Chapter Seven Health Systems principled integrated care To meet the formidable challenges described earlier, this chap- ter calls for the reinforcement of health systems to be based on the core principles of primary health care as outlined Alma-Ata in 1978: universal access and coverage on the ba sis of need; health equity as part of development oriented to social justice; community participation in defining and imple menting health agendas; and intersectoral approaches to health. These principles remain valid, but must be reinterpreted in light of the dramatic changes in the health field during the past 25 years. Four important issues that health systems must confront are examined: the global health workforce crisis, in adequate health information, lack of financial resources, and the stewardship challenge of implementing pro-equity health policies in a pluralistic environment
Health Systems: principled integrated care 103 Chapter Seven Health Systems: principled integrated care To meet the formidable challenges described earlier, this chapter calls for the reinforcement of health systems to be based on the core principles of primary health care as outlined at Alma-Ata in 1978: universal access and coverage on the basis of need; health equity as part of development oriented to social justice; community participation in defining and implementing health agendas; and intersectoral approaches to health. These principles remain valid, but must be reinterpreted in light of the dramatic changes in the health field during the past 25 years. Four important issues that health systems must confront are examined: the global health workforce crisis, inadequate health information, lack of financial resources, and the stewardship challenge of implementing pro-equity health policies in a pluralistic environment
Health Systems principled integrated care Confronting the global health challenges examined in the previous chapters requires health systems to be strengthened. Without this, the health goals described in this report will remain beyond reach. The lessons learnt from past successes, including the skills and strategies developed from the experiences of tackling polio and SARS, must be applied in combating the HIVIAIDS treatment emergency and in working towards the Millennium Development Goals(MDGs). Progress towards these and other objectives will not be sustainable unless specific health targets- including the 3 by 5 target of reaching three million people developing countries with combination antiretroviral therapy for HIviaidS by the end of 2005-support a broad horizontal build-up of the capacities of health systems Despite the health reforms of recent decades, inadequate progress has been made in building health systems that promote collective health improvement. Now, however, fresh opportuni ies are emerging. Health stands high on the international development agenda, and new funds are becoming available for health work in poor countries. Extending health-enabling conditions and quality care to all is the major imperative for health systems. This chapter explores how the values and practices of primary health care, adapted to the realities of today's complex health landscape, might provide a basis for the improvement of health systems. It reviews basic ideas about primary health care and clarifies the concept of the development of health systems that are based on primary health care. It then examines four major challenges facing health systems: the global health workforce crisis; the lack of appropriate, timely evidence; the lack of financial resources; and the stewardship challenge of implementing pro-equity health policies in a pluralistic environment. The final section looks at how WHO is working with countries to clarify health systems goals and to strengthen systems in line with primary health care principle The health system comprises all organizations, institutions and resources that produce ac tions whose primary purpose is to improve health(1). The health care system refers to the institutions, people and resources involved in delivering health care to individuals. This chapter is mostly concerned with health care systems. Nevertheless, health care providers are often involved in promoting health-enabling conditions in the community. Indeed, this relation- ship between patient care and public health functions is one of the defining characteristics of the primary health care approach The health systems performance assessment framework developed by WHO in the late 1990s was an attempt to put into effect the primary health care concern for equity and population health outcomes, by providing analytical tools to translate these concerns into relevant
Health Systems: principled integrated care 105 7 Health Systems: principled integrated care Confronting the global health challenges examined in the previous chapters requires health systems to be strengthened. Without this, the health goals described in this report will remain beyond reach. The lessons learnt from past successes, including the skills and strategies developed from the experiences of tackling polio and SARS, must be applied in combating the HIV/AIDS treatment emergency and in working towards the Millennium Development Goals (MDGs). Progress towards these and other objectives will not be sustainable unless specific health targets – including the “3 by 5” target of reaching three million people in developing countries with combination antiretroviral therapy for HIV/AIDS by the end of 2005 – support a broad horizontal build-up of the capacities of health systems. Despite the health reforms of recent decades, inadequate progress has been made in building health systems that promote collective health improvement. Now, however, fresh opportunities are emerging. Health stands high on the international development agenda, and new funds are becoming available for health work in poor countries. Extending health-enabling conditions and quality care to all is the major imperative for health systems. This chapter explores how the values and practices of primary health care, adapted to the realities of today’s complex health landscape, might provide a basis for the improvement of health systems. It reviews basic ideas about primary health care and clarifies the concept of the development of health systems that are based on primary health care. It then examines four major challenges facing health systems: the global health workforce crisis; the lack of appropriate, timely evidence; the lack of financial resources; and the stewardship challenge of implementing pro-equity health policies in a pluralistic environment. The final section looks at how WHO is working with countries to clarify health systems goals and to strengthen systems in line with primary health care principles. The health system comprises all organizations, institutions and resources that produce actions whose primary purpose is to improve health (1). The health care system refers to the institutions, people and resources involved in delivering health care to individuals. This chapter is mostly concerned with health care systems. Nevertheless, health care providers are often involved in promoting health-enabling conditions in the community. Indeed, this relationship between patient care and public health functions is one of the defining characteristics of the primary health care approach. The health systems performance assessment framework developed by WHO in the late 1990s was an attempt to put into effect the primary health care concern for equity and population health outcomes, by providing analytical tools to translate these concerns into relevant
