Equity and health sector reforms
Date: Wednesday, September 19 @ 15:48:38 EEST
Topic: Resources
Margaret Whitehead, Göran Dahlgren, Timothy Evans
Equity and health sector reforms: can low-income countries escape the medical poverty trap?
Lancet 2001; 358: 833-36
Department of Public Health, University of Liverpool, Liverpool, UK (Prof M Whitehead PhD); Swedish National Institute of Public Health, Stockholm, Sweden (Prof Göran Dahlgren MA); and Health Equity Division, The Rockefeller Foundation, New York, NY, USA (Timothy Evans MD)
Correspondence to:
Prof Margaret Whitehead, Department of Public Health, University of Liverpool, Whelan Building, The Quadrangle, Liverpool L69 3GB, UK e-mail
In the past two decades, powerful international trends in market-oriented health-sector reforms have been sweeping around the world, generally spreading from the northern to the southern, and from the western to the eastern hemispheres. Global blueprints have been advocated by agencies such as the World Bank to promote privatisation of health-service providers, and to increase private financing--via user fees--of public providers. Furthermore, commercial interests are increasingly promoted by the World Trade Organisation, which has striven to open up public services to foreign investors and markets.1-3 This policy could pave the way for public funding of private operators in health and education sectors,2 especially in wealthy, industrial countries in the northern hemisphere.
Although such attempts to undermine public services pose an obvious threat to equity in the well established social-welfare systems of Europe and Canada, other developments pose more immediate threats to the fragile systems in middle-income and low-income countries. Two of these trends--the introduction of user fees for public services, and the growth of out-of-pocket expenses for private services--can, if combined, constitute a major poverty trap.
Private finance for public services
Introduction of user fees for public services has become entrenched in many developing countries since publication of the World Bank policy document of 1987.4 This strategy was part of a health-policy package, which in turn was one component of common macroeconomic structural-adjustment programmes for countries facing debt.5 The World Bank strategy has been powerfully reinforced by the practice of making user fees a condition of loans and aid from international donors, for example, in Kenya and Uganda.
Private financing of public health services has also increased in countries with high and stable economic growth rates, such as China and Vietnam. Privatisation is claimed to increase the public's appreciation of health services and prevent overuse.4 Fees are assumed to offer financial possibilities to health providers for improvement of quality of services.6
Such privatisation policies in health care, however, are highly regressive, because pooling of risk is reduced and care costs fall more directly on the sick (who are most likely to be poor, children, or elderly), than on healthy individuals. The World Bank's counter-argument was that revenues from user fees could be used to subsidise those least able to afford care.7 Exemption schemes were proposed to get round the difficulty of poor people not being able to afford essential services. During the 1990s, the World Bank predicted that in one sweep, this user-fee policy would improve poorer groups' access to and use of essential health services.7 Why then is there widespread dissatisfaction with this policy in developing countries? The answer lies in the actual, rather than the predicted, effects experienced by families and communities.
Out-of-pocket expenses for private services
A second trend reinforcing the effect of user charges in the public sector, is the increase in private medical practices, and an explosive growth in private pharmacies.8 In developing countries, pharmaceutical drugs now account for 30 to 50% of total health-care expenditure, compared with less than 15% in established market economies.9 Private drug vendors, especially in Asia and parts of Africa, tend to cater for poor people who cannot afford to use professional services. These vendors, who are often unqualified, frequently do not follow prescribing regulations. In parts of China and India, drug vendors can be found on nearly every street corner.10 Limited access to professional health services, and aggressive marketing of drugs on an unregulated market have not only generated an unhealthy and irrational use of medicines, but also wasted scarce financial resources--especially, among poor people.
Medical poverty trap
The positive assumptions on which these strategies have been based are not borne out by the evidence. Results of empirical studies on the effects of these policies point to severe negative consequences.11,12 Rises in out-of-pocket costs for public and private health-care services are driving many families into poverty, and are increasing the poverty of those who are already poor. The magnitude of this situation--known as "the medical poverty trap"--has been shown by national household surveys and participatory poverty alleviation studies.11,13-16 The main effects fall into four categories.
