Global evidence on inequities in rural health protection 23
or nationally and their impact on national-level indicators has been very limited Ministry of Health for Cambodia et al., 2008.
Figure 18 shows high deficits in all dimensions of coverage and access considered. Further, on all five indicators the rural population of Cambodia fares slightly worse than the
urban population, while maternal mortality made a relatively small contribution to the overall access deficit. Over recent years Cambodia has made significant efforts to reduce maternal
mortality, which probably explains why it performed better on this indicator than on the other four. The most striking finding, however, is the huge urbanrural gap in OOP as a percentage
of total health expenditure, which can be considered as a symptom of public health funding being less likely to reach the service delivery points in rural areas than in urban areas.
Figure 18. Health coverage and access to health care in rural and urban Cambodia, 2015
Source: ILO estimates, 2015.
Given that most of the urbanrural gaps are relatively small in Cambodia but that coverage deficits are high, the main challenge for this country will be to address the national
deficits without exacerbating the existing level of inequity. Fair health financing mechanisms must also be a priority.
3.7.2. Mexico
Mexico has a relatively urbanized population, with 21 per cent residing in rural areas World Bank, 2013. Persons employed in the informal sector account for 45.1 per cent of
non-agricultural employment in rural areas and 27 per cent in urban areas ILO, 2012b. By 2012, 52.3 per cent of the country was at the national poverty line. Thus, developments in
rural and urban employment and poverty rates have significant implications for Mexico to move towards a more equitable society that includes protection in health.
Mexico’s health system was first established in 1943. The current national health insurance scheme, Seguro Popular SP, was introduced in 2003 with the purpose of
providing affordable health care to nearly 50 million people who were not yet covered ILO, 2014a. It was intended to encompass dimensions in social protection of health according to
76
77
91 72
27
20 40
60 80
100 Estimate of legal
coverage deficit as a of total population
Coverage gap due to health professional staff
deficit threshold: 41.1
Financial deficit threshold: US239
OOP expenditure as of total health
expenditure Maternal mortality ratio
per 10,000 live births
Urban Rural
24 Global evidence on inequities in rural health protection
the AAAQ framework – providing available, accessible, acceptable and quality care for all.
Total health expenditure grew from 4.4 per cent of GDP in 1990 to 6.3 per cent in 2010 Bosch et al., 2012. Coverage through public health insurance improved substantially
between 2002 and 2012: Seguro Popular enrolees reached 52.6 million in 2012, with the majority belonging to the poorest four income deciles. In addition, coverage was also
extended to 35 per cent of enrolees residing in rural areas and 9 per cent belonging to indigenous communities Knaul et al., 2012. The provisions of Seguro Popular have reduced
the catastrophic expenditure that poor Mexican families had to incur when confronted with a health crisis.
Households enrolled in Seguro Popular are significantly less likely to spend OOP on drugs or outpatient services. The scheme has provided financial protection to urban
households as regards prescription drugs, and to rural households as regards access to health facilities Knaul et al., 2012. Figure 19 shows that despite the progress made nationally over
time, the rural population in Mexico is worse off than the population living in urban areas for legal coverage and the maternal mortality ratio MMR. The deficit in legal coverage is 24.6
per cent in rural areas as opposed to 1 per cent in urban areas. The MMR amounts to 5.5 maternal deaths per 10,000 live births in rural areas versus 4.9 in urban areas
