Introduction: why is health inequity an issue?
Well-being is profoundly impacted by many social and economic determinants. Clearly, access to basic needs such as food, water, shelter, education, decent employment, safe working conditions, and so on are crucial to health. But even many higher-order needs such as social inclusion, involvement in governance issues such as policy development (e.g. on human rights and gender equity), the right to critique unfair administration, or participate in the exercise of political power are also important. Indeed, well-being is so tightly linked to the broad ecology of social determinants, it has become increasingly evident that the health of a population is fundamentally dependent on fair access to social goods and processes within the society. Health equity and social justice are interlinked. Well-being depends on fairness (McKeown 1976; Acheson 2000; Deaton 2003; Wilkinson and Marmot 2005). While the insight may not be new, what is of contemporary relevance is that the causes of health inequity, once thought to be beyond the realms of intervention, are now routinely being considered for inclusion within the parameters of progressive health programming. Close examination of the evidence by expert groups has indeed shown that effective interventions to address injustices in the socioeconomic conditions underpinning health are not only possible, but warranted. Where avoidable systematic disparities in health occur in situations which could be avoided by reasonable, timeous action, then they can be judged as unfair. This unfairness can be labelled as health inequity. These insights formed the basis for the conclusions and recommendations of the Commission for Social Determinants of Health (CSDH) (CSDH 2008), which are discussed in some detail in the following sections.
Health equity relates to the fairness in distribution of health resources and outcomes. This applies both to equity between citizens in specific countries (intra-country) as well as between countries (inter-country) or regions (inter-regional). The World Health Organization (WHO) defines health inequalities as ‘differences in health status or in the distribution of health determinants between different population groups’ (Quigley et al. 2006; WHO n.d.). Putting right these inequities—the huge and remediable differences in health between and within countries—is a matter of social justice, founded on the linked concepts of fairness, justice, and freedom. These ideas echoed the sentiments of strong equity advocates such as Amartya Sen (Sen 1999), who for many years had argued that freedom from poverty, social deprivation, political tyranny, and cultural authoritarianism was crucial if the social and economic development to which all countries aspire was to be achieved. Inequity was anathema for socioeconomic well-being. Development was therefore dependent on social justice, founded on a system of supportive institutions and all citizens having access to basic education and essential health. For John Rawls (Rawls 1958), justice is fairness.
Absolute and relative health inequalities and socioeconomic status
There are health inequities everywhere, but they are more pronounced in certain settings. Rather than viewing this in terms of absolute differences between rich and poor they should be understood as comprising relative social gradients. It follows that where societal resources are maldistributed by elements such as income, class, spatial location, race, and gender, population health will correspondingly be unequally distributed. Interventions to deal with these are discussed in the section entitled ‘Tackle the inequitable distribution of resource and power’.
Improving health inequalities by addressing social determinants
One of the earliest attempts to understand health inequity dates back to the work of Edwin Chadwick, a leading figure in the effort to investigate and combat the considerable differences in health that existed in nineteenth-century Britain. Documented in his famous report on Enquiry into the Sanitary Condition of the Labouring Population of Great Britain and the Means of its Improvement (Chadwick 1843) was a description of the awful living conditions endured by the poorest in society compared to those that were relatively well off (Table 2.4.1). The findings of his report helped pave the way for the introduction of the Public Health Act of 1848 in Britain.
Table 2.4.1 Key finding of Edwin Chadwick’s report
Average age of deceased
Gentry and professional persons
Tradesmen and their families
Labourers, mechanics, and servants
Gentry and professional persons
Tradesmen and their families
Labourers, mechanics, and servants
Reproduced from Edwin Chadwick, Report on the Sanitary Condition of the Labouring Population of Great Britain: A Supplementary Report on the results of a Special Inquiry into The Practice of Internment in Towns, printed by R. Clowes and Sons, for Her Majesty’s Stationery Office, London, UK, 1843.
Despite progress in public health for more than a century and a half, even in developed countries such as Britain, health inequalities continue to persist. Unsurprisingly they present among the biggest of global health challenges.
One of the most significant efforts to counter health inequalities was the ‘Health for All’ (HFA) programme of the WHO, which was based on the 1978 Alma Ata Declaration, which set out the principles of primary healthcare (PHC). This approach introduced a radically new equitable approach to the provision of health services which was of particular relevance to developing countries. During the 1980s this approach became the impetus for health activities based on addressing the range of factors impacting on well-being. Increasingly the social and economic determinants of health became a focal point of HFA programmes (WHO 2003). There were setbacks, however, when a downturn in global economic conditions, accompanied by adverse conditions in developing countries, slowed and in some cases, reversed progress. Sadly, despite growing attention, increased global funding as well as innovative programming, the problem of inequity in health systems is little better. In fact, despite the considerable efforts to achieve the Millennium Development Goals (MDGs), the prospects of achieving these by 2015 is unlikely. A new paradigm is needed to deal with the powerful forces that have shaped and will continue to shape the world health scene. Without such a change, inequity and health injustice will persist (Gostin 2012).
Quite what a new post-MDG framework focused on global health justice will look like is not yet clear, despite the attention that the issue is receiving from many groups. One example of a promising approach, however, is that being pursued by the Joint Action and Learning Initiative on National and Global Responsibilities for Health (JALI). As a global coalition of civil society and academics, JALI is championing an international campaign of advocacy for a Framework Convention on Global Health (FCGH). Its approach includes novel ideas such as defining both national and international responsibilities to improve health equity by setting global health priorities and arguing for reliable, sustainable funding; overcoming fragmented activities; reshaping global health governance; and providing strong global health leadership through the WHO (UN Millennium Project 2005).
The WHO Commission on Social Determinants of Health
In an effort to address the social, economic, and environmental conditions that impact on health and cause health inequity, in 2005, the WHO established the Commission on Social Determinants of Health1 (CSDH) to provide context-specific advice for regions, countries and global health partners (Gostin 2012; The Commission on Social Determinants of Health Knowledge Networks 2011).
