3.3 Health policies in developing countries
Oxford Textbook of Public Health
Health policies in developing countries
Adetokunbo O. Lucas
Epidemics and other emergencies
Major challenges and issues
Health reform: special emphasis on structural reform/decentralization
Tools for policy-making
Financing health care
International organizations and foreign donors
At the close of the twentieth century, health policy-makers and practitioners in developing countries were approaching the future with cautious optimism. The enormous health gains in past decades have generated the expectation of continuing progress in the coming years. Lessons learnt from the application of existing knowledge and the promise of new health technologies raise hopes of further improvements in health as shown by declining mortality, increased expectation of life, and control of major endemic diseases (Table 1 and Fig. 1). This optimism is tempered by the threats posed by the emergence of new diseases and the continuing pressures on the health sector to meet the rapidly escalating costs of health services (WHO 1999). Although much progress has been made in the past few decades, many people in developing countries still do not have access to essential health care (Fig. 2).
Table 1 Under-5 mortality rates (U5MR) in 1996 in 104 countries with under-5 mortality rates of 50 and above in 1960
Fig. 1 The distribution of under-5 mortality rates in 1996 in 104 countries with under-5 mortality rates of 50 per 1000 live births and above in 1960.
Fig. 2 Access to selected elements of primary health care, developing countries 1983 to 1985 and 1991 to 1993.
Although developing countries have some features in common, there is considerable variation within the group with regard to the health situation and each country’s capacity to deal with them. Economic growth in the more advanced developing countries have secured relatively large resources as compared with the least developed countries such that there is a 20-fold difference in national income as measured by gross domestic product between the most affluent developing countries and the poorest nations. Institutional capacity and human resources show the same diversity among developing countries. Although the health systems of these nations share some features, it is difficult to make generalizations that apply equally to all of these countries. One common feature is the large gap between the health needs and demands of the population, and the available resources. Whilst the least developed countries are still struggling to provide basic health services, the more advanced countries are endeavouring to meet the rising expectations and demands of their population for the most up-to-date high technology diagnostic tools and treatments. Much of the debate on health policy in developing countries revolves around this central issue of making the best use of limited resources in environments in which there is a wide gap between needs and resources, expectations and performance.
The process of policy-making for the health sector has become increasingly intricate. Health practitioners, policy-makers, and planners have to contend with three main issues: diversity, complexity, and change.
There is often great diversity within countries, as well as between and within different geographical areas. Ecological and geographical factors account for some of the variation in the pattern of distribution of health and disease but economic, social, and cultural determinants also contribute to the diversity. The association of poverty with poor health status is a consistent finding in both developed and developing countries.
The explosion of new knowledge and innovative health technologies have markedly increased the complexity of health care. The expanding scope of prophylactic, diagnostic, and therapeutic options demands an increasing range of specific programmes with the associated need for specialist personnel, new categories of support staff, high-technology equipment, and infrastructure. Figure 3 illustrates the complex interaction of medical and non-medical factors that are involved in perpetuating the high maternal mortality rates occurring in the developing world. It also offers clues as to the package of interventions that are required to reduce maternal mortality (Box 1) (McCarthy and Maine 1992). The complex interaction of medical and non-medical factors in the dynamics of health and disease calls for a critical analysis of needs and opportunities as the basis of designing and managing health programmes. Rather than blindly attempting to deliver standardized prepackaged stereotyped interventions, health authorities should try to match the services to suit local needs. To complement medical inputs from the health sector it is necessary to mobilize intersectoral action because of the important influence of non-medical factors on health, such as:
agriculture (food security and nutrition)
education (especially women’s education)
waterworks and sanitation
labour and industry (health of workers, pollution).
Fig. 3 The complex interaction of factors involved in the epidemiology of maternal mortality. (Source: McCarthy and Maine 1992.)
