March 2001 Insights Health Issue #1

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Taking the strain
The challenge for health systems

While developing countries continue to battle against infectious diseases, they now face an increasing burden from NCDs. How can health systems deal with this additional strain?

Health sector reforms over the last decade have included decentralisation, enhanced private sector involvement and alternative forms of funding. However, reforms are often:

• insensitive to local contexts

• donor-driven

• focused on health service efficiency rather than wider health objectives

• slowly or poorly implemented.

The latest WHO World Health Report promotes a health systems approach to overcome these limitations. The UK Nuffield Institute for Health is involved in programmes to strengthen health systems in various countries and is co-ordinating research into the strategic planning capacity of Health Ministries in Eritrea, Mozambique and Zimbabwe. Previous exploratory research in seven countries underlines the significance of the broader policy processes of health sector reform. Lessons learnt from these various activities suggest that policy-makers need to consider several important issues.

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Predicting epidemiological patterns

Gathering accurate health statistics is difficult. Understandably, information systems tend to focus on communicable diseases and may fail to capture the national picture. Basic weaknesses in data from studies of the disease burden may limit their usefulness. Fragmentation, privatisation and decentralisation of health systems also complicate data collection.

Setting priorities

It is too simplistic to portray this as a choice between communicable and non-communicable diseases. Priorities will include a mix of both and will depend on the assessment methods used. Cost-effectiveness analyses are influenced by the outcome measures chosen. For example, composite indicators, such as Disability Adjusted Life Years (DALYs), go beyond simple measures of mortality to include disabling conditions.

Future funding

Few countries are likely to see a significant increase in their national health budget. However, recovering costs through user charges can affect equity of access to care. Chronic NCDs, such as diabetes, pose particular problems for funding.

System boundaries

How feasible are interventions for NCDs? Previous reforms have been criticised for focusing on services rather than wider health issues. Long-term control of many NCDs requires preventative activities outside the normal health ministry role. The WHO Tobacco Free Initiative has highlighted the importance of extending boundaries beyond individuals to wider socio-economic factors. Health promotion strategies for NCDs will involve non-health service features such as environmental factors, diet and stress-reduction. This extended role for health systems will have consequences for policy development, advocacy and resource allocation.

Private sector role

Competition-based reforms in the 1990s encouraged the growth of the private health sector. Although these services are often of poor quality and limited to urban areas, they have important implications for the design of NCD interventions. Health planners must address issues such as referral procedures, human resource development and regulatory tools in the private sector. The tobacco, alcohol, food and other industries will also require regulation.

Policy-making capacity

Experience has shown that Health Ministries may lack the authority, skilled personnel, and structures and processes for strategic policy-making. Recent reforms may even have weakened this capacity. Policy-making processes could be strengthened by:

• developing wider policy-making and implementation tools for prioritisation, resource allocation, regulation and capacity assessment

• developing and supplying a wide range of skills to policy-makers, ranging from epidemiology through economics to political science

• assessing the implications of new strategies, using techniques such as stakeholder analysis and political mapping

• employing the knowledge and alternative perspectives of NCD specialists

• incorporating broader input from stakeholders, such as representatives of NGOs, other sectors and professional groups, to ensure that new policies are well-grounded.

Andrew Green and Charles Collins
Nuffield Institute for Health
University of Leeds
71-75 Clarendon Rd
Leeds
LS2 9PL
UK
T: +44 (0)113 233 6953
F: +44 (0)113 246 0899
a.t.green@leeds.ac.uk
c.d.collins@leeds.ac.uk

See also
Health sector reform and the interpretation of policy context, Health Policy 47 by C. Collins, A. Green and D. Hunter (1999)
World Health Report 2000, WHO, Geneva (2000)