Some novel WHO activities have grown out of the insights of the CSDH and several are now global initiatives. The three focal areas of the CSDH findings are to: (1) improve daily living conditions, (2) tackle inequality in the distribution of resources and power, (3) understand and measure the extent of health inequity and take action.
These three focal areas have become the pillars for reducing health inequities, which may require attention in several dimensions such as equality of rights and opportunities as well as equity in living conditions to achieve fairness in distribution.
Improve daily living conditions
Promote equity from conception
Child development begins with the health of the mother during pregnancy. Once born, many factors may affect the child in its physical, social, emotional, linguistic, and cognitive milieu. All of these critically influence the growth, development, and health of the child. Any may influence the child’s life chances and affect well-being, education, and occupational opportunities. In turn, such factors affect diverse risks of individual propensity to obesity, malnutrition, mental health disorders, cardiovascular diseases, and criminality.
The evidence suggests that pre- and postnatal interventions reduce health inequalities and improve maternal and child health outcomes, particularly if these are aimed at the poorest quintiles in low- and middle-income countries (Carrera et al. 2012; Chopra et al. 2012; Countdown 2012 Report Writing Group 2012).
Provide a more equitable start in early life
A comprehensive approach to early life, built on the experience of existing child survival programmes, but including also early learning activities to stimulate social/emotional and language/cognitive development is important. Increased coverage of high-impact child survival interventions such as skilled birth attendants, measles vaccination, treatment of childhood diarrhoea and pneumonia, provision of insecticide-treated bednets for children, offering nutrition support, and introducing appropriate socioeconomic measures can all have these effects. The outcomes may reduce neonatal morbidity as well as longer-term reductions in stunting and underweight (Amouzou et al. 2012; Victora et al. 2012).
Create healthy places for people
The environments where people live and work profoundly affect their lives and well-being. Taking action to promote fair planning and improving habitats in both rural and informal urban areas through proactive town planning is essential for long-term health equity. Sustained investment in rural development, removing exclusionary policies and processes that lead to rural poverty, dealing with landlessness, and reducing the displacement of people from their homes are all measures that improve the settings in which people live and work. Climate change and other policies or programmes to prevent environmental degradation should also take health equity into account.
Meaningful employment and decent work
Unemployment is one of the major determinants of health inequity.
Meaningful employment and work opportunities for disadvantaged populations profoundly affects health equity. When people have jobs they value the opportunity for work as this boosts their self-esteem and provides financial security. This in itself may be a prerequisite to self-development, enhancement in social standing, and better relationships both within the family and society. Working people are less vulnerable to physical dangers and societal hazards such as alcohol dependency. Unemployment, precarious employment, indecent work, or poor working conditions can result in the opposite with damage to self-esteem, and exposure to a variety of social ills including the need to engage in transactional sex, sell or use drugs, or resort to crime.
Actions to make full and fair employment, as well as decent work, the cornerstones of national and international social and economic policymaking are crucial to achieving health equity. Improving working conditions for all workers reduces accidents, minimizes harmful exposures to material hazards, decreases work-related stress, and diminishes health-damaging behaviours. If health equity is to be achieved, safe, secure, fairly paid, all- year-round work opportunities, and a sound work–life balance are basic needs for all citizens.
Social protection throughout the full life cycle
People of all ages, whether they are infants, toddlers, children, adolescents, young people, working adults, or older persons, need social protection. Everyone is at all times vulnerable to adverse life events which can strike even those who are well endowed. Especially during periods of grave disturbances in their lives such as catastrophic diseases, disabilities, and unemployment, social protection is important.
All governments should be proactive in creating social protection policies that mitigate the impacts of life-disturbing events that may affect individuals.
Comprehensive social protection should include the public provision of basic utilities such as free or low-cost water, sanitation, electricity, housing services, as well as education, health, and welfare services. Provision of such public goods and services, also known as the social wage, comprises the building blocks of a fair and just society.
The health system itself can be considered a social determinant of health. While a good system with a well-trained, capable, and motivated workforce can improve health equity, a poor system may make things worse by imposing costs through out-of-pocket expenses without offering sufficiently good care. This can delay or deny health services and may also aggravate poverty. To deal with this, the action that is necessary is for governments to strive to provide universal health coverage of sound quality based on the principles of PHC. This would include the provision of equitable, accessible, appropriate, affordable services focused on health promotion, disease prevention, and multi-sectoral social development in which citizens are active participants.
Tackle the inequitable distribution of resources and power
Health equity in policies and programmes
All dimensions of societal activity, the economy and finance, education, sanitation, housing, transport, employment creation, and so on, have the potential for affecting health and well-being of the population and individuals. Socioeconomic status (SES) and health are associated across a continuous gradient at all levels (Alder et al. 1994), and not just at the extremes of wealth and poverty. This relationship is true whether measured as income, employment, education, residential environment, social status, occupation, or other stratifications. Action requires placing responsibility for action-on-health and health equity at the highest level of government, to ensure its coherent implementation across all policies. This requires that ministries of health adopt a social determinants approach and develop a framework across all of its policy and programmatic functions. Indeed, ministries of health should become champions advocating adoption of the social determinants approach across government. Where such attempts at coherence are being made in developing countries, as described later under ‘National health insurance and universal coverage’, there has been opposition from many vested interests, such as the private sector, pharmaceutical companies, international corporations with investments in developing countries, and right-wing social groups. The lack of will by governments in the developing world, often buttressed by demands of their elites, exacerbates the implementation of socially just public health programmes.
Many health indicators such as standard mortality ratios, annual death rates, and infant mortality are strongly correlated with SES, even though the full explanation underlying the environmental, biological, psychosocial, and behavioural mechanisms that explain this association are not fully understood (Alder et al. 1994) (Fig. 2.4.1).
In the past researchers usually simply controlled for SES rather than attempting to change it. And even today, only the effects on lower, poverty-level SES are generally examined. Excessive wealth, for example, is not considered a problem. There might, however, in the light of recent findings, be good reasons to undertake wealth studies to supplement those on poverty and to demonstrate that greater equity is beneficial for all, even the wealthy (Wilkinson and Pickett 2010). This observation requires that fresh thinking and novel approaches about the domains through which SES may exert its health effects are needed.
