Related Articles

Background

In 2001, the Government of Thailand introduced a universal coverage scheme with the aim of ensuring equitable health care access for even the poorest citizens. For a flat user fee of 30 Baht per consultation, or for free for those falling into exemption categories, every scheme participant may access registered health services. The exemption categories include children under 12 years of age, senior citizens aged 60 years and over, the very poor, and volunteer health workers. The functioning of these exemption mechanisms and the effect of the scheme on health service utilisation among the poor is controversial.

Methods

This cross-sectional study investigated the prevalence of 30-Baht Scheme registration and subsequent self-reported health service utilisation among an urban poor population in the Teparuk community within the Mitrapap slum in Khon Kaen city, northeastern Thailand. Furthermore, the effectiveness of the exemption mechanisms in reaching the very poor and the elderly was examined. Factors for users' choice of health facilities were identified.

Results

Overall, the proportion of the Teparuk community enrolled with the 30-Baht Scheme was high at 86%, with over one quarter of these exempted from paying the consultation fee. User fee exemption was significantly more frequent among households with an above-poverty-line income (64.7%) compared to those below the poverty line (35.3%), χ2 (df) = 5.251 (1); p-value = 0.018. In addition, one third of respondents over 60 years of age were found to be still paying user fees. Self-reported use of registered medical facilities in case of illness was stated to be predominantly due to the service being available through the scheme, with service quality not a chief consideration. Overall consumer satisfaction was high, especially among those not required to pay the 30 Baht user fee.

Conclusion

Whilst the 30-Baht Scheme seems to cover most of the poor population of Mitrapap slum in Khon Kaen, the user fee exemption mechanism only works partially with regard to reaching the poorest and exempting senior citizens. Service utilisation and satisfaction are highest amongst those who are fee-exempt. Service quality was not an important factor influencing choice of health facility. Ways should be sought to improve the effectiveness of the current exemption mechanisms.

To examine ways of ensuring access to health services within the framework of primary health care (PHC), since the goal of PHC to make universal health care available to all people has become increasingly neglected amid emerging themes of globalization, trade, and foreign policy. From a public health point of view, we argue that the premise of PHC can unlock barriers to health care services and contribute greatly to determining collective health through the promotion of universal basic health services. PHC has the most sophisticated and organized infrastructure, theories, and political principles, with which it can deal adequately with the issues of inequity, inequality, and social injustice which emerge from negative economic externalities and neo-liberal economic policies. Addressing these issues, especially the complex social and political influences that restrict access to medicines, may require the integration of different health initiatives into PHC. Based on current systems, PHC remains the only conventional health delivery service that can deal with resilient public health problems adequately. However, to strengthen its ability to do so, we propose the revitalization of PHC to incorporate scholarship that promotes human rights, partnerships, research and development, advocacy, and national drug policies. The concept of PHC can improve access; however, this will require the urgent interplay among theoretical, practical, political, and sociological influences arising from the economic, social, and political determinants of ill health in an era of globalization.

Introduction

Equity and universal coverage currently dominate policy debates worldwide. Health financing approaches are central to universal coverage. The way funds are collected, pooled, and used to purchase or provide services should be carefully considered to ensure that population needs are addressed under a universal health system. The aim of this paper is to assess the extent to which the Kenyan health financing system meets the key requirements for universal coverage, including income and risk cross-subsidisation. Recommendations on how to address existing equity challenges and progress towards universal coverage are made.

Methods

An extensive review of published and gray literature was conducted to identify the sources of health care funds in Kenya. Documents were mainly sourced from the Ministry of Medical Services and the Ministry of Public Health and Sanitation. Country level documents were the main sources of data. In cases where data were not available at the country level, they were sought from the World Health Organisation website. Each financing mechanism was analysed in respect to key functions namely, revenue generation, pooling and purchasing.

Results

The Kenyan health sector relies heavily on out-of-pocket payments. Government funds are mainly allocated through historical incremental approach. The sector is largely underfunded and health care contributions are regressive (i.e. the poor contribute a larger proportion of their income to health care than the rich). Health financing in Kenya is fragmented and there is very limited risk and income cross-subsidisation. The country has made little progress towards achieving international benchmarks including the Abuja target of allocating 15% of government's budget to the health sector.

