Several successful programmes addressing the problem of health care inequality have been documented in recent years. This chapter draws on 14 such case studies to suggest general lessons learned. It presents a menu of pro-poor policies, and identifies recurring themes and emerging ‘rules of thumb’. Success in reducing inequality can be achieved through programmes that are: developed with an empirical and exploratory spirit; crafted with input from the poor; responsive to specific local realities; and continually evaluated and adjusted.
Successful policy actions can be organised into a ‘menu’ of pro-poor policies – by their scope (macro, health system, or micro level) and by the five most common health sector reform functions they address (finance, provider payment, organisation, regulation and persuasion). The diversity of the examples suggests, however, that there is no universal way of successfully addressing inequality in the health sector. Unique solutions were obtained variously from government intervention, public-private partnerships, improving the supply of services, community involvement, or changes in resource allocations.
There are, however, common themes regarding attitude and strategy:
- Analysing the causes of inequality: Analysis reveals the factors that drive inequality in the use of services. Identifying the nature of the problem and prioritising bottlenecks is the best way forward.
- Customising answers to address local constraints and capacities: A policy that works in one country will not automatically work in a different context. Successful programmes take into account local causes of inequality, existing capacities, and cultural context.
- Trying out new ways of doing business: Systems fail for structural reasons that tend to be persistent and hard to change. Attacking inequality sometimes requires innovative thinking and the courage to attempt new ways of doing business.
- Improving results over time by learning from pilots and experimentation: The complex and persistent nature of poverty and inequality means that new policies need to be adjusted as they are implemented. Patience and a long-term view are required.
- Verifying that the use of services by the poor is improving and that bottlenecks are being eliminated: Merely starting a project to address inequality does not guarantee success – vigilance is critical.
It is both difficult and dangerous to reduce a complex problem into rules of thumb. However, some basic principles emerge that may help policymakers to select the most appropriate options in a particular context:
- Delink payment by the poor from use: In a number of reforms, policy actions decreased inequality if they minimised or eliminated the financial disincentives for poor households to seek care.
- Make the money follow the poor: Hospital services are overwhelmingly pro-wealthy in low- and middle-income countries. Successful reforms included actions that reoriented resources to serve the poor.
- Link provider payment to use by the poor: Managers and service providers respond to financial incentives. Provider payment mechanisms influence the services provided and the population served.
- Close the distance between the poor and services: Reforms that brought services geographically and socially closer to the poor had a positive impact on inequality.
- Amplify the voice of the poor: Policies successfully reduced inequality by engaging the poor in the design and implementation of health sector reforms.
- Close the gap between need and demand by the poor: Need for health services does not automatically translate into demand. Closing this gap may require information, persuasion and incentives.
