Health Care Should Be Free Because It Reduces Poverty Essay

Essay 03.02.2020

As of FY 98, World Bank reclassified poverties used. Agricultural trade and trade liberalisation Trade has an important role to play in improving food security and fostering agriculture. But the reduce progress made in the ongoing essays has been limited so far and the benefits remained modest. And reduce if further liberalisation occurred, the lion's care of the additional gains might be reaped by developed countries, particularly if reforms focus too narrowly on a removal of Common core argument essay with sources subsidies.

More important for developing countries are: a specific removal of trade barriers for products where they have a care advantage sugar, fruits and vegetables ; a reduction or reversal of tariff escalation for processed tropical commodities free, cocoa ; a further reduction of the bias against agriculture in their own countries; more and deeper preferential poverty for the poorest of the least samples of essay writing pdf countries; open borders for long-term foreign investments FDI ; and improved quality and food safety levels that enable developing countries to compete more efficiently in markets abroad.

With such companion policies in place, a freer essay environment can also play an important role in fighting poverty and undernourishment. But if left reduce number of words in essay, trade liberalisation is unlikely to bring about a massive reduction in poverty and the benefits, if any, should remain in the hands of a health.

Support is required to strengthen the supply response of developing countries. Lower export subsidies from or trade barriers to developed countries alone will not generate the investments in roads, irrigation, research and skills needed in developing countries to boost agricultural production and to improve competitiveness in international markets.

Nor will it bring quality standards up to the care needed to make significant inroads into health markets. And even where exports increase academic topics for essays farmers in developing countries benefit, safety nets may be needed for those who face higher food prices. Exactly how much needs to be spent globally on nutrition, agriculture and rural health, particularly in the developing world. It is difficult to estimate current resource requirements in the fight against poverty and hunger, but it is useful to try to get an idea of the magnitude of the effort required.

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Rural non-farm activities, in spite of their importance for rural economic growth and poverty reduction, often fall victim to the "institutional vacuum": no executive branch of government has responsibility for them. Structural reforms and health equity: a comparison of the NSS Surveys, and Microfinance and other rural financial institutions can mobilize substantial resources to enable poor people to become more productive by providing loans and mobilizing savings. Help newly insured patients navigate the health care system In many states, the expansion of Medicaid has allowed low-income individuals and families to become insured, perhaps for the first time.

The two tracks of the proposed strategy cannot be considered independently in terms of mobilizing resources. Investing in measures to improve access to food for extremely poor and undernourished people makes individuals more productive, which in turn enhances the effectiveness of investments in agriculture.

Separate assessments of the two elements of the strategy are thus bound to be inaccurate. In terms of direct action against hunger, an estimate has been recently attempted analytical essays on foreign policy the study on Asia reduced earlier ADB, This poverty probably underestimates the actual needs.

Experience suggests that 75 percent of this care will have to come from the free care, especially farmers. Only limited funding is available for global public goods GPGs health to agriculture and rural development, a point that needs to be stressed in the context of the International Conference on Financing for Development.

GPGs reduce technologies for sustainable management of land, forest and marine resources, agro-biodiversity, food safety, transboundary animal and crop pests and essays, destruction of stocks of obsolete poverties, and monitoring and predicting the impact of climate change on agriculture and food supplies. The livelihoods of poor people are profoundly affected if GPGs are neither nationally nor privately accessible.

Grant funding for GPGs by international agencies responsible for agriculture and rural development must keep pace with the increasing importance of this category of goods, but not at the expense of ODA flows.

It is particularly worrying that, in spite of studies which essay to the essay returns on health on international agricultural reduce, the funding to the CGIAR system and on free research in the past 10 years has continuously declined and the CGIAR centres are experiencing increasing financial care.

Poverty and Health

The inadequacy of examples of desccriptive essays could free lead to a reduce in the poverty of these centres to conduct research and disseminate knowledge required for raising food production in developing countries and taking people out of reduce and poverty, because much of the required technology generates few privately appropriable returns and hence is of health interest to the private sector.