Adopting the health equity paradigm requires rephrasing of commonly asked questions which challenge the structural issues underpinning inequity to shift the burden away from its ‘victims’: ‘How can we promote healthy behaviour?’ by ‘How can we target dangerous conditions and reorganize resource use and public policies to ensure healthy spaces and places?’. Instead of ‘How can we reduce disparities in the distribution of disease and illness?’ ask instead, ‘How can we eliminate differentials in the distribution of power and resources that shape health outcomes?’. Similarly, we could ask ‘What types of institutional and social changes are necessary to tackle health inequities?’ and ‘What kinds of alliance building and community organizing are necessary to mobilize and protect communities?’. This different paradigm recognizes that structural social, economic, historical, and ideological factors play a fundamental role shaping health outcomes and in the increasing health inequities that characterize many aspects of the global landscape.
There is considerable empirical evidence that health inequities are growing between the advantaged and marginalized, wealthy and poor, both within and between different countries (Dahl et al. 2002) as well as global regions (Kahn et al. 2000; Lochner et al. 2001; Deaton 2003; UC Atlas of Global Inequality 2007).
The greater the differences in health between social groups within a society or between countries the steeper the gradient or the greater the inequity (WHO 2003). This relationship between an Index of Health and Social Problems and Income Inequality has been extensively documented (Wilkinson and Pickett 2006, 2010, figure 13.1; Inequality.org 2012).
The relationship between longevity and healthcare spending in the public sector, in selected countries, at varying levels of development, is shown in Fig 2.4.2 (UC Atlas of Global Inequality 2007). Levels of development are clearly linked, unsurprisingly, to life expectancy. As important, is the group of countries (ringed) which gain years of longevity similar to those reached by the upper income countries but at much lower cost. Similar graphs with a wider spread of countries are available from the UC Atlas of Global Inequality (2007).
It is clear that above a certain threshold of health expenditure there is no commensurate benefit in life expectancy, as dramatically illustrated by the differences between high expenditures in the United States and far lesser expenditures in Singapore and Cuba. There are also discrepancies if one considers only averages. One reason for the discrepancy is that these averages mask in- equalities. Nevertheless, it is clear that disparities within countries explain the outliers as shown in the comparison of the following Gini2 coefficients (Central Intelligence Agency 2009). South Africa (Gini 65 per cent in 2005), for example, which has very high levels of inequity, has low levels of life expectancy (Weissman 1999). In comparison, Cuba (Gini 30 per cent) and Singapore (Gini 47 per cent), which have a much lower level of inequity, correspondingly have life expectancies that are as high as the wealthiest countries. And extreme wealth does not guarantee equity. For example, in the United States (Gini 45 per cent), despite the clinical excellence of its private health services, millions of Americans lack basic health insurance, and are therefore less likely to receive preventive care. In contrast, Cuba, despite its limited resources, and many economic problems, has achieved a similar longevity in its population by prioritizing the provision of universal health. It has, despite its evident lack of resources, even created very high doctor-to-patient ratios.
Public financing for the social determinants of health is fundamental to the promotion of health and prevention of disease. Public financing and the progressive achievement of universal coverage in the developed world has historically led to socioeconomic progress. Accepting that there is market failure (as, for example, in the United States), in the delivery of equitable health services and the prevention of certain diseases (public goods), public finance is therefore necessary to ensure universal access to health. As a result, strong public sector leadership and adequate budgets are the foundations of an equitable health system. Action is required to strengthen public finance for action on the social determinants of health. It means that national governments fairly allocate tax resources for implementation of the social determinants of health. A national health insurance, as one of the components of social spending, funded from progressive taxation and from other sources, should become the cornerstone of redistributive policies aimed at counteracting health inequity and reducing poverty. This is necessary at country level, but important also globally. Increased international finance for health equity, coordinated through a ‘social determinants of health action framework’, is as important as redistribution at a national or regional level. The United Kingdom, Australia, Canada, Italy, New Zealand, and Sweden are examples of developed countries in which general taxes are the main source of public funds for health services (National Audit Office 2003). In middle- and low-income countries there are several examples as well. Thailand (Evans et al. 2012), Israel (Cohen 2012), Taiwan (Chiang 1997; Cheng 2003; Lu and Hsiao 2003), Mexico (Anonymous 2012), Trinidad and Tobago (Tsountal 2009), and Chile (Government of Chile 2005) also have publicy funded schemes that provide universal access.
Using an unfettered market-orientated approach to health development is a double-edged sword. While it may assist with introducing new technologies and services which provide some benefit, it is as likely to cause unintended consequences in creating unnecessary or unhealthy goods and services, exacerbating unhealthy working conditions, and increasing health inequity by serving mainly those with financial resources.
At the international level, the World Trade Organization’s Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) provides a case in point. While efforts to protect the intellectual property rights of innovating companies has encouraged investment in drug discovery, the creation of the 20-year patent for new drugs has meant that many poor people have not been able to afford them and therefore access to novel medicines in poor countries has been limited. This contradiction was brought to the fore in the late 1990s when life-saving antiretroviral drugs were initially denied to those in developing countries because of the unreasonably high costs of the drugs. This led to an intense struggle against injustice. Although vigorous global advocacy eventually forced concessions from patent holders, TRIPS remains. Health equity in respect of access and availability to medicines will be severely challenged until there is greater flexibility or elimination of this restriction (Gwatkin and Ergo 2011; Latko et al. 2011).
Responsible governments should take steps to introduce some degree of market regulation to enable the realization of the benefits of free enterprise, while limiting the damage that could exist in a free-for-all situation. It remains important for governments to continue to play an active role in the provision of basic services essential to health (such as water, sanitation, housing, and education) and the regulation of goods and services with a major impact on health (such as medicines, medical devices, alcohol, tobacco, and food).