Conclusions

The Kenyan health system is highly inequitable and policies aimed at promoting equity and addressing the needs of the poor and vulnerable have not been successful. Some progress has been made towards addressing equity challenges, but universal coverage will not be achieved unless the country adopts a systemic approach to health financing reforms. Such an approach should be informed by the wider health system goals of equity and efficiency.

Background

Inequity in use of physician services has been detected even within health care systems with universal coverage of the population through public insurance schemes. In this study we analyse and compare inequity in use of physician visits (GP and specialists) in Norway based on data from the Surveys of Living Conditions for the years 2000, 2002 and 2005. A patient list system was introduced for GPs in 2001 to improve GP accessibility, strengthen the stability of the patient-doctor relationship and ensure equity in the use of health care services for the entire population.

Method

We measure horizontal inequity by concentration indices and investigate changes in inequity over time when decomposing the concentration indices into the contribution of its determinants.

Results

We find that pro-rich inequity in the probability of seeing a private outpatient specialist has declined, but still existed in 2005.

Conclusion

Improved patient-doctor stability as well as better GP accessibility facilitated by the introduction of patient lists improved access to private specialist services. In particular the less well off benefited from this reform.

Background

Globally, extending financial protection and equitable access to health services to those outside the formal sector employment is a major challenge for achieving universal coverage. While some favour contributory schemes, others have embraced tax-funded health service cover for those outside the formal sector. This paper critically examines the issue of how to cover those outside the formal sector through the lens of stakeholder views on the proposed one-time premium payment (OTPP) policy in Ghana.

Discussion

Ghana in 2004 implemented a National Health Insurance Scheme, based on a contributory model where service benefits are restricted to those who contribute (with some groups exempted from contributing), as the policy direction for moving towards universal coverage. In 2008, the OTPP system was proposed as an alternative way of ensuring coverage for those outside formal sector employment. There are divergent stakeholder views with regard to the meaning of the one-time premium and how it will be financed and sustained. Our stakeholder interviews indicate that the underlying issue being debated is whether the current contributory NHIS model for those outside the formal employment sector should be maintained or whether services for this group should be tax funded. However, the advantages and disadvantages of these alternatives are not being explored in an explicit or systematic way and are obscured by the considerable confusion about the likely design of the OTPP policy. We attempt to contribute to the broader debate about how best to fund coverage for those outside the formal sector by unpacking some of these issues and pointing to the empirical evidence needed to shed even further light on appropriate funding mechanisms for universal health systems.

Summary

The Ghanaian debate on OTPP is related to one of the most important challenges facing low- and middle-income countries seeking to achieve a universal health care system. It is critical that there is more extensive debate on the advantages and disadvantages of alternative funding mechanisms, supported by a solid evidence base, and with the policy objective of universal coverage providing the guiding light.

Thailand implemented a Universal Coverage Scheme (UCS) of national health insurance in April 2001 to finance equitable access to health care. This paper compares inequalities in health service use before and after the UCS, and analyses the trend and determinants of inequality.

The national Health and Welfare Surveys of 2001 and 2005 are used for this study. The concentration index for use of ambulatory care among the population reporting a recent illness is used as a measure of health inequality, decomposed into contributing demographic, socio-economic, geographic and health insurance determinants.

As a result of the UCS, the uninsured group fell from 24% in 2001 to 3% in 2005 and health service patterns changed. Use of public primary health care facilities such as health centres became more concentrated among the poor, while use of provincial/general hospitals became more concentrated among the better-off.

Decomposition analysis shows that the increasingly common use of health centres among the poor in 2005 was substantially associated with those with lower income, residence in the rural northeast and the introduction of the UCS. The increasing use of provincial/general hospitals and private clinics among the better-off in 2005 was substantially associated with the government and private employee insurance schemes.

Although the UCS scheme has achieved its objective in increasing insurance coverage and utilization of primary health services, our findings point to the need for future policies to focus on the quality of this primary care and equitable referrals to secondary and tertiary health facilities when required.

Objectives

Universally offered child health reviews form the backbone of the UK child health programme. The reviews assess children's health, development and well-being and facilitate access to additional support as required. The number of reviews offered per child has been reduced over recent years to allow more flexible provision of support to families in need: equitable coverage of the remaining reviews is therefore particularly important. This study assessed the coverage of universal child health reviews, with an emphasis on trends over time and inequalities in coverage by deprivation.