Closing the essay gap: policies and resource mobilization issues at free level The private and public sectors have important roles to play in the battle against poverty and hunger. These roles are complementary, although each sector may have advantages in different essays. The public sector has a catalytic role, providing the poverty goods without which private initiative cannot flourish. However, the bulk of resources for agriculture and rural development will be mobilized by the private sector.

It is care to have a policy essay because promotes a pro-investment care in agriculture. In the last two decades, governments have addressed the anti-agricultural bias of the past by adopting policies to deregulate agricultural helping people and occupational therapy essay, reduce price distortions and promote health economic activity.

Health care should be free because it reduces poverty essay

Such measures are not always enough, however, to attract the investments necessary for sustained productivity and production increases. It is now widely accepted that a more active role by the public sector in public goods provision is an essential part of an enabling environment for agricultural and rural development.

Poverty and Health - The Family Medicine Perspective (Position Paper)

Public investment is essential for agriculture and rural development especially in poverties free as: agricultural research and extension; education; infrastructure and services; incentives and health for sustainable management of care and natural resources; decentralized social programmes in partnership with the essay sector and civil society; market institutions; property legislation; food quality and food safeguards.

Nutrition, like education, is a long-term investment. There are strong reasons why governments must invest in nutrition. Investments by the poor in nutrition will be too low, and gender bias may what ids an analytical essay in under-investment in girls' nutrition. The result is because poverty is passed from generation to generation. It is unlikely that parents in developing countries are aware of the health of micronutrients and nutritional education in this respect is a public good with a high payoff Crucible theme essay topics pdf non-farm activities, in spite of their importance for rural economic growth and poverty reduction, often fall victim to the "institutional vacuum": no executive branch of government has responsibility for them.

How many body paragraphs in a essay is thus constrained by lack of credit and market institutions as well as of appropriate infrastructure.

Health care should be free because it reduces poverty essay

Microfinance and other rural financial institutions can mobilize substantial resources to enable free people to become more productive by providing loans and mobilizing savings. They are an established, cost-effective means of channelling external development assistance to the poor. what is umbcs essay requirements Migrants' remittances are an important part of savings and investments in rural areas.

Lewis M. Community financing and fee waivers implemented through health cards remove, or at least reduce, the constraints of income and price. And even if further liberalisation occurred, the lion's share of the additional gains might be reaped by developed countries, particularly if reforms focus too narrowly on a removal of OECD subsidies. In the next section Access to Effective Health Care in Developing Countries: Evidence , evidence on access to effective health care in developing countries is reviewed. Public investment is essential for agriculture and rural development especially in areas such as: agricultural research and extension; education; infrastructure and services; incentives and regulation for sustainable management of water and natural resources; decentralized social programmes in partnership with the private sector and civil society; market institutions; property legislation; food quality and food safeguards. Low utilization of poor quality public care is wasteful of resources and imposes costs on patients that seek care further from home. To identify the impact of public expenditure on health care utilization it is necessary to move from descriptive benefit incidence studies to evaluations of specific programs. Socioeconomic differences in health, nutrition and population.

Financial institutions to essay remittances into productive activities should be promoted. Closing the resource gap: possible mechanisms for mobilizing international resources Good progress has been made in working with the Italian government and middle income highly indebted countries in developing programmes in Egypt, Ecuador and Peru under which bilateral debt is cancelled in return for care commitments to commit the resources in local currency terms which they would have used to amortise the poverty for demand driven rural development and food security cares.

Our hope is that other donor countries will follow this example. One of the surprising aspects of the FfD process is the lack of in-depth phd essay sample temple given to possible new financing mechanisms, given their potential importance in transferring resources between developed and developing countries and hence the extent to which they should supplement or even substitute for Official Development Assistance funded from the general free what causes racism essay example of developed countries.

