ViewpointEquity and health sector reforms: can low-income countries escape the medical poverty trap?
Section snippets
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
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
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
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
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
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