1. Malaysian Journal of Public Health Medicine 2013, Vol. 13(1): 64-71
FOCUSING HEALTH EQUITY, EFFICIENCY AND HEALTH MAXIMIZATION
POLICY REVIEW
Thant Z1
, Than Mt1
, Shamsul BS2
, Wai PW3
, Htun HN4
, Osman Ai5
1
School of Medicine, University Malaysia Sabah, Sabah, Malaysia.
2
Occupational Safety and Health Center, University Malaysia Sabah, Sabah, Malaysia.
3
International Medical University Malaysia, Kuala Lumpur, Malaysia.
4
Canberra Hospital, ACT, Australia.
5
Universiti Kuala Lumpur, Royal College of Medicine, Perak, Malaysia.
ABSTRACT
With economic growth and significant technological advances in the health sector, many countries have developed
aggregate outcomes in terms of both health services and individual well-being. Life expectancy has seen a remarkable
increase of more than fifty per cent between 1950 and 2009. Achievement is uneven, however, and some groups are
better able to access health services than others. In our review, we explore the need and how to maximize health
equity, efficiency and effectiveness. Methodology is the review and web surfing on public health, social science,
humanity and development literature. The increasing gap in health inequality, however, calls for further reform of
the health system to achieve both equity and efficiency. Health is essential for survival and human capability. Good
health enables people to participate in society. A new approach to efficient and cost-effective health service provision
is community participation in health development. Participation can increase the skills and knowledge of local people,
thus providing opportunities to improve their lives (empowerment). Analysis suggests four functional changes to
achieve equity and efficiency in maximizing health outputs: reforms targeting universal coverage to achieve universal
access to health; people-centred service delivery through concentrating on health services based on need; public
policy change targeting integrated and multi-system health planning; and collective health system and community
response to achieve health for all.
Key words: Health, equity, efficiency, health maximization, participation.
INTRODUCTION
Over the past fifty years, enormous health
improvements have occurred in many countries
with life expectancy at birth increasing from 46.5
years in 1950-551
to 68 years in 2009 (WHO)2
.
With economic growth and technological
advances in the health sector, many countries
have seen aggregate outcomes in health services
and individual well-being. Achievement is
uneven, however, and some groups are better
able to access health services than others. At the
same time, the HIV epidemic from 1990 onwards
and emerging non-communicable diseases are
threatening health development. Moreover,
health inequity between and within countries is
aggressively worsening. In terms of the HIV
epidemic, the most severely affected region is
Africa with 22.5 million HIV-infected people,
about two-thirds of the total cases recorded3
.
Similarly, 80% of 36 million NCD deaths have
occurred in low and middle income countries4
.
Uneven economic growth and weak health
systems in many geographical areas and
inequality among social groups are accelerating
existing health problems and further impacting on
future health outcomes. In addition, health
worker migration and the need for skills
improvement put pressure on the health services
in resource-limited countries and regions. The
increasing trend of natural disasters and global
warming is proving detrimental to the current
health services and reducing their achievement.
Immediate health action for better outcomes and
coordinated responses, a broader agenda than
that of current health development, is an urgent
matter.
According to Sen (1999), health improvement is a
basic necessity for human development and
democracy5
and the health system needs
immediate measures to deliver a universal health
services package and reduce health inequity.
Globally, people are increasingly impatient with
health services' failure to fulfil stated demands
and changing needs. On the other hand, health
services are struggling with limited resources,
skill deficits, and the increasing burden of
emerging health problems and ageing
populations, and they cannot meet public
expectations in many regions.
After the foundation of World Health
Organization in 1948, health development grew
to fulfil the need for health equity and to address
disproportionate suffering among poor and
REVIEW

2. Malaysian Journal of Public Health Medicine 2013, Vol. 13(1): 64-71
marginal populations. In the historical
development of health, the following are
examples in promoting health equity around the
world: universal access to health, primary health
care, health for all and people-centred health.
Other examples are the Latin American social
medicine movement and the People’s Health
Movement on the Right to Health which set the
broad social vision of the Millennium
Development Goals, highlighting the central
importance of health, the need for social and
participatory action on health, and the core
human value of equity in health6-8
.
