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Social Protection

More than half of the global rural population excluded from health care

ILO report shows huge differences in health care access between rural and urban areas worldwide.

News | 27 April 2015
GENEVA (ILO News) – A new ILO report shows that 56 per cent of people living in rural areas worldwide do not have access to essential health-care services – more than double the figure in urban areas, where 22 per cent are not covered.

The report Global evidence on inequities in rural health protection: New data on rural deficits in health coverage for 174 countries reveals major health access disparities between rural and urban areas around the globe, particularly in developing countries.

The highest number of people in rural areas who are not covered by essential health-care services is in Africa where it amounts to 83 per cent. The most affected countries also face the highest levels of poverty.

The largest differences between rural and urban areas, however, exist in Asia. For example, in Indonesia the percentage of people that are not covered is twice as high in rural areas as in urban areas.

Health is a human right and should be provided to all residents within a country.”

Isabel Ortiz, Director of the ILO’s Social Protection Department.
“Decades of underinvestment in health interrupted efforts to develop national health systems and ultimately resulted in the neglect of health in rural areas. This has a huge human cost. Health is a human right and should be provided to all residents within a country,” said Isabel Ortiz, Director of the ILO’s Social Protection Department.

Lack of health workers in rural areas

The ILO study further finds that even if access to health care is guaranteed by law, people in rural areas remain excluded from health care because such laws are not enforced where they live.

The situation is worsened by the lack of health workers in the world’s rural areas. Although half of the world’s population lives in them, only 23 per cent of the global health workforce is deployed to rural areas. The ILO estimates that 7 million out of the total 10.3 million health workers who are lacking globally are needed in these areas.

Africa and Latin America are the two regions where this problem is most acute. In Nigeria, for example, more than 82 per cent of the rural population is excluded from health-care services due to insufficient numbers of health workers compared to 37 per cent in urban areas.

Underfunding is closely linked to the unavailability of services. The ILO study shows that financial resource gaps are nearly twice as high in rural than in urban areas. The largest gaps are found in Africa. However, significant inequities also exist in Asia and Latin America.

The extent of impoverishing out-of-pocket payments (OOPs) is also high in rural areas. The study shows that rural populations in Africa and Asia are burdened with OOPs that amount to 42 and 46 per cent of total health expenditure respectively. In many Asian countries such as Afghanistan, Bangladesh, Cambodia and Sri Lanka, OOPs are two to three times higher in rural than in urban areas.

“The lack of legal coverage, insufficient numbers of health workers, inadequate funding, and high OOPs have created life-threatening inequities in many countries,” said Xenia Scheil-Adlung, Health Policy Coordinator at the ILO.

“Strengthening both the demand and supply side of services is crucial when moving towards universal health protection, particularly in rural areas. Legal health coverage is necessary, but not sufficient. Only when quality services are actually made available and affordable for all those in need can effective access to health care be ensured,” she added.

Closing the gaps

The study explains that closing rural health access gaps requires a comprehensive and systematic approach that simultaneously addresses missing rights, health workers, funding, financial protection and quality. Such an approach needs to be based on the principles of universality and equity and calls for solidarity in financing and burden sharing.

“Addressing such inequities needs to consider the specific characteristics of rural populations, including high poverty rates and informality of work. This means moving from charity to rights, the provision of health workers with decent working conditions that enhance productivity, and the minimization of out-of-pocket payments by patients to avoid poverty. It also requires complementary socio-economic and labour market policies to trigger inclusive economic growth,” said Scheil-Adlung.

The study highlights the key role that national social protection floors can play in reducing and eliminating rural/urban gaps through human rights-based approaches. In this sense, it points to the importance of ILO Recommendation 202 on social protection floors.

“This study shows that investing in rural health, as part of a national health system, is affordable and yields significant economic and social returns. Progress towards universal health protection is possible in any country, irrespective of its level of income,” Ortiz concludes.