Gender inequities, characterized by harmful masculine norms, pervasive in almost all societies, impact significantly on child health and survival. The uneven power relationships, resources, entitlements, norms and values, as well as the way in which organizations are structured, and programmes are run, although they impact mostly on girls and women also have serious consequences for boys and men. There are innumerable ways that gender impacts on inequity whether as a result of unfair feeding patterns, violence against women, unfair divisions of work, leisure, and opportunities to improve life as well as inequitable decision-making. This ultimately leads to poor access to health resources. Profound as these gender inequities are, they are socially generated and therefore can be changed. Interventions to counter this require that the gender biases in the structures of society be challenged and new norms established in the formulation of laws and their enforcement. Also important is to reorganize the way institutions are run. Creative rethinking is necessary in regard to the development of national economic policies to close the gaps in education and skills development such that they are supportive of female economic participation. Greater spending on sexual and reproductive health services and programmes as part of universal coverage and rights are very important.
Democratic participation in a full and unrestricted manner is a very important aspect in creating an equitable society which is free of material and psychosocial deprivation. Exclusion from participatory processes is one of the key dimensions that adversely affect well-being. People’s movements and community empowerment initiatives can mitigate exclusionary social practices. Ultimately, however, although civil society and the private sector can support policies which advocate for active social inclusion, it is the government that has to adopt legislation that will guarantee citizen rights to participation. Action steps to improve this require that all groups in society be empowered to participate in democratic, participatory processes. Inclusive social practices enable civil society organizations to promote political and social rights in a way that improves health equity.
Good global governance
The huge disparities between the lives and health of people in different parts of the world are a reflection of the unequal distribution of power and wealth of different countries. While there are benefits to globalization, there are also severe consequences for the poor and this has highlighted the need for the WHO’s efforts to strengthen multi-sectoral action for development and improve global leadership to take proactive steps to tackle the social determinants of health and to institutionalize these efforts as a guiding principle.
Measure and understand the problem and assess the impact of action
The social determinants of health: monitoring, research, and training
Reliable data are essential to identify health problems and devise solutions to factors impacting the social determinants of health. This requires: ensuring that routine monitoring systems for health equity and the social determinants of health are in place, locally, nationally, and internationally; investing in generating and sharing new evidence on the ways in which social determinants influence population health equity; and on evaluating the effectiveness of measures to reduce health inequities through action on social determinants.
Differences of SES can be measured in two main ways: individual household measures and geographic/area based measures, each with advantages and disadvantages.
Individual measures use indicators such as income (personal or individual), educational levels, or occupation. Although the value of these is their specificity, often such information is not generally available. Within countries the income inequities between the top 20 per cent and the bottom 20 per cent of the population can be used for this purpose.
Geographic-based information relates to areas and although not applicable to all individuals can be applied to a group of people.
South Africa—an example measuring extreme inequality
Measuring changes in such inequalities is of great importance in monitoring and evaluating programmes designed to ameliorate this.
South Africa has the worst global indicators of inequality. One example of an approach to measure this is charting the relative deprivation of populations across districts within the country as developed by a South African non-governmental organization, the Health Systems Trust (Day et al. 2011). It ranks districts in relation to a Deprivation Index (DI) derived from a set of demographic and socioeconomic variables (see list) obtained from national General Household and Community Surveys, which are generally available in the country. These surveys provide measurements of various indicators of vulnerability:
◆ Under-5 population.
◆ Black Africans as a proportion of the total population.
◆ Female-headed households.
◆ Household heads with no formal education.
◆ Working-age population that is unemployed (not working, whether looking for work or not—the official definition of unemployment in South Africa).
◆ People living in a traditional dwelling, informal shack, or tent.
◆ Households with no piped water in their house or on site.
◆ Households with a pit or bucket toilet or no form of toilet.
◆ Households which do not have access to electricity, gas, or solar power for lighting, heating, or cooking.
A technique called principal component analysis (PCA) was then used to produce a composite index of deprivation. The objective of the PCA was to create an index of composite measurements that reflects social and material deprivation from a set of variables that are indicators of deprivation. Using the DI, the 52 districts in South Africa were then ranked into socioeconomic quintiles. Those districts that fell into the lowest quintile (the bottom 20 per cent) were the most deprived districts.
In the final part of the analysis various health problems and indicators could be correlated with the DI to provide an understanding of the impact that deprivation contributes to health inequalities. The result is displayed in a bar chart showing the districts ranked by district and grouped by quintile with unique colours for each of the nine provinces in which the districts fall. This provides a simple graphic way of illustrating the districts needing intervention.
National health insurance and universal coverage
The terms national health insurance (NHI) and universal coverage (UC) have been used interchangeably, to indicate the two essential components of an equitable health system, universal access to services at health facilities and elimination of financial barriers to care. For example, the World Health Report 2011, endorsed by the World Health Assembly, urged member states to ‘aim for affordable universal coverage and access for all citizens on the basis of equity and solidarity’ (World Health Assembly 2011). Several countries have lately developed policy proposals to pursue this goal. NHI and UC are rooted in a human rights philosophy: the right to health and the right to social security, which could, at a stretch, be extended to the rights to life and freedom. These policy tools aim at achieving social justice through establishing equity in health. These systems, common and effective in richer countries, have been introduced recently in countries at different levels of development: Brazil, Thailand, China, Mexico, Ghana, and Tanzania. Before we describe a few of the most striking examples, we dwell on the substantial difficulties in the early stages of implementation, and use South Africa, the most extreme example of inequity, as a case in point
South Africa—the legacy of colonialism and systematic oppression
South Africa, with its population of about 51 million people, has a nominal gross domestic product (GDP) per capita of US $8066 and Human Development Index (HDI) of 0.6193 and is a middle-income country. Despite almost a century-long positive engagement with the idea of a NHI and more recently a willing political leadership with a receptive population, the country illustrates the numerous hurdles to achieving UC to healthcare. South Africa, although the largest economy in Africa, has a high rate of poverty and low GDP per capita with an unemployment rate of about 25 per cent and among the top ten countries globally for income inequality as measured by the Gini coefficient. The Lancet South Africa Series in 2009 (Abdool Karim et al. 2009; Chopra et al. 2009; Coovadia et al. 2009; Mayosi et al. 2009; Seedat et al. 2009) showed clearly the residual imprint of the colonial and apartheid eras, an inequitable and inefficient health system, feeling the weight of multiple health burdens, and a backdrop of pervasive racial disparities in socioeconomic indicators, with high levels of poverty and unemployment, despite progressive policies.