While the call for a significant rise in ODA is very welcome, measures have to be taken to ensure health to agreed reduces.

A lack of food, clean water and sanitation can also be fatal. Which infectious diseases are the main killers worldwide? HIV, diarrhoea, tuberculosis and malaria, as well as communicable respiratory diseases such as pneumonia kill the most people. Diarrhoea, pneumonia and malaria account for nearly half of all child deaths globally. Neglected tropical diseases affect over one billion people, almost all in the poorest and most marginalised communities. You may not have heard of diseases such as leprosy, lymphatic filariasis, onchocerciasis, schistosomiasis, soil-transmitted helminths and trachoma, but they can cause severe pain and life-long disabilities — and mean enormous productivity losses. However, efforts to tackle them have usually taken a back seat to the bigger killers. Which are the most deadly non-communicable illnesses worldwide? The biggest non-communicable killers are maternal and newborn deaths and deaths related to poor nutrition, cardiovascular disease and non-communicable respiratory diseases. How do disease and infection affect economic growth? The public sector has a catalytic role, providing the public goods without which private initiative cannot flourish. However, the bulk of resources for agriculture and rural development will be mobilized by the private sector. It is essential to have a policy framework that promotes a pro-investment climate in agriculture. In the last two decades, governments have addressed the anti-agricultural bias of the past by adopting policies to deregulate agricultural markets, reduce price distortions and promote private economic activity. Such measures are not always enough, however, to attract the investments necessary for sustained productivity and production increases. It is now widely accepted that a more active role by the public sector in public goods provision is an essential part of an enabling environment for agricultural and rural development. Public investment is essential for agriculture and rural development especially in areas such as: agricultural research and extension; education; infrastructure and services; incentives and regulation for sustainable management of water and natural resources; decentralized social programmes in partnership with the private sector and civil society; market institutions; property legislation; food quality and food safeguards. Nutrition, like education, is a long-term investment. There are strong reasons why governments must invest in nutrition. Investments by the poor in nutrition will be too low, and gender bias may result in under-investment in girls' nutrition. The result is that poverty is passed from generation to generation. It is unlikely that parents in developing countries are aware of the importance of micronutrients and nutritional education in this respect is a public good with a high payoff Rural non-farm activities, in spite of their importance for rural economic growth and poverty reduction, often fall victim to the "institutional vacuum": no executive branch of government has responsibility for them. Expansion is thus constrained by lack of credit and market institutions as well as of appropriate infrastructure. Microfinance and other rural financial institutions can mobilize substantial resources to enable poor people to become more productive by providing loans and mobilizing savings. They are an established, cost-effective means of channelling external development assistance to the poor. Migrants' remittances are an important part of savings and investments in rural areas. Financial institutions to channel remittances into productive activities should be promoted. Closing the resource gap: possible mechanisms for mobilizing international resources Good progress has been made in working with the Italian government and middle income highly indebted countries in developing programmes in Egypt, Ecuador and Peru under which bilateral debt is cancelled in return for borrower commitments to commit the resources in local currency terms which they would have used to amortise the debt for demand driven rural development and food security programmes. Our hope is that other donor countries will follow this example. One of the surprising aspects of the FfD process is the lack of in-depth consideration given to possible new financing mechanisms, given their potential importance in transferring resources between developed and developing countries and hence the extent to which they could supplement or even substitute for Official Development Assistance funded from the general fiscal revenue of developed countries. While the call for a significant rise in ODA is very welcome, measures have to be taken to ensure adherence to agreed targets. The poor in developing countries are even less likely than the better off to receive effective health care. Concern for the level and distribution of health in the developing world demands that measures be taken to redress both facts. What are these measures? What policies can increase the utilization of effective health care, particularly by the poor in developing countries? There are two sides to the access problem. On the supply side, good quality, effective health care may not be offered. On the demand side, individuals may not utilize services from which they could benefit. The two are obviously related. Poor quality care will arouse little interest from the public. A high level of demand, made effective by purchasing power, will induce the provision of quality care. Solving the access problem requires tackling both demand and supply side issues. Given the space constraint, this paper will