28 Global evidence on inequities in rural health protection
4. Policies to end the ruralurban divide:
Extending health protection to all and targeting the social determinants of
inequities
The above findings suggest that the place of residence largely determines coverage and access to health care. The ruralurban divide is a consistent feature across the world,
existing in all regions and within all countries. Currently, the place of residence can be considered as an entry door or a key barrier to accessing better health protection. The root
causes range from a lack of rights to severe deficits in service delivery, as well as poverty, uneven employment opportunities and social exclusion. Ending the ruralurban dualism
requires efforts to build more adequate structures that are based on a concept of inclusive societies where everybody can equally receive quality care when in need.
Such a concept needs to aim at extending health coverage and access to all, as well as addressing the social determinants and main causes of the inequities that impact on access
gaps − such as poverty, discrimination, unemployment, and working in the informal
economy. It needs to acknowledge that the right to health and social protection is a key tool to prevent and reduce inequalities and at the same time help support a transition to more
sustainable economies. The prioritization of such policies will support social inclusion and reduce the divergences within and across rural and urban regions.
The most important policies in this context are the establishment and development of national social protection systems and in particular social protection floors that incorporate
strategies to extend health protection to the rural populations, guided by ILO social security standards, particularly the ILO Social Security Minimum Standards Convention, 1952 No.
102 and Recommendation No. 202 concerning national floors of social protection.
While it is not possible to outline specific policy approaches that would apply to all countries, overall objectives and some key principles should be applied in all policies that
allow for accelerating progress towards more and better health protection for rural populations and eliminating inequalities.
4.1. Key objectives and principles: Removing the leading causes of inequities
Putting into practice the human right to health and social security, as reaffirmed in
ILO Recommendation No. 202, requires an approach characterized by universality that does not limit coverage to specific target groups, socio-economic groups or groups defined by
place of living, age, gender or ethnicity. It is important to aim at inclusiveness in the formulation of national legislation, as well as its implementation and enforcement.
Thus, universal health protection should be the key policy objective when aiming to address inequities in access to health care. It should be anchored in legislation and
implemented according to fixed timelines for the progressive realization of coverage and access to health care in rural areas. This also includes that entitlements to benefits, such as
quality care services, preventive care, maternal care, medicines and others, are prescribed by law and meet at least minimum standards of adequate and essential care.
The underlying principle of equitable access requires non-discrimination, including
by place of living and meeting core requirements such as gender equality and responsiveness
Global evidence on inequities in rural health protection 29
to specific needs such as those of the rural population. It also requires respect for all people and an acknowledgement of their human dignity. In addition, equity requires that legislation
does not implicitly or explicitly favour urban residents over rural. Where such discrimination exists it should be progressively removed, with a view to achieving equity in coverage and
access.
Universality and equity also call for solidarity in financing and fairness in burden
sharing for health protection. This entails risk pooling based on financing mechanisms such as tax funding and contribution-based social or national health insurance. Thus, various
financing mechanisms can be chosen, particularly to reach out and best include those living in rural areas. Particularly important for rural populations is to consider a diversity of
methods and approaches such as national health services, national insurance schemes or mixed protection mechanisms that complement each other
– for example, insurance schemes with tax subsidies to cover contributions of the vulnerable.
Further, it is vital to avoid financial hardship or an increased risk of poverty for those
who need health care. This might occur if benefit packages are too limited or OOP are unaffordable, particularly in the case of severe or chronic diseases. Thus, the financial
consequences of accessing health care must be carefully considered in order to avoid barriers and thus inequities.
Finally, it is imperative to ensure that during sickness income generation is sufficient or income support available to address the worst forms of health-related impoverishment due
to loss of income or work. This entails coverage for and access to social protection benefits such as paid sick leave, pension or unemployment schemes or other income support through
social assistance programmes. Such income support is necessary to address the problem of avoidance, where those who need care do not seek it because it is unaffordable.
4.2. A shared agenda for the future: Addressing inequities in a coherent multi-sectoral approach