 Before discussing the relationship between equity and efficiency, it is important to discern between the three types of efficiency:
Technical efficiency is maximizing outputs based on a given level of resources by ensuring the proper mix of resources (vaccines, equipment, drugs, and so on).
Economic efficiency consists of producing a level of effective services at the lowest cost possible.
Allocative efficiency consists of “doing the right things.”  In other words, devoting resources to the most critical services and doing so in a cost-effective way.
	These concepts can seem at times to be in direct opposition to the idea of equity.  A good example of this tension between equity and efficiency can be seen in Oregon in the 1990s when their Medicaid system decided to prioritize health interventions based on their DALYs and what services were most cost efficient.  This ground-breaking system was based on the idea of allocative efficiency.  It wasn't long until a child diagnosed with leukemia was denied care because the services weren't viewed as cost-effective in Medicaid's new system.  The uproar over denial of care for cancer treatments eventually led to Oregon abandoning the system altogether.
	That being said, efficiency and equity are not in direct opposition, per se.  One of the most attractive elements of efficiency is that it should in theory free up funding that can be devoted to providing services for the poor.  “Doing more with less,” in theory at least, should mean there is more for those who rely on subsidized or free services.  
	In addition, efficiency does stress preventative care, as vaccinations and prevention are much more efficient options than treatment of disease.  This falls in line with equality issues, as long as who to vaccinate does not become an issue, but is viewed as an allocative efficiency issue (IE coverage for all) rather than a technical efficiency issue, which may value vaccinating those close to a clinic, but devalue the cost of reaching those in hard-to-reach communities.
	Equity should be one of the most fundamental considerations in all health systems strengthening efforts, and should be the aim of any system.  While there may not be any perfectly equitable system, it is clear that those systems that run largely on out-of-pocket payments (as in most developing countries) or private insurance-based systems like the US (where insurance providers often participate in adverse selection to decrease their risk) largely are not equitable.  While health systems that provide universal coverage are generally more equitable, there are still other considerations, such as how funds are raised, the distribution of healthcare providers across the country, and so on.


	The reason for the mixed success of many donor-funded rural insurance schemes is complicated.  In theory, providing a risk-pooling scheme for areas where nothing existed before seems rather straightforward.  In practice, however, these communities often have certain issues developing viable, sustainable health insurance schemes.	
	The primary reason many of the rural insurance schemes have failed in the past is due to insufficient funding. 