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Public health in the rural United States is a complex and underfunded enterprise. While urban-rural disparities have been a focus for researchers and policymakers alike for decades, inequalities continue to grow. Life expectancy at birth is now 1 to 2 years greater between wealthier urban and rural counties, and is as much as 5 years, on average, between wealthy and poor counties.This article explores the growth in these disparities over the past 40 years, with roots in structural, economic, and social spending differentials that have emerged or persisted over the same time period. Importantly, a focus on place-based disparities recognizes that the rural United States is not a monolith, with important geographic and cultural differences present regionally. We also focus on the challenges the rural governmental public health enterprise faces, the so-called \"double disparity\" of worse health outcomes and behaviors alongside modest investment in health departments compared with their nonrural peers.Finally, we offer 5 population-based \"prescriptions\" for supporting rural public health in the United States. These relate to greater investment and supporting rural advocacy to better address the needs of the rural United States in this new decade.

In the United States, rural populations have a lower life expectancy than urban populations and face shortages of health care providers. This report discusses the challenges facing rural health care systems and efforts to expand the rural health care workforce.

Hai Fang and colleagues highlight the need for better financial protection for poor people

In India, despite improvements in access to health care, inequalities are related to socioeconomic status, geography, and gender, and are compounded by high out-of-pocket expenditures, with more than three-quarters of the increasing financial burden of health care being met by households. Health-care expenditures exacerbate poverty, with about 39 million additional people falling into poverty every year as a result of such expenditures. We identify key challenges for the achievement of equity in service provision, and equity in financing and financial risk protection in India. These challenges include an imbalance in resource allocation, inadequate physical access to high-quality health services and human resources for health, high out-of-pocket health expenditures, inflation in health spending, and behavioural factors that affect the demand for appropriate health care. Use of equity metrics in monitoring, assessment, and strategic planning; investment in development of a rigorous knowledge base of health-systems research; development of a refined equity-focused process of deliberative decision making in health reform; and redefinition of the specific responsibilities and accountabilities of key actors are needed to try to achieve equity in health care in India. The implementation of these principles with strengthened public health and primary-care services will help to ensure a more equitable health care for India's population.

Objectives To evaluate the effects of a government insurance program covering tertiary care for people below the poverty line in Karnataka, India, on out-of-pocket expenditures, hospital use, and mortality. Design Geographic regression discontinuity study. Setting 572 villages in Karnataka, India. Participants 31 476 households (22 796 below poverty line and 8680 above poverty line) in 300 villages where the scheme was implemented and 28 633 households (21 767 below poverty line and 6866 above poverty line) in 272 neighboring matched villages ineligible for the scheme. Intervention A government insurance program (Vajpayee Arogyashree scheme) that provided free tertiary care to households below the poverty line in about half of villages in Karnataka from February 2010 to August 2012. Main outcome measure Out-of-pocket expenditures, hospital use, and mortality. Results Among households below the poverty line, the mortality rate from conditions potentially responsive to services covered by the scheme (mostly cardiac conditions and cancer) was 0.32% in households eligible for the scheme compared with 0.90% among ineligible households just south of the eligibility border (difference of 0.58 percentage points, 95% confidence interval 0.40 to 0.75; P<0.001). We found no difference in mortality rates for households above the poverty line (households above the poverty line were not eligible for the scheme), with a mortality rate from conditions covered by the scheme of 0.56% in eligible villages compared with 0.55% in ineligible villages (difference of 0.01 percentage points, −0.03 to 0.03; P=0.95). Eligible households had significantly reduced out-of-pocket health expenditures for admissions to hospitals with tertiary care facilities likely to be covered by the scheme (64% reduction, 35% to 97%; P<0.001). There was no significant increase in use of covered services, although the point estimate of a 44.2% increase approached significance (−5.1% to 90.5%; P=0.059). Both reductions in out-of-pocket expenditures and potential increases in use might have contributed to the observed reductions in mortality. Conclusions Insuring poor households for efficacious but costly and underused health services significantly improves population health in India.

The maldistribution of health workers between urban and rural areas is a policy concern in virtually all countries. It prevents equitable access to health services, can contribute to increased health-care costs and underutilization of health professional skills in urban areas, and is a barrier to universal health coverage. To address this long-standing concern, the World Health Organization (WHO) has issued global recommendations to improve the rural recruitment and retention of the health workforce. This paper presents experiences with local and regional adaptation and adoption of WHO recommendations. It highlights challenges and lessons learnt in implementation in two countries - the Lao People's Democratic Republic and South Africa - and provides a broader perspective in two regions - Asia and Europe. At country level, the use of the recommendations facilitated a more structured and focused policy dialogue, which resulted in the development and adoption of more relevant and evidence-based policies. At regional level, the recommendations sparked a more sustained effort for cross-country policy assessment and joint learning. There is a need for impact assessment and evaluation that focus on the links between the rural availability of health workers and universal health coverage. The effects of any health-financing reforms on incentive structures for health workers will also have to be assessed if the central role of more equitably distributed health workers in achieving universal health coverage is to be supported.