The World Health Rep evidence. The framework drew the attention of policy-makers to issues such as the cata strophic health expenditure in a number of countries. Although this report does not directly apply the framework, it assumes that policy-makers will use this and other relevant tools to measure the success of an approach to health systems scale-up based on primary health care Valuable knowledge has been gained in recent years about how health systems work and why they fail. Initiatives such as the European Observatory on Health Care Systems are producing important insights(see Box 7.1), though fundamental questions remain unresolved. This report does not propose a complete model of the development of health systems based on primary health care, which would be impossible given the current state of evidence. The aim is to open lines of enquiry that will be of use to countries and international health partners as they weigh options and take action to strengthen systems, making them responsive to the needs and demands of all, especially the poor. The core principles of primary health care Primary health care became a core policy for WHO in 1978, with the adoption of the Decla ration of Alma-Ata and the strategy of"Health for all by the year 2000". Twenty-five years later, international support for the values of primary health care remains strong. Preliminary results of a major review suggest that many in the global health community consider a pri- mary health care orientation to be crucial for equitable progress in health(2) No uniform, universally applicable definition of primary health care exists. Ambiguities were present in the Alma-Ata document, in which the concept was discussed as both a level of care and an overall approach to health policy and service provision. In high-income and middle- income countries, primary health care is mainly understood to be the first level of care. In low-income countries where significant challenges in access to health care persist, it is seen more as a system-wide strategy. Box 7.1 The European Observatory on Health Care Systems Countries in the European Region-diverse in terms of language, his- set of questions and uses clear definitions to create a baseline of infor tory and wealth -have an array of approaches to the organization of mation, drawing attention to what is distinct about a particular country health systems. The European Observatory on Health Care Systems and The Observatory covers the whole European Region and some addi olicies seeks to disseminate information on more than a decade of tional OECD countries, to allow systematic comparisons and the review change, analysing the reforms and generating evidence on what works of reforms over time. in different contexts and why. It ensures that Europe's national policy Analysis. The Observatory produces comprehensive studies on key makers can set their own experiences in the European context and make health system and policy areas, including hospitals, funding, regulation, comparisons across borders, draw on thematic and comparative analy- European enlargement, social health insurance, purchasing, primary care, sis of the key challenges they face, and have access to clear, practical pharmaceuticals, mental health, human resources, and targets. It uses evidence secondary or meta-analytical research, bringing together experts from The Observatory is a partnership that brings together the WHo across Europe to synthesize existing findings, to work country experi- Regional Office for Europe, governments(Greece, Norway and Spain), ences into a conceptual framework and to draw out practical lessons international and nongovernmental agencies (the European Investment and options Bank, the Open Society Institute, and the World Bank) and academia Dissemination. Engaging with policy-makers and their advisers (the London School of Economics and Political Science and the London helps ensure they can use the information and analyses generated. The School of Hygiene and Tropical Medicine). All the Observatorys materi- Observatory runs seminars and workshops for small groups of high level ls are available on its web site I policy-makers, often in partnership with agencies supporting health Information and monitoring. The Health System in Transition tem and policy reform, on matters such as funding options, the implica- series of 70 country profiles provides analytical answers to a standard tions of EU accession for new Member States, or equity Iwww.observatory.dk
106 The World Health Report 2003 evidence. The framework drew the attention of policy-makers to issues such as the catastrophic health expenditure in a number of countries. Although this report does not directly apply the framework, it assumes that policy-makers will use this and other relevant tools to measure the success of an approach to health systems scale-up based on primary health care. Valuable knowledge has been gained in recent years about how health systems work and why they fail. Initiatives such as the European Observatory on Health Care Systems are producing important insights (see Box 7.1), though fundamental questions remain unresolved. This report does not propose a complete model of the development of health systems based on primary health care, which would be impossible given the current state of evidence. The aim is to open lines of enquiry that will be of use to countries and international health partners as they weigh options and take action to strengthen systems, making them responsive to the needs and demands of all, especially the poor. The core principles of primary health care Primary health care became a core policy for WHO in 1978, with the adoption of the Declaration of Alma-Ata and the strategy of “Health for all by the year 2000”. Twenty-five years later, international support for the values of primary health care remains strong. Preliminary results of a major review suggest that many in the global health community consider a primary health care orientation to be crucial for equitable progress in health (2). No uniform, universally applicable definition of primary health care exists. Ambiguities were present in the Alma-Ata document, in which the concept was discussed as both a level of care and an overall approach to health policy and service provision. In high-income and middleincome countries, primary health care is mainly understood to be the first level of care. In low-income countries where significant challenges in access to health care persist, it is seen more as a system-wide strategy. Box 7.1 The European Observatory on Health Care Systems Countries in the European Region – diverse in terms of language, history and wealth – have an array of approaches to the organization of health systems. The European Observatory on Health Care Systems and policies seeks to disseminate information on more than a decade of change, analysing the reforms and generating evidence on what works in different contexts and why. It ensures that Europe’s national policymakers can set their own experiences in the European context and make comparisons across borders, draw on thematic and comparative analysis of the key challenges they face, and have access to clear, practical evidence. The Observatory is a partnership that brings together the WHO Regional Office for Europe, governments (Greece, Norway and Spain), international and nongovernmental agencies (the European Investment Bank, the Open Society Institute, and the World Bank) and academia (the London School of Economics and Political Science and the London School of Hygiene and Tropical Medicine). All the Observatory’s materials are available on its web site.1 Information and monitoring. The Health System in Transition series of 70 country profiles provides analytical answers to a standard set of questions and uses clear definitions to create a baseline of information, drawing attention to what is distinct about a particular country. The Observatory covers the whole European Region and some additional OECD countries, to allow systematic comparisons and the review of reforms over time. Analysis. The Observatory produces comprehensive studies on key health system and policy areas, including hospitals, funding, regulation, European enlargement, social health insurance, purchasing, primary care, pharmaceuticals, mental health, human resources, and targets. It uses secondary or meta-analytical research, bringing together experts from across Europe to synthesize existing findings, to work country experiences into a conceptual framework and to draw out practical lessons and options. Dissemination. Engaging with policy-makers and their advisers helps ensure they can use the information and analyses generated. The Observatory runs seminars and workshops for small groups of high level policy-makers, often in partnership with agencies supporting health system and policy reform, on matters such as funding options, the implications of EU accession for new Member States, or equity. 1 www.observatory.dk