Design

Assessment of the coverage of child health reviews by area-based deprivation using routinely available data. Supplementary audit of the quality of the routine data source used.

Setting

Scotland.

Participants

Two cohorts of around 40 000 children each. The cohorts were born in 1998/1999 and 2007/2008 and eligible for the previous programme of five and the current programme of two preschool reviews, respectively.

Outcome measures

Coverage of the specified child health reviews for the whole cohorts and by deprivation.

Results

Coverage of the 10 day review is high (99%), but it progressively declines for reviews at older ages (86% for the 39–42 month review). Coverage is lower in children living in the most deprived areas for all reviews, and the discrepancy progressively increases for reviews at older ages (78% and 92% coverage for the 39–42 month review in most and least deprived groups). Coverage has been stable over time: it has not increased for the remaining reviews after reduction in the number of reviews provided.

Conclusions

The inverse care law continues to operate in relation to ‘universal’ child health reviews. Equitable uptake of reviews is important to ensure maximum likely impact on inequalities in children's outcomes.

Article summary

Article focus

A series of universally offered child health reviews providing assessment of children's health, development and well-being forms the backbone of the UK child health programme.

The number of reviews offered per child has been reduced over recent years to increase capacity to provide effective individualised support to families in need: equitable coverage of the remaining reviews is therefore particularly important.

We used routinely available data to assess the coverage of the various child health reviews (overall and by deprivation) before and after the change in the number of reviews offered.

Key messages

Coverage of reviews offered in early infancy is high, but it progressively declines for reviews at older ages (around 99% coverage for the 10 day review and 86% for the 39–42 month review).

Coverage is lower in the most deprived groups for all reviews, and the discrepancy progressively increases for reviews at older ages (78% and 92% coverage for the 39–42 month review in most and least deprived groups).

Coverage has not changed for the remaining reviews after reduction in the number of reviews offered: the inverse care law continues to operate in relation to provision of ‘universal’ child health reviews.

Strengths and limitations of this study

To our knowledge, no quantitative assessment of the coverage of child health reviews offered in the UK has previously been published.

This analysis involved large numbers of children: over 80 000 children eligible to receive their child health reviews in Scotland were included.

Careful consideration must be given to data quality when analysing routinely available data: we conducted an audit of data quality to allow the uncertainty in the results to be quantified.

Background

A variety of studies have considered the affects of India's son preference on gender differences in child mortality, sex ratio at birth, and access to health services. Less research has focused on the affects of son preference on gender inequities in immunization coverage and how this may have varied with time, and across regions and with sibling compositions. We present a systematic examination of trends in immunization coverage in India, with a focus on inequities in coverage by gender, birth order, year of birth, and state.

Methods

We analyzed data from three consecutive rounds of the Indian National Family Health Survey undertaken between 1992 and 2006. All children below five years of age with complete immunization histories were included in the analysis. Age-appropriate immunization coverage was determined for the following antigens: bacille Calmette-Guérin (BCG), oral polio (OPV), diphtheria, pertussis (whooping cough) and tetanus (DPT), and measles.

Results

Immunization coverage in India has increased since the early 1990s, but complete, age-appropriate coverage is still under 50% nationally. Girls were found to have significantly lower immunization coverage (p<0.001) than boys for BCG, DPT, and measles across all three surveys. By contrast, improved coverage of OPV suggests a narrowing of the gender differences in recent years. Girls with a surviving older sister were less likely to be immunized compared to boys, and a large proportion of all children were found to be immunized considerably later than recommended.

Conclusions

Gender inequities in immunization coverage are prevalent in India. The low immunization coverage, the late immunization trends and the gender differences in coverage identified in our study suggest that risks of child mortality, especially for girls at higher birth orders, need to be addressed both socially and programmatically.

Abstract in Hindi

See the full article online for a translation of this abstract in Hindi.

Background

The 58th World Health Assembly called for all health systems to move towards universal coverage where everyone has access to key promotive, preventive, curative and rehabilitative health interventions at an affordable cost. Universal coverage involves ensuring that health care benefits are distributed on the basis of need for care and not on ability to pay. The distribution of health care benefits is therefore an important policy question, which health systems should address. The aim of this study is to assess the distribution of health care benefits in the Kenyan health system, compare changes over two time periods and demonstrate the extent to which the distribution meets the principles of universal coverage.

