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The Many Faces of Exclusion from Care

Table of Contents Introduction Obstacles to progress: context or policy? Context Matters The Many Faces of Exclusion from Care Different Exclusion Patterns, Different Challenges

Many more mothers and children have access to reproductive, maternal and child care entitlements than ever before in history. In many countries, however, universal access to the goods, services and opportunities that improve or preserve health is still a distant goal. A varying but large proportion of mothers and children remain excluded from the health benefits that others in the same country enjoy. Exclusion is related to socioeconomic inequalities. In many countries it is a sign of increasing dualism in society: as growing middle classes in urban areas gain disproportionate access to public services, including education and health care, they effectively enter into competition with the poor for scarce resources, and easily come out on top ( ²⁴ ).

The result is that exclusion from access to health care is commonplace in poor countries. In the 42 countries that in 2000 accounted for 90% of all deaths of children under five years of age, 60% of children with pneumonia failed to get the antibiotic they needed, and 70% of children with malaria failed to receive treatment ( ²⁵ ). One third of children did not receive the vitamin A available to others in the same countries, and half had no safe water or sanitation. From 1999 to 2001, less than 2% of children from endemic malaria areas slept under insecticide-treated nets every night. Stagnation of progress in coverage for a number of interventions has meant that large parts of the population have continued to be excluded ( ²⁶ ). Immunization coverage, for example, maintained its upward trend during the 1990s in the WHO European Region, the Region of the Americas and the Western Pacific Region, but in the other regions it has levelled off at a mere 50% to 70% (see Figure 2.2).

Sources of exclusion

In many of the countries experiencing stagnation and reversal (particularly in sub-Saharan Africa), barriers to the uptake of health benefits, and specifically the lack of an accessible supply of services, are a critical source of exclusion. For many people, services simply do not exist, or cannot be reached. For example, lack of access to hospitals where major obstetric interventions can be performed is the prime reason why large numbers of mothers in rural areas are excluded from life-saving care at childbirth (see Box 2.4).

But there are many other barriers to the uptake of health benefits: service use is often constrained because of women’s lack of decision-making power, the low value placed on women’s health and the negative or judgemental attitudes of family members ( ²⁸ , ²⁹ ). Gender is thus a frequent source of exclusion: in India, for example, a girl is 1.5 times less likely to be hospitalized than a boy ( ³⁰ ) - and up to 50% more likely to die between her first and fifth birthdays ( ³¹ ).

People excluded from health care benefits by such barriers to the uptake of services are also usually excluded from other services such as access to electricity, water supply, basic sanitation, education or information. Their exclusion from care is also reflected in inferior health indicators. In Kazakhstan, for example, children born to ethnic Kazakh parents have a 1.5 times higher risk of death than those born to parents of Russian ethnicity; in Nigeria, children of uneducated mothers have about a 2.5 times higher risk of death than those of mothers with secondary school or higher education.

As part of its work on extension of social protection in health, the Pan American Health Organization has started mapping exclusion from health benefits in a number of Latin American countries ( ³² ). Nearly half of the population is excluded from some, and usually from most health care benefits. The relative importance of underlying reasons for exclusion varies from country to country.

"External" sources of exclusion, such as the ones described above, include geographical isolation, as well as barriers generated by poverty, race, language and culture - often in association with unemployment or informal employment. For many people the critical factor is the deterrent effect of uncertainty about the cost of care, or of the awareness that care will be unaffordable or catastrophically expensive. Such external factors affecting uptake of services are the most important source of exclusion in, for example, Peru and Paraguay ( ³² ).

Other, "internal", sources of exclusion lie within the way the health system actually operates. Even for people who do use services, what is offered may be untimely, ineffective, unresponsive or discriminatory. Being poor or being a woman is often a reason for being discriminated against, and may result in abuse, neglect and poor treatment, poorly explained reasons for procedures, compounded by the view sometimes held by health workers that women are ignorant. When, for example, in a busy urban maternity hospital in India, the nurses in the labour ward do not complete patient case notes for low-caste women, that deprives them of the quality safeguards given to other women ( ³³ ). Poor and anonymous patients often have to wait longer, are examined more superficially, or are treated with disdain; they may get inferior treatment, especially when scarce resources are reserved for richer patients. In rural areas of the United Republic of Tanzania, for example, children from the poorest part of the population who sought care for probable pneumonia were less than half as likely to be given antibiotics as richer children ( ³⁴ ).

Such factors internal to health services can be important sources of exclusion; throughout the world, many mothers and children are excluded from what they are entitled to because of the failure of the health system to deliver the right services at the right time, to the right people, and in the right manner. In Ecuador and Honduras, for example, what happens within the health system, rather than failed uptake, is the dominant source of exclusion ( ³² ).

Exclusion from "normal" treatment - what a patient can expect, based on what other people are given - does not go unnoticed by those concerned. In India, for example, 55% of poorer mothers said they had been made to wait too long (only half as many of the richer mothers had that impression), and only 50% were given clear information about their treatment, as against 89% of the richer patients. Other patients are also aware of such practices: 67% of the patients in Conakry, Guinea, are convinced that rich and well-dressed patients get better treatment ( ³⁴ ).

The - often justified - expectation of ill-treatment or discrimination in turn discourages uptake of services, completing a vicious circle of exclusion, compounded by the absence of adequate systems to protect mothers and children against catastrophic expenditure or financial exploitation.

