health care inequities

BOX 3.5 WHAT HAS TO CHANGE: HEALTH FINANCING GAPS WIDEN HEALTH CARE INEQUITIES

Few governments fund comprehensive, universal primary health care (PHC) services at adequate levels to equitably meet population health needs; most governments in low- and middle-income countries (LMICs) cover well under half of the PHC costs through general government revenue. Beyond absolute resource constraints, the allocation of scarce resources is often skewed toward hospitals and relatively advantaged urban populations. In this context, patients must often pay out of pocket for critical health needs, pushing about 100 million people into poverty each year (WHO 2019b). Although many associate catastrophic health expenditure with unexpected hospitalization, most out-of-pocket expenses across LMICs and the World Health Organization’s (WHO) European region go to outpatient care and medicines, both of which fall within the remit of PHC (WHO 2019b). Even when PHC services are financially accessible, patients commonly report disrespectful, impersonal, or even abusive care (Larson et al. 2019; McMahon et al. 2014; Wang et al. 2015). Such substandard care experience particularly affects marginalized populations, including migrants, racial minorities, sexual minorities, and youth. Financial barriers can also deter poor or marginalized families from seeking care early, leading to preventable hospitalizations and death. Low- and middle-income countries:Among households in rural Malawi where a family member required chronic disease medication, two-thirds incurred at least some out-of-pocket expenditure; the poorest quartile of households spent up to one-half of its monthly income on chronic disease care (Larson etal. 2019). Upper-middle-income countries: In Russia, 27 percent of patients report that they were not treated with “respect for [their] values, preferences, and expressed needs” during their last consultation; and 34 percent report that care was not “personalized to reflect [their] needs and choices” (Ipsos 2018). High-income countries: In the United States, over one-third of surveyed adults and almost two-thirds of uninsured adults skipped needed medical care in the past year due to cost barriers (Commonwealth Fund 2019). Families under the poverty line are more than three times as likely as the wealthiest families to delay or forgo care for their children due to cost or lack of insurance coverage (Wisk and Witt 2012).

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reduce socioeconomic and cultural disparities that act as distal or proximal determinants of health. However, there are few well-documented instances globally in which PHC services have fully incorporated this function. In many settings, PHC still stands for a limited set of health care services, too often provided only to those who can afford to pay and/or who live in close proximity.

What are the drivers of fairness and accountability in PHC?

At the PHC level, fairness is achieved by eliminating or at least mitigating avoidable inequities in health and health care through accurate targeting of public health and primary care services to those most in need, while protecting the empaneled population from catastrophic health expenditure or health-related impoverishment. Fairness also means responding to people’s expectations for humane, respectful, and dignified care, without any discrimination based on age, gender, income, area of residence, sexual orientation, disability, or other factors. This would imply not only that PHC is available, but that it is also geographically, socio-culturally, economically, and organizationally accessible to all.4

Accountability in PHC could be operationalized as the mandate and capacity to hold relevant health care institutions, facilities, and health professionals to account for their performance in providing people-centered, appropriate, comprehensive, continuous, safe, timely, and cost-conscious care to their empaneled population. As such, it would require an accountability results framework and a set of metrics mutually agreed by providers, payers, and the empaneled population alike.

In this sense, fair and accountable PHC rests on a social contract with the community it serves (the empaneled population). It also requires a transparent mechanism to collect, compile, analyze, and interpret data for continuous improvement and summative evaluation. The most useful data will include patient-reported experience and outcome measures (PREM and PROM) and input from the community at large. Measures would need to be customized considering community baseline characteristics (epidemiologic, demographic, socio-cultural, and economic), the level of ambition (goals, anticipated health outcomes), the time frame, and the rules and regulations pertaining to broader health system governance. Most important is a realistic estimation of resource needs—and the effective provision of resources based on those estimates. The estimation and the provision include both human resources (numbers, skills mix, and the applicable incentives to recruit and retain) and financial resources for full functionality regardless of short-term surges in demand. Planning and resource estimation need to be demand oriented, that is, derived through an assessment of a community’s needs and expectations, rather than supply driven.

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