The solutions proposed in the Series dealt primarily with recommendations on health systems strengthening. It was believed that these actions could be implemented from 2009 when a new administration took office, by an established and more capable Health Ministry working with functioning provincial counterparts, and a receptive population willing to participate in public health programmes.
Leadership has indeed been a critical element of change in South Africa’s recent history. Within the health management bureaucracy there has been stasis for more than 10 years (Abdool Karim et al. 2009). Weakness in the supervision and leadership of the public sector has resulted in falling performance of public servants which is a major factor in poor government delivery of health, educational, and other services. The public sector faced a shortage of staff and specialized skills, and corruption undermined state legitimacy and service delivery. Leadership flaws cause tensions in the political–administrative interface in the public service with an erosion of accountability and authority, a lack of effective organizational design, inappropriate staffing, and low staff morale (Coovadia et al. 2009).
At the highest levels, the Health Minister and his senior staff have made radical policy changes and vigorously engaged leadership and civil society. The role of managers has been identified as crucial for transformation. Some of the other major forces envisaged likely to influence change in the health system were relative stability, growth of the economy, intersectoral engagement (government, civil society, business, funders and global initiatives), high-quality research, and a clear programme of action.
The outcomes from these programmes may be realized if the policy proposals by the government of South Africa, especially on ‘universal coverage’ (Republic of South Africa 2011; Mills et al. 2012), are successfully implemented. Recent policies envisage that the NHI will be phased in over a period of 14 years and it will gradually transform the existing health system distorted currently by both race and class into a new NHI providing universal coverage based on principles such as social cohesion, equity, social solidarity, fairness, affordability, appropriateness, and effectiveness.
Recent progress on the NHI following release of a Green Paper described later in this section has been regularly reported in the media (South Africa Council for Medical Schemes 2009; KPMG 2011; National Planning Commission 2011). Over 75 per cent of all public health facilities have been audited, but few facilities yet comply with standards and norms.
The new policy aims, in particular, to overcome the inequities and inefficiencies of the current two-tier system between a well-resourced private sector and poorly resourced public sector (Shisana 2010). The inequities are worsening: over the past decade, private hospital costs and specialist costs have increased above the Consumer Price Index (South Africa Council for Medical Schemes 2009), and there is further maldistribution of specific skilled human resources to the advantage of the private sector. The arguments in favour of an NHI, and comparisons with other countries, have been provided in the ‘Green paper’ (Republic of South Africa 2011) and shown in recent studies (South Africa Council for Medical Schemes 2009; Mills et al. 2012).
A ‘re-engineered PHC’ will realign the dominance of a curative and hospital-centred service. Quality control and regulation will be implemented through the Office of Health Standards Compliance. The NHI will be funded from a number of sources: a mandatory tax, the fiscus, and from a payroll tax (South Africa Minister of Finance 2012); ‘sin taxes’ have also been raised unofficially in public discussions by state officials. A fundamental criticism is that there is very little chance of successful implementation of the NHI in the present situation of a debilitated, inefficient, ineffective, and dysfunctional state.
We have shown that it is not simply a lack of funds or even facilities which are the central factors to explain the poor health and development returns under the current system (Coovadia et al. 2009). There is, as pointed out earlier, a national unevenness in the capabilities of the civil service (Chopra et al. 2009). A recent publication comes to similar conclusions on the central problem of implementation and capability of the state (National Planning Commission 2011). The costing of the NHI has been both supported (Shisana 2010) and criticized by local economists (van den Heever n.d.). The 2012 Budget anticipates that the real GDP growth will stabilize to 4.2 per cent per annum by 2014 (South Africa Minister of Finance 2012). KPMG’s recent report is much more optimistic and indicates the benefits of externalities (KPMG 2011). It is evident that much more operational and implementation research will be required given the complexity and scale of the transformation necessary to establish the NHI.
In a recent comparison of financing of health services in Ghana and Tanzania in comparison to South Africa (Republic of South Africa, 2011):
overall health-care financing was progressive in all three countries, as were direct taxes. Indirect taxes were regressive in South Africa but progressive in Ghana and Tanzania. Out-of-pocket payments were regressive in all three countries. Health-insurance contributions by those outside the formal sector were regressive in both Ghana and Tanzania. The overall distribution of service benefits in all three countries favoured richer people, although the burden of illness was greater for lower-income groups. Access to needed, appropriate services was the biggest challenge to universal coverage in all three countries.
Syria has a population of 20.8 million people and a nominal GDP per capita of US $2802 and HDI of 0.632. For many years, joblessness, food riots, and hunger have become commonplace, and like many lower- and middle-income countries much of this being related to structural reforms and austerity measures promoted in the past by the International Monetary Fund and World Bank.
More recently, the volatility and uprisings of several countries in the Arab world, typified by Syria, have often been oversimplified as simply being viewed as an expression of the popular clamour for democracy. What is often less understood is that the situation is a manifestation of underlying economic dysfunction which has been fuelled, inter alia, by misplaced development efforts of Western countries keen to promote market reforms. Kasturi Sen and Waleed al Faisal (Sen and Faisal 2012) investigated the neo-liberal economic policies implemented in Syria and showed that it is leading to rising health inequity in the country. Although health indicators have been improving in Syria over the last 30 years, infant mortality rate (132 in 1970 to 14 in 2010); under-5 mortality (164 in 1970 to 16 in 2010); and maternal mortality rate (482 per 100,000 registered live births in 1970 to 45 in 2010), the introduction of neo-liberal market reform policies from 2003, several years before the current volatility, have begun to reverse these gains. Supported by the European Union and German Technical Cooperation agency, the Syrian State included in its 10th Five-Year Plan (2006–2010) a package of economic liberalization policies. Changes made to the operation of the health sector and the labour environment included: new health insurance schemes to replace universal coverage, fee-for-service charges introduced at public hospitals, which also led to numerous job losses. The impact was felt mainly at primary healthcare level where the increases of user fees have increased out-of-pocket expenses with the net result that the people can no longer afford the service, and rising disparity and inequity.