Box 1 Prevention of maternal mortality
Half a million or more women die each year from complications of pregnancy and childbirth
Most of these deaths occur in developing countries
The clinical causes of the deaths are well known and are amenable to treatment These deaths occur against the background of intermediate and remote causes as illustrated in Fig. 3
The prevention of maternal mortality must ultimately address all these issues but the interventions must be ranked in an appropriate order of priority and designed to suit the local circumstances
In countries with very high maternal mortality rates, the highest priority should be assigned to improving emergency obstetric care; other interventions will include reduction of exposure to high-risk and unwanted pregnancies by the provision of family planning services, safe abortion, training and supervision of traditional birth attendants, and improvement of other aspects of maternal health services
Source: McCarthy and Maine (1992); McCarthy (1997).
Policy-making in developing countries has to be fluid and dynamic to adapt strategies and programmes to the many changes that are occurring in the environment.
As in developed countries, developing countries are undergoing epidemiological transition. The traditional health problems, such as childhood diseases and communicable diseases, are declining, whilst chronic diseases, such as cancers, cardiovascular diseases, diabetes, etc., are becoming increasingly prominent causes of morbidity and mortality. Many developing countries present a mixed picture with the persistence of infectious diseases compounded by malnutrition and the emergence of chronic diseases especially among the urban élite (Frenk et al. 1989). However, there is the constant threat of the emergence of new infections and the re-emergence of old diseases that were previously controlled, as shown respectively by the recent examples of HIV/AIDS and tuberculosis (Institute of Medicine 1992).
Epidemics and other emergencies
In addition to this slowly evolving epidemiological transition, more rapid changes occur in the form of epidemics and other acute problems, for example natural disasters (floods, drought, etc.).
Changes in the economic and social situation in the country may have a profound effect on the health sector. Health policies have had to be modified in the light of rapid development in some countries and economic recession in others. In the immediate post-Second World War era, macroeconomic policies emphasizing central planning and welfare programmes gained popularity. This trend has been reversed in recent decades, with national policies increasingly favouring free-market economy in place of welfare programmes and central control. These changes have important implications with regard to policies in health and other social sectors.
Major challenges and issues
Policy-making in the health sector of developing countries involves many complex problems. This chapter highlights seven critical issues:
health reform with special emphasis on structural reform and decentralization;
tools for policy-making—assessment of burden of disease, cost-effectiveness, and health accounts;
financing health care—cost recovery schemes, user fees, and private insurance;
public–private partnerships in the delivery and financing of health care and in drug policy;
international agencies such as the World Health Organization (WHO), the World Bank, the United Nations International Children’s Emergency Fund (UNICEF), and bilateral donor agencies;
equity in health.
Health reform: special emphasis on structural reform/decentralization
The rapid advances in health technologies, the increasing demands and expectations of populations, and the escalating costs of health care are challenging governments in both developed and developing countries. Governments are responding to these dramatic changes and the associated challenges by undertaking reforms of the health sector. In order to meet the needs and demands of their populations, they are redesigning mechanisms for delivering care and paying for the services (World Bank 1993).
Health reform has been defined as ‘sustained purposeful change to improve efficiency, equity and effectiveness of the health sector’ (Berman 1995). The decentralization of the planning and management of health services is a common feature of these reforms. Governments cannot efficiently manage the delivery of health care in large countries with dispersed populations. In a decentralized system, the central Ministry of Health can set national goals and targets, whilst devolving the responsibility for detailed management of the services to peripheral authorities—provincial, state, municipal, and local governments.
Models of decentralization
The exact details of decentralization vary from country to country. Although the idea of decentralization of health services has gained favour in recent years, there is no consensus on the ideal pattern for allocating functions, and sharing and dividing power, between the various levels of government. Some of the variations relate to the type of government (federal or unitary), but other factors, such as the size of country, political systems, and other variables, influence decisions about decentralization. A simple model considers the management of health services at three levels:
primary health care through community level services and local referral hospitals
provincial or state level co-ordinating services in defined geographical parts of the country
setting up a ministry of health at central government level.
Decentralization involves allocating functions to provincial and local governments as well as defining their relationships with each other and with the central government.
Primary health care
The responsibility for community health care is usually devolved to local or municipal governments. In developed countries, primary health care is largely doctor based with the support of nurses and other paramedical staff; the aim is to provide comprehensive health care and associated social services through community-based facilities and referral hospitals.