Methods

Two nationally representative cross-sectional households surveys conducted in 2003 and 2007 were the main sources of data. A comprehensive analysis of the entire health system is conducted including the public sector, private-not-for-profit and private-for-profit sectors. Standard benefit incidence analysis techniques were applied and adopted to allow application to private sector services.

Results

The three sectors recorded similar levels of pro-rich distribution in 2003, but in 2007, the private-not-for-profit sector was pro-poor, public sector benefits showed an equal distribution, while the private-for-profit sector remained pro-rich. Larger pro-rich disparities were recorded for inpatient compared to outpatient benefits at the hospital level, but primary health care services were pro-poor. Benefits were distributed on the basis of ability to pay and not on need for care.

Conclusions

The principles of universal coverage require that all should benefit from health care according to need. The Kenyan health sector is clearly inequitable and benefits are not distributed on the basis of need. Deliberate efforts should be directed to restructuring the Kenyan health system to address access barriers and ensure that all Kenyans benefit from health care when they need it.

Background

Women and men face different gender-based health inequities in relation to HIV, including HIV testing as well as different challenges in accessing HIV care, treatment and support programs and services when testing HIV-positive. In this article, we discuss the findings of a mixed methods study exploring the various individual and structural barriers and facilitators to HIV counselling and testing experienced among a sample of adult women and men living in Nova Scotia, Canada.

Methods

Drawing from testing demographics, qualitative interview data and a review of existing testing policies and research, this paper focuses on understanding the gendered health inequities and their implications for HIV testing rates and behaviours in Nova Scotia.

Results

The findings of this research serve as the basis to further our understanding of gender as a key determinant of health in relation to HIV testing. Recognizing gender as a key determinant of health in terms of both vulnerability to HIV and access to testing, this paper explores how gender intersects with health equity issues such as access to HIV testing, stigma and discrimination, and sexual behaviours and relationships.

Conclusions

Drawing on the current gender and HIV literatures, in conjunction with our data, we argue that an enhanced, gender-based, context-dependent approach to HIV counselling and testing service provision is required in order to address the health equity needs of diverse groups of women and men living in various settings. Further, we argue that enhanced HIV testing efforts must be inclusive of both men and women, addressing uniquely gendered barriers to accessing HIV counselling and testing services and in the process moving beyond routine HIV testing for pregnant women.

Background

In 1997 there was a major reform of the government run urban health insurance system in China. The principal aims of the reform were to widen coverage of health insurance for the urban employed and contain medical costs. Following this reform there has been a transition from the dual system of the Government Insurance Scheme (GIS) and Labour Insurance Scheme (LIS) to the new Urban Employee Basic Health Insurance Scheme (BHIS).

Methods

This paper uses data from the National Health Services Surveys of 1998 and 2003 to examine the impact of the reform on population coverage. Particular attention is paid to coverage in terms of gender, age, employment status, and income levels. Following a description of the data between the two years, the paper will discuss the relationship between the insurance reform and the growing inequities in population coverage.

Results

An examination of the data reveals a number of key points:

a) The overall coverage of the newly established scheme has decreased from 1998 to 2003.

b) The proportion of the urban population without any type of health insurance arrangement remained almost the same between 1998 and 2003 in spite of the aim of the 1997 reform to increase the population coverage.

c) Higher levels of participation in mainstream insurance schemes (i.e. GIS-LIS and BHIS) were identified among older age groups, males and high income groups. In some cases, the inequities in the system are increasing.

d) There has been an increase in coverage of the urban population by non-mainstream health insurance schemes, including non-commercial and commercial ones.

The paper discusses three important issues in relation to urban insurance coverage: institutional diversity in the forms of insurance, labour force policy and the non-mainstream forms of commercial and non-commercial forms of insurance.

Conclusion

The paper concludes that the huge economic development and expansion has not resulted in a reduced disparity in health insurance coverage, and that limited cross-group subsidy and regional inequality is possible. Unless effective measures are taken, vulnerable groups such as women, low income groups, employees based on short-term contracts and rural-urban migrant workers may well be left out of sharing the social and economic development.