Health Systems: principled integrated care It is useful to understand primary health care as involving both core principles and a variable set of basic activities. For the purposes of this discussion, it is the principles that are most significant(3), including: universal access to care and coverage on the basis of need; commitment to health equity as part of development oriented to social justice; community participation in defining and implementing health agendas intersectoral approaches to health Enduring principles in a changing environment The global, national and local environments in which primary health care values must be translated into action have changed fundamentally in the past 25 years. Key demographic and epidemiological shifts include ageing populations, the explosion of HIV/AIDS, and the expanding double burden of diseases in low-income and middle-income countries(see the example in Box 7. 2). Advances in health technology have transformed many aspects of medi cal practice and raised expectations concerning the types of functions and services that health systems should provide The institutional context of health policy-making and health care delivery has also changed Government responsibilities and objectives in the health sector have been redefined, with in health care provision. The r profit and not-for-profit, playing an increasingly visible role reasons for collaborative patterns vary, but chronic underfunding of publicly financed health services is often an important factor. Processes of decentralize tion and health sector reform have had mixed effects on health care system performance (4) The ideas and activities associated with primary health care have themselves undergone changes In the 1980s, the approach termed "selective primary health care"gained favour By focusing on the technical challenges of delivering limited basic interventions in poor areas, this strategy encouraged"" programme structures. These programmes produced Box 7. 2 Primary care in a changing environment: the"health houses"of the Islamic Republic of Iran The Government of the Islamic Republic of Iran has invested strongly in tion is increasing, with an associated change in lifestyle. The private training health care providers. Primary health care facilities, popularly health sector is increasing. Clinical case management is often not as known as"health houses, provide an active network staffed by com- evidence-based as it could be. A recent study on health financing dem- munity health workers, or behvarzes, who are trained and regularly su- onstrated that the financing system is not as equitable as had been ervised by staff from district health centres. The behvarzes provide basic thought: out-of-pocket payments are high, and the poor are less well are and advice on many aspects of maternal and child health and com- protected from catastrophic health expenditures than they were previously mon communicable diseases. They also record local health information The government is moving to respond to these new challenges. It through the"vital horoscope" data system, which includes information is already beginning to reorient the primary health care activities deliv- ollected during annual household visits. This system provides valuable ered in health houses. Technical guidelines for interventions and train- information for planning services both locally and nationally. There are ing for different cadres of health worker are being reviewed as part of high levels of community involvement in the delivery of community-based an effort to improve quality of care. There are discussions about a com- health care: 90% of the population belongs to a health insurance scheme, mon benefit package, what it should include and by whom it should be and some schemes are explicitly designed to protect the poor provided; specifically, how to involve private providers more effectively Today, the Islamic Republic of Iran faces several challenges to main. in the delivery of critical interventions, both preventive and curative, for taining these achievements in a changing environment. The country's example through contracting. The different insurance schemes are epidemiological profile has changed, partly as a consequence of the being reviewed within a broader analysis of overall health system success of the strategy led by primary care. The major burden of disease financing, and there are debates about what sort of organizational is attributable to noncommunicable diseases and injuries, though there arrangements within the public sector would enhance the quality and are some differences between richer and poorer provinces. Urbaniza. efficiency of public providers
Health Systems: principled integrated care 107 It is useful to understand primary health care as involving both core principles and a variable set of basic activities. For the purposes of this discussion, it is the principles that are most significant (3), including: – universal access to care and coverage on the basis of need; – commitment to health equity as part of development oriented to social justice; – community participation in defining and implementing health agendas; – intersectoral approaches to health. Enduring principles in a changing environment The global, national and local environments in which primary health care values must be translated into action have changed fundamentally in the past 25 years. Key demographic and epidemiological shifts include ageing populations, the explosion of HIV/AIDS, and the expanding double burden of diseases in low-income and middle-income countries (see the example in Box 7.2). Advances in health technology have transformed many aspects of medical practice and raised expectations concerning the types of functions and services that health systems should provide. The institutional context of health policy-making and health care delivery has also changed. Government responsibilities and objectives in the health sector have been redefined, with private sector entities, both for-profit and not-for-profit, playing an increasingly visible role in health care provision. The reasons for collaborative patterns vary, but chronic underfunding of publicly financed health services is often an important factor. Processes of decentralization and health sector reform have had mixed effects on health care system performance (4). The ideas and activities associated with primary health care have themselves undergone changes. In the 1980s, the approach termed “selective primary health care” gained favour. By focusing on the technical challenges of delivering limited basic interventions in poor areas, this strategy encouraged “vertical” programme structures. These programmes produced Box 7.2 Primary care in a changing environment: the “health houses” of the Islamic Republic of Iran The Government of the Islamic Republic of Iran has invested strongly in training health care providers. Primary health care facilities, popularly known as “health houses”, provide an active network staffed by community health workers, or behvarzes, who are trained and regularly supervised by staff from district health centres. The behvarzes provide basic care and advice on many aspects of maternal and child health and common communicable diseases. They also record local health information through the “vital horoscope” data system, which includes information collected during annual household visits. This system provides valuable information for planning services both locally and nationally. There are high levels of community involvement in the delivery of community-based health care; 90% of the population belongs to a health insurance scheme, and some schemes are explicitly designed to protect the poor. Today, the Islamic Republic of Iran faces several challenges to maintaining these achievements in a changing environment. The country’s epidemiological profile has changed, partly as a consequence of the success of the strategy led by primary care. The major burden of disease is attributable to noncommunicable diseases and injuries, though there are some differences between richer and poorer provinces. Urbanization is increasing, with an associated change in lifestyle. The private health sector is increasing. Clinical case management is often not as evidence-based as it could be. A recent study on health financing demonstrated that the financing system is not as equitable as had been thought: out-of-pocket payments are high, and the poor are less well protected from catastrophic health expenditures than they were previously. The government is moving to respond to these new challenges. It is already beginning to reorient the primary health care activities delivered in health houses. Technical guidelines for interventions and training for different cadres of health worker are being reviewed as part of an effort to improve quality of care. There are discussions about a common benefit package, what it should include and by whom it should be provided; specifically, how to involve private providers more effectively in the delivery of critical interventions, both preventive and curative, for example through contracting. The different insurance schemes are being reviewed within a broader analysis of overall health system financing, and there are debates about what sort of organizational arrangements within the public sector would enhance the quality and efficiency of public providers
