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Persistent health inequalities are evident within and between countries. While in rich countries, such as Japan and Australia, the average life expectancy of people is over 80 years, in some African countries, such as Sierra Leone, it is only 45 years.1 Within countries, socioeconomic status difference creates considerable gaps in life expectancy.2 Health inequalities caused by avoidable and unfair socioeconomic or cultural inequalities are recognised as health inequities.3 Reducing these health inequities is a central concern of international agencies and national governments. Evidence on how best to achieve this reduction is improving and suggests that, while the health sector has a crucial role, responsibility for the reduction also lies with other sectors where the social and economic inequalities that drive health inequities are created and maintained.4 Health systems do not sit apart from these structural drivers of inequities but are entwined within them.
Economic globalisation has led to an increase in the commercialisation of healthcare services, has weakened national health systems (for instance through the imposition of structural adjustment packages in poor countries) and reduced the opportunity for comprehensive primary healthcare. Individuals’ opportunities to access healthcare are shaped by their education, income, social support and the nature of the health system they have available. The difference in health systems between low and high income countries is massive, and within both groups of countries, health systems differ widely. Contrast the privatised system in the …