Untreated morbidity
The most severe effects are felt by those who are denied services because they cannot afford them and whose sickness goes untreated. Such people are at risk of further suffering and deterioration in health. In the Caribbean, between 14 and 20% of people who reported illness indicated that they did not seek care because of lack of funds for treatment or transport.17 In the Kyrgyz Republic, more than half the patients referred to hospital were not admitted, because they could not afford hospital costs.15 In some Indian rural areas, 17% of people who reported illness did not seek care, of whom more than a quarter cited financial reasons.18
Untreated sickness among poor people is recorded not only in countries with serious economic difficulties, but also in those with high and stable economic growth. For example, access to essential health services in rural China was renowned, but has been drastically reduced despite a yearly economic growth rate of almost 10% in the past two decades. In household surveys in rural China, 35-40% of people who reported that they had had an illness did not seek health care, with financial difficulties cited by poor people as the main reason.13,19 Additionally, 60% of those referred to hospital by a doctor never contacted the hospital because they knew they could not afford to pay the high user charges.13 Costs to individuals and society from untreated morbidity are potentially devastating.
Reduced access to care
Introduction of high user fees has typically caused an indiscriminate reduction in access to care. The United Nations Research Institute for Social Development has recently summarised the experiences of user fees: "Of all measures proposed for raising revenue from local people this [user fees] is probably the most ill advised. One study of 39 developing countries found that the introduction of user fees had increased revenues only slightly, while significantly reducing the access of low-income people to basic social services. Other studies have shown that fees reinforce gender inequality.20 Poor people delay seeking care until an emergency situation arises, because of financial constraints.11 This delay often forces them eventually to seek care at a more expensive level, typically at a hospital, rather than at a health centre. The negative effects of user fees are therefore two-fold: poorer health and increased medical expenditure. High user fees are thus inefficient and inequitable.
However, advocates of private finance argue that negative effects of user fees are not inevitable. Efficient and fair systems for waiving user fees could be established, and thereby secure access to public health-care services for those not able to pay.7 In practice, establishment of well functioning systems for waiving fees has proved very difficult.21 A major difficulty is to identify very poor people in a population in which poverty is rife. Another difficulty is that no public funds are set aside to compensate local providers for reduction or elimination of fees for some of their poorer patients. Public health-care providers, who depend on revenue from fees, are likely to start to give priority to patients who can pay. In many countries, this trend is reinforced because revenue from fees is directly linked to health staff payments and salaries.22 In such a financial climate, public hospitals tend to favour rich people, who generally gain greater shares of public funds than poor people.
Long-term impoverishment
People buy care even if it costs them their long-term livelihood, because medical expenses are often forced payments. Their difficulty is not in allocation of scarce resources, but rather whether or not they can find money for urgent treatment such as surgery. The negative social effects of direct user fees for health care are also greater than most other fees, because these expenses are unexpected and total cost is often not known until after treatment.
The economic effect of ill health has long been a cause of bankruptcies in the USA,23 but in the 1990s, ill health became a leading cause of household impoverishment in transitional economies, such as rural China,13 and some of the Asiatic republics of the former USSR.15 Poor households reporting illness in a rural area in northern Vietnam, spent an average 22% of their household budget on health-care costs, whereas rich households spent 8%.14 Moreover, poor people tended to pay more than rich people at a health centre, and poor communes charged more than rich communes.24 In Thailand, poor people also pay proportionally more for health care than rich people.25 So-called free maternity services in Dhaka, Bangladesh, have hidden and unofficial payments that necessitate more than a fifth of families spending the equivalent of 50-100% of their monthly income on maternity care.16 In Vietnam, the average cost of hospital admission is the equivalent of 2 months' wages,14 and in rural China, hospital care costs up to seven times the net monthly income of a poor household.26
Loans and debt are common consequences of such expenses. In rural North Vietnam, 60% of poor households were in debt, with a third citing payment for health care as the main reason.24 Similar patterns of debt occur in parts of Africa, China, and Cambodia. In Phnom Pen, Cambodia, 20% of patients who had obtained money for treatment costs had taken out loans from private lenders, and were paying extortionate interest of 20-30% per month. 10% of these patients cut down on food to offset the cost of borrowing. In two rural districts of Uganda, between 20% and 40% of patients raised money for health-care bills not only by borrowing, but also by working for others, or selling off assets such as land or cattle. Withdrawal of children from school is another common coping strategy--to save on school fees and so that children can help out on the farm while parents seek temporary jobs to pay off loans for hospital bills.11 In traditional economic analyses, poorer groups' payment for health care is typically used as evidence of willingness to pay. However, it is increasingly clear that payment is not the same as ability to pay. Many poor people cannot afford to pay, but still do so, at great long-term cost to themselves and their families.
