O conteúdo em Portugês estará disponível em breve.
People expect their health systems to be equitable. The roots of health inequities lie in social conditions outside the health system’s direct control. These root causes have to be tackled through intersectoral and cross-government action. At the same time, the health sector can take significant action to advance health equity internally. The basis for this is the set of reforms that aims at moving towards universal coverage, i.e. towards universal access to health services with social health protection. Health inequities also find their roots in the way health systems exclude people, such as inequities in availability, access, quality and burden of payment, and even in the way clinical practice is conducted.
The fundamental step a country can take to promote health equity is to move towards universal coverage: universal access to the full range of personal and non-personal health services required, with social health protection. The technical challenge of moving towards universal coverage is to expand coverage in three ways (see figure).:
- The breadth of coverage – the proportion of the population that enjoys social health protection – must expand progressively to encompass the uninsured, i.e. the population groups that lack access to services and/or social protection against the financial consequences of taking up health care.
- The depth of coverage must also grow, expanding the range of essential services that is necessary to address people’s health needs effectively, taking into account demand and expectations, and the resources society is willing and able to allocate to health. The determination of the corresponding “essential package” of benefits can play a key role here, provided the process is conducted appropriately.
- The height of coverage, i.e. the portion of health care costs covered through pooling and prepayment mechanisms, must also rise, diminishing reliance on out-of-pocket copayment at the point of service delivery. Prepayment and pooling institutionalizes solidarity between the rich and the less well-off, and between the healthy and the sick. It lifts barriers to the uptake of services and reduces the risk that people will incur catastrophic expenses when they are sick. Finally, it provides the means to reinvest in the availability, range and quality of services.
Esta seção do perfil do sistema de saúde está estruturado da seguinte forma:
O conteúdo em Portugês estará disponível em breve.
For ease of management and coordination, Botswana's public health sector is organized into 29 health districts through district health management teams. Each district is responsible for taking stock of its population to ensure accessibility of health services to all. The National Health Policy incorporates socioeconomic determinants of health such as poverty and lifestyle such that the economically disadvantaged populations have access to quality health care.
The involvement of local structures such as village development committees ensures identification of populations that need special attention, such as the poor, orphans and vulnerable populations, young people, older people and people with disability. The organization of the health care delivery system by facility level and the referral system provides some degree of standardization of service packages at different levels of facilities.
For instance, the range of services provided at the district hospitals is more comprehensive than that provided in clinics. Treatment guidelines are provided in health facilities to help standardize treatment, care and referral and enhance equity in service provision.
However, unless there is a form of social insurance with a defined service package, Botswana cannot claim universal coverage. The medical schemes that are available in the country cover only the 20% of the population that is constituted mainly by those who are employed.
The insured population can access high-technology specialized health services, partly paid for by the employer, while those without insurance (comprising mainly of the unemployed and the poor), have to pay 100% of the bill out-of-pocket to be able to access high-technology specialized services. Access to public sector high-technology specialized care for the uninsured is controlled through the referral system. The uninsured have therefore limited opportunity to choose the services that they prefer because the decision rests with the public service provider at the basic level who triages patients and determines who passes to the next level based on criteria such as disease category, demographic group or level of care.
Botswana has therefore yet to come up with a financing system that gives equal access to all. The country has not developed a reliable mechanism of determining who can afford to pay the nominal fee for health services and who can not.
Other potential challenges yet to be explored through systematic research include:
- the possibility of stigma of being classified as poor;
- the difficulty in determining income in the informal sector such as farming (particularly as Batswana may be reluctant to disclose their wealth);
- the cost of cost recovery that may actually exceed what is collected.