The Ghanaian National Health Insurance Scheme (NHIS) was introduced to provide access to adequate health care regardless of ability to pay. By law the NHIS is mandatory but because the informal sector has to make premium payment before they are enrolled, the authorities are unable to enforce mandatory nature of the scheme. The ultimate goal of the Scheme then is to provide all residents with access to adequate health care at affordable cost. In other words, the Scheme intends to achieve universal coverage. An important factor for the achievement of universal coverage is that revenue collection be equitable. The purpose of this study is to examine the vertical and horizontal equity of the premium collection of the Scheme. The Kakwani index method as well as graphical analysis was used to study the vertical equity. Horizontal inequity was measured through the effect of the premium on redistribution of ability to pay of members. The extent to which the premium could cause catastrophic expenditure was also examined. The results showed that revenue collection was both vertically and horizontally inequitable. The horizontal inequity had a greater effect on redistribution of ability to pay than vertical inequity. The computation of catastrophic expenditure showed that a small minority of the poor were likely to incur catastrophic expenditure from paying the premium a situation that could impede the achievement of universal coverage. The study provides recommendations to improve the inequitable system of premium payment to help achieve universal coverage.

Conclusion

New York and the nation stand at the brink of an unprecedented opportunity to improve health care coverage and access for children. New York can continue to be a national leader in ensuring access to coverage and care for low-income children by combining eligibility expansions with effective outreach and enrollment efforts. Between half and three-quarters of a million children could benefit if these activities are successful. As monumental an accomplishment as that would be, however, three-quarters of the state's total uninsured population would remain without coverage. Successful advocacy for low-income children should serve as models for additional efforts to provide health care coverage to their parents and to other uninsured adults in the state. During a strong state economy and renewed interest in health care issues, the time is now to seize this momentum and fulfill New York's historic commitment to health care for all its citizens.

Background

There is need for new information about the socio-economic and geographic differences in health seeking and expenditures on many health conditions, so to help to design interventions that will reduce inequity in utilisation of healthcare services and ensure universal coverage.

Objectives

The paper contributes additional knowledge about health seeking and economic burden of different health conditions. It also shows the level of healthcare payments in public and private sector and their distribution across socioeconomic and geographic population groups.

Methods

A questionnaire was used to collect data from randomly selected householders from 4,873 households (2,483 urban and 2,390 rural) in southeast Nigeria. Data was collected on: health problems that people had and sought care for; type of care sought, outpatient department (OPD) visits and inpatient department (IPD) stays; providers visited; expenditures; and preferences for improving access to care. Data was disaggregated by socio-economic status (SES) and geographic location (urban versus rural) of the households.

Results

Malaria and hypertension were the major communicable and non-communicable diseases respectively that required OPD and IPD. Patent medicine dealers (PMDs) were the most commonly used providers (41.1%), followed by private hospitals (19.7%) and pharmacies (16.4%). The rural dwellers and poorer SES groups mostly used low-level and informal providers. The average monthly treatment expenditure in urban area was 2444 Naira (US$20.4) and 2267 Naira (US$18.9) in the rural area. Higher SES groups and urbanites incurred higher health expenditures. People that needed healthcare services did not seek care mostly because the health condition was not serious enough or they could not afford the cost of services.

Conclusion

There were inequities in use of the different providers, and also in expenditures on treatment. Reforms should aim to decrease barriers to access to public and formal health services and also identify constraints which impede the equitable distribution and access of public health services for the general population especially for poor people and rural dwellers.

Policy and finance barriers reduce access to preconception care and, reportedly, limit professional practice changes that would improve the availability of needed services. Millions of women of childbearing age (15–44) lack adequate health coverage (i.e., uninsured or underinsured), and others live in medically underserved areas. Service delivery fragmentation and lack of professional guidelines are additional barriers. This paper reviews barriers and opportunities for financing preconception care, based on a review and analysis of state and federal policies. We describe states’ experiences with and opportunities to improve health coverage, through public programs such as Medicaid, Medicaid waivers, and the State Children's Health Insurance Program (SCHIP). The potential role of Title V and of community health centers in providing primary and preventive care to women also is discussed. In these and other public health and health coverage programs, opportunities exist to finance preconception care for low-income women. Three major policy directions are discussed. To increase access to preconception care among women of childbearing age, the federal and state governments have opportunities to: (1) improve health care coverage, (2) increase the supply of publicly subsidized health clinics, and (3) direct delivery of preconception screening and interventions in the context of public health programs.

