Global evidence on inequities in rural health protection
New data on rural deficits in health coverage for 174 countries
ILO – ESS (Extension of Social Security) Paper Series No. 47
Edited by Xenia Scheil-Adlung, ILO
2015 :: 83 pages
Summary
This paper presents global estimates on rural/urban disparities in access to health-care services. The report uses proxy indicators to assess key dimensions of coverage and access involving the core principles of universality and equity. Based on the results of the estimates, policy options are discussed to close the gaps in a multi-sectoral approach addressing issues and their root causes both within and beyond the health sector.

Foreword
While inequities in health protection are increasingly recognized as an important issue in current policy debates on universal health coverage (UHC) and in the post-2015 agenda, the rural/urban divide is largely ignored. A key reason for disregarding equity in coverage and access to health care of large parts of the population relates to the nearly complete absence of disaggregated data providing sufficient information at national, regional and global level. Only vague and fragmented information, often limited to microdata, can be found.

Given this gap in information, it is hardly possible to quantify and assess the extent of disparities and deficits experienced by rural populations as regards key aspects of their rights to health and social protection; the availability, affordability and financial protection of needed health services; and increases or decreases in inequities. Further, governments and policy-makers lack evidence to set priorities, and thus face challenges in addressing the issues that are spread over various policy domains including health, social protection, labour market and more generally economic and fiscal policies.

This paper presents and analyses for the first time related global, regional and national data. It is developed and made available by the ILO. The data allow investigating both the extent of and major causes of rural/urban inequities in coverage and access to health care. Further, it discusses impacts and policy options to achieve more equitable results.
The data development and related assessments provided in this paper are anchored in the framework of universal health protection along the lines of international legal standards, particularly the ILO Social Protection Floors Recommendation, 2012 (No. 202) and the UN Resolution on Universal Health Coverage (12 December 2012).

The paper has been developed as part of the mandate of the ILO Areas of Critical Importance (ACI) on Decent Work in the Rural Economy as well as the ACI on Creating and Extending Social Protection Floors, and has been reviewed by a significant number of experts in relevant development agencies. It highlights the needs of disadvantaged, marginalized and vulnerable rural populations and contributes to related global research products and statistics. Further, it provides guidance to ILO member States on establishing and extending social protection floors for all as a fundamental element of national social security systems.

The evidence provided in the paper suggests that inequalities in coverage and access to health care exist globally, in every region and nearly every country. In fact, the place of residence can be considered as the entry door or key barrier to accessing needed health care. Against this background, the paper aims at contributing to the development of urgently needed policy responses realizing the universal human rights to social protection and health, particularly for rural populations.
Isabel Ortiz
Director
Social Protection Department
International Labour Organization

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Press Release
Social Protection
More than half of the global rural population excluded from health care
ILO report shows huge differences in health care access between rural and urban areas worldwide.
27 April 2015
GENEVA (ILO News) – A new ILO report shows that 56 per cent of people living in rural areas worldwide do not have access to essential health-care services – more than double the figure in urban areas, where 22 per cent are not covered…

…The highest number of people in rural areas who are not covered by essential health-care services is in Africa where it amounts to 83 per cent. The most affected countries also face the highest levels of poverty.

The largest differences between rural and urban areas, however, exist in Asia. For example, in Indonesia the percentage of people that are not covered is twice as high in rural areas as in urban areas.

“Decades of underinvestment in health interrupted efforts to develop national health systems and ultimately resulted in the neglect of health in rural areas. This has a huge human cost. Health is a human right and should be provided to all residents within a country,” said Isabel Ortiz, Director of the ILO’s Social Protection Department.

Lack of health workers in rural areas
The ILO study further finds that even if access to health care is guaranteed by law, people in rural areas remain excluded from health care because such laws are not enforced where they live.

The situation is worsened by the lack of health workers in the world’s rural areas. Although half of the world’s population lives in them, only 23 per cent of the global health workforce is deployed to rural areas. The ILO estimates that 7 million out of the total 10.3 million health workers who are lacking globally are needed in these areas.

Africa and Latin America are the two regions where this problem is most acute. In Nigeria, for example, more than 82 per cent of the rural population is excluded from health-care services due to insufficient numbers of health workers compared to 37 per cent in urban areas.

Underfunding is closely linked to the unavailability of services. The ILO study shows that financial resource gaps are nearly twice as high in rural than in urban areas. The largest gaps are found in Africa. However, significant inequities also exist in Asia and Latin America.

The extent of impoverishing out-of-pocket payments (OOPs) is also high in rural areas. The study shows that rural populations in Africa and Asia are burdened with OOPs that amount to 42 and 46 per cent of total health expenditure respectively. In many Asian countries such as Afghanistan, Bangladesh, Cambodia and Sri Lanka, OOPs are two to three times higher in rural than in urban areas.

“The lack of legal coverage, insufficient numbers of health workers, inadequate funding, and high OOPs have created life-threatening inequities in many countries,” said Xenia Scheil-Adlung, Health Policy Coordinator at the ILO.

“Strengthening both the demand and supply side of services is crucial when moving towards universal health protection, particularly in rural areas. Legal health coverage is necessary, but not sufficient. Only when quality services are actually made available and affordable for all those in need can effective access to health care be ensured,” she added.

Closing the gaps
The study explains that closing rural health access gaps requires a comprehensive and systematic approach that simultaneously addresses missing rights, health workers, funding, financial protection and quality. Such an approach needs to be based on the principles of universality and equity and calls for solidarity in financing and burden sharing.

“Addressing such inequities needs to consider the specific characteristics of rural populations, including high poverty rates and informality of work. This means moving from charity to rights, the provision of health workers with decent working conditions that enhance productivity, and the minimization of out-of-pocket payments by patients to avoid poverty. It also requires complementary socio-economic and labour market policies to trigger inclusive economic growth,” said Scheil-Adlung.

The study highlights the key role that national social protection floors can play in reducing and eliminating rural/urban gaps through human rights-based approaches. In this sense, it points to the importance of ILO Recommendation 202 on social protection floors.

“This study shows that investing in rural health, as part of a national health system, is affordable and yields significant economic and social returns. Progress towards universal health protection is possible in any country, irrespective of its level of income,” Ortiz concludes.