Irrational use of drugs
Irrational prescribing and drug resistance make an important, but overlooked, contribution to the inequities of the medical poverty trap. For example, in India, 52% of out-of-pocket health expenditure went towards medicines and fees, as did 71% of in-patient expenditure.18 People in parts of rural China spend between two and five times the average daily-per-capita income on a typical prescription.27 In a growing number of low-income countries, profits from sales of drugs have become an important part of health-related workers' incomes, and an incentive for workers to increase sales to their maximum.28
Increasingly, in developing countries, sale of drugs without prescription by unqualified people, who have financial incentives to overprescribe, leads to unnecessary and irrational use of medicines. In rural areas and poor quarters of cities in India, indiscriminate prescription of injections and drips is rife. For example, in an analysis of prescriptions in the Indian district of Satara in Maharashtra,29 19% of prescriptions were thought irrational, 47% were unnecessary, and 11% were hazardous. Unnecessary injections were given in 24% of cases. Up to 70% of all expenditure on drugs in India is thought unnecessary.18
In a national household survey in Vietnam, 67% of all those who reported illness in the previous 4 weeks had obtained medicines without consultation with a medical practitioner.30 Furthermore, rural commune health-workers frequently prescribed oral antibiotics, gentamicin injections, potent steroids, and oral and intravenous vitamin preparations inappropriately.31 Vietnam's high frequency of antibiotic resistance is a clear indication of the adverse health effects of inappropriate drug sales and irrational consumption.32 In a poor region of Mexico, 74% of health-care visits resulted in inadequate treatment or advice, especially from traditional healers or retail drug sellers.33 On average, the equivalent of 13 days minimum wage was spent unnecessarily per patient, in 1 month, because of inadequate prescribing.33
Poor people receive ineffective, or even dangerous treatment, including inappropriate or inadequate antituberculosis treatment regimens,34 and contraindicated drugs for women in pregnancy.35 If people can afford only a part course of drugs (eg, for tuberculosis or malaria), these drugs are not only ineffective, but also create drug resistance that can threaten whole communities.36 The same situation occurs with widespread overprescription (or self-medication) of antibiotics for straightforward cases of diarrhoea, for which oral-rehydration therapy would be most appropriate.37 For example, in a periurban community in Mexico, antibiotics were used in 37% of diarrhoeal episodes, although this therapy was indicated in only 5% of episodes.38 In six other Latin American countries, a quarter of drugs bought over the counter should have been dispensed on a prescription, because they needed medical follow-up.39
What can be done about the medical poverty trap?
The actual outcomes of previous and current market-oriented reforms have often been contrary to stated objectives, as economic access for poor people has declined and total costs increased. These gaps between stated objectives and outcomes have shown lack of, and need for, a firmer evidence base for health-sector policies. The overall view is clouded by rhetoric and unsupported assumptions about the merits of policies that are widely advocated. There is a need for policy research to assess the validity of assumptions that underly market-oriented reforms, and the options for, and constraints on, development of efficient and equitable health-care systems.
The need to be vigilant and to ascertain what is really happening in low-income countries, rather than to rely on assumptions, is vividly illustrated by policy on user fees. Some commentators accept that the World Bank has ceased pushing user fees as a strategy in low-income countries, and therefore, that this strategy is a thing of the past and no longer a problem. Unfortunately, this discredited policy is still alive and well, and causes immense distress in many countries of the southern hemisphere. Noting the persistence of this policy, the US House of Representatives approved a measure in July, 2000, to pressure the World Bank to stop requiring impoverished countries to charge "user fees" for basic health services and primary education. This opens up an opportunity to influence the user-fee policy of the Bank, by use of the best evidence available, although that evidence has yet to be fully marshalled.
