Equitable access to health care

As the world grapples with the problems of poverty and ill health, most people would agree that urgent action is needed to reduce the unacceptably high number of deaths of children living in resource constrained countries.1 Three studies in this week's BMJ provide evidence to improve health services in less resourced countries.2 3 4 The first study, by Biai and colleagues, is a randomised controlled trial from Guinea Bissau in West Africa. They show that supervising healthcare workers to adhere to standard treatment protocols reduces mortality in children admitted to hospital with severe malaria.2 This may not seem surprising. What is surprising, though, and of major policy importance, is that a key part of this effective intervention was to provide a small financial incentive to health workers (equivalent to one month's rent).

Many agencies, including governments in countries in sub-Saharan Africa with less resources, have been reluctant to give financial incentives to their staff. They have opted instead for non-financial incentives such as acknowledging staff professionalism, offering career development and training, enforcing strict codes of conduct, and setting benchmarks for performance—all to no avail.5

In the 1980s and 1990s the policies of economic structural adjustment and health sector reform saw expenditure on health by many governments in the developing countries drastically reduced, at the behest of the World Bank and the International Monetary Fund.6 Although these policies are no longer in vogue, expenditure on health has not improved substantially, and the hospital wards in many of these countries are best described as pathetic. For example, in the paediatric ward in Guinea Bissau patients are diagnosed by an underpaid doctor who has to supplement his or her income through moonlighting.2 The patients might get the first emergency dose of the prescribed drugs from the hospital if they are lucky. Often however, the parents have to buy the drugs, intravenous cannula, and nasogastric tubes from private pharmacies that have mushroomed around the government run hospitals in the capital cities of these countries. Often, time is lost, and mortality in the first 24 hours is high.7

Several approaches have been tried to redress this situation—tackling the basic causes of ill health such as poverty, training of health staff on standardised treatment protocols, and increasing staff morale through sponsorship at training workshops where they can earn an extra income through per diems (daily allowances for accommodation and food).1 5 8 Some hospitals have introduced strict logging of arrival and departure times by staff. Campaigners have advocated the availability of free drugs at the point of care. Unfortunately few, if any, of these interventions seem to have led to clear reductions in mortality.

In the study by Biai and colleagues, all the patients received free medical kits for treating severe malaria and all the staff were trained and told to follow up the patients. In the intervention group, however, adherence to existing standards and case management guidelines and strict patient monitoring were ensured.2 In addition, this group of health workers was offered a financial incentive ($50 (£25; €35)/month). The quality of heath care and subsequent better health of children on the paediatric wards depended not only on training, availability of free drugs and treatment kits, but also on these modest financial incentives. The extra pay was enough to enable staff to work efficiently, rather than moonlighting to pay rent and meet their obligations to their immediate and extended families.

The second study, by Bleich and colleagues, also reports on a financial intervention, and it finds that expansion of healthcare coverage to uninsured people in Mexico is associated with greater use of antihypertensive treatment.3 Both of these studies provide powerful evidence on ways to improve access to health care in places where poverty is prevalent. Meanwhile, Dorling and colleagues' study shows that income inequality—a measure of relative poverty—has a negative effect on overall health in less resourced as well as wealthy countries, especially for younger adults.4

Income inequality may be hard to tackle. But good evidence is now available for ministries of health and non-governmental organisations in less developed countries to tackle the urgent problems dogging health systems—inequitable access to care and poorly paid, demotivated, and overworked staff. Without concrete action it will be difficult to improve the effects of poverty on global health.