Investing in Global Health Systems Sustaining Gains, Transforming Lives (2014) / Chapter Skim
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2 The United States' Strategic Imperative to Invest in Health Systems
2 The United States' Strategic Imperative to Invest in Health Systems
Pages 17-56
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From page 17... ...
The WHO has identified six building blocks of a health system: • the leadership, who steer the health sector and set the country's policies; • the information system that supports vital registration, surveillance, and monitoring, financing, human resources, coverage, and quality of care; • an accountable financing system to raise and pool funds; • a productive workforce and tools to ensure they are deployed efficiently; • an affordable supply of essential medicines, vaccines, and technology and a functional regulatory authority to protect their quality; • and, lastly, a service delivery system that can work through public or private sector providers (WHO, 2007a, 2010a)
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From page 18... ...
, which support more comprehensive care. Vertical programs generally have separate management and logistics systems: this can include a separate workforce, surveillance system, and method of assuring drug quality (Victora et al., 2004)
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To put it another way, failure to plan for the careful integration of vertical programs with general health services aggravates the very staffing and organizational constraints that made foreign assistance necessary in the first place. The future of global health will require building off established platforms, integrating HIV, tuberculosis, malaria, and maternal and child health programs with primary care systems, using targeted investments to improve the broader health infrastructure countries' depend on (Atun et al., 2013; Samb et al., 2009)
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* Health sector as ssistance is that giv ven directly to deveeloping country governments to spen on health system strengthening.
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. Sustainability and judicious integration of vertical programs with health systems are especially salient topics for the U.S.
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Donors tend to value vertical health programs because of their immediate, but less sustainable, effects. Conclusion • When donors run vertical programs in a way that undermines the partner country's health system, or when they fail to integrate vertical programs with general health services, they only aggravate their partner countries' staffing and organizational problems.
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A functional health system is the most important prerequisite to maintain ground against the HIV epidemic in Africa. A stronger health system in poor countries is also the best insurance against a complicated and changing future burden of disease.
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. More often poor countries cope with the dual burden of infectious and chronic diseases in different sub-populations.
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. Either way, it is a reminder that shifting patterns of illness in poor countries are overwhelming the health infrastructure.
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. The challenge for the future of development is to use our remaining influence and a proportionately decreasing share of national budgets, to benefit the most 1 Defined by the World Bank as <$1.25 a day, adjusted for 2005 purchasing power parity (Ravallion et al., 2008)
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. Health aaid for fraagile states often comes as humanitar o rian relief wwithout links to longer r-term health systems deve s elopment (Farrmer, 2013; H 2014)
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The Post-2015 Development Agenda Improving systemic effectiveness in poor countries, increasing social protection, and setting up resilient local management are important themes in post-2015 development discussion (OECD, 2013a; UN Open Working Group on Sustainable Development Goals; UN SecretaryGeneral's High-Level Panel of Eminent Persons on the Post-2015 Development Agenda, 2013; UN System Task Team, 2013)
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Their investment would yield considerable returns to the world economy, and will have a substantial diplomatic value beyond that. As donors' proportional contribution to health spending in developing countries decreases, it will be more important to use donor influence judiciously.
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• Global economic growth has created a broader tax base in developing countries, making donor assistance a proportionately smaller piece of national funding for health. • Using development aid to help the billion people left in dire poverty is complicated.
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Boxes 2-1, 2-2, and 2-3 give examples of innovative systemic changes that have improved health indicators or service delivery in poor countries. Dysfunctional Health Systems Spread Disease, Good Health Systems Prevent It Organization is often the biggest challenge in delivering health.
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These posts helped meet the increased demand for primary care, particularly in rural areas, where hospitals had closed. The reforms allowed for nearly universal coverage in essential primary services, and drove improvements in health outcomes.
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District health offices tailor the health worker trainings to suit local needs and, because the trainees are chosen from the communities they work in, they are well received by their clients. District health planning and delivery has helped increase access to health posts from 38 percent in 1991 to 89 percent in 2011.
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From page 34... ...
. Global Fund3 activities have improved the drug procurement system, and procurement for HIV supplies is now integrated with the national system; the Global Fund also supported health infrastructure improvements such as health post modernization, laboratory equipment, and vehicles for field supervision (Atun et al., 2011)
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The Medical Services Corporation commands a purchasing power that has brought down the cost of certain classes of drugs, resulting in savings that have been used to furnish district hospitals with diagnostic equipment previously available only at expensive private hospitals. The corporation's emphasis on openness, quality, and efficiency, has improved drug quality and patient confidence in the health system.
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Health coverage schemes that start in rural areas and offer free treatment for the conditions poor people suffer from, can improve health with minimal increased expense. In Thailand, universal coverage cost slightly less than $25 per capita (Gruber et al., 2012)
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4 Adjusted for USD purchasing power parity.
