22 Global evidence on inequities in rural health protection
3.7. Inequities in rural and urban areas at national level: Selected country studies
How does the situation look at country level? In this section we assess selected countries in Africa, Asia and Latin America: Cambodia, Mexico, Nigeria and Zambia. An
overview of the results for these countries is presented in table 2. It shows significant differences that will be discussed in the following sections.
Table 2. Inequities in coverage and access to health care: Cambodia, Mexico, Nigeria and Zambia, 2015
Cambodia Mexico Nigeria
Zambia
Estimate of health coverage as a percentage of total population
National 26
85.6 2
8 Urban
34 99
3 12
Rural 24
75.4 1
6 Health expenditure not financed by OOP
National 38
47.1 29
74 Urban
81 48.2
30 57
Rural 28
8.1 29
84 Coverage gap due to financial resources deficit
, threshold: US239 National
91 -
87 73
Urban 88
78 52
Rural 91
91 82
Coverage gap due to health professional staff deficit , threshold: 41.1 physicians, nurses and
midwives per 10,000 population National
75 60
81 Urban
67 37
68 Rural
77 82
89 Maternal deaths per 10,000 live births
National 25
5 63
44 Urban
19 4.9
37 25
Rural 27
5.5 88
65 Source: ILO estimates, 2015.
3.7.1. Cambodia
Cambodia has a largely rural population about 80 per cent, most of whom are engaged in subsistence agriculture, and even in other sectors there have traditionally been low
levels of formal employment. Primary health care is delivered through a district-based system, and quality of care and health financing are persistent challenges. Over the last 20
years the national Government has attempted to address these issues, for example through the introduction of the 1996 Health Financing Charter which attempted to regulate the charging
of fees for the use of health services. However, concerns about the cost and quality of public health services has led to the growth of the private health sector and low utilization of health
services due to financial and other barriers. Furthermore, the Government estimates that only a small proportion of public health funding actually reaches the service delivery level, leading
to high levels of OOP and expansion of the private sector. Attempts have been made to address these chronic problems, including setting up health equity funds, and several have
been successful in doing so, but initiatives have tended to operate at a local level.
Cambodia is a low-income country with weak taxation systems and high dependence on donor resources, so these local-level successes have tended not to be rolled out regionally
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
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