Table 1 A comparison of pro-equity policy interventions in Israel and in 24 developing countries using the Horev-Avni framework

 Overcoming economic barriers by improving affordability

Relief in copayments for targeted users; inclusion of additional benefits (e.g., pediatric dental health) into statutory benefits package for targeted users

New instruments are implemented to reduce user fees at the point of service. All UHC programs include fully subsidized programs for the poor. For the non-poor, some countries use contributory and others use non-contributory schemes.

Most developing countries are expanding the statutory BP (benefits package).

 Overcoming economic barriers by developing payment system incentives

Prospective payments to incentivize HMOs to invest in the periphery; retrospective payments conditioned on specific targets being met in the periphery; auditing tools developed to enforce compliance with equity targets and cultural competence

Most countries are experimenting with new forms of contracting and paying health care providers. Many countries are experimenting with incremental autonomy for public hospitals. Half of governments are now contracting with private sector health care providers.

 Overcoming cultural barriers

Setting of norms in cultural and linguistic access to care (e.g., appointment of a cultural official in each establishment); introduced telephone translation services; introduced multi-media compulsory cultural training system for health care staff.

Most countries are in a process of decentralization; in many cases this is expected to strengthen ethnic representation. Some countries are considering inclusion of traditional medicine in statutory benefits packages, but this is not common.

 Overcoming information barriers

Information on health rights for citizens and executives describing specific entitlements of vulnerable or disadvantaged populations. Synthesized, translated into Arabic and Russian, backed up by a call center.

Know-your-rights communications are common, including greater transparency about user fees and services in the statutory BP. Also, some countries are experimenting with “charters of patient rights”.

 Improving the distribution of staff

Expanding training capacities in peripheral areas (e.g., new medical school in Galilee); the new collective agreement with the Israel Medical Association includes significant incentives linked to service in peripheral areas; a national ceiling in hiring of physicians was lifted for service in the periphery; targets set to train health care personnel from specific ethnic groups.

Developing countries typically have huge disparities in the geographic allocation of human resources for health. While urban areas have a relative abundance of health professionals, rural areas and poor urban areas tend to have very few. Most of the 24 developing countries have policies to attract professionals to underprovided areas, but they do not seem to work for various reasons, including the lack of national ceilings (see text).

 Improving the distribution of physical infrastructure

Ceilings (in hospital beds, MRI, line accelerator) were lifted by the Ministry of Finance with priority assigned to periphery; special budget created to build up health care infrastructure in the periphery. Developed and imposed standards of waiting times and distance to medical service.

Most developing countries have policies to expand investments in physical infrastructure. They often do not have minimum standards, so often the new investments are not sufficient to provide access to high-in-demand interventions included in the BP. Also, few countries have ceilings so the investments are not made within a priority framework.

 Incentivizing use of technologies

Growing use of tele-medicine to improve the quality of services provided in the periphery.

There is high interest in, but very incipient use of tele-medicine

 Capacity building within the MoH

Establishing a dedicated national research unit on health inequality funded by the MoH

There is much interest in the concept, but few documented cases of units linked to the MoH or another National Health Authority dedicated to monitoring or researching progress towards UHC or health equity.

Publication of an annual report on health inequality

There is no documented commitment to an annual public report on coverage or on health inequality.

 Capacity building in the health policy community

Significant investments in quality indicators

Analysis of data disparities in quality indicators, based on a well-developed national system for monitoring clinical quality

There is substantial availability of household survey data and widespread efforts of analysis from household surveys. There is increasing availability, but very limited use, of administrative data. The systems of information related to clinical quality are very weak.

Establishing an annual national conference on health inequity

There is one documented effort (in the Philippines) to hold annual national conference with attendance of policy makers on topics related to UHC or health equity.

 Funding

Progressivity in funding

Multiple efforts are under way to measure and monitor the progressivity in the funding of public health care

 Representation

Adequate representation of diverse cultural backgrounds

Awareness of the need for the representation of diverse cultural backgrounds is increasing; there are many ongoing efforts to increase diversity in representation, but often these are linked to the process of decentralization rather than the process of health reform.

 Community empowerment

Community empowerment such as public participation in policy formulation and interventions with Civil Society Organizations related to underserved groups and Ethiopian Israelis

There are many efforts of community empowerment in different areas.