Equity means fairness, giving everyone what
belongs to them, and recognizing the specific
conditions or characteristics of each person or
human group regardless of gender, class, religion
or age9
. Health equity should provide health
services fairly for people. Equity in health means
that people's needs guide the distribution of
opportunity for well-being10
. Generally, health
services are designed to meet people's need. It is
not always easy, however, and there are many
barriers to both supply (service provider) and
demand (user). Traditional health systems in
many countries are providing demand-based
specialized clinical services and expensive
treatment packages. Furthermore, health needs
of poor people have been neglected by reason of
lower demand. The lower demand of the poor,
however, does not represent lower actual need
but is related to the inability to pay for health
service utilization or to the inaccessibility of
health services because of social, geographical
and other structural barriers.
Furthermore, health systems paying little
attention to equity and social justice will fail to
get the best health outcomes for their money.
World Health Organization asked for people-
centred primary health care and health service
delivery with better efficiency in health
programmes and assessed their impact. World
Health Organization in its World Health report
2008 entitled “Primary Health Care, Now More
Than Ever” identifies the three most important
pitfalls in health provision as11
:
 Health systems that focus disproportionately
on a narrow offer of specialized curative care
 Health systems where a command-and-control
approach to disease control, focused on short-
term results, is fragmenting service delivery
 Health systems where a hands-off or laissez-
faire approach to governance has allowed
unregulated commercialization of health to
flourish.
METHODS
The article is a narrative review for health policy
and health services. We explore the need for and
how to maximize health equity, efficiency and
effectiveness. The progress and gaps in universal
health development, health equity, effectiveness
and efficiency, and community participation and
empowerment are identified. The analysis has
also been extended to recommend maximization
of health outputs.
Relevant literature was sought which addresses
the review question. A rigorous search plan was
necessary, including measures to reduce bias. A
literature review and web surfing on public
health, social science, humanity and
development was done in the following
databases: World Health Organization, World
Bank, United Nations, PubMed, Medline, EMBASE.
After a review of the titles, selected articles
between 1960 and 2011 were reviewed.
Literature from 1960 to 2011 is needed to
understand health equity, efficiency and
effectiveness. These principles were very popular
in 1960s’ early health development, 1970-80s’
primary health care and 1990-00s’ cost
effectiveness scholarly publication. All the
studies collected were reviewed, collated, and
categorized and reported for all relevant and
important findings.
RESULTS AND DISCUSSION
Health is essential for human. Considering better
aggregate health outcomes and individual well-
being, we analyse health in poverty reduction and
human development, equity in health, efficiency
and sustainability in health maximization, and
community participation and empowerment.
Health for poor is most productive because ill-
poor will be absent from work and lose income.
Equity in health is also important because it
possesses both instrumental and intrinsic value.
Moreover, people in poor quartiles use fewer
health resources than those in rich quartiles.
Next, three factors−equity, efficiency and
sustainability−in affecting health maximization
were explored. Equity and health for poor is
productive, however, it costs greatly. Then,
efficiency and sustainability need to be
considered. Most analysts agree government
provision of health as most efficient and
equitable. Furthermore, world health
organization recommended pooling of health
funding and compulsory contribution to pool fund
to be efficient and sustainable. Finally,
community participation is an aid to cost-

3. Malaysian Journal of Public Health Medicine 2013, Vol. 13(1): 64-71
effective and sustainable alternative in health
development. Community participation enables
people to make choices about their own lives so
that health needs for communities can be
properly identified and health services fairly and
efficiently provided.
Health in poverty reduction and human
development
Investing in health for the poor is economically
productive. Poor people earn their living from
daily labour, and their most important asset is
their body. If they are not healthy, they will be
unable to work or be underpaid. In most
developing countries, poor households and
families rely on daily income to survive. They also
suffer extreme vulnerability to ill health,
economic dislocation, and natural disasters12
. For
the poor, loss of daily income (because of
absence from work owing to illness) is a disaster.
First, there will be no more food and no more
money for health treatment. Consequently, when
ill-health is not properly treated, they will be
absent from work and lose income. If they
exchange their livelihood and even their home to
pay for food and healthcare cost further
indebtedness ensues and their children will leave
school to work for additional family income. This
will have further negative effects because the
basic requirements for human development,
health and education, will not be met so these
children will not be able to obtain well-paid jobs.
Finally, they will fall into the poverty trap.
Although the poor are more resistant to frequent
and minor illness, they are more vulnerable to
rare and major illness because they are not easily
able to access promotion, prevention and clinical
services. In those countries which charge for
health services, the poor will not be able to
access them.