Apart from the user-fee issue, other aspects of reforms are proving pernicious to poor people, and require a much more active approach to monitor trends in the health sector; one such approach, termed an equity gauge, is already underway and provides a model for how this might be done.40 In this context, the potential of an essential drugs watch is being assessed, which would monitor equity and quality of countries' drug policies, raise awareness of health issues, and inform health policies.
Effects of reform efforts need to be assessed from a household perspective. What do health reforms mean for households of low, middle, and high income? How affordable are the results of different policy options for families? How do reforms affect the ability of different population groups to secure health services according to need? In such an approach, questions would also be asked about why an increasing number of households do not use available public health services, but treat themselves at home. Qualitative studies are needed to fully understand all the factors involved in these decisions. The fact that many people pay for health care has for too long been taken as synonymous with willingness and ability to pay, but with no assessment of how much of a burden payment is on the household budget.41 Affordability should have a more important place in investigation of health reform. The potential to do this type of household-focused research is increasing, because many low-income countries are undertaking national standard-of-living household surveys and various participatory poverty assessment studies.
How could the medical poverty trap be prevented? What are the policy options for prevention of medical poverty traps in different countries? The answer to these questions will be crucial in the next few years, and will need to encompass not only health-systems policy, but also broad development issues to alleviate poverty.
Furthermore, the weaknesses in public health services need to be acknowledged and tackled. Cultural access is an especial problem that encompasses: lack of responsiveness; disrespect shown towards disadvantaged groups of people; and widespread use of informal so-called under-the-table payments, which all contribute to underuse of public services in some low-income countries. This underuse is also caused partly by chronic under-resourcing, partly by the ways staff treat patients, and partly by indirect costs of service use, such as transport and loss of income.22,42 Furthermore, public hospital services are mainly used by better-off people, who can afford high direct costs. This tendency to crowd out less-privileged people is reinforced in times of economic recession, when rich people find paying the market price for private health-care services difficult to afford. The way forward is certainly country specific, but policy-oriented research is needed to assess the most promising options.
Such options include strategies for public finance that encompass tax polices and tax evasion, to ensure effective pooling of risks across the whole population. Also needed is gradual change from direct payments to social health-insurance systems, in which healthy, high-income groups subsidise care for low-income groups. These insurance systems would include community-based health insurance subsidised by public funds, which could also cover costs for essential drugs. Efforts should be intensified to reduce, and even eliminate, informal payments for public health-services. Ways of strengthening the regulatory role of governments should be investigated, to empower governments to develop and implement essential drug programmes and systematic assessments of medical technologies. This shift in power could ensure the highest possible value for money spent on health services and drugs in terms of improved health, minimum negative side-effects, and reductions in inequities in access to care.
At the international level, financial institutions should focus on how to tax rich rather than poor people--for example, by promotion of a tax on funds hidden in tax-free offshore accounts. If these off-shore deposits (estimated by International Monetary Fund to be around US$8 trillion) earned income of around 5% per year, which was taxed at 40%, about US$160 billion per year would be raised--estimated to be more than the cost of providing basic social services for developing countries.20
Conclusion
An evidence-based approach to secure efficient, equity-oriented health-sector reforms is long overdue, but would require policy makers to refocus their efforts on many fronts.43 The research community has an important part to play in distinguishing myths from realities, and making explicit the underlying values of proposed policies.44 People studying health systems should widen their perspective to include links with poverty-alleviation strategies, and vice versa. Above all, a shift in perspective is needed to give greater emphasis to equity when assessing the effects of any proposed policy changes on health and social wellbeing of families. In particular, changes need to be reviewed with poorer, more vulnerable sections of society in mind, to ensure that these groups are winners and not losers in global health-policy reform.
Contributors
Margartet Whitehead, Göran Dahlgren, and Timothy Evans generated the original idea, developed the approach, appraised the evidence, agreed on the structure, and contributed to the writing of the paper. All three authors read and approved the final manuscript.
