the measure
for health expenditures, the poor fall far short of their fair share.
MEASURING THE QUALITY OF HEALTH
SYSTEMS Equity in the health sector is often defined
as equal access to health services according to need,
financed according to ability to pay. This is or should
be one aim of reform in the health sector. However,
there is little practical evidence to guide how to achieve
equity at the same time as making public and private
health care more efficient, cost-effective, and sustainable
(49). One way to
promote equity is to emphasize services the poor can
use, including family planning, safe motherhood and
other elements of reproductive health. Care should be
taken to protect these services under decentralization.
Paradoxically, the poor often do not use government
health services, even when they are available (50).
One reason is that the poor, like all other groups,
respond to quality when making choices for health care,
and the poor usually receive the worst quality care-harsh
treatment by poorly motivated, low-paid staff who demand
payment for care and often have little to offer. The
health workers are themselves often victims of poorly
functioning health care systems that fail to provide
the drugs, equipment and support the staff need to do
their jobs (51).
So, in many countries, poor people would rather pay
private-sector or NGO providers for what they see as
better quality (52).
The 2000 World Health Report concluded
that health and wellbeing depend on how well health
systems perform. Virtually all health systems could
make better use of resources: misuse "leads to large
numbers of preventable deaths and disabilities, unnecessary
suffering, injustice, inequality and denial of an individual's
basic rights to health."(53).
Proposals to strengthen the delivery of health services
include suggestions that governments should change their
role from provider to financer, providing subsidies
and letting the poor choose among providers in the private
and NGO sectors.
Financing mechanisms (54)
in large part determine where health care is available
and who has access to services, which affects not only
equity and quality (55)
but also the degree to which people are protected from
catastrophic costs due to illness. USER FEES Most governments
recognize that they cannot provide free services for
all citizens with funding from general revenues and
taxes. However, few people in developing countries have
access to social or private insurance, and fees for
service are becoming more common.
Fees were introduced in public health
services to relieve financial pressure and help pay
for improved quality (56),
but reports about their effect on the poor are mixed
and contradictory. Some studies show that small increases
in user fees have no adverse affect, particularly if
the quality of care improves 57),
but there is ample evidence that user fees have denied
poor women and children needed health care (58).
Removing fees can also create problems: in one health
district in South Africa, removing user fees for all
primary care in 1997 brought more patients to curative
services, but that led to clinic congestion and reduced
consultation times and may have discouraged mothers
from bringing their children for antenatal care, growth
monitoring and immunization (59).
Most countries with user fees also
have exemption schemes for the poor, but exemptions
have been difficult to implement and enforce. In Uganda,
for example, guidelines allow for an exemption rate
of around 30 per cent for the poor. However, those who
cannot pay are more likely to be turned away than to
be exempted from paying; many poor patients believe
it is pointless even trying to get health care under
these conditions (60).
Reports from Lesotho, Ghana and Bangladesh also suggest
that those who need the exemptions do not get them (61).
OTHER APPROACHES Community-financed
schemes show promise, but most communities need government
support to set them up, as in Indonesia's Dana Sehat
system (62), which
covered 13 per cent of Indonesia's villages in 1994.
India and China have also used community-financing schemes
for health care. Social financing or social insurance
can increase access to reproductive health care. The
West African Society for Prevention of Maternal Mortality
set up a fund to buy fuel for emergency transport to
obstetric facilities in Kebbi State in Nigeria (63).
In Indonesia, a successful community insurance scheme
resulted in more women reaching emergency obstetric
Managed care, introduced in Latin
America as part of health reform, has exacerbated inequalities.
Health maintenance organizations have skimmed off the
young and relatively healthy who make few claims, leaving
under-funded local governments to cover the older, sicker,
and more expensive patients (65).
Services need to balance the need for revenue with the needs
of service users, especially the poor. The poorest of the poor-the
estimated 1.2 billion people who live on less than $1 a day-cannot
afford to pay fees, however low, in whatever form, for health
care. Formal and informal fees widely imposed around the world
to shore up sagging health budgets are effectively denying access
to even primary and reproductive health care to millions of the
HEALTH AND ECONOMIC GROWTH
Better health, including reproductive health, and education,
contribute to economic growth (66).
Improvements in health and mortality help the poorest
people most, because they are most at risk (67).
Better education helps women especially to protect their
own and their children's health and widens economic
choices. Higher incomes improve living environments,
reduce malnutrition and provide a buffer against the
costs of poor health.
As incomes rise people become healthier
on average, but at the same time health inequalities
increase, possibly because the better off are first
to take advantage of the new health technologies that
accompany economic growth. The result is that countries
with higher overall per capita income have steeper child
health inequalities than poorer countries where there
are wide gaps between richest and poorest (68).