The World Health Report 2003 ortant gains, for example in immunization coverage and child mortality reduction, but were at odds with the comprehensive vision of primary health care developed at Alma-Ata, notably its emphasis on tackling the socioeconomic determinants of ill-health. In the 1990s, the World Bank recommended a set of core public health interventions and a package of essential clinical services influenced by primary health care models, though critics questioned whether these strategies responded adequately to the messages of equity and community tion delivered at Alm Originally, primary health care and the health-for-all movement represented an effort to change practices and structures in the health sector based on population health criteria. Subsequent health sector reform efforts have often been steered by criteria largely extrinsic to health(for xample, broad commitments to decentralization or civil service reform, or the need to re- duce government spending). Reaffirmation of primary health care principles by global health stakeholders signals a recognition of the need to return to population health criteria as the basis for decisions affecting how health care services are organized, paid for and delivered. Principles in a systems perspective This report reinforces an important conceptual shift towards the model of health systems based on primary health care. In a systems perspective, the potential conflict between pri- mary health care as a discrete level of care and as an overall approach to responsive, equitable health service provision can be reconciled. This shift emphasizes that primary health care is integrated into a larger whole, and its principles will inform and guide the functioning of the em A health system based on primary health care will build on the Alma-Ata principles of equity, universal access, community participation, nd intersectoral approaches take account of broader population health issues, reflecting and reinforcing public health functions: create the conditions for effective provision of services to poor and excluded groups organize integrated and seamless care, linking prevention, acute care and chronic care across all components of the health system continuously evaluate and strive to improve performance. Intervention across the disease continuum is needed to achieve the comprehensive care en visaged by such a system. To deal with the increasing burden of chronic diseases, both noncommunicable and communicable, requires upstream health promotion and disease pre- vention in the community as well as downstream disease management within health care services. Two integrated health care models, the chronic care model and its extension-WHO innovative care for chronic conditions framework- promote primary health care concepts intersectoral partnerships, community participation and seamless population-based care Evidence supports the use of these integrated models as a means of implementing primary health care principles, with demonstrated reduction in health care costs, lower use of health care services, and improved health status(6-9) ded Hiviaids treatment and health challenge. No blueprint exists, but valuable examples are emerging. Since May 2001, Medecins Sans Frontieres has provided antiretroviral therapy for HIVIAIDS through primary health care centres in the township of Khayelitsha, South Africa(10). The delivery of HIV/AIDS treatment in a primary health care setting underscores the potential for integration of differ ent types of care and begins to show how scaling up treatment could fit into-and help drive
108 The World Health Report 2003 important gains, for example in immunization coverage and child mortality reduction, but were at odds with the comprehensive vision of primary health care developed at Alma-Ata, notably its emphasis on tackling the socioeconomic determinants of ill-health. In the 1990s, the World Bank recommended a set of core public health interventions and a package of essential clinical services influenced by primary health care models, though critics questioned whether these strategies responded adequately to the messages of equity and community participation delivered at Alma-Ata (5). Originally, primary health care and the health-for-all movement represented an effort to change practices and structures in the health sector based on population health criteria. Subsequent health sector reform efforts have often been steered by criteria largely extrinsic to health (for example, broad commitments to decentralization or civil service reform, or the need to reduce government spending). Reaffirmation of primary health care principles by global health stakeholders signals a recognition of the need to return to population health criteria as the basis for decisions affecting how health care services are organized, paid for and delivered. Principles in a systems perspective This report reinforces an important conceptual shift towards the model of health systems based on primary health care. In a systems perspective, the potential conflict between primary health care as a discrete level of care and as an overall approach to responsive, equitable health service provision can be reconciled. This shift emphasizes that primary health care is integrated into a larger whole, and its principles will inform and guide the functioning of the overall system. A health system based on primary health care will: – build on the Alma-Ata principles of equity, universal access, community participation, and intersectoral approaches; – take account of broader population health issues, reflecting and reinforcing public health functions; – create the conditions for effective provision of services to poor and excluded groups; – organize integrated and seamless care, linking prevention, acute care and chronic care across all components of the health system; – continuously evaluate and strive to improve performance. Intervention across the disease continuum is needed to achieve the comprehensive care envisaged by such a system. To deal with the increasing burden of chronic diseases, both noncommunicable and communicable, requires upstream health promotion and disease prevention in the community as well as downstream disease management within health care services. Two integrated health care models, the chronic care model and its extension – WHO’s innovative care for chronic conditions framework – promote primary health care concepts: intersectoral partnerships, community participation and seamless population-based care. Evidence supports the use of these integrated models as a means of implementing primary health care principles, with demonstrated reduction in health care costs, lower use of health care services, and improved health status (6–9). Linking expanded HIV/AIDS treatment and health care systems development is a crucial challenge. No blueprint exists, but valuable examples are emerging. Since May 2001, Médecins Sans Frontières has provided antiretroviral therapy for HIV/AIDS through primary health care centres in the township of Khayelitsha, South Africa (10). The delivery of HIV/AIDS treatment in a primary health care setting underscores the potential for integration of different types of care and begins to show how scaling up treatment could fit into – and help drive
Health Systems: principled integrated care an overall strengthening of health care systems based on primary health care principles The Khayelitsha antiretroviral programme uses a nurse-based service model and relies on strong community mobilization for peer support. It has shown that HIV/AIDS treatment can be rolled out most effectively if: the entire health system is mobilized and HIviaIdS treatment activities are integrated into the basic package of care; treatment services are decentralized to ensure coverage and community involvement; treatment and care are part of a continuum of care" supported by a facility-linked home- based care system and a referral system. The additional resources that must flow into countries'health sectors to support HIV/AIDS control efforts, including 3 by 5", can be used in ways that will strengthen health systems horizontally. Developing context-specific strategies to achieve this will be part of WHO technical collaboration with countries. Similarly, if the recommendations of the Commis sion on Macroeconomics and Health for large increases in global investment in health are followed by the international community, the coming years will offer a crucial opportunity for development of health systems that are led by primary health care. Enormous obstacles to the scale-up of health systems based on primary health care persist In some countries, violent conflicts and other emergencies have seriously damaged health sys- tems(see Box 7.3). Multiple forms of inefficiency undermine systems, such as government health expenditure disproportionately devoted to tertiary care and programmes that do not focus on a significant burden of disease(11). Lack of financial resources remains a funda- mental problem. Total health expenditure is still less than US$ 15 per capita in almost 20% of Box 7.3 Rebuilding Iraqs health sector The Gulf War of 1991 and the economic sanctions marked the start of undertake essential public health functions; lack of a package of health the decline of a health care delivery system that had been a model for services that includes catastrophic care in the event of emergency and the region during the 1980s Health indicators dropped to levels com- diagnostic and laboratory facilities; external brain drain of human re- arable to some of the least developed countries: in 1996, infant, child, sources: lack of an information system for informed decisions at the and maternal mortality rates were estimated at 100/1000, 120/1000, policy and implementation levels; inadequate finandal