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The final section presents some key conclusions. Access to effective health care in developing countries: evidence. Access to health care can be defined in a variety of ways. In its most narrow sense, it refers to geographic availability. A far broader definition identifies four dimensions of access: availability, accessibility, affordability, and acceptability 1.

Some define access as the opportunity to use health care; others draw no distinction between access and use. This paper circumvents such discussions and proposes that the central concern is whether individuals that can potentially benefit from effective health care do in fact receive it. Health programs and systems should be evaluated against this objective through examination of the rate of utilization of effective health care among the population in need, which has been referred to as effective coverage 2.

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In practice, it is often difficult to identify both the population in need and the effectiveness of the care on offer. Much of the evidence reviewed below refers simply to the rate of utilization of health care in the population. Effective interventions are not fully exploited. There is ample evidence confirming that access to effective health care is a major problem in the developing world.

Many millions of people suffer and die from conditions for which there exist effective interventions.

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For each disease there is at least one effective prevention and one effective treatment 3. The gap between the potential and actual benefits of health care is also large in the area of reproductive health. For example, in South Asia, less than half of pregnant women get an antenatal check-up, and only one-fifth of births are supervised by someone with medical training 3. Because of this gross underutilization of effective health care, there exist large unrealized health gains in developing countries.

Raising coverage rates of maternal health interventions the most important of which is essential obstetric care to the same level would reduce maternal deaths by three-fourths 3 preliminary estimates. A multitude of factors is responsible for these missed opportunities to realize major gains in population health.

On the demand side, cultural and educational factors may obscure the recognition of illness and the potential benefits from health care, while economic constraints may suppress utilization, even if benefits are recognized.


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On the supply side, appropriate interventions may not be provided at all, perhaps due to a lack of resources. The substantial gaps that exist between the actual health spending of many poor countries and the spending required to provide a package of essential health services suggest that lack of availability is the root of the problem in many instances 7.

It is important to recognize, however, that many effective interventions are not prohibitively expensive, even for very poor countries. For example, one half of avoidable child deaths in sub-Saharan Africa could be realized through home-delivered interventions 3. Where health care is available, the quality is often severely deficient, leaving its effectiveness well short of potential efficacy.

One review concludes that, despite the claimed efficacy of primary health care interventions, the evidence is mixed on whether primary care clinics have any impact on population health 8. This discouraging conclusion is attributed to the poor quality of public primary health care in many parts of the developing world. As long as such quality deficiencies persist, the estimates cited above of avoidable deaths through the utilization of effective interventions will remain purely hypothetical. In practice, supply and demand side issues are not so easily separated.

If the available health care is poor quality, it is not surprising to find there is little demand for it. There is evidence that demand does react to quality 9. A detailed survey in a rural region of India finds very low use of public health facilities despite these being, in principle, free The reason is the very poor quality of care, although the private sector alternatives are also of dubious quality. It is futile to develop and implement policies that remove constraints on the demand for effective health care if there is little hope of such care being provided.

Policy interventions on the demand and supply sides must progress in tandem.

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The poor make least use of effective interventions. The first stylized fact about access to health care in the developing world is the underutilization of effective interventions. The second stylized fact is that utilization is lowest among the least well off.

This is of concern from both efficiency and equity perspectives. The poor also tend to be the least healthy and most probably have the most to benefit from health care. The greatest health gains could be realized through concentrating marginal resources on treatment of the poor. The fact that those most in need make least use of health care is widely considered inequitable.

Unfortunately, the evidence shows that there is pro-rich bias in the distribution of benefits even from these programs The strongest evidence on the distribution of child and reproductive health interventions is from the Demographic Health Surveys DHS 12, Households are ranked by an index of assets possessed e.

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Coverage is highest in sub-Saharan Africa, but so is inequality in coverage. Inequalities in immunization rates are even greater. The fact that one third of children in the better off households are not immunized is far from acceptable.


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Even worse is that 3 in 5 poor children lack such protection. No more than a third of the poorest children in South Asia and sub-Saharan Africa are fully immunized. On average, the higher the overall coverage rate in a country, the greater is the rich-poor disparity. This suggests that the better off are first to benefit from marginal gains in coverage.

Socioeconomic disparities in the utilization of reproductive health services are still greater. On average 55 countries , women in the richest quintile are 5.

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Average coverage is lowest in South Asia and parts of sub-Saharan Africa, while inequalities are very strong in most regions with the exception of Eastern Europe and Central Asia. Inequalities in the use of contraceptives are of a similar magnitude. Comparison of results from DHS conducted in the mids with those years later reveal some encouraging examples of progress with respect to both average coverage rates and rich-poor disparities.

Egypt, Kazakhstan, and Nepal have raised immunization coverage rates among the poor and reduced inequalities between the rich and poor Egypt and Nepal increased full immunization for the poorest quintile by 26 and 22 percentage points respectively.

For professionally attended deliveries, coverage has been raised and inequality reduced in Benin, Egypt, India, Nicaragua, Turkey, and Vietnam. If this does represent a genuine increase, rather than some artifact of the data, it deserves close examination to draw lessons. Unfortunately, there are also many examples of little or no progress in tackling severe gaps in coverage and startling disparities in use.

In Peru, Cameroon, Ghana, Malawi, and Mali, the coverage rate for medically supervised births actually fell for the poorest fifth. Evidence from a non-DHS source suggests that income-related inequalities in access to health care increased in India between and Besides the correction of market failures, public funding of health care is usually justified on a distributional basis. Equity, it is claimed, is inconsistent with the free market distribution of health care.

Opinions may differ on the conception of equity underlying this position. Without touching on this issue, the empirical validity of this case for public intervention rests on whether it does in fact shift the health care distribution in the desired direction.

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The evidence shows, with a remarkable degree of consistency, that the poor actually receive a lesser share of public health expenditures in developing countries than the better off 16,17, The evidence is summarized in Figure 1. There are differences in the distributions of different levels of care. With the exceptions of Ghana and Madagascar, the share of primary care received by the poor is greater than its share of the total public health subsidy.


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This implies that the utilization of public hospital services is very concentrated on the better off. Even for primary care, the share of the subsidy going to the poor reaches its population share in only eight countries. In most cases, there is a pro-rich bias in the distribution of public primary care even though this is exactly the type of health care that is supposed to best meet the health needs of the poor. Admittedly, some of the benefit incidence evidence is somewhat crude.

There is often no allowance for regional variation in expenditures, and quality differences are not taken into account. Correction of either of these deficiencies is likely to strengthen, rather than overturn, the conclusion that the better off get proportionately more.