Human Development Report 2013 - UNDP

Universal public healthand education policiescan be designed andimplemented withoutsacrificing quality for thesake of greater coveragecare providers were given incentives by linkingresources to performance. As a result,health care became more affordable in ruralareas. And there were visible improvementsin health outcomes. Under-five mortality fellfrom 196 deaths per 1,000 live births in 2000to 103 in 2007, and the maternal mortalityratio declined more than 12% a year over2000–2008. Rwanda is on track to reach theMillennium Development Goal for maternalhealth.One concern in a number of countries is theemergence of dual-track services. Even if publicprovision is universal in principle, quality andaccess may be poor, driving people towardsexpensive private providers.• China. Much of China’s health care successtook place between 1950 and 1980, whenthe government established a three-levelsystem of village clinics, township healthcentres and county hospitals in rural areasand health centres and district hospitals inurban areas. Since the 1980s, however, thehealth sector has been driven by a fee-forservicemodel. As a result, while China’soverall health status has continued to improve,disparities have grown between theeastern and western provinces and betweenrural and urban areas. In many parts of thecountry quality health care has become unaffordablefor the poor.• Chile. Before 1980, Chile’s health systemwas publicly financed through social securityand public funds. After health reformin 1981, however, risk insurance was introduced,and market mechanisms beganto regulate levels of protection. By 2006, adual system of coverage was in place. TheNational Health Care Fund, funded by federalgovernment tax revenues and by premiumsfrom beneficiaries, covered 69% of thepopulation, but its resource constraintshave prevented it from ensuring timely andquality services. Private health insurancecompanies covered 17% of the population.The National Health Care Fund offers auniversal health plan. This dual system hasbeen criticized because it leaves low-incomeand high-risk populations to be treatedmainly in the public system, which is poorlyresourced and thus tends to provide lowerquality service. In 2004, aware of the risks,the state introduced El Plan de AccesoUniversal de Garantías Explícitas, whichguarantees a medical benefits package consistingof a prioritized list of diagnoses andtreatment for 56 health conditions, as wellas universal coverage for all citizens.Providing universal health care and at leastnine years of compulsory education requiresstrong state commitment, involvement andconsistency over time. The challenge for countriesin the South is to ensure equity in access tohealth and education services and basic qualitystandards to prevent a dual-track service industrythat provides low-quality public services(or none at all) to the poor and higher qualityprivate services to the rich.Universal public health and educationpolicies can be designed and implementedwithout sacrificing quality for the sake ofgreater coverage. Poor people have no alternativesto a public system, while wealthierpeople can pay for private services. Suchdynamics entrench inequalities, reduce socialintegration and undermine sustainable humandevelopment. New programmes, such as thosein China, Mexico and Thailand, illustrate thepossibilities of ensuring that basic services areuniversal and of reasonable quality. Whenfinancial resources are adequately provided,publicly provided services need not be inferiorto private services.Increasing social cohesion bybroadening developmentTransforming development requires that allcitizens feel vested in the broader goals ofsociety, showing respect and compassion forothers and a commitment to building socialcohesion. This requires that states and citizensunderstand that human development is aboutmore than just enhancing individual capabilities.Individual capabilities are embedded ina broader social system whose health requiresenhanced social competencies (see box 1.7 inchapter 1).More effective social protection systems arealso needed to help individuals and communitiesmanage risks to their welfare. Globalizationhas contributed to the dismantling of someaspects of social protection and social insurance,especially for systems relying on universal82 | HUMAN DEVELOPMENT REPORT 2013