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British Journal of Healthcare and Medical Research - Vol. 11, No. 3

Publication Date: June 25, 2024

DOI:10.14738/bjhmr.113.17102.

Jahun, I., Udod, S., Roskoshnyi, I., Kurawa, M. S., & Miko Mohammed, A. M. (2024). Building Equitable Healthcare Institutions in

Low- and Middle-Income Countries: Lessons from Wealthy Nations. British Journal of Healthcare and Medical Research, Vol - 11(3).

183-196.

Services for Science and Education – United Kingdom

Building Equitable Healthcare Institutions in Low- and Middle- Income Countries: Lessons from Wealthy Nations

Ibrahim Jahun MD, PhD

College of Nursing, Rady Faculty of

Health Sciences University of Manitoba

Sonia Udod RN, PhD

College of Nursing, Rady Faculty of

Health Sciences University of Manitoba

Illia Roskoshnyi PhD

Faculty of Law, University of Manitoba

Musbahu S. Kurawa MD

Department of Ophthalmology, Faculty of Medicine,

Bayero University Kano, Nigeria

Abdullahi Mustapha Miko Mohammed MD

Department of Intensive Care and Anesthesiology,

Bayero University Kano, Nigeria

ABSTRACT

Healthcare disparity continues to serve as serious obstacle in addressing health

needs among disadvantaged populations across the globe. The member states of the

Organization of Economic Co-operation and Development (OECD) have attained

universal health coverage (UHC) for the past decades, and therefore, there are

lessons Low- and Middle-Income Countries (LMICs) can learn from them and

contextualize to their settings to strengthen their health systems and minimize

healthcare disparities. We reviewed the health system strengthening (HSS) journey

of the OECD member states, identified, discussed, and provided recommendations

on key HSS pillars that can be adapted by the ten poorest countries to accelerate

their health system strengthening efforts toward minimizing healthcare disparities

and improving the quality of life for their citizens. The HSS pillars are expansion in

healthcare access, improved healthcare spending, demand for more responsive

healthcare, cross country study and experience sharing, and prevention policies to

promote better health. In the report we also discussed the interwoven relationship

between suboptimal governance, pervasive poverty, and fragile health systems in

LMICs and suggested how addressing them will pave way to bridging health

disparity in LMICs. The strategies and recommendations discussed in the review are

critical to enacting good governance, strengthening health systems, and bridging

healthcare disparities in LMICs. Strong political will and commitments by the

governments of the LMICs, effective, transparent, and accountable partnership with

OECD serve as the prerequisites for the strategies and recommendations provided

in this report to yield desired impact.

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British Journal of Healthcare and Medical Research (BJHMR) Vol 11, Issue 03, June-2024

Services for Science and Education – United Kingdom

INTRODUCTION

Globally, there is an increased rate of inequalities not only in low- and middle-income (LMIC)

countries but even in developed and economically viable nations due to the escalation of

economic and social imbalances [1] with potential public health catastrophes as observed

during the recent COVID-19 pandemic. This healthcare crisis resulted in the disruption of

routine healthcare delivery services including the supply chain of essential medicines and

equipment, overstretched healthcare workforce and their psychological and mental health,

among others. Health disparity or inequity refers to gaps in the quality of and delivery of health

across racial, ethnic, gender and socioeconomic groups and these disparities occur in most

countries across the globe with different intensity [2]. Variations associated with race, socio- economic and social imbalances among nations and within countries continue to pose

significant obstacles to building equitable institutions [3]. The concentration of wealth and

resources in the hands of a few can undermine efforts to establish fair and accountable

governance systems. Good governance, adequate transparency and accountability are critical

for ensuring that resource wealth is managed for the benefit of the whole population [4].

Transparency and accountability in governance promotes trust in governing officials thereby

strengthening institutions and making them be more accountable.

Corruption remains a pervasive problem in many parts of the world and in 2018 statistics

revealed at least $2.6 trillion was spent on bribes, kickbacks and other unethical transactions,

equivalent to 5% of global gross domestic product [5]. Corruption increases the cost of health

care and education services, thereby lowering their quality and accessibility; it weakens

institutions, erodes public trust, and hinders the equitable distribution of resources and

services, while its absence results in better health and education outcomes [6]. Fighting

corruption and establishing transparent systems is crucial for building accountable institutions

[7]. In developing countries where in some cases poor governance fuels corruption, an

inadequate rule of law can lead to impunity for those in power, fostering a climate of injustice

and undermining public confidence in institutions. Therefore, in developing countries,

strengthening the rule of law and legal institutions such as strong, accountable, and

independent judicial systems, rigorous and impartial public administration, and transparent

laws with predictable enforcement are critical toward strengthening other public institutions

[8].