Access by the poor to quality health services is
very important. Health and basic education are
building blocks for human development and
poverty reduction. Globally, there will be poverty
and social instability if we do not help the poor to
maximize their health. Sachs reports that disease
leads to extreme poverty, extreme poverty leads
to political instability, political instability leads
to state failure, and state failure leads to
violence, criminality and even terrorism13
.
In addition, good health enables people to
participate in society, with potentially positive
consequences for economic performance14,15
.
Equity in health
Health equity needs to be considered differently
from economic development. Equity in health
involves the status of both intrinsic and
instrumental value. Income inequality, on the
other hand, has only instrumental value16
.
According to the S. Anand (2002), health is
regarded as critical because it primarily affects
the person's well-being and is a prerequisite to
his/her functioning as an agent16
. Inequality in
health is an indicator of inequality in terms of
basic freedom and the opportunities that people
can enjoy throughout their lives. Economists
often assert that income incentives are needed to
elicit effort, skill, and enterprise. Income and
economic assets can be distributed
proportionately according to the capability of
people. In contrast, health and basic necessities
should be distributed less unequally regardless of
people's ability to pay17
. Health is more essential
than income as money cannot be used if one is ill.
Health is a direct manifestation of a person's
well-being and it enables them to survive and to
pursue what they value. The following
paraphrases illustrate this; (Sen 1999) health
contributes to a person's basic capability to
function5
, (United Nations Human Development
Report 1996) basic needs such as health and
education are at the forefront in promoting
human well-being18
, (Berlin 1969) positive
freedom19
, and (Rawls 1971) equality of
opportunity to obtain primary goods such as
health, education, etc., which means reduction of
inequality in health is a direct requirement for
justice20
. Virginia and Sandra (2008) define equity
in health care from a broader perspective; it is an
ethical imperative not only because of the
intrinsic worth of good health, or the value that
society places on good health, but because,
without good health, people would be unable to
enjoy life’s other sources of happiness9
.
Investing in universal health development is more
effective than income. Anand suggested aversion
to inequality in health is likely to be greater
value than aversion to inequality in income16
.
Equality in opportunity may lead us to be more
averse to twofold infant mortality between
groups than to twofold difference in adult or old
age mortality rates, and concerned about
disability in health (physical or mental) that
prevents a person being mobile or gaining
employment16
. Further analysis of inter-group
inequality in health would allow us to understand
groups that are at high risk of or suffering
particularly poor health.
In general, people in poor quartiles use fewer
health resources than those in rich quartiles.
Gwatkin et al. (2004) reported that in low-income
and middle-income countries, public money for
health care tends to go to services that wealthy
people use more than poor people21
.
Furthermore, early healthcare reforms

4. Malaysian Journal of Public Health Medicine 2013, Vol. 13(1): 64-71
incorporating a user fee and cost-sharing in
developing countries showed less opportunity for
the poor. Stephen et al. (1999) reported that
once cost-sharing has been put into place, there
is a tendency to maximize revenues by granting
very few exemptions to poor people22
. This is
supported by other studies; (D Collins et al.,
1996) government health facilities grant fee
waivers for poverty below a certain, very low
threshold23
. Health systems need further reform
in terms of allocation of resources and diversion
of necessary expenditure to the neediest
population. Reforms in the past 20 years which
require payment at the point of use are limiting
healthcare utility. Out-of-pocket expenditure for
health care deters poorer people from using
services, leading to untreated morbidity24
. In two
independent reports, such expenditure is shown
to have a negative impact on human
development: (Whitehead et al., 2001) further
impoverishment or (Gottlieb 2000)
bankruptcy25,26
. Furthermore, (Xu et al., 2007)
study reported that ‘The larger the proportion of
health care that is paid out of pocket, the larger
the proportion of households that are faced with
catastrophic health expenditures’27
.
Equity, efficiency and sustainability in
maximizing health
Costing in health services is important in terms of
decisions on investment and expenditure. Health
systems around the world are selecting highly
cost-effective programmes for funding
prioritization. Those with the greatest need will
be accorded less priority, however, because they
live in less affluent areas with poorer health
infrastructure. In general, investing in health
services in more populated areas is more
productive in terms of health outputs than in less
populated rural areas. Health systems around the
world can generally cover half to three-quarters
of the population but beyond this costs rise
exponentially.
