Elsevier

The Lancet

Volume 364, Issue 9441, 2–8 October 2004, Pages 1273-1280
The Lancet

Series
Making health systems more equitable

https://doi.org/10.1016/S0140-6736(04)17145-6Get rights and content

Summary

Health systems are consistently inequitable, providing more and higher quality services to the well-off, who need them less, than to the poor, who are unable to obtain them. In the absence of a concerted effort to ensure that health systems reach disadvantaged groups more effectively, such inequities are likely to continue. Yet this situation need not be accepted as inevitable, for there are many promising measures that might be pursued: establishment of goals for improved coverage in the poor, rather than in entire populations, and use of those goals to direct planning toward the needs of the disadvantaged; use of one or more of the several techniques that seem to have been effective in at least some of the settings where they have been tried; and empowerment of poor clients to have a more central role in health system design and operation.

Section snippets

Public and private components of health systems

The growing attention paid to government services of developing countries over the past few years has produced a set of findings that indicate clearly that such services usually favour the better-off. The record of private services has not been nearly so well established, but they seem to be even more oriented toward higher-income groups.

The attention given to government services has focused especially on curative care provided through government facilities supported by general tax revenues.

Specific services delivered through health systems

Maternal and child health services, for which the most detailed information is available, are usually regressive. This also seems to be the case for most chronic disease programmes. Primary care, although regressive in most countries, generally seems less so than higher-level services.

The most complete set of information about the use of maternal and child health services is summarised in figure 2. The data presented show the coverage rates, from public and private programmes together, for six

The nature of the challenge

Judged by the standard definition of health service equity, which suggests that access to services should correspond to the need for them, the situation just described is clearly inequitable. So inequitable, some might plausibly argue, that drastic measures are called for to redistribute existing health services to right the imbalance—perhaps by closing down government hospitals in high-income urban areas and applying the recurrent cost savings to the distribution of free basic pharmaceuticals

Ways to meet the challenge

If one accepts the proposition that it will be a substantial challenge to ensure that the poor receive the highest possible proportion of increased services made available through progress toward national health development objectives, what can be done to meet the challenge? Thus far, this question has been asked so infrequently that there is no complete or fully satisfying answer. However, several initial steps can be suggested that, if not entirely proven, are at least plausible on the basis

Health system objectives

Typically, such health system output objectives as exist have been stated in terms of raising population average coverage rates. Since overall coverage can be raised through coverage increases in any subgroup of the population, whether well-off or poor, progress toward an increased average does not necessarily mean that the poor are benefiting substantially. In fact, as illustrated in figure 3 with respect to an increase in average attended delivery coverage, the better-off could well be the

Applications of lessons learned

Important as revised objectives and monitoring might be for focusing attention, revising them does not in itself change the proportion of service programme benefits that accrue to the poor. A change in the distribution of benefits, which is what counts, needs modified service delivery approaches.

Efforts to find modified approaches have begun to accelerate, and these have produced growing numbers of instances where services delivered through health and other systems are considerably more

Empowering poor clients

Most if not all of the experiences described above were mainly supply-driven—eg, designed and initiated mainly by those who operate health systems and supply health services. An alternative, complementary approach is to focus on creating an effective demand and pressure for relevant health services on the part of the poor, to counterbalance the influence of well-off groups that traditionally define priorities and design programmes.

A prominent illustration of the empowerment approach is the

Conclusion

In brief, health systems are consistently inequitable, providing more and higher quality services to the well-off who need them less than the poor who are unable to obtain them. In the absence of a concerted effort to ensure that health systems reach disadvantaged groups more effectively, such inequities are likely to continue. Yet these inequities need not be accepted as inevitable, for there are many promising measures that can be pursued: establishing goals for improved coverage in the poor,

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