Addressing health systems strengthening through an health equity lens

Abstract

Addressing inequalities in health outcomes especially for women and children is, perhaps, the most important challenge towards achieving sustainable health gains. Despite impressive improvements in overall indicators of health over recent decades, health inequalities within and between countries persist and, in many cases, have widened and continue to widen. At the global level, the survival gap between poor and rich children has been growing. For example, a child born in Sub-Saharan Africa in 1970 faced a risk of dying before his or her fifth birthday that was nine times greater than a child born in an industrialized country. In 1990, the base year of the Millennium Development Goals (MDGs), the same risk was 19 times greater; in 2006, it was 27 times greater. A new global movement called A Promise Renewed aims to work with countries to end all preventable child deaths and reduce the widening inequalities between countries. Inequalities between poor and rich children within developing countries are responsible for half or more of the global under-5 mortality gap. On average, children in the poorest 20% of a developing country population are about twice as likely to die or to be malnourished as those in the better-off 20%. If the death rates of all children in developing countries could be reduced to the level currently prevailing in the best-off child population of those countries, the number of under-5 deaths could be reduced by half or more. There is ample evidence that packages of simple, highly cost-effective interventions have the potential to prevent the majority of maternal, newborn, and child deaths. Attaining universal coverage, especially for essential high-impact interventions for maternal and child health, is therefore rightly being promoted as a global health priority. However, whilst there is a consensus on the goal of universal coverage, divergent paths are being taken — leading to very different outcomes. Many countries have generally focused upon a geographical expansion of a facility-based health care delivery model, with the aim of achieving universality. The success of this strategy has depended upon significant donor and domestic investment in a primary health care approach and, when applied consistently, has succeeded in expanding accessibility to basic maternal, child, and other MDG-related health services. But the relative high costs and difficulty in deploying and retaining skilled health professionals to serve marginalized populations has meant that large segments of the population, mostly very low-income families in urban slums and those living in rural areas, remain beyond the reach of the conventional facility-based model. As new and more sophisticated interventions are introduced they are being captured predominantly by those served with existing health care infrastructure, and widening inequalities. Of the 24 countries making the greatest reductions in under-5 mortality, 16 have widened disparities in mortality between the richest and poorest during the same time. Experience and evidence clearly showing that a “business as usual” approach with a focus on secondary and tertiary services in urban areas will result, at best, in reaching the MDGs by vastly increasing inequalities, as the elites rapidly capture both public and private health and social welfare resources. One analysis of expenditures in Guinea, Ghana, and Cote d’Ivoire, for example, found that the richest quintile consumed three to four times the public subsidizes than the poorest quintile. This was mostly because they had far greater access to secondary and tertiary hospital care. But there are a minority of low income countries that have achieved significant improvements in outcomes in an equitable manner. Countries such as Malawi, Ethiopia, Nepal, Bangladesh, and, more recently, India have sought to achieve universal coverage through innovations in the delivery of services, such as expanding the employment and scope of community health workers; utilizing new technologies to allow community workers to safely diagnose and treat the most important causes of newborn Correspondence: mchopra@unicef.org Chief of Health, UNICEF, NY, USA Chopra BMC Health Services Research 2013, 13(Suppl 2):S13 http://www.biomedcentral.com/1472-6963/13/S2/S13