Tim Evans

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

2especially 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

Demystifying Nonparticipation in Microcredit: A Population-Based Analysis

Abstract Given the current popularity of microcredit schemes as a means of poverty alleviation, their accessibility to the poorest is of obvious concern. This paper examines a targeted microcredit program in Bangladesh to assess its coverage among the poor, and to identify program- and client-related barriers impeding participation. A population survey of over 24,000 households reveals that although three-quarters are eligible for microcredit, less than one-quarter participate. Rates of participation in microcredit are higher among poorer households. Multivariate analysis identifies lack of female education, small household size and landlessness as risk factors for nonparticipation, based on a 7% random sample of this population. The implications of these findings for poverty alleviation policies and programs are discussed.

Promoting Equity in Health

There is evidence that widening income gaps are a global phenomenon; that in many advanced industrialised countries unemployment rates are rising; that globalisation of the world economy has led to several countries becoming marginalised with a concomitant increase in poverty; and that the absolute number of poor has steadily increased over the last decade. All of these phenomena emphasise the need to focus on equity as a global concern.

Systems Science for Universal Health Coverage

It is 20 years since an international consultation in Lejondal, Sweden, highlighted the need for more and better research to understand and improve how societies organize themselves in achieving collective health goals, and how different actors interact in the policy and implementation processes to contribute to policy outcomes. (1) One outcome was the creation of the Alliance for Health Policy and Systems Research. (1) There have since been several important milestones on the path towards more and better health systems research. The Alliance for Health Policy and Systems Research found its home at the World Health Organization (WHO) in 1998 and subsequently issued a series of reports on health systems. (2,3) Health systems research entered the mainstream of global health policy--not only at WHO (4) and the World Bank, (5) but also with the founding of Gavi, the Vaccine Alliance, in 2000, (6) and the Global Fund to Fight AIDS, Tuberculosis and Malaria in 2002. Ministerial meetings on health research, in 2004 and 2008, (7) increased the demand for--and the national priority given to--such research. In 2010, a biennial global symposium on health systems research was initiated and this development led to the first global society of health systems researchers: Health Systems Global. More recent efforts in low- and middle-income countries--e.g. the establishment of a knowledge platform in India (8)--are indicative of a shift towards systems thinking at national level. Such encouraging developments need to be carefully balanced against areas where progress has not met expectations. The development of national capacity for financing and institutional leadership of health policy and systems research has been slow. (9) Such research also remains constrained by several common challenges--e.g. the complexity of health systems, the context specificity of research findings and the large numbers of disciplines and epistemological perspectives involved. (10) Looking forward, however, we see a brighter future for health policy and systems research. Sustainable development goal (SDG) 3--particularly its target of universal health coverage--has promoted the establishment of common performance metrics against which the relative effectiveness of alternative policies and programmes can be compared. There is a growing global interdependence in health--as reflected by infectious diseases such as the Ebola virus that requires systems knowledge and public health investments in global readiness. The rapid growth seen in the health sector is raising systems-wide demand for knowledge and innovation to improve value for money and overcome inefficiencies related to high prices, lack of equity and poor quality. Finally, the paradigm shift towards patients being recognized as the co-designers and co-creators of their own health and health care is raising the demand for evidence that would make it possible to navigate the promises and perils of accountable care, personalized medicine and big data. How can health policy and systems research seize this favourable context and contribute more effectively to universal health coverage, greater health security, improved value in health and effective engagement of citizens? First, we need a comprehensive review of the progress that has been made and the progress that might be anticipated in the future. Second, we need to accelerate the development of capacity and opportunity for health policy and systems research in low- and middle-income countries. …