Background:

The role of gender inequities in explaining women’s access to reproductive health care was examined in four countries (two sub-Saharan African and two South Asian countries). The extent of gender inequities varies across and within countries, and is rooted in the different cultural practices and gender norms within these different countries, and differences in the status and autonomy of women.

Methods:

Demographic and Health Survey data from women aged 15–49 years within these countries were analyzed with multivariate logistic regression analysis to examine the role of multidimensional characteristics of gender inequities, operationalized as access to skilled antenatal care, tetanus toxoid injection during pregnancy, and access to skilled antenatal care.

Results:

Significant associations were found between several dimensions of gender inequities (with the exception of decision-making autonomy) and reported use of maternal reproductive health care services. Several pathways of influence between the outcome and exposure variables were also identified.

Conclusion:

Dimensions of gender inequities (with the exception of decision-making autonomy) differentially influenced woman’s use of reproductive health care services, thus highlighting the urgent need for concerted and sustained efforts to change these harmful traditional values if several of these countries are to meet Millennium Development Goal-5.

A narration of the development of staff, infrastructure and buildings in the various parts of the country is given in this paper. The role of universities and other institutions of learning, public health, palliative care, nuclear medicine and cancer registries is described together with the networking that has been developed between the government, non-governmental organisations and private hospitals. The training of skilled manpower and the commencement of the Master of Clinical Oncology in the University of Malaya is highlighted. Efforts taken to improve the various aspects of cancer control which includes prevention of cancer, early detection, treatment and palliative care are covered. It is vital to ensure that cancer care services must be accessible and affordable throughout the entire health system, from the primary care level up to the centres for tertiary care, throughout the whole country.

Conclusion

Numerous studies throughout the last 30 years and the results presented here from theKaiser/Commonwealth Five State Low Income Survey support Medicaid's role in improving access to care for poor minority children. Since minority children are affected disproportionately by the unavailability of health insurance, Medicaid's role as a financing source is particularly important to these groups. It is also clear that reducing financial barriers will not eliminate completely the inequalities in health care utilization and disparities in health status across different racial and ethnic groups. As discussed above, despite Medicaid's influence, minority children still exhibit poorer quality of health. Thus, strategies for the next century should focus on ensuring that all barriers to care are removed. This will involve not only the guarantee of universal health care coverage for all children, but also the elimination of social, cultural, and behavioral barriers to optimum health and health care as well.

The Public Health Resource Network is an innovative distance-learning course in training, motivating, empowering and building a network of health personnel from government and civil society groups. Its aim is to build human resource capacity for strengthening decentralized health planning, especially at the district level, to improve accountability of health systems, elicit community participation for health, ensure equitable and accessible health facilities and to bring about convergence in programmes and services.

The question confronting health systems in India is how best to reform, revitalize and resource primary health systems to deliver different levels of service aligned to local realities, ensuring universal coverage, equitable access, efficiency and effectiveness, through an empowered cadre of health personnel. To achieve these outcomes it is essential that health planning be decentralized. Districts vary widely according to the specific needs of their population, and even more so in terms of existing interventions and available resources. Strategies, therefore, have to be district-specific, not only because health needs vary, but also because people's perceptions and capacities to intervene and implement programmes vary. In centrally designed plans there is little scope for such adaptation and contextualization, and hence decentralized planning becomes crucial.

To undertake these initiatives, there is a strong need for trained, motivated, empowered and networked health personnel. It is precisely at this level that a lack of technical knowledge and skills and the absence of a supportive network or adequate educational opportunities impede personnel from making improvements. The absence of in-service training and of training curricula that reflect field realities also adds to this, discouraging health workers from pursuing effective strategies.