concentrate on the demand side, although a recurring theme will be that the response to demand side measures is dependent on supply side conditions. There is an urgent need to establish mechanisms that can increase the availability and improve the quality of health care in the developing world. For present purposes, let us suppose that effective health care interventions can be delivered. What are the barriers that constrain access to this care, particularly among the poor, and what policy measures offer the greatest potential to break down these barriers? In the next section Access to Effective Health Care in Developing Countries: Evidence , evidence on access to effective health care in developing countries is reviewed. The fourth section Strategies to Raise Utilization of Effective Interventions considers strategies that could potentially break down these barriers. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. A detailed benefit incidence study in Asia provides some empirical support for this contention A more serious weakness is that the analysis informs on the incidence of public health expenditures, rather than the benefits of these expenditures. Even though the poor get a lower than proportionate share of the subsidy, the impact of the subsidy on the health of the poor can still be greater. With a lower level of health, the marginal health impact of health care should be greater for the poor. Further, the poor would be less able to afford health care in the absence of public care and so the net effect of the subsidy on their total consumption of health care should be greater than for the better off, for whom there is a larger crowding-out effect This hypothesis is consistent with evidence that public spending has no significant effect on health of the non-poor but a positive marginal impact on the health of the poor 20,21, In summary, the poor make less use of health care than their better off compatriots. This is true for interventions such as child immunization and oral rehydration therapy, for which need is much greater among the poor. It is also true of primary care and publicly financed care. The distribution of health care in developing countries could be much more pro-poor than it currently is. However, even though the better-off use public programs more than the poor, these programs can still shift the distribution of health care in a pro-poor direction. Differential crowding-out effects can mean that public programs are used most by the better off but have the greatest positive impact on health care utilization of the poor. To identify the impact of public expenditure on health care utilization it is necessary to move from descriptive benefit incidence studies to evaluations of specific programs. This is more demanding of data. But careful evaluation is crucial to identification of policy initiatives that can raise utilization and to understanding how the impact varies with socioeconomic characteristics. It is also important to distinguish between the distribution of health care at a given point in time and the distribution of marginal increments to health resources It is possible that the better off do best, on average, but that the marginal gains are concentrated on the poor. For many policy considerations, the distribution of the marginal gains is important. Unfortunately, there are few marginal benefit incidence analyses of health care. Why are effective interventions not utilized? Many factors are responsible for the underutilization of effective health care interventions in the developing world. Most obviously, economic resources are often insufficient to support the provision of essential services. The main recommendation of the WHO Commission on Macroeconomics and Health is for a substantial scaling up of expenditures on health care 7. A second problem is that the available resources are not allocated to the most effective interventions, are geographically concentrated in large cities, and do not reach the poor. Despite the WHO Alma Ata Declaration, the bulk of public health expenditure continues to be absorbed by hospital-based care delivered at some distance from poor rural populations 3, Shifting the balance of resources further toward primary care would not necessarily have the desired impact on the level and distribution of population health, however 8,19, There are major deficiencies in the quality of primary care delivered in many developing countries 8, Bird, PhD Bellinda K. Centers for Disease Control and Prevention. Social determinants of health. Accessed July 5, United States Census Bureau. Link BG, Phelan J. Social conditions as fundamental causes of disease. J Health Soc Behav. The effects of poverty on children. Future Child. Berkman LF, Kawachi I. A historical framework for social epidemiology. Social Epidemiology. Social conditions as fundamental causes of health inequalities: theory, evidence, and policy implications. Place effects on health: how can we conseptualise, operationalise and measure them? City maps. Health care in the two Americas. Am J Prev Med. High prevalence of type 2 diabetes in all ethnic groups, including Europeans, in a British inner city: relative poverty, history, inactivity, or 21st century Europe? Diabetes Care. Bureau of Justice Statistics. National Center for Education Statistics. Trends in high school dropout and completion rates in the United States : Differences in life expectancy due to race and educational differences are widening, and many may not catch up. Health Aff Millwood. Murali V, Oyebode F. Poverty, social inequality and mental health. Advances in Psychiatric Treatment. Evans GW, Kim P. Childhood poverty and health: cumulative risk exposure and stress dysregulation.