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. The episode can go on for years, as with a chronic disease, 5 Economists derive the cut point from the average poverty lines in the world's 15 poorest countries, measured in 2005 dollars and adjusted for differences in purchasing power parity (Towards the end of poverty, 2013)
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FIGURE 2-3 Employment by econom class (2005 constant $, adjusted for purchasing pow parity, per day) , from 1991-2011, mic wer as a percentage of total employmen in all low- and middle-income coun o nt m ntries (2005 $, adj usted for purchasing power parity, per day)
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40 FIGURE 2-4 Employment by econom class (2005 constant $, adjusted for purchasing pow parity, per day) , in sub-Saharan mic wer Africa, 1991-2011, as a percentage of total employment.
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FIGURE 2-5 Employment by econom class (2005 co mic onstant $, adjusted for purchasing po ower parity, per day in South Asia, y) , 1991-2011, as a per rcentage of total em mployment.
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count me SOUR RCE: Copyrighted and publis shed by Projec HOPE/Health Affairs as Xu ct h u, et al., Protecting households from catastrop hic health spending, Health h Affair (Millwood)
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. Out-of-pocket health spending endangers patients, and prepayment (a system of collecting for health expenses before an illness)
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. In India, government data indicates that about 9 percent of all public health spending benefits the poorest fifth of the population, while the richest fifth take about 40 percent (Chakraborty et al., 2013)
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Efficient Health Spending Improves Productivity Making the most of financial contributions to the health system is one of the main challenges facing governments today. The potential payoffs for increasing efficiency are substantial.
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Medicines: inappropriate Inappropriate prescriber Separate prescribing and • Medical products, and ineffective use incentives and unethical dispensing functions; regulate vaccines, and promotion practices; promotional activities; technologies consumer improve prescribing guidance, • Health workforce demand/expectations; limited information, training and knowledge about therapeutic practice; disseminate public effects; inadequate regulatory information framework
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Health care services: Lack of alternative care Provide alternative care (e.g., • Service delivery inappropriate hospital arrangements; insufficient day care) ; alter incentives to admissions and length of incentives to discharge; hospital providers; raise stay limited knowledge of best knowledge about efficient practice admission practice 7.
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Health system leakages: Unclear resource allocation Improve • Leadership and waster, corruption, and guidance; lack of regulation/governance, governance fraud transparency; poor including strong sanction • Financing accountability and mechanisms; assess governance mechanisms; low transparency/vulnerability to salaries corruption; undertake public spending tracking surveys; promote codes of conduct 10. Health interventions: Funding high-cost, low-effect Regular evaluation and • Service delivery inefficient mix and interventions when low-cost, incorporation into policy of • Financing inappropriate level of high-impact options are evidence on the costs and strategies unfunded.
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. In an y a nalyses that acccount for booth the inncrease in inc come and th value of a he added life y years caused by improv health, the benefits of re ved e educing infecti ions and impr roving matern nal and child health exce the costs by a factor of 9 to 20 (Jamiso et al., 2013)
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For one-third of all households in sub-Saharan Africa and Southeast Asia health expenses pose a financial hardship. • Households respond to hardship by selling assets in distress, taking on high-interest debt, or forfeiting their future earnings through debt bondage.
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Health Infrastructure Supports Emergency Response Concern with developing countries' public health systems has grown over the past 10 years, partly because of the threat of emerging pandemic diseases such as Ebola. In 2004, David Heymann and Guénaël Rodier observed that the SARS epidemic "made one lesson clear early in its course: inadequate surveillance and response capacity in a single country can endanger … the entire world" (Heymann and Rodier, 2004, p.
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It will be impossible to implement the International Health Regulations without improving the health system foundation they draw on. Investments in the health system (such as laboratories, health information systems, communication, and human resource management)
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. Natural disasters and acts of violence are only more common in poor countries, so the need for resilience is even
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The ministry also used the new emergency response system twice in 2013: once a preventative measure at a large cultural event, and once to screen pilgrims returning from the Hajj for Middle East respiratory syndrome coronavirus. SOURCE: Borchert et al., 2014 greater.
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Medical tourism is common. Even in Yemen, one of the poorest countries in the region, which has a maternal mortality ratio of 270 deaths per 100,000 live births, 29 percent of all health spending is on curative treatment abroad (UNDP, 2009; WHO et al., 2014)
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From page 56... ...
• The emerging Ebola pandemic would tax any health system, but the West African countries affected have particular vulnerabilities. • Neglect of health systems undermines governments, all of which have an interest in health reform and controlling medical inflation Conclusions • The Ebola pandemic has drawn attention to the consequences of neglecting health systems development in low- and middle-income countries.
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