Poverty, humanitarian crises, and the HIV/AIDS epidemics all directly affect the health and survival of mothers and children. But they also affect their health by creating barriers to the uptake of services. Furthermore, they influence the way services are provided to mothers and children who do use them, and thus add to sources of exclusion within the health system.

Patterns of exclusion

The extent and depth of exclusion vary from region to region within countries, but also between countries. At one extreme are the poorest countries where large parts of the population are deprived of care, even among the better off: only a small minority enjoys reasonable access to a reasonable range of health benefits, creating a pattern of massive deprivation. At the other extreme are countries where a large part of the population enjoys a wide range of benefits but a minority is excluded: a pattern of marginalization.

Looking at health care coverage by wealth group provides a crude illustration of these different patterns (see Figure 2.3). Between the extremes of massive deprivation (typical for countries with major problems of supply of services and low-density health care networks) and marginalization (typical for rich or middle-income countries with dense health care networks) are the countries where poor populations have to queue behind the better off, waiting to get access to health services and hoping that benefits will eventually trickle down.

As countries move from a pattern of massive deprivation towards one of marginalization, the poor-rich gap in coverage and uptake of services grows in size, to diminish only as the curves flatten out when universal access is within reach (see Figure 2.4). Unless specific measures are taken to extend coverage and promote uptake in all population groups simultaneously, improvement of aggregate population coverage will go through a phase of increasing inequality.

These complex dynamics also affect the distribution of health outcomes. For a long time policy-makers used aggregate health indicators - particularly the under-five mortality rate - to monitor health policies. As more sophisticated analyses of health outcomes by asset quintile have become possible ( ³⁷ ), attention has been drawn to the occurrence of increasing survival gaps between the poorest and the better off ( ³⁸ ). The gaps in mortality rates between the children of rich and poor families have increased in the majority of 21 developing countries that had reduced their overall rate of mortality among children under five years of age (see Figure 2.5). Health and survival among the poorest actually deteriorated in eight of these countries, while the richest children in the same countries improved their chances of survival. As a result, national averages that show progress may conceal persisting or widening inequalities. Similar divergence appears to be occurring for maternal mortality in some countries ( ³⁹ ).

Footnotes

²⁴ Pronk, J. Collateral damage or calculated default. The Millennium Development Goals and the politics of globalisation. The Hague, Institute of Social Studies, 2003.

²⁵ Jones G, Steketee RW, Black R, Bhutta, ZA, Morris S and the Bellagio Child Survival Study Group. How many child deaths can we prevent this year? Lancet, 2003, 362: 65-71.

²⁶ Bryce J, el Arifeen S, Pariyo G, Lanata C, Gwatkin D, Habicht JP. Reducing child mortality: can public health deliver? Lancet, 2003, 362:159-164.

²⁷ L’approche des besoins obstétricaux non couverts pour les interventions obstétricales majeures. Etude comparative Bénin, Burkina Faso, Haiti, Mali, Maroc, Niger, Pakistan et Tanzanie. [Tackling unmet needs for major obstetric interventions. Case studies in Benin, Burkina Faso, Haiti, Mali, Morocco, Niger, Pakistan and Tanzania]. Antwerp, Unmet Obstetric Needs Network, 2002:1–47 (www.uonn.org).

²⁸ Matthews Z, Ramasubban R, Rishyasringa B, Stones WR. Autonomy and maternal health-seeking among slum populations of Mumbai. Southampton, Southampton Statistical Sciences Research Institute, 2004.

²⁹ Reproductive health strategy to accelerate progress towards the attainment of international development goals and targets. Geneva, World Health Organization, 2004.

³⁰ Bhan G, Bhandari N, Taneja S, Mazumder S, Bahl R, and other members of the Zinc Study Group. The effect of maternal education on gender bias in care-seeking for common childhood illnesses. Social Science and Medicine, 2005, 60:715-724,

³¹ Claeson M, Bos ER, Mawji T, Pathmanathan I. Reducing child mortality in India in the new millennium. Bulletin of the World Health Organization, 2000, 78:1192-1199.

³² Exclusion in health in Latin America and the Caribbean. Washington, DC, Pan American Health Organization, 2004.

³³ Hulton L, Matthews Z, Stones RW. A framework for the evaluation of quality of care in maternal services. Southampton, University of Southampton, 2000.

³⁴ Jaffré Y, Olivier de Sardan JP. Une médecine inhospitalière: les difficiles relations entre soignants et soignés dans cinq capitales d’Afrique de l’Ouest [Inhospitable medicine: difficult relations between carers and cared for in five West African capital cities]. Paris, Karlhala, 2003.

³⁵ Ferguson BD, Tandon A, Gakidou E, Murray CJL. Estimating permanent income using indicator variables. Geneva, World Health Organization, 2003 (Global Programme on Evidence for Health Policy Discussion Paper No. 42).

³⁶ Demographic and Health Surveys. Country statistics (http://www.measuredhs.com/ countries/start.cfm, accessed 16 December 2004).

³⁷ Gwatkin D, Rutstein S, Johnson K, Pande R, Wagstaff A. Socio-economic differences in health, nutrition and population. Washington, DC, World Bank, 2000 (Health, Nutrition and Population Discussion Papers).

³⁸ Gwatkin D. Who would gain most from efforts to reach the MDGs for health? An enquiry into the possibility of progress that fails to reach the poor. Washington, DC, World Bank, 2002.

³⁹ Graham W, Fitzmaurice AE, Bell JS, Cairns JA. The familial technique for linking maternal death with poverty. Lancet, 2004, 363:23-27.

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