The Public Health Resource Network is thus an attempt to reach out to motivated though often isolated health workers. It interacts with, and works to empower, health personnel within the government health system as well as civil society, to meaningfully participate in and strengthen decentralized planning processes and outcomes. Structured as an innovative distance-learning course spread over 12 to 18 months of coursework and contact programmes, the Public Health Resource Network comprises 14 core modules and five optional courses. The technical content and contact programmes have been specifically developed to build perspectives and technical knowledge of participants and provide them with a variety of options that can be immediately put into practice within their work environments and everyday roles. The thematic areas of the course modules range from technical knowledge related to maternal and child health and communicable and noncommunicable diseases; programmatic and systemic knowledge related to health planning, convergence, health management and public-private partnerships; to perspective-building knowledge related to mainstreaming gender issues and community participation. Currently the Public Health Resource Network has been launched in four states of India – Chhattisgarh, Jharkhand, Bihar and Orissa – in its first phase, and reaches out to more than 500 participants with diverse backgrounds. The initiative has received valuable support from central and state government departments of health, state training institutes, the National Rural Health Mission – the current comprehensive health policy in the country – and leading civil society organizations.

There is a more and more emerging consensus claiming universal access to health care in order to achieve the desired Millennium Development Goals related to health in Africa. Unfortunately, the debate of the universal coverage has focussed so far mainly on financial affordability, while it is also a human resource matter. Many countries in sub-Saharan Africa are experiencing severe shortages of skilled health care workers. There are several causes, the importance of which varies by country, but one of the most significant factors is brain drain. In those countries, scarcity of doctors increases the distance between a doctor and patients, and bridging that increased distance implies costs, both time and money. Adequate number of qualified health personnel is then vital to increase coverage and improve the quality of care. In as much as access to health services is also determined by access to qualified health workers, any reflection on the universal health coverage has to also consider the inequities in qualified health personnel distribution throughout the world.

Both the rising numbers of uninsured Americans and the recent presidential election have put the issue of universal health insurance coverage back on the national agenda. Lack of health insurance is a major barrier to care for 44 million Americans, and lack of high-quality, comprehensive insurance is a barrier to millions more. Universal coverage is one of the best ways to ensure that all Americans have equitable access to quality care, and it also contributes to the financial stability of health care providers, especially those in the urban safety net. A wide variety of ideas to expand health care coverage were proposed, and in some cases enacted, during the last century. At the beginning of the 21st century, the American health care system is made up of varied elements, ranging from employer-sponsored health insurance for the majority of working-age adults to the public Medicare program for the elderly. While this patchwork system leaves many Americans without health insurance, it also creates many different ways to expand coverage, including various options in both the private and public sectors. By understanding howthe current health care system developed, howthe various proposals for universal health coverage gained and lost political and public support, and the pros and cons of the various alternatives available to expand coverage, we create a solid base from which to solve the problem of the uninsured in the 21st century.

OBJECTIVE: To develop recommendations for office-based physicians who wish to make their offices accessible to all patients. OPTIONS: Include taking steps to make offices more accessible, or not; offices may be accessible to varying degrees. OUTCOMES: Outcomes of accessibility involve patient-care, economic, ethical and legal issues. Stakeholders in these outcomes include patients, physicians, government and society. EVIDENCE: Data were obtained from a series of searches of MEDLINE, CINAHL and Healthstar (previously Health) databases for articles on disability and family medicine, primary (health) care and family practice, and on access and offices, and health services accessibility, and from a telephone survey of 50 stakeholders. VALUES: A high value was placed on services to persons with disabilities and on stakeholder input. Universal accessibility was valued as an overall goal; improved accessibility was also highly valued. BENEFITS, HARMS AND COSTS: Benefits to patients include improved access to care as guaranteed by the Canada Health Act and in keeping with provincial Human Rights Codes. Benefits to physicians include contact with a broader patient population and freedom from fear of litigation. Costs of improved accessibility vary depending on individual circumstances and on whether an office is being built or renovated; some improvement costs are minimal. RECOMMENDATIONS: All physicians should take measures to improve practice accessibility. Improved access should be considered in each of the following areas: transportation and entrance to the facility, entrance to the office, waiting rooms, rest rooms, examination rooms, general building features and other features. VALIDATION: No similar guidelines exist. To assess the content validity of these guidelines, the authors had a draft document reviewed by 18 stakeholders. All specific recommendations met the minimum criterion of adherence to current legislation, including national and provincial building codes. The specific recommendations are endorsed by the Canadian Paraplegic Association (national and Ontario offices), the DisAbled Women's Network (Ontario) and the Centre for Independent Living (Toronto). SPONSORS: Development of these guidelines was supported in part by the Department of Family and Community Medicine, Toronto Hospital, Toronto, Ont.