There is now evidence (Sen and Faisal 2012) that the economic liberalization measures are playing a significant role in reversing the gains previously made, reinforcing the rich–poor divide, fostering inequality, suffering, social divisions, and creating discontent, consequences which have often been overlooked by Western observers. In Syria, previously providing a top-down centrally managed state with a command and control structure and a strong emphasis on public health, primary care, health promotion, and disease prevention which, while being directive, had led to important health gains. The new measures, however, introduced to liberalize and commercialize the health system, despite benevolent intentions, have produced the opposite effect. While the West views discontent in Syria as largely political, the fact that it had been behind the promotion of liberalizing economic reforms is either discounted or dismissed (Sen and Faisal 2012).
Thailand—transforming towards universal access to health
Thailand has a population of 70 million, a nominal GDP per capita of US $5394 and HDI of 0.682. After improving health infrastructure for 30 years and implementing a range of different financial risk protection schemes over 40 years, Thailand was finally able to achieve universal health coverage in 2002 (Evans et al. 2012). This provides health insurance for all Thai citizens which guaranteed them access to a comprehensive package of health services. Although this achievement was the result of many factors, the most significant intervention was an inspiring health reform scheme known as the Universal Coverage Scheme (UCS).
The intervention included policy formulation and implementation to provide an equitable entitlement to healthcare for all Thais in the form of a universal coverage system with three main features: (1) a tax-financed scheme providing services at the point of delivery free of charge. Although a small co-payment or fee of 30 baht or US$ 0.70 was charged per visit or admission, this was later abandoned in 2006. (2) A comprehensive benefits package with a primary care focus, including disease prevention and health promotion. (3) A fixed budget with caps on provider payments to control costs. In addition to this several mechanisms were set up to protect UCS beneficiaries. This included more stringent hospital accreditation requirements, an information hotline, a patient complaints service, and a no-fault compensation fund.
By the end of 2001 the UCS provided coverage to 75 per cent (47 million) of the Thai population. This was an especially impressive achievement given that 18 million people had previously been uninsured. Furthermore the 25 per cent of the population (18 million people) not covered in the UCS were either civil servants, retired people and dependants, covered by the Civil Servant Medical Benefit Scheme (CSBMS), or participants of the contributory Social Security Scheme (SSS) which covered private-sector employees.
Achieving the establishment of the UCS was remarkable. Not only was it achieved in the aftermath of the 1997 Asian financial crisis when the per capita gross national income was very modest (US $1900), but it went against the advice of external experts sceptical of its financial viability and was implemented with unprecedented speed.
In a recent 2011 assessment, which, a decade after its implementation, aimed to review the scheme’s performance, the results show the impressive extent to which health inequities have been addressed, teasing out also what worked well and what did not; the reasons for these outcomes in equity were also elucidated (Evans et al. 2012). It was found that between 2003 and 2010 the number of outpatient visits rose from 2.45 to 3.22 per member per year and the number of hospital admissions rose from 0.094 to 0.116 per member per year. This improved access has led to much greater service equity and reduced medical impoverishment, which are indicators of the additional number of non-poor households falling below the national poverty line caused by the out-of-pocket costs of medicines and/or health services. This decreased significantly from 2.71 per cent in 2000 before the UCS was introduced to 0.49 per cent in 2009. It is not surprising that there is now a very low level of unmet need for health services in Thailand.
The UCS has led to a situation where there has been a marked decrease of out-of-pocket expenditure, which has been compensated for by an increase of government health sector spending through public subsidy. This progressive pro-poor spending has eliminated the rich–poor gap in out-of-pocket expenditure.
In addition to the described outcomes the scheme’s success has proved to be resoundingly popular. The high percentage of UCS members who express satisfaction has grown from 83 per cent in 2003 to 90 per cent in 2010. Encouragingly also for the private sector, was that although many contracted healthcare providers were initially unhappy with the UCS, their own satisfaction rose from 39 per cent in 2004 to 79 per cent in 2010.
Although there has been much impressive improvement as already described, some other important areas that were part of the ambitious UCS reform did not make the same gains. There was very little strengthening of the primary healthcare system, primary prevention was not effective, and the reliability of the referral system is still weak. Furthermore there has not been much progress towards rationalizing the three insurance schemes; this revealed that further challenges were related to the political influences and power dynamics of institutional reform.
It is important to note that politicians, civil society, and technocrats all played major roles in pushing for the UCS reform. It required securing parliament’s commitment to universal health coverage and advocacy through the policy, design, implementation, and evaluation processes. Prior experience gained from existing health insurance schemes was both positive and negative, and the lessons learned proved helpful in designing the UCS. The rapidity with which the plan was rolled out was because, even in 2001, Thailand already had a firm foundation upon which to implement the scheme. There was an extensive network of government-owned district health facilities, well-established health policy and systems, research institutions, public health administration capacities, and a computerized civil registration system.
One of the important innovations in the creation of the UCS was the creation of the National Health Security Office (NHSO) which acted as the purchaser on behalf of UCS beneficiaries. This meant that the Ministry of Public Health (MOPH) no longer wielded control over government spending on healthcare services and was able to focus on improving the quality of service provision. Throughout the process, research was vital in building up a supportive body of evidence. This was essential in countering fierce resistance to change from some stakeholder groups and establishing a critical mass of support.
There are important lessons in establishing universal coverage including extension of access to services, containment of costs, and strategic purchasing. Financing reform must go hand in hand with improving physical access to services.