resources and and 300/100 000 live births, respectively, a twofold increase over 1990 unclear mechanisms for smooth flow of funds to meet the investment levels. The Oil for Food programme brought a relative improvement of and operational costs of the system; and the need for improved coordi the health of Iraqi people, although still far from pre-1990 levels. Health nation among all stakeholders in health to optimize donated resources. outcomes are now among the poorest in the region nior staff from the Ministry of Health, officials from the Coali. aq is below the regional average in terms of physicians to popu- tion Provisional Authority, and representatives of organizations of the lation(5.3 doctors per 10 000 population in 2002): there are too many United Nations system, nongovernmental organizations and donors met pecialists but too few primary health doctors and nurses. Following the in Baghdad in August 2003 to determine immediate and medium-term 2003 war, the health infrastructure, which had suffered from years of priorities to enable the health sector to provide health services that are disrepair, was further weakened by the widespread looting, inadequate accessible, equitable, affordable and of adequate quality electricity and water supply, and institutional instability. Re-establishing the functioning of the health sector to pre-war The pre-2003 war health system was hospital-based and driven levels requires funds for salaries and other priority recurrent expendi by curative care, and did not respond adequately to health needs. The ture. It is estimated that lraq's financial requirements for health services challenge for Iraqi policy-makers and the donor community is to in 2004-from government and donor sources-will be in the order of inefficient and inadequate health services to a system based on primary and increasing income, the projections for the period 2004-2007 are in care, prevention, and evidence-based policy. The new system should the range of USS 3. 7-7.8 billion, which at the end of the period trans. tackle the disease burden faced by Iraq's people and be affordable within late into a per capita public expenditure of USS 40-84. Forecasting the available envelope of public finance economic performance, fiscal capacity and donors' willingness to sus. Major challenges face the health sector: limited capacity of tain lrag for the period 2004-2007, however, is an exercise fraught the Ministry of Health (and health directorates in governorates)to with difficulties
Health Systems: principled integrated care 109 – an overall strengthening of health care systems based on primary health care principles. The Khayelitsha antiretroviral programme uses a nurse-based service model and relies on strong community mobilization for peer support. It has shown that HIV/AIDS treatment can be rolled out most effectively if: – the entire health system is mobilized and HIV/AIDS treatment activities are integrated into the basic package of care; – treatment services are decentralized to ensure coverage and community involvement; – treatment and care are part of a “continuum of care” supported by a facility-linked homebased care system and a referral system. The additional resources that must flow into countries’ health sectors to support HIV/AIDS control efforts, including “3 by 5”, can be used in ways that will strengthen health systems horizontally. Developing context-specific strategies to achieve this will be part of WHO’s technical collaboration with countries. Similarly, if the recommendations of the Commission on Macroeconomics and Health for large increases in global investment in health are followed by the international community, the coming years will offer a crucial opportunity for development of health systems that are led by primary health care. Enormous obstacles to the scale-up of health systems based on primary health care persist. In some countries, violent conflicts and other emergencies have seriously damaged health systems (see Box 7.3). Multiple forms of inefficiency undermine systems, such as government health expenditure disproportionately devoted to tertiary care and programmes that do not focus on a significant burden of disease (11). Lack of financial resources remains a fundamental problem. Total health expenditure is still less than US$ 15 per capita in almost 20% of Box 7.3 Rebuilding Iraq’s health sector The Gulf War of 1991 and the economic sanctions marked the start of the decline of a health care delivery system that had been a model for the region during the 1980s. Health indicators dropped to levels comparable to some of the least developed countries: in 1996, infant, child, and maternal mortality rates were estimated at 100/1000, 120/1000, and 300/100 000 live births, respectively, a twofold increase over 1990 levels. The Oil for Food programme brought a relative improvement of the health of Iraqi people, although still far from pre-1990 levels. Health outcomes are now among the poorest in the region. Iraq is below the regional average in terms of physicians to population (5.3 doctors per 10 000 population in 2002); there are too many specialists but too few primary health doctors and nurses. Following the 2003 war, the health infrastructure, which had suffered from years of disrepair, was further weakened by the widespread looting, inadequate electricity and water supply, and institutional instability. The pre-2003 war health system was hospital-based and driven by curative care, and did not respond adequately to health needs. The challenge for Iraqi policy-makers and the donor community is to re-establish basic services in the short term while transforming the inefficient and inadequate health services to a system based on primary care, prevention, and evidence-based policy. The new system should tackle the disease burden faced by Iraq’s people and be affordable within the available envelope of public finance. Major challenges face the health sector: limited capacity of the Ministry of Health (and health directorates in governorates) to undertake essential public health functions; lack of a package of health services that includes catastrophic care in the event of emergency and diagnostic and laboratory facilities; external brain drain of human resources; lack of an information system for informed decisions at the policy and implementation levels; inadequate financial resources and unclear mechanisms for smooth flow of funds to meet the investment and operational costs of the system; and the need for improved coordination among all stakeholders in health to optimize donated resources. Senior staff from the Ministry of Health, officials from the Coalition Provisional Authority, and representatives of organizations of the United Nations system, nongovernmental organizations and donors met in Baghdad in August 2003 to determine immediate and medium-term priorities to enable the health sector to provide health services that are accessible, equitable, affordable and of adequate quality. Re-establishing the functioning of the health sector to pre-war levels requires funds for salaries and other priority recurrent expenditure. It is estimated that Iraq’s financial requirements for health services in 2004 – from government and donor sources – will be in the order of US$ 0.8–1.6 billion (or US$ 33–66 per capita). Assuming a sustained and increasing income, the projections for the period 2004–2007 are in the range of US$ 3.7–7.8 billion, which at the end of the period translate into a per capita public expenditure of US$ 40–84. Forecasting economic performance, fiscal capacity and donors’ willingness to sustain Iraq for the period 2004–2007, however, is an exercise fraught with difficulties