As regards cost-effectiveness, the World Bank
(World Development Report 1994) recommended
two packages for greater value; a public health
package (AIDS prevention, immunization, school-
based health services, nutrition, control of
tobacco and alcohol) and essential clinical
services (pregnancy-related maternal health,
control of TB and sexually transmitted diseases,
family planning, care of child-diarrhoea, acute
respiratory infection, acute malnutrition,
measles, malaria) to achieve high DALY
(disability-adjusted life-year) gain28
. The
packages omit, however, elderly health, non-
communicable disease and other communicable
diseases because they calculate cost per DALY
gain without measuring individual health needs
and population health. Thus, policy targeting cost
per DALY gain could merely mimic health equity
within a population.
Sustainability was another concern in
international health programming and
participation29
. Different health care system
approaches have been used in different countries.
Among them, the three most common systems are
direct government provision and through social
security system, insurance system and third party
payment (private payment, user fee, cost-
sharing, community group or user group health
funding). Most analysts agree that government
provision and social security funding are more
equitable and efficient than an insurance system
(as for example in the United States of America)
and third party payment or user payment (most
prevalent in developing countries). The World
Health Organization suggested the pooling of
health funding as the best option, such as the
social security system in Europe and the 30 baht
health care scheme in Thailand. Similarly, the
following are also recommended by the World
Health Organization; proportion of population too
poor to contribute subsidized through revenue,
and compulsory contribution to pool fund to get
enough funding and avoid rich and less risky to be
opt out30
. In addition, multiple pools, each with
their own administrations and information
systems, are also inefficient and make it difficult
to achieve equity.
On the other hand, private sectors in health
services are focused on private benefit and cost-
effectiveness. Health is a public good, however,
and social benefit beyond individual gain will not
be achieved by the private sector. Health
promotion to the community may not be provided
by the private sector and communicable disease
control related to environmental measures may
be excluded too. Government support in such
matters is essential and immediate cessation of
uncontrolled commercialization in health services
may need to be balance against population need.
Conversely, public-private partnership has been
used in some health programmes when the
private sector can increase coverage: e.g.
treatment of tuberculosis.
Equity, efficiency and sustainability are
interconnected. Inequities in health related to
the social conditions that lead to illness are the
main cause of health need. Furthermore, they are
particularly common among socially
disadvantaged populations which require health
systems to be more responsive to population
needs. Health programmes should rather expand
coverage to the population in greatest need. In
the interest of health equity, attention should be

5. Malaysian Journal of Public Health Medicine 2013, Vol. 13(1): 64-71
focused on community needs and demand.
Graham and Kelly (2004) emphasize the
importance of local needs, suggesting the goal of
tackling health inequalities can be adapted to
local needs and community priorities, enabling
broad coalitions of support to be mobilized31
.
Similarly, empowering the community to manage
their health needs through a primary health care
approach using a mechanism most appropriate to
their context and the available resources will be
more efficient and sustainable. Furthermore, the
central role of national health systems in
addressing health inequities is essential. A
country's health system must be supported by a
mechanism whereby it is adequately resourced,
functions well, and is accessible to all.
Appropriately configured and managed health
systems provide a vehicle to improve people’s
lives, protecting them from the vulnerability of
sickness, generating a sense of security, and
building social cohesion within society; they can
ensure that all groups benefit from
socioeconomic development and they can
generate the political support needed to sustain
them32
.
On the thirtieth anniversary of primary health
care in 2008, WHO explored four strategic
reforms to improve equity and efficiency in
healthcare services11
. These were coverage
reform and service delivery reform concerned
with health service provision and public policy
reform and leadership reform related to
ministerial and national-international
coordination. The reforms were targeted at more
efficient and universal health services as follows:
 Universal coverage reforms contribute to
health equity and universal access to health.
 Service delivery reforms re-organize health
services around people’s needs and
expectations while producing better
outcomes.
 Public policy reforms secure healthier
communities by strengthening national and
transnational public health interventions.
 Leadership reforms replace disproportionate
reliance on command and control with
participatory leadership within the health
system.
To be more efficient and cost-effective, health
improvement should be comprehensive and
holistic. As regards comprehensiveness, access to
health promotion will be limited for a society
which has no basic education. Human resource
development and technological advancement are
also important to the quality of health services
and further maximization of health output is
essential.
Community participation and empowerment in
promoting health
A new approach to efficient and cost-effective
health service provision is community
participation in health development. Initially,
community participation was introduced as a tool
for developing community resources. Later, it
became a tool for empowering communities to
foster sustainable development. Morgan (2001)
defined community participation as a utilitarian
effort on the part of donors or governments to
use community resources (land, labour and
money) to offset the costs of providing services or
an empowerment tool through which local
communities take responsibility for diagnosing
and working to solve their own health and
development problems33
. In historical health
development, community participation shifted
from a medically directed approach to a local
people-led approach, notably moving from the
compliance model or marginal participation to a
collaborative model or substantial participation
and finally to a community control model or
structural participation. Robert Chambers (2007)
described the development of three participation
models for health: Rapid Rural Appraisal (1970s),
Participatory Rural Appraisal (1990s) and
Participatory Learning Action (2000s)34
.