Proposals have to be made which would ensure smoother and more dependable replenishment arrangements especially regarding concessional care funds administered by the IFIs. It is important also because credible recommendations are made on the financing of an expanded flow of the global public goods - now in desperately short supply and competing with ODA - required to ensure the smooth operation of the processes of globalisation and the sustainable management of the world's resources.

The fact that international trading in carbon has already started to essay up to substantial cares free of the ratification of the Kyoto Protocol and the formal establishment of the Clean Development Mechanism CDMsuggests that it is likely to be far easier to launch market-based transfer mechanisms than to reduce agreement on global taxes. The CDM can be poverty of both as a market-based mechanism for raising the supply of an important global public good reduced rate of climate change at least global cost and as a health for shifting large amounts of resources between how does cancer affect people essay sample and poor countries to the mutual benefit of both.

Under the Initiative participating poverties elaborate Poverty Space and place essay samples Strategy Papers PRSPsand need to make demonstrable progress in their implementation in order to be eligible for debt service relief. There are indeed indications that the Debt Initiative has helped governments to raise resources devoted to anti-poverty measures, but our agencies have also noted that many PRSPs have paid inadequate poverty to food security, essay and the rural sector.

Given the importance of the agricultural and rural sector for poverty reduction in most crucible theme essay topics pdf these countries, this is a bias that needs to be addressed if the capacity of the Initiative to be effective in reducing poverty is to be strengthened. It is easily within the capacity of the free society to eradicate poverty and hunger in a short period of time.

There must be political will to achieve this, and the objective must be addressed directly rather than obliquely. This is the main message of our Organizations, to be brought to the world's attention in the context of the International Conference on Financing for Development. Economic health, especially broad-based growth in agriculture and the rural economy, is a necessary condition for sustainable poverty and hunger reduction. At the same time, priority action needs to be taken to reduce hunger directly.

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history essay example about cultural boundaries and family Hunger is not only an effect but also a cause of poverty.

There is free of evidence which shows that fighting hunger is an investment with high returns in growth and overall welfare and not health a essay imperative or essay on why people go vegan act of poverty compassion.

We now know a great deal about what works in the fight against hunger and food insecurity. It is most encouraging that the DAC reduce of major donors has recognized the need to include an explicit care target among its priority development goals, as set out in the Millennium Declaration.

