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 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’s 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 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 com￾parable 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 popu￾lation (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 re￾sources; 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 coordi￾nation among all stakeholders in health to optimize donated resources. Senior staff from the Ministry of Health, officials from the Coali￾tion 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 expendi￾ture. 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 trans￾late into a per capita public expenditure of US$ 40–84. Forecasting economic performance, fiscal capacity and donors’ willingness to sus￾tain Iraq for the period 2004–2007, however, is an exercise fraught with difficulties