VIEWPOINT
Viewpoint
Equity and health sector reforms: can low-income countries escape
the medical poverty trap?
Margaret Whitehead, Göran Dahlgren, Timothy Evans
In the past two decades, powerful international trends in
market-oriented health-sector reforms have been sweeping
around the world, generally spreading from the northern to
the southern, and from the western to the eastern
hemispheres. Global blueprints have been advocated by
agencies such as the World Bank to promote privatisation
of health-service providers, and to increase private
financing—via user fees—of public providers. Furthermore,
commercial interests are increasingly promoted by the
World Trade Organisation, which has striven to open up
public services to foreign investors and markets.1–3 This
policy could pave the way for public funding of private
operators in health and education sectors,2 especially in
wealthy, industrial countries in the northern hemisphere.
Although such attempts to undermine public services
pose an obvious threat to equity in the well established
social-welfare systems of Europe and Canada, other
developments pose more immediate threats to the fragile
systems in middle-income and low-income countries. Two
of these trends—the introduction of user fees for public
services, and the growth of out-of-pocket expenses for
private services—can, if combined, constitute a major
poverty trap.
Private finance for public services
Introduction of user fees for public services has become
entrenched in many developing countries since publication
of the World Bank policy document of 1987.4 This strategy
was part of a health-policy package, which in turn was
one component of common macroeconomic structural-
adjustment programmes for countries facing debt.5 The
World Bank strategy has been powerfully reinforced by the
practice of making user fees a condition of loans and aid
from international donors, for example, in Kenya and
Uganda.
Private financing of public health services has also
increased in countries with high and stable economic
growth rates, such as China and Vietnam. Privatisation is
claimed to increase the public’s appreciation of health
services and prevent overuse.4 Fees are assumed to offer
financial possibilities to health providers for improvement
of quality of services.6
Such privatisation policies in health care, however, are
highly regressive, because pooling of risk is reduced and
Lancet 2001; 358: 833–36
Department of Public Health, University of Liverpool, Liverpool, UK
(Prof M Whitehead PhD); Swedish National Institute of Public Health,
Stockholm, Sweden (Prof Göran Dahlgren MA); and Health Equity
Division, The Rockefeller Foundation, New York, NY, USA
(Timothy Evans MD)
Correspondence to: Prof Margaret Whitehead, Department of Public
Health, University of Liverpool, Whelan Building, The Quadrangle,
Liverpool L69 3GB, UK
(e-mail: mmw@liverpool.ac.uk)
THE LANCET • Vol 358 • September 8, 2001
For personal use. Only reproduce with permission from The Lancet Publishing Group.
care costs fall more directly on the sick (who are most likely
to be poor, children, or elderly), than on healthy
individuals. The World Bank’s counter-argument was that
revenues from user fees could be used to subsidise those
least able to afford care.7 Exemption schemes were
proposed to get round the difficulty of poor people not
being able to afford essential services. During the 1990s,
the World Bank predicted that in one sweep, this user-fee
policy would improve poorer groups’ access to and use of
essential health services.7 Why then is there widespread
dissatisfaction with this policy in developing countries? The
answer lies in the actual, rather than the predicted, effects
experienced by families and communities.
Out-of-pocket expenses for private services
A second trend reinforcing the effect of user charges in the
public sector, is the increase in private medical practices,
and an explosive growth in private pharmacies.8 In
developing countries, pharmaceutical drugs now account
for 30 to 50% of total health-care expenditure, compared
with less than 15% in established market economies.9
Private drug vendors, especially in Asia and parts of Africa,
tend to cater for poor people who cannot afford to use
professional services. These vendors, who are often
unqualified, frequently do not follow prescribing
regulations. In parts of China and India, drug vendors can
be found on nearly every street corner.10 Limited access to
professional health services, and aggressive marketing of
drugs on an unregulated market have not only generated an
unhealthy and irrational use of medicines, but also wasted
scarce financial resources—especially, among poor people.
Medical poverty trap
The positive assumptions on which these strategies have
been based are not borne out by the evidence. Results of
empirical studies on the effects of these policies point to
severe negative consequences.11,12 Rises in out-of-pocket
costs for public and private health-care services are driving
many families into poverty, and are increasing the poverty
of those who are already poor. The magnitude of this
situation—known as “the medical poverty trap”—has been
shown by national household surveys and participatory
poverty alleviation studies.11,13–16 The main effects fall into
four categories.