Background:

Globally, and in Africa, after adjusting for age, women are about 1.4 times more likely to be blind than men. While women generally live longer than men, the lack of accessibility to and use of services is likely the most important reason for excess blindness in women in Africa.

Aim:

We sought to review the literature on vision loss in Africa and summarize the findings related to gender equity.

Materials and Methods:

Information from across sub-Saharan Africa was collected on the evidence of gender inequity and reasons for this inequity. Finally, the results were used to generate suggestions on how gender equity could be improved.

Results:

In all published surveys (except one), cataract surgical coverage among women was lower than cataract surgical coverage among men. Although data available are limited, similar findings appeared in the use of services for other disease conditions, notably, childhood cataract and glaucoma. Evidence suggests that a variety of approaches are needed to improve the use of eye care services. Three main strategies are needed to address gender inequity in vision loss in Africa. First, it is important to address transport needs. Second, counseling of patients and family members is required. Finally, programs need to put in place pricing systems that make the services affordable the population.

Conclusions:

VISION 2020 can be achieved in Africa, but investment is needed in a variety of strategies that will ensure that eye care services are affordable, accessible, and acceptable to women and girls.

Background

Inadequate public action in vulnerable communities is a major constraint for the health of poor and marginalized groups in low and middle-income countries (LMICs). The south Indian state of Kerala, known for relatively equitable provision of public resources, is no exception to the marginalization of vulnerable communities. In Kerala, women’s lives are constrained by gender-based inequalities and certain indigenous groups are marginalized such that their health and welfare lag behind other social groups.

The research

The goal of this socially-engaged, action-research initiative was to reduce social inequalities in access to health care in a rural community. Specific objectives were: 1) design and implement a community-based health insurance scheme to reduce financial barriers to health care, 2) strengthen local governance in monitoring and evidence-based decision-making, and 3) develop an evidence base for appropriate health interventions.

Results and outcomes

Health and social inequities have been masked by Kerala’s overall progress. Key findings illustrated large inequalities between different social groups. Particularly disadvantaged are lower-caste women and Paniyas (a marginalized indigenous group), for whom inequalities exist across education, employment status, landholdings, and health. The most vulnerable populations are the least likely to receive state support, which has broader implications for the entire country. A community based health solidarity scheme (SNEHA), under the leadership of local women, was developed and implemented yielding some benefits to health equity in the community—although inclusion of the Paniyas has been a challenge.

The partnership

The Canadian-Indian action research team has worked collaboratively for over a decade. An initial focus on surveys and data analysis has transformed into a focus on socially engaged, participatory action research.

Challenges and successes

Adapting to unanticipated external forces, maintaining a strong team in the rural village, retaining human resources capable of analyzing the data, and encouraging Paniya participation in the health insurance scheme were challenges. Successes were at least partially enabled by the length of the funding (this was a two-phase project over an eight year period).

Equity and gender, despite being universal concerns for all health programmes in Bangladesh, are often missing in many of the health agenda. The health programmes fail to address these important dimensions unless these are specifically included in the planning stage of a programme and are continually monitored for progress. This paper presents the situation of equity in health in Bangladesh, innovations in monitoring equity in the use of health services in general and by the poor in particular, and impact of targeted non-health interventions on health outcomes of the poor. It was argued that an equitable use of health services might also result in enhanced overall coverage of the services. The findings show that government services at the upazila level are used by the poor proportionately more than they are in the community, while at the private facilities, the situation is reverse. Commonly-used monitoring tools, at times, are not very useful for the programme managers to know how well they are doing in reaching the poor. Use of benefit-incidence ratio may provide a quick feedback to the health facility managers about their extent of serving the poor. Similarly, Lot Quality Assurance Sampling can be an easy-to-use tool for monitoring coverage at the community level requiring a very small sample size. Although health problems are biomedical phenomena, their solutions may include actions beyond the biomedical framework. Studies have shown that non-health interventions targeted towards the poor improve the use of health services and reduce mortality among children in poor households. The study on equity and health deals with various interlocking issues, and the examples and views presented in this paper intend to introduce their importance in designing and managing health and development programmes.