Health and Poverty

	Overview
	Reproductive Health and Poverty
	Measuring Health Differentials between Rich and Poor
	Supporting More Equitable Health Care

Supporting More Equitable Health Care

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 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 HIV/AIDS (37).

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 in Colombia."(38) 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).

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 modest facilities.

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 care (64).

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 poorest people.

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).

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