Untreated morbidity
The most severe effects are felt by those who are denied
services because they cannot afford them and whose
sickness goes untreated. Such people are at risk of further
suffering and deterioration in health. In the Caribbean,
between 14 and 20% of people who reported illness
indicated that they did not seek care because of lack of
funds for treatment or transport.17 In the Kyrgyz Republic,
more than half the patients referred to hospital were not
admitted, because they could not afford hospital costs.15 In
some Indian rural areas, 17% of people who reported
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illness did not seek care, of whom more than a quarter cited
financial reasons.18
Untreated sickness among poor people is recorded not
only in countries with serious economic difficulties, but also
in those with high and stable economic growth. For
example, access to essential health services in rural China
was renowned, but has been drastically reduced despite a
yearly economic growth rate of almost 10% in the past two
decades. In household surveys in rural China, 35–40% of
people who reported that they had had an illness did not
seek health care, with financial difficulties cited by poor
people as the main reason.13,19 Additionally, 60% of those
referred to hospital by a doctor never contacted the hospital
because they knew they could not afford to pay the high
user charges.13 Costs to individuals and society from
untreated morbidity are potentially devastating.
Reduced access to care
Introduction of high user fees has typically caused an
indiscriminate reduction in access to care. The United
Nations Research Institute for Social Development has
recently summarised the experiences of user fees: “Of all
measures proposed for raising revenue from local people
this [user fees] is probably the most ill advised. One study
of 39 developing countries found that the introduction of
user fees had increased revenues only slightly, while
significantly reducing the access of low-income people to
basic social services. Other studies have shown that fees
reinforce gender inequality.20 Poor people delay seeking
care until an emergency situation arises, because of
financial constraints.11 This delay often forces them
eventually to seek care at a more expensive level, typically at
a hospital, rather than at a health centre. The negative
effects of user fees are therefore two-fold: poorer health and
increased medical expenditure. High user fees are thus
inefficient and inequitable.
However, advocates of private finance argue that negative
effects of user fees are not inevitable. Efficient and fair
systems for waiving user fees could be established, and
thereby secure access to public health-care services for
those not able to pay.7 In practice, establishment of well
functioning systems for waiving fees has proved very
difficult.21 A major difficulty is to identify very poor people
in a population in which poverty is rife. Another difficulty is
that no public funds are set aside to compensate local
providers for reduction or elimination of fees for some of
their poorer patients. Public health-care providers, who
depend on revenue from fees, are likely to start to give
priority to patients who can pay. In many countries, this
trend is reinforced because revenue from fees is directly
linked to health staff payments and salaries.22 In such a
financial climate, public hospitals tend to favour rich
people, who generally gain greater shares of public funds
than poor people.
Long-term impoverishment
People buy care even if it costs them their long-term
livelihood, because medical expenses are often forced
payments. Their difficulty is not in allocation of scarce
resources, but rather whether or not they can find money
for urgent treatment such as surgery. The negative social
effects of direct user fees for health care are also greater
than most other fees, because these expenses are
unexpected and total cost is often not known until after
treatment.
The economic effect of ill health has long been a cause of
bankruptcies in the USA,23 but in the 1990s, ill health
became a leading cause of household impoverishment in
transitional economies, such as rural China,13 and some of
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the Asiatic republics of the former USSR.15 Poor
households reporting illness in a rural area in northern
Vietnam, spent an average 22% of their household budget
on health-care costs, whereas rich households spent 8%.14
Moreover, poor people tended to pay more than rich
people at a health centre, and poor communes charged
more than rich communes.24 In Thailand, poor people also
pay proportionally more for health care than rich people.25
So-called free maternity services in Dhaka, Bangladesh,
have hidden and unofficial payments that necessitate more
than a fifth of families spending the equivalent of 50–100%
of their monthly income on maternity care.16 In Vietnam,
the average cost of hospital admission is the equivalent of
2 months’ wages,14 and in rural China, hospital care costs
up to seven times the net monthly income of a poor
household.26
Loans and debt are common consequences of such
expenses. In rural North Vietnam, 60% of poor households
were in debt, with a third citing payment for health care as
the main reason.24 Similar patterns of debt occur in parts of
Africa, China, and Cambodia. In Phnom Pen, Cambodia,
20% of patients who had obtained money for treatment
costs had taken out loans from private lenders, and were
paying extortionate interest of 20–30% per month. 10% of
these patients cut down on food to offset the cost of
borrowing. In two rural districts of Uganda, between 20%
and 40% of patients raised money for health-care bills not
only by borrowing, but also by working for others, or selling
off assets such as land or cattle. Withdrawal of children
from school is another common coping strategy—to save
on school fees and so that children can help out on the farm
while parents seek temporary jobs to pay off loans for
hospital bills.11 In traditional economic analyses, poorer
groups’ payment for health care is typically used as
evidence of willingness to pay. However, it is increasingly
clear that payment is not the same as ability to pay. Many
poor people cannot afford to pay, but still do so, at great
long-term cost to themselves and their families.