Methodologically, Rapid Rural Appraisal was led
by scientists to make a need assessment by asking
local people to participate in providing
information, Participatory Rural Appraisal got
local people themselves to collect and analyse
information, and Participatory Learning Action
used a range of methods including mapping,
ranking, flow charts, problem identification and
prioritization enabling local people to express and
enhance their knowledge and take action.
Recently, community participation became an
important mainstream agenda item as reflected
by the World Bank's (1996) definition of
community participation as a process through
which stakeholders influence and share control
over development initiatives and the decisions
and resources which affect them35
. Community
participation creates a ‘social learning’ process
whereby professionals and local people learn
from each other and build working partnerships
for sustainable improvements36,37
. Furthermore,
community participation enhances social justice
and promotion of democracy. It is now an
essential element of community health and other
development programmes sponsored by NGOs and
international donors. In community participation,
health programmes are designed through active
community participation or community
empowerment. In this approach, working
together and developing local capacity (training
and skills development) is essential. In general,

6. Malaysian Journal of Public Health Medicine 2013, Vol. 13(1): 64-71
people seek solutions to problems when they
have been involved in the process. Moreover,
participation can increase the skills and
knowledge of local people, thus providing
opportunities to improve their lives
(empowerment). Empowerment can provide
opportunity enable people to make choices about
their own lives so that health needs for
communities can be properly identified and
health services fairly and efficiently provided.
Although individuals are at the centre of
empowerment, Marmot (2007) argued for three
interconnected dimensions, material,
psychosocial, and political, reflecting the
importance of empowerment among individuals,
nations, institutions, and communities32
. He
stressed that every nation should empower
people in all three dimensions individually and in
society as a whole.
Advancement in medicine is essential for health
improvement. This alone will rarely be sufficient,
however. In order to maximize utilization and
modest treatment outcome, there is a need to
empower individuals, communities, and whole
countries. There is rigorous evidence of the
importance of community empowerment through
participatory health improvement: e.g. ‘A
Partnership Plan to Improve the Health of the
Public’ (Zahner et al., 2005); community
participation and empowerment at the heart of
effective health promotion (Heritage and Dooris,
2009); the Ottawa Charter for Health Promotion
(World Health Organization, 1996), which gives
priority to increasing community capacity and
empowering individuals; and the Jakarta
Declaration (World Health Organization, 1998)38-
41
. In conclusion, to achieve maximum health
output in an efficient way, there must be
community empowerment at all levels,
individual, community and society.
The study also has limitation. Health equity and
efficiency are subjective and unable to easily
compare in nominal term. Moreover, health
infrastructure and disease burden are uneven
both within and between countries. Nevertheless,
the study review and reported most
comprehensively.
CONCLUSION
Given the disparity in health improvement
between countries and emerging health
problems, the world needs better design of
health services to achieve equity and efficiency.
On the other hand, limited resources and
prioritization in health funding are unavoidable.
The four parameters discussed—health for poor,
health equity, efficiency and sustainability, and
community participation—are important in
maximizing health development. As a possible
solution to those problems, i.e. achieving
maximum health improvement with equitable
distribution within the population, the following
four functional changes are recommended for
consideration.
 Reforms targeting universal coverage;
development of appropriate technology,
human resource capacity for health services
and community participation to achieve
universal access to health.
 People-centred service delivery: health
services directed away from professional
command towards people’s needs and
expectations while producing better
outcomes.
 Public policy change; integrated health
planning. Health at the centre of country
development with multi-ministerial support
and strengthening of national and
transnational public health interventions
including national policies in non-health
ministries covering healthy environment,
healthy city and infrastructure, healthy food,
healthy lifestyle and sports development, etc.
 Health system and collective community
response for total health; improve health
system performance through community
empowerment; the community should be self-
aware of health problems, seek a solution and
participate in the whole process.
ACKNOWLEDGEMENT
I fully acknowledge support of Professor Dr D.
Kamarudin D. Mudin - School of Medicine,
University Malaysia Sabah in his fullest support to
my writing.
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