The WHO’s Commission on Macroeconomics and Health recommends a large increase in funding for health interventions in poor countries. But money alone is unlikely to be able to address the constraints facing health systems. What factors hamper the widespread implementation of health programmes for the poor and what options are available to tackle them?

A relatively small number of health conditions are responsible for the majority of the burden of ill-health in poor countries. Effective interventions exist to prevent and treat most of these conditions, but these interventions are not available or accessible to the world's poor. A dramatic expansion in access to these priority services is urgently needed.

In choosing how to "scale-up" these interventions, policy-makers must decide which health service delivery strategies to adopt, the sequence of these actions, and the pace at which services can be expanded. These decisions require a clear understanding of the type and depth of constraints that affect a country’s health system. Researchers from the London School of Hygiene and Tropical Medicine developed a framework for understanding these constraints and categorised 84 countries accordingly.

The framework has two dimensions. The first is the level at which a constraint operates, categorised as:

• I – community and household
• II – health services delivery
• III – health sector policy and strategic management
• IV – public policies cutting across sectors
• V – environment and context.

The second dimension is the extent to which increased health sector funding can reduce different constraints. Low level constraints, especially those linked to shortages of resources, are likely to be more susceptible to additional funding than higher level constraints. Money is unlikely to change greatly the governance and policy framework or geographical and climatic constraints.

Researchers classified 84 low-income and sub-Saharan African countries according to their level of constraints using three approaches:

• examination of individual constraints
• two-by-two analysis of health systems and governance variables
• a composite constraints index.

They found that:

• Countries are extremely varied in the constraints they face.
• Countries such as Afghanistan, Mali, Niger and Somalia fall into the lowest quartiles across all variables. China, Cuba, Mongolia, South Africa and Sri Lanka always fall into the highest two quartiles.
• Weak health systems and weak governance coincide most often in poor sub-Saharan countries. Many countries with strong health systems but weak governance are in Eastern Europe and the Former Soviet Union.
• Countries with strong health systems and governance indicators include India and China and some of the wealthier countries.
• Using the combined constraints index, the two most constrained quartiles consist largely of countries in sub-Saharan Africa. The least constrained quartile is dominated by South Asian countries and China.
• There is a strong and significant relationship between mortality levels and the constraints index.

The researchers find some cause for optimism. Despite high levels of poverty, the most constrained countries include only 12 per cent of the total population in low-income countries living on less than a dollar a day. Thus, nearly 90 per cent of the poorest people live in countries where the constraints to scaling up are less severe. However, it will be critical to understand also within country variation, for example between different regions (or indeed Indian states), when considering the best way to expand access to priority health interventions.

Source(s):
‘Expanding access to priority health interventions: a framework for understanding the constraints to scaling-up’, Journal of International Development 15: 1-14, by K. Hanson, K. Ranson, V. Oliveira-Cruz and A. Mills, 2003
‘Constraints to expanding access to health interventions: an empirical analysis and country typology’, Journal of International Development 15: 15-39, by K. Ranson, K. Hanson, V. Oliveira-Cruz and A. Mills, 2003

Funded by: World Health Organisation; University of Lausanne; London School of Hygiene and Tropical Medicine; Bill and Melinda Gates Foundation; World Bank; UK Department for International Development

id21 Research Highlight: 23 April 2003

Further Information:
Kara Hanson
Health Policy Unit
London School of Hygiene and Tropical Medicine
Keppel Street
London WC1E 7HT
UK

Contact the contributor: kara.hanson@lshtm.ac.uk

London School of Hygiene and Tropical Medicine, UK

Kent Ranson
Health Policy Unit
London School of Hygiene and Tropical Medicine
Keppel Street
London WC1E 7HT
UK

Contact the contributor: kent.ranson@lshtm.ac.uk

Commission on Macroeconomics and Health

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'Where there is no regulator' >

'Can it be done? Prospects for improving health of the global poor'

'Economies of scale-up? The cost of expanding access'

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Commission on Macroeconomics and Health