The lack of effective equitably accountable institutions deprives people of education,

employment and income which have a marked influence on the health of a population. In all

countries – whether low-, middle- or high-income – there are wide disparities in the health

status of different social groups. The lower an individual’s socio-economic position, the higher

their risk of poor health [9]. Health institutions, such as healthcare systems, hospitals, clinics,

and public health agencies, face various challenges in building effective, equitable, and

accountable structures. Similarly, factors contributing to health inequalities significantly vary

between countries and are linked to many factors, including differences in exposure to health

risk factors and in access to healthcare. Recently, health disparity mapping conducted in eleven

high-income countries revealed that the United States leads in terms of geographical health

disparity with majority of rural dwellers reporting skipping healthcare interventions due to

lack of access [10]. Generally, the people in poor countries tend to have less access to healthcare

compared to those in high-income countries and despite effective strategies that could improve

health in these countries, the governments rarely focus on the poor in their policies or the

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Jahun, I., Udod, S., Roskoshnyi, I., Kurawa, M. S., & Miko Mohammed, A. M. (2024). Building Equitable Healthcare Institutions in Low- and Middle- Income Countries: Lessons from Wealthy Nations. British Journal of Healthcare and Medical Research, Vol - 11(3). 183-196.

URL: http://dx.doi.org/10.14738/bjhmr.113.17102.

implementation or monitoring of health service strategies [11]. While high-income countries

continue to experience gaps in healthcare, these countries have successfully dealt with many

challenges that persist and prevent equitable and accountable healthcare systems in the LMICs.

Through a health equity lens, we provide recommendations to improve access to care and

improve the quality of health of people in LMICs.

Therefore, the purpose of this review is to identify key challenges that contribute to health

disparities in LMICs and to develop recommendations by contextualizing some of the strategies

used in some selected high-income countries to bridge the health inequality in the LMICs

thereby improving healthcare access and service quality.

Rational and Approach for the Review

The pattern of health disparity varies between wealthiest nations and LMICs. For example,

racial health disparity is still highly prevalent in the United States despites the many strides

that have been made to improve healthcare [12]. On the other hand, most African countries are

disproportionately affected by infectious diseases such as HIV, Tuberculosis, Malaria among

others. Additionally, within many African nations, women are disproportionately affected by

lack of access to quality sexual and reproductive health and rights thereby making these

countries to have the highest maternal mortality rates in the world [13]. Based on several socio- economic indicators, member countries of the Organization for Economic Cooperation and

Development (OECD) serve as the wealthiest nations in the world and have the healthiest

population [14]. The OEDC member states such as Finland, Canada, France, Germany, UK

among others have attained universal health coverage decades ago due to strong public health

policies and institutions because of political will and good governance. Therefore, this article

will review the health systems of the OECD member states, identify best practices, and suggest

how they can be adapted to the context of some selected LMICs. Equatorial Guinea, South Sudan,

Madagascar, Guinea Bissau, Eritrea, Burundi, Democratic Republic of Congo, Central African

Republic, Guatemala and Eswatini are ranked as the poorest nations in the world [15]. The

income per Capita of most of these countries when compared to the wealthy OEDC nations is

about 40 times less [16]. Poverty in most of these countries is precipitated by persistent civil

unrests, wars, corruptions, and poor governance. The two sets of countries (OECDs versus

LMICs) are incomparable in all parameters, therefore in this article the authors will try to

contextualize the best practices from the OECD nations to suit the realities and contexts of the

selected LMICs keeping in mind their socioeconomic wellbeing and viability.

DISCUSSION

Several strategies have been deployed by the OEDC countries toward promoting better health

and narrowing healthcare disparities, however in this article we will review basic strategies

that can be adapted to the context of LMICs. Specifically, we will review the following strategies:

expansion in healthcare access, improved healthcare spending, demand for more responsive

healthcare, cross country study and experience sharing, and prevention policies to promote

better health.

Expanding Access to Healthcare

Lack of access to healthcare service is one of the critical barriers toward minimizing healthcare

disparity. Ill-health is a cause and a consequence of poverty: sick people are more likely to

become poor, and the poor are more vulnerable to disease and disability, while good health is