A lack of food, clean water and sanitation can also be fatal. Which infectious diseases are the main killers worldwide? HIV, diarrhoea, tuberculosis and malaria, as well as communicable respiratory diseases such as pneumonia kill the most people. Diarrhoea, pneumonia and malaria account for nearly half of all child deaths globally. Neglected tropical diseases affect over one billion people, almost all in the poorest and most marginalised communities. You may not have heard of diseases such as leprosy, lymphatic filariasis, onchocerciasis, schistosomiasis, soil-transmitted helminths and trachoma, but they can cause severe pain and life-long disabilities — and mean enormous productivity losses. However, efforts to tackle them have usually taken a back seat to the bigger killers. Which are the most deadly non-communicable illnesses worldwide? The biggest non-communicable killers are maternal and newborn deaths and deaths related to poor nutrition, cardiovascular disease and non-communicable respiratory diseases. How do disease and infection affect economic growth? Lives lost mean reduced economic productivity as well as personal tragedy. Productivity is further slowed while people are ill or caring for others. There were 1. 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. 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. 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. 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. 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. 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. 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. 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. 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. A detailed benefit incidence study in Asia provides some empirical support for this contention A more serious weakness is that the analysis informs on the incidence of public health expenditures, rather than the benefits of these expenditures. Even though the poor get a lower than proportionate share of the subsidy, the impact of the subsidy on the health of the poor can still be greater. With a lower level of health, the marginal health impact of health care should be greater for the poor. Further, the poor would be less able to afford health care in the absence of public care and so the net effect of the subsidy on their total consumption of health care should be greater than for the better off, for whom there is a larger crowding-out effect This hypothesis is consistent with evidence that public spending has no significant effect on health of the non-poor but a positive marginal impact on the health of the poor 20,21, In summary, the poor make less use of health care than their better off compatriots. This is true for interventions such as child immunization and oral rehydration therapy, for which need is much greater among the poor. It is also true of primary care and publicly financed care. The distribution of health care in developing countries could be much more pro-poor than it currently is. However, even though the better-off use public programs more than the poor, these programs can still shift the distribution of health care in a pro-poor direction. Differential crowding-out effects can mean that public programs are used most by the better off but have the greatest positive impact on health care utilization of the poor. To identify the impact of public expenditure on health care utilization it is necessary to move from descriptive benefit incidence studies to evaluations of specific programs. This is more demanding of data. But careful evaluation is crucial to identification of policy initiatives that can raise utilization and to understanding how the impact varies with socioeconomic characteristics. It is also important to distinguish between the distribution of health care at a given point in time and the distribution of marginal increments to health resources It is possible that the better off do best, on average, but that the marginal gains are concentrated on the poor. For many policy considerations, the distribution of the marginal gains is important. Unfortunately, there are few marginal benefit incidence analyses of health care. Why are effective interventions not utilized? Many factors are responsible for the underutilization of effective health care interventions in the developing world. Most obviously, economic resources are often insufficient to support the provision of essential services. The main recommendation of the WHO Commission on Macroeconomics and Health is for a substantial scaling up of expenditures on health care 7. A second problem is that the available resources are not allocated to the most effective interventions, are geographically concentrated in large cities, and do not reach the poor. Despite the WHO Alma Ata Declaration, the bulk of public health expenditure continues to be absorbed by hospital-based care delivered at some distance from poor rural populations 3, Shifting the balance of resources further toward primary care would not necessarily have the desired impact on the level and distribution of population health, however 8,19, There are major deficiencies in the quality of primary care delivered in many developing countries 8, Insufficient resources, inappropriate allocation, and inadequate quality are major impediments to the delivery of effective health care that reaches the poor. The access problem cannot be solved without tackling each of these deficiencies. Although the importance of these supply side issues is not underestimated, the primary focus of this paper is the low demand for health care, where it is available. Two sets of factors may suppress demand, those that limit ability to consume and those that lower willingness to consume. In the economist's parlance, constraints and preferences. Constraints are determined by the income of the household, the charges made for health care, and costs incurred to reach health services. Preferences are influenced by