110 The World Health Report 2003 WHO Member States. In many countries, especially the poorest, people in need of treatment for themselves or their families still pay for the bulk of health services out of pocke All efforts to improve health care systems in developing countries must confront several main challenges: workforce development and retention; health information management; financ ing; and government stewardship within a pluralistic health landscape. The remaining sec tions of this chapter consider these topics. Systems face difficulties in numerous other areas as well, but all four of these problems demand urgent action in order to scale up the system to meet health targets. If constraints in these areas are not overcome, little progress will be made in improving access to care among the poorest. The global health workforce crisis The most critical issue facing health care systems is the shortage of the people who make them work. Although this crisis is greatest in developing countries, particularly in sub-Saha- ran Africa, it affects all nations. It severely constrains the response to the aIds treatment emergency and the development of health systems driven by primary health care, even as AIDS reduces the available workforce. Botswana's commitment to provide free antiretroviral therapy to all eligible citizens is frustrated, not by financing, but by the severe lack of health personnel(12) Unfortunately, workforce issues are still considered to be relatively unimportant by both national governments and international agencies. Rapid and substantial strengthening of the workforce is urgently required to capitalize on the funds and pharmaceuticals that are The health workforce crisis has to be confronted in an economic and policy environment very different from that of 25 years ago. Traditional models in which the government directly recruits, trains, hires and deploys health professionals no longer reflect the reality of most developing countries. Most countries have undergone decentralization and reforms of the civil service and the health sector. There has been a great expansion in the health care roles of nongovernmental organizations and private providers. Furthermore, all countries are now part of the global marketplace for health professionals, and the effects of the demand-supply imbalance will only increase as trade in health services increases(13). Accordingly, new mod- els for health workforce strengthening must be developed and evaluated (14) Size, composition and distribution of the health workforce The number of health workers in a country is a key indicator of its capacity to scale up deli ery of interventions. This crisis is nowhere greater than in sub-Saharan Africa, where limita tions on staffing are now recognized as a major constraint to achieving national health goals and the MDGs(15). In Chad and the United Republic of Tanzania, for example, the current workforce is grossly insufficient for the extensive delivery of priority interventions(16).Coun tries facing such extreme personnel shortages urgently need a rapid increase in the numbers of health workers to perform key tasks, particularly the delivery of services at community level in underserved areas The number of health workers in a country is not the only determinant of access to primary health care. Figure 7. 1 shows that the number of births at which skilled attendants are present is only partially related to the number of health professionals in a country. Guinea, Indone- The term" health professionals"is defined for the WHO database as including physicians, nurses, midwives, dentists and pharmacists
110 The World Health Report 2003 WHO Member States. In many countries, especially the poorest, people in need of treatment for themselves or their families still pay for the bulk of health services out of pocket. All efforts to improve health care systems in developing countries must confront several main challenges: workforce development and retention; health information management; financing; and government stewardship within a pluralistic health landscape. The remaining sections of this chapter consider these topics. Systems face difficulties in numerous other areas as well, but all four of these problems demand urgent action in order to scale up the system to meet health targets. If constraints in these areas are not overcome, little progress will be made in improving access to care among the poorest. The global health workforce crisis The most critical issue facing health care systems is the shortage of the people who make them work. Although this crisis is greatest in developing countries, particularly in sub-Saharan Africa, it affects all nations. It severely constrains the response to the AIDS treatment emergency and the development of health systems driven by primary health care, even as AIDS reduces the available workforce. Botswana’s commitment to provide free antiretroviral therapy to all eligible citizens is frustrated, not by financing, but by the severe lack of health personnel (12). Unfortunately, workforce issues are still considered to be relatively unimportant by both national governments and international agencies. Rapid and substantial strengthening of the workforce is urgently required to capitalize on the funds and pharmaceuticals that are now available. The health workforce crisis has to be confronted in an economic and policy environment very different from that of 25 years ago. Traditional models in which the government directly recruits, trains, hires and deploys health professionals no longer reflect the reality of most developing countries. Most countries have undergone decentralization and reforms of the civil service and the health sector. There has been a great expansion in the health care roles of nongovernmental organizations and private providers. Furthermore, all countries are now part of the global marketplace for health professionals, and the effects of the demand–supply imbalance will only increase as trade in health services increases (13). Accordingly, new models for health workforce strengthening must be developed and evaluated (14). Size, composition and distribution of the health workforce The number of health workers in a country is a key indicator of its capacity to scale up delivery of interventions. This crisis is nowhere greater than in sub-Saharan Africa, where limitations on staffing are now recognized as a major constraint to achieving national health goals and the MDGs (15). In Chad and the United Republic of Tanzania, for example, the current workforce is grossly insufficient for the extensive delivery of priority interventions (16). Countries facing such extreme personnel shortages urgently need a rapid increase in the numbers of health workers to perform key tasks, particularly the delivery of services at community level in underserved areas. The number of health workers in a country is not the only determinant of access to primary health care. Figure 7.1 shows that the number of births at which skilled attendants are present is only partially related to the number of health professionals in a country.1 Guinea, Indone- 1 The term “health professionals” is defined for the WHO database as including physicians, nurses, midwives, dentists and pharmacists
Health Systems: principled integrated care 11 sia and Paraguay have similar workforce numbers but wide differences in the level of cover age. This is caused by several factors, including the skill mix of health workers, their geo- graphical and functional distribution, and their productivity. These data indicate the importance of using the existing workforce more effectively. Gender discrimination in the health professions has many serious implications for the long term strength of the health care system and especially for the delivery of services to poor and disadvantaged populations. A specific issue concerns the under-representation of women among those who manage and direct services, even though most health care workers are women. For example, in South Africa, men represent only 29% of personnel in administra tion overall, but they occupy 65% of all senior management posts(17). Without proper rep- resentation at the managerial and leadership levels, womens needs as employees within the health system will continue to be neglected. More generally, workforce policy and planning must consider gender and life-cycle issues, not only out of concern for equity, but also to enable efficient and effective development of a health care system that responds to and meets the particular needs of women Workforce training Meeting urgent health challenges while laying stronger foundations for health systems re- quires that health planners consider the composition of the health workforce in terms of training levels and skill categories. In developed countries, experimentation with new cat gories of health worker is a response to cost-containment and quality of care concerns. In developing countries such experimentation is a direct response to limited supply To achieve the goals associated with health care systems driven by primary health care, new options for the education and in-service training of health care workers are required so as to Figure 7.1 Relationship between births accompanied by skilled attendants and number of health professionals, a 33 developing and transition countries ◆ Brazil Namibia 50 Indonesia 30 Guinea ◆ Pakistan Density of physicians, nurses and midwives (per 100 000 population) WHO/UNICEF latest estimates
