David Evans: "We Need to Make Sure that People Do Not Get Scared of Getting Sick because They Can't Afford to Pay"

At the "Mind the Gap" seminar organized on October 13 and 14 by ISGlobal, ODI and Save the Children, David Evans gave the opening keynote speech on the Sustainable Development Goals (SDGs) and their implications for health and equity. After the lecture he kindly agreed to answer some questions on the subject.

Do you think that Universal Health Coverage is the best way to reduce inequalities?

By definition, Universal Health Coverage doesn't have inequalities; it means that everyone gets what they need: good quality health services and without paying an excessive amount out-of-the-pocket. So if you get there, then you don't have inequalities in that sense. However, on the path there, you have to be very careful. There are different paths that might exacerbate inequalities even if in the end you reach a fairly equal situation. It's always easier to make progress if you go for the people that are close together or the ones that are easiest to get to or the people that respond quicker. And that's often the more educated or the better-off people.

So, on the path to Universal Health Coverage you have to keep a very strong eye on inequalities to make sure that you don't prioritize the better-off in the early days. But in the end, if you get there, you are going to reduce inequalities.

On the path to Universal Health Coverage you have to keep a very strong eye on inequalities to make sure that you don't prioritize the better-off in the early days

In that sense, do you think one should focus from the beginning in giving access to everyone or more specifically to those who need it most?

I would take a very pragmatic approach to that because in different countries it works differently. Some countries have tried to prioritize the poor and focus on them and found it very difficult to identify them, and to restrict the services to them. Often there are leakages to people that are not poor while some poor are still not reached. In other countries they've found it much easier to target everyone and make sure they get the poor in it. Thailand, for example, introduced its universal health scheme that covers everyone that is not covered by the insurance in the formal sector and the insurance for civil servants. They decided it was just too difficult to identify the poor and to restrict the services to them, so they made it universally applicable.

So which path countries choose has to be pragmatic in the early days. In some cases they might be able to identify and target the poor in the early days but in others it is just too difficult and expensive to do it.  In those cases, you might as well go universal from the beginning.

Which are the most cost-effective actions to address health inequalities?

I would probably start with the affordability question: how much do people have to pay out-of--pocket to use health services, because that's certainly at the hub of the poverty and equality issue.

I would start by reducing the requirements of out-of-pocket payments for key services that the poor need to use

By reducing the requirements of out-of-pocket payments for key services that the poor need to use, I think you're getting the most cost-effective hit. Rather than focusing on particular diseases, think of how much people are forced to pay, how much it's deterring them from using services and how much it's putting them at financial risk of their families. Reducing these payments would be the first thing I would start to look at.

Do you think the Sustainable Developmental Goals (SDGs) effectively address health inequalities?

If used correctly, yes. The new SDGs focus on all health problems, from the cradle to the grave. They focus on the diseases that the poor get as well as the other sources of inequalities that affect health. That's a good thing.

The question of what happens as they are implemented will depend partly on our ability to measure inequalities over time. Our measurement systems have to be improved a lot because it is very hard to track progress on coverage by income, by education, by residence, etc. We don't have systems yet for doing that in many countries.

What happens with the ODS as they are implemented will depend partly on our ability to measure inequalities over time I do think the SDGs have the potential to address the inequalities issues.

But it also depends on the political will to take an approach that says "we are worried about the most disadvantaged". Because, politically speaking, the most disadvantaged often don't have the voice in the elections or to get to the politicians, so there will always be some compromise with the rich wanting tertiary hospitals in big towns and the poor wanting something in slums or rural areas. How that political process works out in countries will be interesting to watch. 

Which are the best health indicators to measure health inequalities? Is it mortality?

I think mortality is fine in low-income countries for a lot of things. It tells you the end result. In high-income countries it's healthy life expectancy, really. How long people live in good health differs between the poor and the rich: the poor live more of their life in poor health.

the poor live more of their life in poor health

But I think it has to be supplemented by coverage questions in the sense of who gets the services that they need – not just treatment but also promotion, prevention, rehabilitation and palliation. The poor often also miss out on the prevention, for example, and they are more likely to engage in risky behaviors than the more educated, richer people. So coverage indicators are really important to know for example what proportion of people that need to control high blood pressure actually have their blood pressure controlled. And, where there is data, you'll find it is less among the disadvantaged than the advantaged - the rich look after themselves. Those coverage indicators are critical.  For treatment, for the non-communicable diseases (NCDs), we don't have good coverage data at the population level, let alone at a disaggregated level.

It´s not just mortality, you got to have coverage, not only regarding treatment, but prevention and promotion as well.

Could you cite successful examples of the role of public involvement in health?

In every country there are people that can't afford health services. And that is why the European systems have taken this social solidarity approach to pool money and cover the people who can't afford to pay. All of the European systems and now the new Obama care are ways where society shows solidarity for people who cannot afford to pay.  And that's through compulsion, whether its taxes or compulsory insurance as it is in much of continental Europe; it is government and society saying "we are not going to accept the fact that people cannot afford health services". Now a lot of low-income countries are moving in that direction as well, towards some sort of pooling mechanism that allows people to use health services, whether they are rich or poor. Rwanda, Thailand, Mexico, Ghana, China, Indonesia are moving in that direction, as well as Sri Lanka, one of the older examples, and Malaysia, that is more or less high-income now.  

For the public health part, there are many things the government needs to get involved in. You cannot leave the health promotion and the non-personal prevention to the insurance system because it won't do it. So governments have taken strong stances to promote behaviors such as reduction in smoking. Unfortunately, not many developing countries are doing it but Iran is one of the countries that have displayed a very strong ambition to reduce risky behaviors. Among high-income countries, Australia is a good example because it has been one of the leaders in health promotion. But many low-income countries haven't really put a lot of money there yet.

And then research is another area where governments have to be involved. You cannot leave it just to the industry. Virtually every country has some form of public involvement in health research to one degree or another.

In terms of the financial risk protection, that's the critical issue: making sure that people do not get scared of getting sick because they can't afford to pay.