Will Equity in Health Work?

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Will Equity in Health Work?

All civilized societies acknowledge health as a basic human right just as to deny education is a sin so is the act of depriving anyone of access to health care for whatever reason. Health is a basic as the right to life, yet, health inequities persist and even get worse between countries and within countries. 

Social inequities are as old as human societies. I would like to purpose that equity in health is not only achievable and largely non-controversial, but also may help reduce other forms of social inequities. It would also be naïve to assume that even health inequities are left to persist.

But wherefore the idea of removal of health inequity arise? First, all civilized societies acknowledge health as a basic human right just as education is, Just as to deny education is a sin so is the act of depriving anyone of access to health care for whatever reason. Health is as basic as the right to life, yet, health in inequities persist and even get worse between countries and within countries. Ironically too, those who need health care more also usually those who have it least.

The very word inequity means different things to various schools of thought, But suffice it to say that it means, at the least for present discussion, equal access to essential health care irrespective of anything to the contrary. It does not mean all will enjoy equal state of health or that health resources will be equally distributed to all. But certainly it will mean shift of available resources for heath care to areas and people where and whose needs are greater; it will mean less to the already privileged and more to the under- privileged, the vulnerable, the weak and the poor. No doubt, there will be resistance to such a shift from those who are used to more, but the writer would believe the resistance will be less than what will be for shift to income directly to the poor from the rich. Taxation of the rich to make direct transfer to the poor will be less tolerated than mere making more health care available to those who need it more.

We know there are existing inequities of access to or possession of production; there are subtle and harsh forms of class inequities free market allows more to flow to where there is already more. The affluent consume many times more than the and needy. But does the necessarily get the rich more health security ? I believe not or at best only a temporary and uncertain sense of security. Disease agents travel with any regulation; need no visa to cross country borders nor to cross class boundaries. If for no other reason, there is enough to support inequity in health care by the society for the security of all and enlightened self-interest of its affluent class.

Now, if there is merit and more than moral reason in health equity, how to bring it about? First, let us get clear of academic or semantic controversy about the meaning of equity. We can settle for simple easy to apply meaning. To repeat, for the present discussion, equity in health means equal and unrestricted access to health care by all and not by a few as at present.

Now, we are under a regime of market economy and structural adjustment, The state is being “downsized” Some are saying it actually is “right- sizling.” Whatever it is, the state is withdrawing from public financing of health the private market is getting prominent, But by definition the private market must maximize profit. Health private market is no exception as is already well shown. Total national health expenditure is rising, and rising rapidly. But its distribution is tilted more towards those who can afford to pay and they are indeed paying more. Those who cannot are left out of the market or are made to pay by selling their assets in emergency illness.

Is it equitable ?

No it is not.

Whatever else, Private health care market is notoriously inequitable. But then what can be done ? But then what can be done? The public sector in health is already poorly financed; it will be even more starved of founds with time as costs go up and budgets come under security. It will be asked to raise its own funds to supplement its budget and fill the gap.

But that will compel the public sector to start collecting charges which the very poor will not be able to pay. Those who can pay may not do so for services they feel are irregular and of low quality of inconvenient. But this writer would argue the situation need not be as skeptical or grim as it appears to be.

First, there in no need for the government or voluntary nonprofit agencies to withdraw from the market. There is need for them to select priorities and make meaningful and transparent partnership with the clients and among themselves. There is need to put more resources into primary care specially at the remote and peripheral health facilities that are closest to the population in need (for rural as well as urban poor) yet are ironically the most neglected or under equipped and under financed.

There is need to resuscitate public health environment and sanitation programmes and related services especially to the most needy population. There is every need to put more money and management into local health organization with informed and institutionalized people’s participation. And there is every reason to shift resources preferentially to essential public health functions that serve and protect the population as a whole.

Is it any surprise that the corollary of doing all these will be intelligent and courageous reallocation of resources; more for services that protect equity for example away from expensive tertiary care for the few that gives low net health outcomes. The writer is under no illusion there are very hard and unlikely choices not easily made or implemented. But then can the society and the government of people do anything less ?

Can the profession or the custodians of liberal society condone and congratulate the perpetuation of existing inequities? Rather than engage in leisurely and sterile academic debate on the definition and description of social inequities, is it not time to do something in practice and begin to learn lessons that are to be learnt?

As stated before, I am aware of the fact that with persisting inequities in income, assets and access to other means of production, education, shelter, compounded by class and cultural barriers, there is no health “Utopis’ in sight any where or anytime soon, if ever. Take for example education. Do you the reader honestly believe that by mere lofty intentions or by allocation of more money to “education” sector of the five year plan we will achieve full literacy? Do we not have enough evidence that without a revolutionary commitment, all allocations have a way of being absorbed by a lethargic bureau cracy (red parkinso’s Law) ?

Even a kemalist revoluation may fall a little short of what is needed to attain full literacy in early next century. This writer does not belittle the need for financial investments but wishes to suggest that without full and bold commitment by the state and the society and without he “sacrifices” of the affluent and privileged willing or enforced social goals as fundamental as equity will remain distant.

Yet, it seems that the reduction of health inequities may indeed be a less difficult task. The infrastructure is there, the means and methods are affordable and available, less commotion and available, less commotion and clash of interest is st stake. And a responsive private and non-profit voluntary sector may even lend a helping hand. Hopefully this can happen. And when there is equity in health it may generate enough evidence of a success story to inspire, who knows perhaps a thirst for other success stories say in education.

The creative energy released by health equity may well create the confidence needed to go through few other difficult reformation processes in the society as a whole. For let us all hope that healthy population with creative energy and self confidence is the most precious asset and a powerful engine for change of the society.

By Dr M Zakir Hussain

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