In developing countries, the package of services that are delivered at this level were formerly labelled as ‘basic health services’ but were further refined into the eight elements of primary health care as defined at the Alma-Ata Conference (WHO 1978) including at least the following items:
immunization against major infectious diseases
education concerning prevailing health conditions
promotion of food supply and proper nutrition
adequate supply of safe water and basic sanitation
maternal and child health care including family planning
appropriate treatment of common diseases and injuries
prevention and control of locally endemic diseases
provision of essential drugs.
This list has been further elaborated to make more explicit items that were not clearly expressed such as family planning and reproductive health with maternal and child health, and the promotion of mental health.
The usual pattern of primary health care is a network of community-based services with appropriate back-up from referral hospitals which deal with difficult problems that cannot be effectively handled at health centres and other community-based facilities. In the least developed countries, nurses and other ancillary staff play an important part at the primary health care level. Regardless of the specialties of the primary health care services, two common issues often arise:
the extent to which local government has the authority to define local policy and strategies for health care
the degree to which local communities are involved in decision-making.
There are sharply divergent views regarding the autonomy of local authorities in shaping the health services. At one end of the spectrum, the WHO proposes integrated health care at the district level involving all health-care providers, both public and private, and all health systems, whether they are modern, traditional, orthodox, or non-orthodox. This model defines the district as the smallest planning unit for health care, involving community-based services through health centres and other institutions providing ambulatory care as well as the referral hospital (WHO 1987). The WHO model is inclusive and involves collaboration of all stakeholders: the public sector represented by the local government, the private sector (both for profit and non-profit), traditional healers, and other representatives of civil society. The hope is that the consensus that emerges from the interaction of these stakeholders would lead to the development of realistic health programmes that are culturally sensitive, financially sustainable, and capable of growth and expansion as the community develops (Tarimo 1991).
Some critics, who regard the WHO’s approach as being too broad and therefore unrealistic, proposed an alternative strategy that aims at delivering a limited number of interventions of proven efficacy and cost-effectiveness, for example immunization and mass chemotherapy for some endemic infections (Walsh and Warren 1979; Warren 1988). UNICEF’s GOBI-FFF plan and the World Bank’s clinical and public health packages are examples of proposed cost-effective interventions (Box 2), which include measures on growth monitoring, oral dehydration, breast feeding, immunization (GOBI), family planning, female education, and supplementary feeding of pregnant women (FFF).
Box 2 Cost-effective public health and clinical packages recommended by the World Bank (World Bank Report 1993)
Public health package
The expanded programme on immunization, including micronutrients (iron, vitamin A, and iodine) supplementation
School health programmes to treat worm infections and micronutrient deficiencies and to promote health education
Programmes to increase public knowledge about family planning and nutrition, about self-care or indications for seeking care, and about vector control and disease surveillance activities
Programmes to reduce consumption of tobacco, alcohol, and other drugs; and AIDS prevention programmes with a strong sexually transmitted disease component
Prenatal and delivery care
Family planning services
Treatment of tuberculosis
Case management of sexually transmitted diseases
Rather than grant local authorities the right to define local priorities and strategies, this selective primary health care programme would require each community to conform to a centrally determined national programme, which is made up of a limited list of well-defined specific interventions. There is some danger that selective primary health care would merely recreate vertical programmes in which practitioners in the field would be required to implement prepackaged interventions blindly. An acceptable compromise would be to develop primary health care systematically using elements of UNICEF’s GOBI-FFF plan, the World Bank’s clinical and public health packages, and similar cost-effective interventions as building blocks of primary health care whilst retaining local flexibility and decision-making.
Provincial or state level provision
In federal states, health services are usually devolved to provincial authorities, which serve an intermediate role between the central government and the local health authorities; they develop regional policies and programmes in the context of the overall national policy and plans. They support, supervise, and co-ordinate the local health services and they provide services such as specialist hospitals that cannot be replicated in individual local government areas. Again, the question arises over the extent to which provincial health departments have the authority to undertake independent action in designing the services, and how they relate to the private sector and the civil society in drawing up their strategies and plans.