Health Systems: principled integrated care 111 sia and Paraguay have similar workforce numbers but wide differences in the level of coverage. This is caused by several factors, including the skill mix of health workers, their geographical and functional distribution, and their productivity. These data indicate the importance of using the existing workforce more effectively. Gender discrimination in the health professions has many serious implications for the longterm strength of the health care system and especially for the delivery of services to poor and disadvantaged populations. A specific issue concerns the under-representation of women among those who manage and direct services, even though most health care workers are women. For example, in South Africa, men represent only 29% of personnel in administration overall, but they occupy 65% of all senior management posts (17). Without proper representation at the managerial and leadership levels, women’s needs as employees within the health system will continue to be neglected. More generally, workforce policy and planning must consider gender and life-cycle issues, not only out of concern for equity, but also to enable efficient and effective development of a health care system that responds to and meets the particular needs of women. Workforce training Meeting urgent health challenges while laying stronger foundations for health systems requires that health planners consider the composition of the health workforce in terms of training levels and skill categories. In developed countries, experimentation with new categories of health worker is a response to cost-containment and quality of care concerns. In developing countries such experimentation is a direct response to limited supply. To achieve the goals associated with health care systems driven by primary health care, new options for the education and in-service training of health care workers are required so as to 0 100 200 300 400 500 600 Density of physicians, nurses and midwives (per 100 000 population) Percentage of deliveries assisted by skilled birth attendant aWHO/UNICEF latest estimates. 0 10 20 30 40 50 60 70 80 90 100 Figure 7.1 Relationship between births accompanied by skilled attendants and number of health professionals,a 33 developing and transition countries Nepal Pakistan Guinea Indonesia Paraguay Brazil Namibia Turkey Egypt
112 The World Health Report 2003 ensure a workforce more closely attuned to country needs. Training of students from devel- oping countries at high-prestige institutions in developed countries is useful only when th is no local or regional alternative. Although there are about twice as many nursing schools as medical schools worldwide, in the African Region there are 38 nursing schools and 64 medi- cal schools. This suggests that too many expensive health workers are produced in places that ight have a greater need for new types of providers with an education more focused on primary health care. The public health workforce also needs strengthening, based on a new approach to in-country or regional training that emphasizes the management of health prob- lems at the district level (18) The workforce of doctors is often complemented by training nurse practitioners,assistant nedical officers"and mid-level professionals. These categories are health professionals who can assume many of the responsibilities previously reserved for those with a full medical degree(see Box 7.4). For example, many studies in developed countries show that nurse prac- titioners can reduce the costs of care without harming, and sometimes actually improving, health outcomes(21, 22). In the Pacific Islands, mid-level practitioners, with various titl such as medex, health assistant, or health officer, play an important role in meeting curative and preventive needs, especially in remote or rural areas(23). In other countries, community health workers are trained in very specific and high-priority activities, making it possible to serve populations that are out of the reach of formal health care services. In the past, primary health care strategies based on community health workers or other alter- native health care providers have been difficult to sustain(24). However, evidence suggests that such strategies can be effective, given appropriate training(25, 26). To be successful, the creation of new types of health worker requires that they be valued for their distinctive con tribution, rather than treated as second-class providers. This means offering them career development prospects, rotation to and from rural and underserved areas, good working conditions, the chance to work as a team with other professionals, and an adequate salary. New cadres can be seen not only as a pragmatic response to current shortages, but as a cohort term to their incorporation in the more highly qualified professional categores. Evidences whose skills can be continually upgraded through in-service training, leading in the longe growing that community members can carry out a wide range of health care tasks, including treatment of more complex conditions(10, 25-28) Migration of health workers Policy-makers in all countries are concerned about"brain drain"of the health workforce within and between countries, although relevant research is still in its infancy (29). The move ment of health professionals closely follows the migration pattern of all professionals. while ox 7.4 Training assistant medical officers: the tecnicos of Mozambique In 1984, a three-year programme was initiated to create assistant medi- rty-six assistant medical officers were trained between 1984 and edures in remote areas where consultants were not available(19). The ing For example, a comparison of 1000 r on quality of care is promis. programme trains middle-level health workers in skills required for three conducted by tecnicos de cirurgia with the same number conducted by broad priority areas: pregnancy-related complications, trauma-related obstetricians or gynaecologists indicated that there were no differences complications and emergency inflammatory conditions. Two years of lec. in the outcomes of this type of delivery or in the associated surgical tures and practical sessions in the Maputo Central hospital are followed interventions (20). Many countries have now started or are considering by a one-year internship at a provincial hospital, under the direct super- similar programmes, based on their claimed cost-effectiveness. The vision of a surgeon. potential impact of this type of health worker on both quality and efficiency of health care must continue to be evaluated
112 The World Health Report 2003 ensure a workforce more closely attuned to country needs. Training of students from developing countries at high-prestige institutions in developed countries is useful only when there is no local or regional alternative. Although there are about twice as many nursing schools as medical schools worldwide, in the African Region there are 38 nursing schools and 64 medical schools. This suggests that too many expensive health workers are produced in places that might have a greater need for new types of providers with an education more focused on primary health care. The public health workforce also needs strengthening, based on a new approach to in-country or regional training that emphasizes the management of health problems at the district level (18). The workforce of doctors is often complemented by training nurse practitioners, “assistant medical officers” and mid-level professionals. These categories are health professionals who can assume many of the responsibilities previously reserved for those with a full medical degree (see Box 7.4). For example, many studies in developed countries show that nurse practitioners can reduce the costs of care without harming, and sometimes actually improving, health outcomes (21, 22). In the Pacific Islands, mid-level practitioners, with various titles such as medex, health assistant, or health officer, play an important role in meeting curative and preventive needs, especially in remote or rural areas (23). In other countries, community health workers are trained in very specific and high-priority activities, making it possible to serve populations that are out of the reach of formal health care services. In the past, primary health care strategies based on community health workers or other alternative health care providers have been difficult to sustain (24). However, evidence suggests that such strategies can be effective, given appropriate training (25, 26). To be successful, the creation of new types of health worker requires that they be valued for their distinctive contribution, rather than treated as second-class providers. This means offering them career development prospects, rotation to and from rural and underserved areas, good working conditions, the chance to work as a team with other professionals, and an adequate salary. New cadres can be seen not only as a pragmatic response to current shortages, but as a cohort whose skills can be continually upgraded through in-service training, leading in the longer term to their incorporation in the more highly qualified professional categories. Evidence is growing that community members can carry out a wide range of health care tasks, including treatment of more complex conditions (10, 25–28). Migration of health workers Policy-makers in all countries are concerned about “brain drain” of the health workforce within and between countries, although relevant research is still in its infancy (29). The movement of health professionals closely follows the migration pattern of all professionals. While Box 7.4 Training assistant medical officers: the técnicos of Mozambique In 1984, a three-year programme was initiated to create assistant medical officers (técnicos de cirurgia) to perform fairly advanced surgical procedures in remote areas where consultants were not available (19). The programme trains middle-level health workers in skills required for three broad priority areas: pregnancy-related complications, trauma-related complications and emergency inflammatory conditions. Two years of lectures and practical sessions in the Maputo Central hospital are followed by a one-year internship at a provincial hospital, under the direct supervision of a surgeon. Forty-six assistant medical officers were trained between 1984 and 1999, and the evaluation of their influence on quality of care is promising. For example, a comparison of 1000 consecutive caesarean sections conducted by técnicos de cirurgia with the same number conducted by obstetricians or gynaecologists indicated that there were no differences in the outcomes of this type of delivery or in the associated surgical interventions (20). Many countries have now started or are considering similar programmes, based on their claimed cost-effectiveness. The potential impact of this type of health worker on both quality and efficiency of health care must continue to be evaluated
