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Achieving equity in access to health care is a central element of health systems reforms in many developing countries. But, how equitable are health systems in reality? This paper assesses the equity in distribution and financing of health care services in Bangladesh, Sri Lanka and Nepal, using national health accounts, and compares the performance of existing health care systems in the three countries. However, due to data constraints (Nepal does not have national health accounts), the paper focuses mainly on Bangladesh and Sri Lanka.

The study finds that:

• the poor are less likely to report sickness when sick than the rich, which then translates into reduced utilisation of medical care in relation to need
• In Bangladesh, compared to Sri Lanka, the poor are less likely to seek care from qualified, modern medical providers
• the incidence of government subsidies favours the poor in Sri Lanka more than in Bangladesh
• In all three countries, there are inequalities in government expenditures by region, with subsidy expenditure highest in the region containing the capital city. This disparity in government expenditure between the capital region and other regions is greatest in Nepal

In terms of financing, the paper concludes that in all three countries, the dominant sources of financing are taxes and direct out-of-pocket payments by households. The extent of state financing and provision varies between countries, being greatest in Sri Lanka, and least in Nepal.

Comparing Bangladesh and Sri Lanka, the paper observes that there are significant differences in the actual performance of health systems in the two countries. In Sri Lanka, both tax and out-of-pocket payments were progressive means of financing. Moreover, government health care expenditures were pro-poor in their distribution. On the other hand, in Bangladesh, the paper states that the same financing mechanisms were modestly regressive, and the distribution of government health expenditures was not pro-poor.

Drawing on Sri Lanka’s experience, the paper suggests that Bangladesh could improve equity in its health systems by:

• increasing health awareness amongst the poor
• substantially improving the access of the poor to modern medical services
• improving the progressiveness of taxation in general

Summary originally provided by GDNet, an Eldis content partner

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