India—shifting towards NHI at scale
India, the second largest country by population (with over 1.2 billion people), is the most populous democracy in the world. It has a nominal GDP per capita US $1388 and HDI of 0.547. Despite enormous recent development strides, the Indian economy is still, however, only the world’s tenth-largest by nominal GDP. From 1991 the country began to adopt market-based economic reforms and has since become one of the fastest-growing major global economies, even though it is still a newly industrializing country. India faces many challenges. These include poverty, illiteracy, malnutrition, poor healthcare, and corruption. Indeed, though planning for a UC has begun, there remain deep flaws in the Indian Health System (High Level Expert Group 2011). The Lancet ran a series of seven papers on India with the final article (Reddy et al. 2011) concluding on one of the points of major relevance to this paper: the creation of an integrated national health system through universal health insurance. It is recognized that for this to work it will have to offer good quality healthcare provided by well-trained health staff. Given the current organization of healthcare this will mean restructuring of health governance. It will also be necessary to develop greater engagement with the community and being proactive in developing the necessary legislation that would enshrine the important health entitlements that the Indian people need and deserve. The current public health system which is the primary provider of promotive, preventive, and curative health services to most of the people in India, has to be greatly improved, and the other providers in the health system (including the private sector) need to be steered towards integration. A call is made in The Lancet series for India to achieve universal healthcare for all by 2020. Given the massive scale and need for reorganization, this call appears to be unrealistic. Sengupta and Prasada (2011) point out that the economic growth path of India is dominated by a powerful corporate private sector, whose actions exacerbate rather than ameliorate inequities. Hence the de facto planning process does not concern itself with the health burdens of the majority nor indeed deal with the persistent, widespread, and crippling poverty, and the need for a public sector response, but tends rather to drift towards a laissez-faire, free-market approach. Although India desperately needs an efficiently managed and well-resourced public health system based on the principles of UC, the markedly dysfunctional health system requires a paradigm shift in making the transition.
Mexico—a labour-based approach
Mexico, with a population of 115 million people (13th largest in the world), a nominal GDP of US $10,153 per capita, and an HDI of 0.770, has a tragic history of colonization, dictatorship, rebellion, civil conflict, territorial wars, and economic instability. Against this background and despite great challenges, there has been surprising progress in implementing a UC scheme based on the principle of broadening coverage of workers (Knaul et al. 2012). In 2003, the country introduced Seguro Popular, an NHI scheme, which by 2012 had virtually become a UC which provided healthcare access to more than 50 million Mexicans previously excluded from insurance. The programme is based on three principles of protection: insurance against health risks, providing quality healthcare assurance, and insurance against the financial consequences of disease and injury. Seguro Popular has been successful in improving access to health services, providing financial protection, and reducing the prevalence of catastrophic health expenditures, which further impoverish the poor. Seguro Popular provides access to a package of universally comprehensive health services, which in Mexico is synonymous with social protection of health. Initially the system was a labour-based social security system but has progressed from then to become a vehicle for the universal social protection of health. The ethical basis for the reform is that access to effective healthcare is seen as a universal right based on citizenship. Each year the effects and impacts of the reform initiative are published and made available in the public domain through the scientific literature and release of new data. Despite the progress, the struggle to shift the health system so that it becomes an increasingly effective, equitable, and responsive health service remains a challenge. Further reforms will be required before the health system has been reorganized to function correctly. Nevertheless this carefully recorded documentation of the process to establish UC has considerable relevance for low- and middle-income countries.
Brazil—promoting equity through health and human rights
Brazil, the largest country in South America and the world’s 5th largest country, both by geographical area and by population with over 193 million people (with a nominal GDP per capita of US $12,788 and HDI of 0.718), provides a striking example of how a country steeped in a long tradition of inequity can rapidly transform. It also shows that this can be achieved in a manner that is compatible with economic growth. Indeed with an impressive economic growth rate of 7.5 per cent (2010) Brazil has made formidable health achievements in recent years in fulfilment of the goal of universal, equitable, and sustainable healthcare and the right to health enshrined in its 1988 constitution (Kleinert and Horton 2011).
The historical development of the current health system has several unique features. Public health, created at the end of the nineteenth century has always featured as an important aspect of the health system. For example, two of Brazil’s greatest scientific leaders, Oswaldo Cruz and Carlos Chagas, acted decisively against public health threats of the time. These included tropical diseases such as yellow fever, bubonic plague, and smallpox. In the process these public health interventions laid the foundation for the internationally renowned Oswaldo Cruz Foundation (FIOCRUZ) which continues these efforts and now employs over 7500 people across the country. It remains an institution which specializes in education, research, pharmaceutical, and vaccine production. Regrettably the health system was not always so progressive. Until 1985 a hospicentric, biomedical approach backed by a military dictatorship dominated the approach. Although it suppressed moves towards social and health equity, it nevertheless created the conditions for a strong civil-society movement that still flourishes today. With a change in government, that movement mounted a powerful drive for health reform, that ultimately resulted in the Unified Health System (SUS). These reforms broadened the definition of health beyond the biomedical paradigm. They incorporated stewardship into the thinking of the social determinants of health, education, poverty reduction, and preventive measures within the broader context of health as a human right. Especially interesting was the promotion of community participation at all administrative levels.
In 1989, Brazil was one of the most unequal countries. In the two decades since then, much progress has been made, which has significantly reduced regional and socioeconomic inequalities and poverty. According to the World Bank, poverty (at purchasing power parity of US $2 per day) has fallen from 20 per cent of the 190 million citizens in 2004 to 7 per cent in 2009. In the health sector the SUS has vastly improved access to primary and emergency care, notably enabling Brazil to have already achieved one target of MDG 1, to reduce by half the number of underweight children. Brazil is also on track to meet MDG 4 and realize a reduction in the mortality rate of children younger than 5 years by two-thirds. Brazil’s HIV/AIDS policies and achievements have also been widely praised.