Acknowledgments
We thank all participants of the expert consultation at Rockefeller Foundation Study Centre, Bellagio, Italy, July, 2000, for their insight in discussions on equity and health-sector reforms: Celia Almeida, Lincoln Chen, Andrew Creese, Davidson Gwatkin, Benjamin Nganda, Di McIntyre, Martin McKee, Harry Minas, Myrtle Perera, Malcolm Segall, Gita Sen, Karl Theodore, and Meg Wirth. Margaret Whitehead and Göran Dahlgren were funded by Rockefeller Foundation planning grant number RG 99037 number 4 to develop an international programme of research on equity and health-sector reforms.
References
1 Price D, Pollock AM, Shaoul J. How the World Trade Organisation is shaping domestic policies in health care. Lancet , 1999; 354: 1889-92. [Text]
2 Pollock A, Price D. Rewriting the regulations: how the World Trade Organisation could accelerate privatisation in health-care systems. Lancet, 2000; 356: 1995-2000. [Text]
3 Anon. Trading public health for private wealth. Lancet 2000; 356: 1941.
4 Akin J, Birdsall N, Ferranti D. Financing health services in developing countries: an agenda for reform. Washington: World Bank, 1987.
5 Sen K, Koivusalo M. Health care reforms and developing countries--a critical overview. Int J Health Plann Manage 1998; 13: 199-215. [PubMed]
6 Griffin D. Welfare gains from user charges for government health services. Health Policy Plan 1992; 7: 177-80. [PubMed]
7 Shaw P, Griffin C. Financing health care in sub-Saharan Africa through user fees and insurance: directions in development. Washington: World Bank, 1995.
8 Paphassarang C, Tomson G, Choprapawon C, Weerasuriya K. The Lao national drug policy: lessons along the journey. Lancet 1995; 345: 433-35. [PubMed]
9 Velásquez G, Madrid Y, Quick J. Health reform and drug financing: selected topic--health economics and drugs DAP Series No 6. WHO/DAP/98.3, action programme on essential drugs. Geneva: World Health Organisation, 1998.
10 Kamat V, Nichter M. Pharmacies, self-medication and pharmaceutical marketing in Bombay, India. Soc Sci Med 1998; 47: 779-94. [PubMed]
11 Tipping G. The social impact of user fees for health care on poor households: commissioned report to the Ministry of Health, Hanoi, Vietnam; 2000.
12 Creese A, Kutzin J. Lessons from cost-recovery in health. Discussion Paper No 2. Forum for Health Sector Reform. Geneva: World Health Organization, 1995.
13 Fu W. Health care for China's rural poor, international policy programme. Washington: World Bank, 1999.
14 Segall M, Tipping G, Lucas H, et al. Health care seeking by the poor in transitional economies; the case of Vietnam: research report no 43. Sussex: Institute of Development Studies, 2000.
15 World Bank. The Kyrgyz Republic: participatory poverty assessment, prepared for the global synthesis workshop poverty programme. Washington: World Bank, 1999.
16 Nahar S, Costello A. The hidden cost of "free" maternity care in Dhaka, Bangladesh. Health Policy Plan 1998; 13: 417-22. [PubMed]
17 Theodore K. Health sector reform and equity in Jamaica: report to the Pan-American Health Organisation. Washington : PAHO, 1999.
18 Iyer A, Sen G. Health sector changes and health equity in the 1990s in India. In: Roghuram S, ed. Health and equity: technical report series 1.8. Bangalore: HIVOS, 2000.
19 Hao Y, Suhua C, Lucas H. Equity in the utilization of medical services: a survey in poor rural China. IDS Bull 1997: 28.
20 United Nations Research Institute for Social Development (UNRISD). Visible hands--taking responsibility for social development. Geneva: UNRISD, 2000.