Irrational use of drugs
Irrational prescribing and drug resistance make an
important, but overlooked, contribution to the inequities of
the medical poverty trap. For example, in India, 52% of
out-of-pocket health expenditure went towards medicines
and fees, as did 71% of in-patient expenditure.18 People in
parts of rural China spend between two and five times the
average daily-per-capita income on a typical prescription.27
In a growing number of low-income countries, profits from
sales of drugs have become an important part of health-
related workers’ incomes, and an incentive for workers to
increase sales to their maximum.28
Increasingly, in developing countries, sale of drugs
without prescription by unqualified people, who have
financial incentives to overprescribe, leads to unnecessary
and irrational use of medicines. In rural areas and poor
quarters of cities in India, indiscriminate prescription of
injections and drips is rife. For example, in an analysis of
prescriptions in the Indian district of Satara in
Maharashtra,29 19% of prescriptions were thought
irrational, 47% were unnecessary, and 11% were
hazardous. Unnecessary injections were given in 24% of
cases. Up to 70% of all expenditure on drugs in India is
thought unnecessary.18
In a national household survey in Vietnam, 67% of all
those who reported illness in the previous 4 weeks had
obtained medicines without consultation with a medical
practitioner.30 Furthermore, rural commune health-workers
frequently prescribed oral antibiotics, gentamicin
injections, potent steroids, and oral and intravenous
THE LANCET • Vol 358 • September 8, 2001

vitamin preparations inappropriately.31 Vietnam’s high
frequency of antibiotic resistance is a clear indication of the
adverse health effects of inappropriate drug sales and
irrational consumption.32 In a poor region of Mexico, 74%
of health-care visits resulted in inadequate treatment or
advice, especially from traditional healers or retail drug
sellers.33 On average, the equivalent of 13 days minimum
wage was spent unnecessarily per patient, in 1 month,
because of inadequate prescribing.33
Poor people receive ineffective, or even dangerous
treatment, including inappropriate or inadequate
antituberculosis treatment regimens,34 and contraindicated
drugs for women in pregnancy.35 If people can afford only a
part course of drugs (eg, for tuberculosis or malaria), these
drugs are not only ineffective, but also create drug
resistance that can threaten whole communities.36 The
same situation occurs with widespread overprescription (or
self-medication) of antibiotics for straightforward cases of
diarrhoea, for which oral-rehydration therapy would be
most appropriate.37 For example, in a periurban community
in Mexico, antibiotics were used in 37% of diarrhoeal
episodes, although this therapy was indicated in only 5% of
episodes.38 In six other Latin American countries, a quarter
of drugs bought over the counter should have been
dispensed on a prescription, because they needed medical
follow-up.39
What can be done about the medical poverty
trap?
The actual outcomes of previous and current market-
oriented reforms have often been contrary to stated
objectives, as economic access for poor people has declined
and total costs increased. These gaps between stated
objectives and outcomes have shown lack of, and need for,
a firmer evidence base for health-sector policies. The
overall view is clouded by rhetoric and unsupported
assumptions about the merits of policies that are widely
advocated. There is a need for policy research to assess the
validity of assumptions that underly market-oriented
reforms, and the options for, and constraints on,
development of efficient and equitable health-care systems.
The need to be vigilant and to ascertain what is really
happening in low-income countries, rather than to rely on
assumptions, is vividly illustrated by policy on user fees.
Some commentators accept that the World Bank has
ceased pushing user fees as a strategy in low-income
countries, and therefore, that this strategy is a thing of the
past and no longer a problem. Unfortunately, this
discredited policy is still alive and well, and causes immense
distress in many countries of the southern hemisphere.
Noting the persistence of this policy, the US House of
Representatives approved a measure in July, 2000, to
pressure the World Bank to stop requiring impoverished
countries to charge “user fees” for basic health services and
primary education. This opens up an opportunity to
influence the user-fee policy of the Bank, by use of the best
evidence available, although that evidence has yet to be
fully marshalled.
Apart from the user-fee issue, other aspects of reforms
are proving pernicious to poor people, and require a much
more active approach to monitor trends in the health
sector; one such approach, termed an equity gauge, is
already underway and provides a model for how this might
be done.40 In this context, the potential of an essential drugs
watch is being assessed, which would monitor equity and
quality of countries’ drug policies, raise awareness of health
issues, and inform health policies.