There are different approaches to the incorporation of private healthcare into national systems of UC. There are seven countries which finance more than 20 per cent of their healthcare through private health insurance: Brazil, Chile, Namibia, South Africa, the United States, Uruguay, and Zimbabwe. In South Africa, where privatized health services comprise the largest financial proportion of the total health system, there are many barriers. The dominance of the private sector places constraints on achieving a fair, just, and equitable health system (Sekhri and Savedoff 2005).
A recent study (Lagomarsino et al. 2012) examined the structure of NHI reforms in nine countries: Ghana, Indonesia, the Philippines, Rwanda, and Vietnam are five countries which are at intermediate stages of reform. Four (India, Kenya, Mali, and Nigeria) are at a very early stage. On the whole, progress is unsatisfactory. Although the authors report some progress towards UC, citing increasing enrolment in government health insurance, enlarging the benefits packages, and reducing out-of-pocket spending with an increasing of the share of government in health spending, it is suggested that it would be helpful if there was one set of common, comparable indicators of progress towards UC.
Intersectoral action for health
Given the wide range of social determinants of health, it is clear that interventions are required in many sectors of society, hence the importance of intersectoral action.
In a systematic review of intersectoral actions to promote the socioeconomic determinants of health it was found that few studies have been able to assess their extremely complex and context-specific nature. In one such study, an expedited, systematic 3-month review critically appraised some 10,000 selected articles against review criteria and found only 17 which met the inclusion criteria (Ndumbe-Eyoh and Moffatt 2012): a few of these studies reported on interventions which deal with structural determinants of health. The evaluation of the impact of intersectoral action was mixed, showing that it had either a moderate effect or no effect on the social determinants of health, and consequently a limited effect on health equity.
Overall these findings (Ndumbe-Eyoh and Moffatt 2012) suggest that much of the literature on the social determinants of health to advance health equity is mainly descriptive. There has been up until this time little emphasis on undertaking interventions. There has been even less concern with the types of measurements required to evaluate these. The earlier cited study emphasized the lack of available high-quality, rigorously evaluated evidence.
Global initiatives to address health inequality
A book produced by the WHO (Blas and Kurup 2010), Equity, Social Determinants and Public Health Programmes and edited by Erik Blas and Anand Sivasankara Kurup, stemming from the recommendations of the CSDH, offers a collection of different approaches and analyses of the social determinants of health that impact on specific health conditions.
There has been a number of recent global initiatives aimed at reducing health inequities. One notable example of this is that at the conclusion of the 13th World Congress on Public Health, held 22–27 April 2012 in Addis Ababa (Ethiopia), the World Federation of Public Health Associations (WFPHA) produced the Addis Ababa Declaration on Global Health Equity (World Congress on Public Health 2012), which was ‘a call to act on closing some of the critical gaps in global health and well-being’. An article about the 13th World Congress on Public Health and the Addis Ababa Declaration by Dr Peter Byass, a Professor and Director of the Umea Centre for Global Health Research (Sweden), also appeared in the Huffington Post (Byass 2012).
A second example is the Global Health Corps. Founded in 2009, Global Health Corps (GHC) is developing a health equity movement by energizing a global community of emerging leaders. The programme had grown to 68 fellows, by 2012, serving in Burundi, Malawi, Rwanda, Uganda, and the United States (Global Health Corps 2012).
A third example is the Training for Health Equity Network (THEnet) (THEnet n.d.). THEnet is a consortium of health professional education institutions committed to achieving health equity. Responding to the priority needs of communities, it works by reforming medical education, research, and service. THEnet schools are consistent with this vision, demonstrating their social accountability by committing themselves to measure their own success by how well they meet the needs of people they serve.
A final example, the Global Action for Health Equity Network (Global Action for Health Equity Network n.d.) (HealthGAEN), is a global movement for health equity. It develops a programme of action to deal with the social and environmental determinants of health. It was established to build on the momentum, expertise, and partnerships that arose following the establishment of the WHO CSDH.
Global endorsement towards a new great transition
At the 67th meeting of the UN’s General Assembly on 12 December 2012, the assembly unanimously adopted a resolution on global health and foreign policy. It urged governments to begin to move towards providing universal access to affordable and quality healthcare services (UN General Assembly 2012).
The Assembly also recognized that improving social protection was a necessary step towards UC. It saw social protection as empowering investment in people. It could assist people to adjust to changes in the labour market and economy. This was a necessary step to support a transition to a more inclusive, sustainable, and equitable economy. While planning or pursuing the development of UC, Member States were encouraged to continue investing in health-delivery systems. This was to be done to increase and safeguard the range and quality of services. It could also help meet population health needs.
Member States were also encouraged to recognize the interrelationships between the promotion of UC and other international policy issues, such as the social dimension of globalization, which includes inclusive policies, equitable growth, and sustainable development.
These global reforms, like those of demography and sanitation movements of the eighteenth and nineteenth centuries, and the continuing public health improvements in the twentieth century, including the expansion of immunization, promise another great transition—the provision of universal care by altering how the mechanisms of healthcare are financed and how health systems are organized (Forum on Universal Health Coverage 2012; Prince Mahidol Award Conference 2012; World Health Assembly 2011).
Text extracts from Republic of South Africa, National Department of Health, National Health Insurance in South Africa, Policy Paper, Government Gazette No. 34523, Government Notice No. 65712, Copyright © 2011, reproduced with permission from the South African Department of Health.
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2. Gini coefficient: this index measures the degree of inequality in the distribution of family income in a country. The index is calculated from the Lorenz curve, in which cumulative family income is plotted against the number of families arranged from the poorest to the richest. If income were distributed with perfect equality, the Lorenz curve would coincide with the 45-degree line and the Gini index would be zero; if income were distributed with perfect inequality, the Lorenz curve would coincide with the horizontal axis and the right vertical axis and the index would be 100 (Central Intelligence Agency 2012; World Bank 2012).
3. The Human Development Index (HDI) is a composite statistic of life expectancy, education, and income indices to rank countries into four tiers of human development. It was created by economist Mahbub ul Haq, followed by economist Amartya Sen in 1990, and published by the United Nations Development Programme. Its range is between 0 and 1 with higher indices being more desirable.