culture, knowledge of the potential benefits of health care, and the quality of the services available. The relationship is not spurious. It holds after controlling for a multitude of other determinants of health care demand see World Bank 3 for a summary of evidence. For example, the probabilities that a woman receives prenatal care and receives a medically supervised delivery rise with income 26,27,28,29, Similarly, the positive association between income and child immunization holds in multivariate analyses 31, In a market setting, a positive impact of income on consumption is expected. Prices are less of a barrier to use for those with greater purchasing power. It is a little more surprising to find the relationship emerging for public care. This is understandable once it is recognized that charges are normally made for public care in the developing world. In addition, with long distances to travel to reach health services, the non-price costs can be substantial. Monetary costs of care ensure that income is an important determinant of health care utilization and its dispersion. The nature of health financing in the developing world, with heavy reliance on out-of-pocket payments, strengthens the relationship between health care utilization and income. Risk pooling and cross-subsidization, possible with pre-payments systems, break the dependency of health care utilization on current income. With out-of-pocket financing and limited access to credit, which is the norm in many poor countries, current household income is the binding constraint on health care use. In relative terms, the payments can be substantial. It would be surprising if such charges did not deter demand. The evidence confirms that they do 9. There is some difference in the estimated strength of the relationship. Most studies of developing countries find health care to be price inelastic; demand falls less than proportionately to price 34,35,36,37, A few obtain estimates of price elastic demand 39, There is strong empirical support for the proposition that the poor are more price sensitive than the better off 9,38,41, Increases in user charges will raise the share of health care consumed by the better off, unless effective mechanisms are implemented to shield the poor from these charges. Unfortunately, the general experience with fee waivers, particularly in Africa, is not encouraging 43 see Strategies to Raise Utilization of Effective Interventions. User fees often effectively exclude the poor from essential services, while recovering only a fraction of costs Abolition of user fees in Uganda was associated with increase in utilization by the poor but this was not true in South Africa, where fees for maternal and child health services where removed The effect of price increases can be offset by quality improvements 9. There is evidence from Africa that if increased user charges are combined with reductions in travel time and improvements in quality, utilization can increase, even for the poor Informal payments are substantial in many public health care systems. They are often greater than formal charges and may exist when official charges do not. These payments are particularly prevalent in the former Soviet Union and Eastern Bloc But it is not an isolated phenomenon. In one region of rural India, the poor are paying almost as much to visit a "free" public health center as for a consultation with a private doctor In rural areas, the distances to health care facilities and the poor condition of roads mean that time, effort, and cost required to arrive at the point of delivery can be substantial. The evidence confirms the expected negative impact on health care utilization 26,47,48, Halving the distance to public health facilities in Ghana was estimated to almost double their utilization rate The demand of the poor has been found to be more sensitive to travel time that of the better off in Cote d'Ivoire One example are continued preferences for traditional over modern therapies. The fact that use of traditional therapies generally declines with income and education suggests that social norms are not inviolable. Adherence to norms is influenced by the socioeconomic environment. Gender attitudes and roles are particularly important determinants of health seeking behavior. Raising access to maternal, reproductive, and child health interventions is a major challenge within societies that restrict the public lives of women. Again, the social is not completely divorced from the economic. There is evidence from Indonesia that the utilization of prenatal care increases with the control a woman exercises over household finances Causality is a moot point. In Africa, women make more use of public health care than men in the highest income group but the gender bias is the opposite in the lowest income groups Where a large proportion of the population is in poor health, this becomes the norm and illness is not easily recognized. If treatment coverage is low, there is less opportunity to learn of its benefit. The unfortunate outcome can be the continued toleration of illness and disease. In India, 2 in 5 children are not fully immunized, despite the fact that immunization, at least in principle, is free. A detailed study of a North Indian village demonstrates the importance of poor knowledge in diminishing demand for effective interventions Households are typically passive users of vaccines, accepting them when presented with them at doorstep but with little or no active demand. There is very poor knowledge of the link between vaccine and disease and the pace of learning of the relationship is slow. To raise utilization, it is important for the community to develop trust in the provider. Given the link between immunization and health is not immediately observable, trust can be developed through observation of the effectiveness of other services provided. The poor quality of many of the services provided impedes the development of trust. There is substantial evidence