21 Russell S, Gilson L. User fee policies to promote health service access for the poor: a wolf in sheep's clothing? Int J Health Services 1997; 27: 359-79. [PubMed]
22 McPake B, Asiimwe D, Mwesigye F, et al. Informal economic activities of public health workers in Uganda: implications for quality and accessibility of care. Soc Sci Med 1999; 49: 849-65. [PubMed]
23 Gottlieb S. Medical bills account for 40% of bankruptcies. BMJ 2000; 320: 1295.
24 Ensor T, Pham S. Access and payment for health care. The poor of Northern Vietnam. Int J Health Plann Manage , 1996; 11: 69-83. [PubMed]
25 Pannarunothai S, Mills A. The poor pay more: health-related inequality in Thailand. Soc Sci Med 1997; 44: 1781-90. [PubMed]
26 Yu H, Cao S, Lucas H. Equity in the utilisation of medical services: a survey in poor rural China. IDS Bull 1997; 28: 16-23. [PubMed]
27 Zhan S, Tang S, Guo Y. Drug prescribing in rural health facilities in China. IDS Bull 1997; 28: 66-70. [PubMed]
28 Wolffers I. The role of pharmaceuticals in the privatization process in Vietnam. Soc Sci Med 1995; 41: 1325-32. [PubMed]
29 Phadke A. The quality of prescribing in an Indian district. Natl Med J India 1996; 9: 60-65. [PubMed]
30 Prescott N. Poverty, social services and safety nets in Vietnam: World Bank discussion paper no 376. Washington: World Bank, 1997.
31 Tipping G, Truong V, Nguyen T, Segall M. Quality of public heath services and household health care decisions in rural communes of Vietnam. IDS report no 27. University of Sussex: Institute of Development Studies, 1994.
32 Törnqvist N, Wenngren B, Nguyen TKC, et al. Antibiotic resistance in Vietnam: an epidemiological indicator of inefficient and inequitable use of health resources. In: Hung PM, Minas IH, Liu Y, Dahlgren G, Hsiao WC, eds. Efficient equity-oriented strategies for health: international perspectives--focus on Vietnam. CIMH: University of Melbourne, 2000.
33 Briggs J. The economic consequences of inadequate prescribing on health care users and providers: a case study in San Cristobel, Mexico. Liverpool: Liverpool School of Tropical Medicine, 2000.
34 Uplekar M, Shepard D. Treatment of TB by private GPs in India. Tuber Lung Dis 1991; 72: 284-90. [PubMed]
35 Krause G, Borchert M, Benzler J, et al. Rationality of drug prescriptions in rural health centres in Burkina Faso. Health Policy Plan 1999; 14: 291-98. [PubMed]
36 Farmer P, Reichman L, Iseman M, eds. The global impact of drug resistant tuberculosis. Boston: Harvard Medical School/Open Society Institute, 1999.
37 Le Grand A, Hogerzeil H, Haaijer-Ruskamp F. Intervention research in rational use of drugs: a review . Health Policy Plan , 1999; 14: 89-102. [PubMed]
38 Bojalil R, Calva J. Antibiotic misuse in diarrhea: a household survey in a Mexican community. J Clin Epidemiol 1994; 47: 147-56. [PubMed]
39 Drug utilization research group, Latin America. Multicenter study on self-medication and self-prescription in six Latin American countries. Clin Pharmacol Ther , 1997; 61: 488-93. [PubMed]
40 Health Systems Trust. Equity gauge: an approach to monitoring equity in health and in health care in developing countries. Report of an international meeting 17-20 Aug, 2000. Durban: Health Systems Trust, 2000.
41 Evans TG. Socioeconomic consequences of blinding onchocerciasis in West Africa. Bull World Health Organ 1995; 73: 495-506. [PubMed]
42 Bloom G, McIntyre D. Towards equity in health in an unequal society. Soc Sci Med 1998; 47: 1529-38. [PubMed]
43 Whitehead M, Dahlgren G, Gilson L. Developing the policy response to inequities in health: a global perspective. In: Evans T, Whitehead M, Diderichsen F, Bhuiya A, Wirth M. Challenging inequities in health: from ethics to action. New York: Oxford University Press, 2001.
44 Segall M. From co-operation to competition in national health systems--and back? Impact on professional ethics and quality of care. Int J Health Plan Manage 2000; 15: 61-79. [PubMed]
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