"The health sector is part of the reason why there are health inequalities," said Cesar Victora, an emeritus professor of epidemiology at the Federal University of Pelotas, at "Strengthening Health Systems To Reach the Poor," an Environmental Change and Security Program event co-sponsored with the Global Health Initiative on July 15, 2008. "It's not the whole picture, but it's a pretty sizeable part of the problem." Joined by Columbia University's Lynn Freedman, Victora discussed the causes and consequences of unequal health care and recommended steps that governments can take to combat the problem.
A Plan to Combat Inequity
Prioritizing the diseases that mainly afflict the poor is "an essential first step," said Victora, because those diseases make up such a large part of the world's burden of disease, but receive only a small share of the budget in most health systems. For example, Victora reported that pneumonia is responsible for approximately 20 percent of deaths in the world, and diarrhea for another 20 percent, yet as little as five to 10 percent of health system budgets are devoted to fighting these diseases. The largest portion of the budget is usually reserved for chronic diseases like cancer, which are responsible for a very small part of the global disease burden. Allocating resources to the diseases with the greatest impact will ensure that the conditions that disproportionately affect the poor receive equal attention.
Poor and rural communities often lack access to adequate health care, but some programs have successfully overcome this obstacle. According to Victora, since 1996 the Brazilian government's Family Health Program has established primary care facilities in poor regions and lured health care workers with competitive salaries to these areas. Child mortality has been significantly reduced in a number of areas targeted by this program. On the other hand, a Brazilian vaccination program in relatively wealthier areas did not "trickle down" into the poorer, more remote communities, and, according to Victora, is largely regarded as a failure.
Taking services to where the poor live, rather than making them to travel to get health care, is a central component of efforts to reduce health care inequity, said Victora. To achieve universal access, he advocates community-based delivery, such as a UNICEF-sponsored program in Benin that trains community workers to diagnose and treat pneumonia. While he acknowledged that health ministries frequently oppose this approach as unsafe, Victora claimed these programs can be successful and carry little risk of negative health outcomes.
Many countries are singularly focused on reaching the MDG benchmarks, but Victora warned, "You can reach the MDGs by preferentially increasing coverage and reducing mortality among the rich … but the poor will be left behind." Therefore, increasing equity must be the overarching goal, he said, adding that it need not be prohibitively expensive.
Toward a Fuller Understanding of Poverty
Columbia University's Lynn Freedman suggested "that poverty is not just about deficit. It's not just about what you don't have: you don't have money; you don't have food; you don't have education, even—but that poverty is fundamentally relational. It's about interactions with structures of power." She cited a 2000 report from the World Bank in which respondents cited neglect, abuse, voicelessness, and exclusion as part of the experience of poverty.
Freedman called the health system a core social institution and "a building block of a democratic society." As such, she argued that it should move beyond simply providing services to actively addressing inequities. For example, the National Rural Health Mission (NRHM), a program launched in India in 2005, created the Janani Suraksha Yojana (JSY) scheme to address what the government considered an unacceptably high level of home births. The JSY scheme pays women 700 rupees, or about $12, to deliver in a clinic, and offers 600 rupees, or about $10, to the health care worker who brings the woman to the facility.
Superficially, this program appears to be a success. "Institutional delivery rates have skyrocketed," said Freedman, but anecdotal evidence suggests that the program is not producing the desired effects. Some women report that their husbands have sent them, in labor and alone, to collect the reward for giving birth in these facilities, and that they have returned home only hours after delivering. Reportedly, some clinics are small and use inferior equipment; few, if any, skilled workers are available to assist the women.
Freedman's assessment of the JSY scheme is mixed. While it may be successful in some parts of India, "it has not actually dealt with the whole range of power and other problems that make it so that in many parts of India, there are no institutional delivery services." She warns that such programs limit their impact by "not looking at the whole range of dynamics that makes a health system function" properly.
Victora and Freedman both called on health care systems to address broad societal inequities. As part of a larger governance framework, health care systems can begin to remove some of the layers of neglect, abuse, and exclusion that prevent the poor from receiving equal care. "And that," said Freedman, "is what we mean when we talk about strengthening health systems to reach the poor." The important goal, she said, is "not just reaching them, but addressing poverty" in all its forms.
Drafted by Sonia Schmanski and edited by Rachel Weisshaar.
- Director, Averting Maternal Death and Disability Program; Professor of Clinical Population and Family Health, Mailman School of Public Health, Columbia University
- Visiting Professor, Department of International Health, Bloomberg School of Public Health, Johns Hopkins University