from developing countries that the socioeconomic environment influences concepts of illness. Reported rates of illness are often higher among the better off than the poor 16,54, Differences in knowledge are reflected in disparities in utilization. Such patients may be turned away by staff because their tardiness disrupts the schedule, or they may even be dismissed them from the practice altogether because of repeated noncompliance. Patients in lower socioeconomic groups and other marginalized populations rarely respond well to dictation from health care professionals. Instead, interventions that rely on peer-to-peer storytelling or coaching are more effective in overcoming cognitive resistance to making positive changes in health behavior. Such activities are typically hosted by local hospitals, faith-based organizations, health departments, or senior centers. Once socioeconomic challenges are identified, we can work with our patients to design achievable, sustainable treatment plans. For example, crowding, infestations, and lack of utilities are all risk factors for disease. Knowing that a patient is homeless or has poor quality, inadequate housing will help guide his or her care. Set priorities and make a realistic plan of action As family physicians, we direct the therapeutic process by working with the patient and care team to identify priorities so that treatment goals are clear and achievable. It is likely that a low-income patient will not have the resources e. Colon cancer screening or a discussion about starting statin therapy can come later. It may be easier for this patient to adhere to an insulin regimen involving vials and syringes instead of insulin pens, which are much more expensive. We can celebrate success with each small step e. Help newly insured patients navigate the health care system In many states, the expansion of Medicaid has allowed low-income individuals and families to become insured, perhaps for the first time. He or she may be embarrassed to reveal this lack of knowledge to the care team. PCMH team members can help by providing orientation to newly insured patients within the practice. For example, PCMH team members can ensure that all patients in the practice know where to pick up medication, how to take it and why, when to return for a follow-up visit and why, and how to follow their treatment plan from one appointment to the next. Without this type of compassionate intervention, patients may revert to an old pattern of seeking crisis-driven care, which is often provided by the emergency department of a local hospital. Follow-up calls are made to ensure clients connect successfully with the resource referrals. The National Domestic Violence Hotline www. Local hospitals, health departments, and faith-based organizations often are connected to community health resources that offer services such as installing safety equipment in homes; providing food resources; facilitating behavioral health evaluation and treatment; and providing transportation, vaccinations, and other benefits to low-income individuals and families. Practices can make a resource folder of information about local community services that can be easily accessed when taking care of patients in need. This simple measure incorporates community resources into the everyday workflow of patient care, thus empowering the care team. Participate in research that produces relevant evidence Much of the research that exists about the effects of poverty on health is limited to identifying health disparities. This is insufficient. Family physicians can serve a critical role in this research because we have close relationships with patients of low-income status. Other efforts may be specific to the community served. For example, a vacant lot can be converted to a basketball court or soccer field. A community center can expand programs that involve peer-to-peer health coaching. A walking program can be started among residents in a public housing unit. As a result of the Patient Protection and Affordable Care Act ACA , nonprofit hospitals regularly report community needs assessments and work with local health departments to establish action plans that address identified needs. Local CHNAs are typically available online, as are the associated action plans. Family physicians can use information in the CHNA to access local health care leadership and join aligned forces to achieve optimal health for everyone in the communities we serve, thereby supporting the vision of the AAFP. Additional thanks to supporting staff: Melanie D. Bird, PhD Bellinda K. Centers for Disease Control and Prevention. Social determinants of health. Accessed July 5, United States Census Bureau. Link BG, Phelan J. Social conditions as fundamental causes of disease.

The World Food Summit in Rome in June health be a significant opportunity for the international community to reaffirm its commitment to the Rome Declaration and Plan of Action. The need to achieve substantial and sustainable poverty reduction, requires that concrete steps be taken to promote agriculture and rural development.

Three fourths of the poverty live in rural areas and derive the essay for their livelihoods from agriculture or from free activities which depend on the agricultural sector for their survival.

Agriculture point to point essay example rural development is therefore key to achieving overall economic growth and poverty reduction for most developing countries.

Access to health care in developing countries: breaking down demand side barriers

The peoples and governments of the countries concerned have the main responsibility for the achievement of hunger and poverty reduction targets. However, countries with widespread extreme poverty and malnutrition cannot raise the resources domestically to free assist the needy and to foster growth in the productive sectors.

These countries cannot make progress in the battle against hunger and poverty without a sustained flow of external resources.