Health Systems: principled integrated care doctors and nurses make up only a small proportion of professional migrants, their loss weak ns health systems. The internal movement of the workforce to urban areas is common to all countries within a region, there is also movement from poorer to richer countries, for example from Zambia to South Africa or from the United Republic of Tanzania to Botswana. The most controversial brain drain"is international professional migration from poorer to wealthier countries(30) While the departure of doctors receives the most attention, it is the departure of nurses and other health professionals that can easily cripple a health system. Nurses are in high demand in developed countries, partly because of population ageing. Some efforts have been made to promote ethical practices in international recruitment, but results have yet to be assessed (31) Workforce mobility creates additional imbalances just when increased financial resources are beginning to flow to some developing countries. This requires better workforce planning developed countries, attention to issues of pay and other rewards in developing countries, and improved management of the workforce in all countries Paying more and paying differently Raising wages may increase the number of health workers and their productivity and may succeed in countries where health workers are paid less than comparable professions. It may be less successful, however, in countries where health sector wages are higher than those of comparable professions. Wages take the single largest share of health expenditure, so increases have to be carefully evaluated for their impact both on the availability and productivity of health workers and on aggregate budgets. The role of public sector unions in negotiating with governments for pay increases is an additional complexity As well as raising salaries, other strategies to improve productivity include non-financial ben efits such as housing, electricity and telephones, on-the-job training with professional super- vision,and opportunities for rotation and promotion. In rural Senegal, providing nurses with motorcycles not only made it possible to increase immunization coverage but also im- proved their access to technical support and reduced their isolation(32) Both financial and non-financial incentives can also reduce geographical imbalances in the distribution of health workers. For example, in Indonesia, a bonus of as much as 100% of the normal salary attracted medical graduates from Jakarta to the outer islands(33). Recruit ment and training of people from remote areas, who are committed to their region of origin have also been proposed. Finally, nongovernmental organizations concerned with health and private providers are a large and increasing presence in most countries Governments could consider partnerships in which the public sector provides financial support and the nongovernmental organiza tions manage and provide the direct services. Often, private health workers are available in places that the public sector finds difficult to reach. In such situations, establishing formal programmes either to contract private providers or to reimburse the services they provide may be the most pragmatic response. In the mid-1990s, the Government of Guatemala was obliged to expand health care services to unserved populations as part of the negotiated peace agreements that took place at the time It contracted more than 100 nongovernmental or ganizations to provide basic health care services to some 3 million of the country's citizens, predominantly indigenous and rural people, who previously had no access to services(34) Recently, Cambodia has successfully experimented with contracting nongovernmental ganizations and private providers to deliver basic services to underserved groups(35)
Health Systems: principled integrated care 113 doctors and nurses make up only a small proportion of professional migrants, their loss weakens health systems. The internal movement of the workforce to urban areas is common to all countries. Within a region, there is also movement from poorer to richer countries, for example from Zambia to South Africa or from the United Republic of Tanzania to Botswana. The most controversial “brain drain” is international professional migration from poorer to wealthier countries (30). While the departure of doctors receives the most attention, it is the departure of nurses and other health professionals that can easily cripple a health system. Nurses are in high demand in developed countries, partly because of population ageing. Some efforts have been made to promote ethical practices in international recruitment, but results have yet to be assessed (31). Workforce mobility creates additional imbalances just when increased financial resources are beginning to flow to some developing countries. This requires better workforce planning in developed countries, attention to issues of pay and other rewards in developing countries, and improved management of the workforce in all countries. Paying more and paying differently Raising wages may increase the number of health workers and their productivity and may succeed in countries where health workers are paid less than comparable professions. It may be less successful, however, in countries where health sector wages are higher than those of comparable professions. Wages take the single largest share of health expenditure, so increases have to be carefully evaluated for their impact both on the availability and productivity of health workers and on aggregate budgets. The role of public sector unions in negotiating with governments for pay increases is an additional complexity. As well as raising salaries, other strategies to improve productivity include non-financial benefits such as housing, electricity and telephones, on-the-job training with professional supervision, and opportunities for rotation and promotion. In rural Senegal, providing nurses with motorcycles not only made it possible to increase immunization coverage but also improved their access to technical support and reduced their isolation (32). Both financial and non-financial incentives can also reduce geographical imbalances in the distribution of health workers. For example, in Indonesia, a bonus of as much as 100% of the normal salary attracted medical graduates from Jakarta to the outer islands (33). Recruitment and training of people from remote areas, who are committed to their region of origin, have also been proposed. Finally, nongovernmental organizations concerned with health and private providers are a large and increasing presence in most countries. Governments could consider partnerships in which the public sector provides financial support and the nongovernmental organizations manage and provide the direct services. Often, private health workers are available in places that the public sector finds difficult to reach. In such situations, establishing formal programmes either to contract private providers or to reimburse the services they provide may be the most pragmatic response. In the mid-1990s, the Government of Guatemala was obliged to expand health care services to unserved populations as part of the negotiated peace agreements that took place at the time. It contracted more than 100 nongovernmental organizations to provide basic health care services to some 3 million of the country’s citizens, predominantly indigenous and rural people, who previously had no access to services (34). Recently, Cambodia has successfully experimented with contracting nongovernmental organizations and private providers to deliver basic services to underserved groups (35)