Summary We created a comprehensive set of health-system performance measurements for China nationally and regionally, with health-system coverage and catastrophic medical spending as major indicators. With respect to performance of health-care delivery, China has done well in provision of maternal and child health services, but poorly in addressing non-communicable diseases. For example, coverage of hospital delivery increased from 20% in 1993 to 62% in 2003 for women living in rural areas. However, effective coverage of hypertension treatment was only 12% for patients living in urban areas and 7% for those in rural areas in 2004. With respect to performance of health-care financing, 14% of urban and 16% of rural households incurred catastrophic medical expenditure in 2003. Furthermore, 15% of urban and 22% of rural residents had affordability difficulties when accessing health care. Although health-system coverage improved for both urban and rural areas from 1993 to 2003, affordability difficulties had worsened in rural areas. Additionally, substantial inter-regional and intra-regional inequalities in health-system coverage and health-care affordability measures exist. People with low income not only receive lower health-system coverage than those with high income, but also have an increased probability of either not seeking health care when ill or undergoing catastrophic medical spending. China's current health-system reform efforts need to be assessed for their effect on performance indicators, for which substantial data gaps exist.

To determine whether the New Cooperative Medical Insurance Scheme (NCMS) is associated with decreased levels of catastrophic health expenditure and reduced impoverishment due to medical expenses in rural households of China. An analysis of a national representative sample of 38,945 rural households (129,635 people) from the 2008 National Health Service Survey was performed. Logistic regression models used binary indicator of catastrophic health expenditure as dependent variable, with household consumption, demographic characteristics, health insurance schemes, and chronic illness as independent variables. Higher percentage of households experiencing catastrophic health expenditure and medical impoverishment correlates to increased health care need. While the higher socio-economic status households had similar levels of catastrophic health expenditure as compared with the lowest. Households covered by the NCMS had similar levels of catastrophic health expenditure and medical impoverishment as those without health insurance. Despite over 95% of coverage, the NCMS has failed to prevent catastrophic health expenditure and medical impoverishment. An upgrade of benefit packages is needed, and effective cost control mechanisms on the provider side needs to be considered.

We analyzed the likelihood of rural children (aged 6-24 months) being stunted according to whether they were enrolled in Mutuelles, a community-based health-financing program providing health insurance to rural populations and granting them access to health care, including nutrition services. We retrieved health facility data from the District Health System Strengthening Tool and calculated the percentage of rural health centers that provided nutrition-related services required by Mutuelles' minimum service package. We used data from the 2010 Rwanda Demographic and Health Survey and performed multilevel logistic analysis to control for clustering effects and sociodemographic characteristics. The final sample was 1061 children. Among 384 rural health centers, more than 90% conducted nutrition-related campaigns and malnutrition screening for children. Regardless of poverty status, the risk of being stunted was significantly lower (odds ratio = 0.60; 95% credible interval = 0.41, 0.83) for Mutuelles enrollees. This finding was robust to various model specifications (adjusted for Mutuelles enrollment, poverty status, other variables) or estimation methods (fixed and random effects). This study provides evidence of the effectiveness of Mutuelles in improving child nutrition status and supported the hypothesis about the role of Mutuelles in expanding medical and nutritional care coverage for children.

China is in the process of integrating the new cooperative medical scheme (NCMS) and the urban residents' basic medical insurance system (URBMI) into the urban and rural residents' basic medical insurance system (URRBMI). However, how to integrate the financing policies of NCMS and URBMI has not been described in detail. This paper attempts to illustrate the differences between the financing mechanisms of NCMS and URBMI, to analyze financing inequity between urban and rural residents and to identify financing mechanisms for integrating urban and rural residents' medical insurance systems. Financing data for NCMS and URBMI (from 2008 to 2015) was collected from the China health statistics yearbook, the China health and family planning statistics yearbook, the National Handbook of NCMS Information, the China human resources and social security statistics yearbook, and the China social security yearbook. \"Ability to pay\" was introduced to measure inequity in health financing. Individual contributions to NCMS and URBMI as a function of per capita disposable income was used to analyze equity in health financing between rural and urban residents. URBMI had a financing mechanism that was similar to that used by NCMS in that public finance accounted for more than three quarters of the pooling funds. The scale of financing for NCMS was less than 5% of the per capita net income of rural residents and less than 2% of the per capita disposable income of urban residents for URBMI. Individual contributions to the NCMS and URBMI funds were less than 1% of their disposable and net incomes. Inequity in health financing between urban and rural residents in China was not improved as expected with the introduction of NCMS and URBMI. The role of the central government and local governments in financing NCMS and URBMI was oscillating in the past decade. The scale of financing for URRBMI is insufficient for the increasing demands for medical services from the insured. The pooling fund should be increased so that it can better adjust to China's rapidly aging population and epidemiological transitions as well as protect the insured from poverty due to illness. Individual contributions to the URBMI and NCMS funds were small in terms of contributors' incomes. The role of the central government and local governments in financing URRBMI was not clearly identified. Individual contributions to the URRBMI fund should be increased to ensure the sustainable development of URRBMI. Compulsory enrollment should be required so that URRBMI improves the social medical insurance system in China.