Recent scientific health developments in China

See Online/Comment DOI:10.1016/S01406736(10)60003-7, DOI:10.1016/S01406736(10)60241-3, DOI:10.1016/S01406736(10)60398-4 The emphasis on China in today’s themed issue of The Lancet builds on the previous series on health-care developments in China, published in October, 2008. This issue brings together two commissioned theme papers, one research article submitted in response to open solicitation, and fi ve invited Comments. The aim is not only to recognise and promote high-quality scientifi c studies on health in China, but also to engage Chinese scientists in international scientifi c publications, and to accelerate the momentum sparked by the previous Series. The fi rst Series emphasised four core aspects of China in global health. China is an often under-recognised but nevertheless major constituent of virtually every global health challenge. China historically has been a rich source of health innovations, and its scientifi c modernisation portends prospects for future contributions. As China accelerates participation in the global fl ow of goods, services, and people, it increasingly shares transnational health risks in an interdependent health world. Finally, China recognises its responsibilities in global health, and consequently has enhanced and expanded its international cooperation in health substantially with a particular focus on Africa. Today’s issue on China is timely because the country has recently embarked on a major health reform to achieve universal coverage of primary health services by 2020. The reform has four components: medical insurance, public health, service delivery, and essential drugs. A key element is steady expansion of China’s four subsystems of medical insurance to achieve universal health security. Priority is being given to prevention and equity through strengthening public health interventions in health surveillance, disease control, and maternal and child health. Improving the delivery of services requires better provision of community health care, expansion of primary health centres, improved training of health workers, and innovations in fi nancing and management of major hospitals. Additionally, the list and prescribing policies for essential medicines are being updated to ensure widespread accessibility of safe, appropriate, and cost-eff ective drugs. The reform is ambitious—a gigantic undertaking to improve health care for a fi fth of humanity. As an indicator of its commitment, the Chinese Government has budgeted an extra US

Health equity gauges.

125 billion over the next 3 years to support these reforms, an increase of public fi nancing for health by about a third. The papers in this themed issue illustrate ongoing dynamics in health in China. One cluster of papers describes changing health threats. A growing health problem is environmental health, as reported by Junfeng Zhang and colleagues, for which China is experiencing simultaneously traditional threats (contaminated water and indoor-air pollution) as well as new environmental risks (intensive energy use and industrial pollution). Like all countries in the world, China’s emissions of greenhouse gases will contribute to global climate change, aff ecting health in China and the world. China also continues to tackle the unfi nished agenda of childhood mortality. As reported by Igor Rudan and co-workers, China has reduced under-5 mortality by three-quarters in the past two decades, achieving by 2006 Millennium Development Goal 4, even as the major causes of death have shifted from diarrhoea to pneumonia, birth asphyxia, and preterm births. Another cluster of papers reports on health-systems challenges, fi nancing, and information. Probably no greater policy adjustment will determine the success of China’s reform than the re-aligning of fi nancial incentives to health providers. Several new incentive schemes for enhancing health-system quality, effi ciency, and equity are being piloted, as described by Winnie Yip and colleagues. One more specifi c example of healthsystem practices challenged by the rapidly growing demand is the quantity, safety, and developments in Recent scientifi c health developments in China

Health as a Global Public Good

Editor – As highlighted by the Bulletin’s special theme of inequalities in health (Vol. 78, No.1), the central challenge of health equity research now lies in translating the evidence into action to redress inequities. In an effort to advance these frontiers, the Catholic University of Chile, supported by the Rockefeller Foundation, convened a meeting of technical experts and practitioners in Puyuhuapi, Chile, in October 1999, which forged a comprehensive agenda for future work on indicators for health equity. On behalf of all the participants, this letter is about just one aspect of that agenda: devising and using indicators that are relevant for national and global policy. At the national level, although documentation of inequalities in health is becoming more common, monitoring systems are lacking. South Africa’s ‘‘equity gauge’’ is the unique result of legislators, researchers and civil society working together to assess and monitor equity in a post-apartheid setting. It is proposed that parallel monitoring efforts should begin in a small number of vanguard countries as demonstration sites and later be expanded to other countries. Envisaged are equity gauges developed in local contexts that draw on a wide array of sources including nongovernmental organizations, national public health surveillance systems, vital statistics registries, academic institutions and politicians. Equity-monitoring initiatives will be the subject of a follow-up meeting to be held in South Africa in August 2000. Likewise there are no global standards or guidelines for monitoring social inequalities in health. On the other hand, much effort is going into gathering health-related data. This includes, but is not limited to, the following: the Demographic Health Survey, the Living Standards Measurement Surveys of the World Bank, UNICEF cluster surveys and sentinel surveillance, UN Population and Statistics division surveys, the WHO Virtual Network for Descriptive Epidemiology (VINEDE), EUROSTAT, and a new grass-roots network called INDEPTH (International Network for the Demographic Evaluations of Populations and their Health). Although health inequalities have not featured as key considerations in their design, these diverse instruments have great potential to provide a more accurate and comprehensive picture of global health inequalities. As a start, it is important not to overlook information on health inequalities whichmight be gleaned from existing sources, of which a thorough synthesis should be made. Next, it is imperative that we engage in a more forward-thinking analysis of the types and sources of health and socioeconomic indicators needed to assess inequalities. Such a process would yield pragmatic suggestions on how best to modify existing data platforms and build new efforts for more effective global monitoring of health inequalities. n