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70% of the world's 1·4 billion people who are extremely poor live in rural areas. A new report released on April 27 by the UN International Labour Organisation (ILO), Global evidence on inequities in rural health protection: new data on rural deficits in health coverage for 174 countries, presents the first global, regional, and national data on the extent and major causes of rural–urban inequities in coverage, and access to health care. 56% of rural residents worldwide are without legal health coverage (defined as protected by legislation or affiliation with a health insurance scheme)—compared with 22% of the urban population. 83% of Africa's rural population have no entitlements to health care, yet the most extreme rural–urban inequities in legal coverage occur in Asia and the Pacific. Reflected in the context of equity and universal health coverage (UHC), the report abruptly reminds us that the global community, despite all good intentions, are still doing too little too late for the health of rural populations.
Although inequities in health protection are recognised within UHC debates, data about the rural–urban divide are weak and fragmented, with a complete absence of disaggregated data within countries, regions, or globally. Policy makers tend to respond to what is presented to them. The absence of disaggregated data influences decisions on national resource allocation, and in turn perpetuates the neglect of systematic planning for rural populations in many countries. This report is the first step to rectify the gap in evidence by using five proxy indicators, measuring key dimensions of coverage and access to health care: legal coverage, staff access deficit, financial deficit, out-of-pocket spending, and the maternal mortality ratio (MMR).
The report highlights that virtually all rural–urban differences in health staffing, financing of services, and legal coverage occur in rural populations. Health worker shortages are unsurprisingly extreme in rural areas worldwide. Although half of the world's population live in rural areas, only 23% of health workers globally are deployed there, with an estimated seven million health workers missing globally in rural areas compared with 3 million in urban dwellings. 63% of the world's rural population do not access health care because of underfunding of global health financing, compared with 33% of the urban population. Out-of-pocket payments inequities are, at first glance, relatively smaller globally in rural populations, with lower out-of-pocket payments in rural than in urban populations in Africa, Latin America, and central and eastern Europe. Yet the lower out-of-pocket payments in many countries indicates an exclusion of rural populations from access to health care. The harsh reality in rural areas is that what does not exist (eg, health workers, clinics, transport) cannot be paid for, and therefore no cost accrued.
Across all regions except Europe and north America, rural MMR is at least double urban MMR, with Africa reporting the highest MMR regional level of 55 deaths per 10 000 livebirths. Country case studies from Cambodia, Mexico, Nigeria, and Zambia report using the same five indicators to highlight the main challenges to improve health coverage and access. In Nigeria, the country's rural population fares worse than the urban population on the indicators of staff access deficit, financial deficit, and maternal mortality. This situation exists despite rapid urbanisation and a high but inequitable supply of human resources for health relative to other countries. Zambia, with a largely rural population and an urban population reliant on private sector services, has higher out-of-pocket payments in urban than in rural areas. Mexico, with a mostly urbanised population, also reported higher out-of-pocket payments in urban areas—both illustrations of when services remain limited or completely inaccessible for rural populations. Cambodia performed better than the other countries on the MMR indicator, reflecting maternal health efforts.
The ILO report leaves no doubt that the urban–rural gap in access to health care exists. The question is more about the size of the deficit and what can be done. The conclusion that only a comprehensive and systematic approach can address these inequities cannot be overstated, and must be acted on. No single action focusing on one of the indicator areas is enough to achieve UHC. A country's approach must systematically and simultaneously address legal coverage and rights, health-worker shortages, extension of health-care protection, and quality of care. Only then can equitable access for all be fully achieved.