Effects of reform efforts need to be assessed from a
household perspective. What do health reforms mean for
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VIEWPOINT
households of low, middle, and high income? How
affordable are the results of different policy options for
families? How do reforms affect the ability of different
population groups to secure health services according to
need? In such an approach, questions would also be asked
about why an increasing number of households do not use
available public health services, but treat themselves at
home. Qualitative studies are needed to fully understand all
the factors involved in these decisions. The fact that many
people pay for health care has for too long been taken as
synonymous with willingness and ability to pay, but with no
assessment of how much of a burden payment is on the
household budget.41 Affordability should have a more
important place in investigation of health reform. The
potential to do this type of household-focused research is
increasing, because many low-income countries are
undertaking national standard-of-living household surveys
and various participatory poverty assessment studies.
How could the medical poverty trap be prevented? What
are the policy options for prevention of medical poverty
traps in different countries? The answer to these questions
will be crucial in the next few years, and will need to
encompass not only health-systems policy, but also broad
development issues to alleviate poverty.
Furthermore, the weaknesses in public health services
need to be acknowledged and tackled. Cultural access is an
especial problem that encompasses: lack of responsiveness;
disrespect shown towards disadvantaged groups of people;
and widespread use of informal so-called under-the-table
payments, which all contribute to underuse of public
services in some low-income countries. This underuse is
also caused partly by chronic under-resourcing, partly by
the ways staff treat patients, and partly by indirect costs of
service use, such as transport and loss of income.22,42
Furthermore, public hospital services are mainly used by
better-off people, who can afford high direct costs. This
tendency to crowd out less-privileged people is reinforced
in times of economic recession, when rich people find
paying the market price for private health-care services
difficult to afford. The way forward is certainly country
specific, but policy-oriented research is needed to assess the
most promising options.
Such options include strategies for public finance that
encompass tax polices and tax evasion, to ensure effective
pooling of risks across the whole population. Also needed is
gradual change from direct payments to social health-
insurance systems, in which healthy, high-income groups
subsidise care for low-income groups. These insurance
systems would include community-based health insurance
subsidised by public funds, which could also cover costs for
essential drugs. Efforts should be intensified to reduce, and
even eliminate, informal payments for public health-
services. Ways of strengthening the regulatory role of
governments should be investigated, to empower
governments to develop and implement essential drug
programmes and systematic assessments of medical
technologies. This shift in power could ensure the highest
possible value for money spent on health services and drugs
in terms of improved health, minimum negative side-
effects, and reductions in inequities in access to care.
At the international level, financial institutions should
focus on how to tax rich rather than poor people—for
example, by promotion of a tax on funds hidden in tax-free
offshore accounts. If these off-shore deposits (estimated by
International Monetary Fund to be around US$8 trillion)
earned income of around 5% per year, which was taxed at
40%, about US$160 billion per year would be raised—
estimated to be more than the cost of providing basic social
services for developing countries.20
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Conclusion
An evidence-based approach to secure efficient, equity-
oriented health-sector reforms is long overdue, but would
require policy makers to refocus their efforts on many
fronts.43 The research community has an important part to
play in distinguishing myths from realities, and making
explicit the underlying values of proposed policies.44 People
studying health systems should widen their perspective to
include links with poverty-alleviation strategies, and vice
versa. Above all, a shift in perspective is needed to give
greater emphasis to equity when assessing the effects of any
proposed policy changes on health and social wellbeing of
families. In particular, changes need to be reviewed with
poorer, more vulnerable sections of society in mind, to
ensure that these groups are winners and not losers in
global health-policy reform.
Contributors
Margartet Whitehead, Göran Dahlgren, and Timothy Evans generated the
original idea, developed the approach, appraised the evidence, agreed on the
structure, and contributed to the writing of the paper. All three authors read
and approved the final manuscript.
Acknowledgments
We thank all participants of the expert consultation at Rockefeller
Foundation Study Centre, Bellagio, Italy, July, 2000, for their insight in
discussions on equity and health-sector reforms: Celia Almeida,
Lincoln Chen, Andrew Creese, Davidson Gwatkin, Benjamin Nganda,
Di McIntyre, Martin McKee, Harry Minas, Myrtle Perera, Malcolm Segall,
Gita Sen, Karl Theodore, and Meg Wirth. Margaret Whitehead and
Göran Dahlgren were funded by Rockefeller Foundation planning grant
number RG 99037 number 4 to develop an international programme of
research on equity and health-sector reforms.
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