Central government provision
In a decentralized health service, the central government retains certain key functions, which may include the following:
setting national goals and targets
establishment of standards
accreditation of training programmes
registration of drugs
national disease surveillance
provision of highly specialized services including research
emergency response to natural disasters and major epidemics
Formal protocols define the official relationships of the various health authorities but, ideally, the interactions should represent mutual support towards the achievement of the common goal.
Making decentralization work
Decentralization of health services is a common feature of the reform process that many countries are currently undertaking. Other elements in the reform package may include a variety of structural changes, new mechanisms for financing health care, redefined relationships with the private sector, and other policy changes. There is also much variation in the structure of decentralized services but regardless of the specific details, certain important issues need to be addressed as follows:
professional and technical capacity
other health-related sectors
relationship with other health-care providers.
In federal states, constitutional authority may provide provincial governments with higher degrees of autonomy than is given to regional health authorities in unitary states. Provincial and local health authorities in unitary states may have the responsibility of implementing services under the direction of the central government with little authority to make changes in the programmes.
Decentralization of health services is generally accompanied by resource flows from the central government to peripheral authorities. The subvention from the central government may represent the bulk of the resources available to the local health authority but some authorities supplement central funds with revenue derived from local taxes and user fees. In general, local authorities that can raise funds through taxation and/or can retain revenue derived from user fees tend to have more autonomy in making decisions and fine tuning health policies to suit local needs.
Up-to-date information is an essential tool for the management of health services for identifying needs, designing services, and for monitoring performance as well as changes in health status (Rosen 1999). Ideally, the data should be disaggregated by the standard demographic indicators—age, sex, and marital status—but also by variables that may be relevant locally, for example ethnic group, race, religion, etc.
Professional and technical capacity
Local professional and technical capacity is an important issue in decentralized health systems. In order for the devolved services to function efficiently, the peripheral health authorities must have appropriate capacity for planning, implementing, and monitoring services. In particular, they must be able to gather and analyse relevant data as the basis for decision-making and monitoring. Many developing countries are in the process of building such capacity that is available in long established local authorities of developed countries. In any event, even in the most advanced countries, the resources of regional authorities and central government are sometimes required to fill the gaps in local capacity.
Other health-care providers
In addition to the public sector, private providers, both for profit as well as non-profit agencies, are involved in health care. In developing countries, traditional healers still play a prominent role and as in developed countries, practitioners of alternative medicine are also increasingly popular. Local health services relate vertically to regional and central authorities, which provide support for supplementing local capacity both for dealing with emergencies as well as for long-term interventions. They must interact horizontally with other local health authorities especially those that serve neighbouring areas. By sharing information, they can reinforce their programmes by learning from each other and they can also achieve economies of scale by sharing resources.
Other health-related sectors
The well-known effects of socio-economic and environmental factors on health dictate the need for intersectoral action. National policies in such sectors as education, agriculture, welfare, and environment are translated into action through provincial and local authorities. Decentralization of these health-related sectors would facilitate interaction with their colleagues in the health sector.
Tools for policy-making
Previously, policy-making in developing countries was largely determined by the dictates of influential experts rather than by objective analysis. In the immediate postindependence period, some developing countries copy models of health services in developed countries with particular emphasis on the construction of large tertiary hospitals. The high cost of maintaining such establishments often distort the national health budget leaving very little resources for supporting less expensive but highly effective community-based services. Because of severe resource constraints, developing countries should set clear priorities, and adopt policies that would help to achieve maximum improvement in health in return for minimum expenditure.
It was relatively easy to establish priority lists in the traditional epidemiological situation where a few major conditions, mainly acute infectious diseases, accounted for a high proportion of deaths. In such situations, it was possible to rank priorities by considering the mortality rates from specific acute infectious diseases or the prevalence of chronic disabling diseases like onchocerciasis (river blindness). As major epidemic and endemic conditions come under control, the process of priority setting has become more complex. The increasing pressure on policy-makers to base their decisions on sound evidence has led them to use three new types of tools:
measurement of ‘burden of disease’
assessment of the cost-effectiveness of interventions
analysis of national health accounts.
Burden of disease
Objective decisions in setting priorities require measurements of the impact of individual conditions and risk factors, and their amenability to control. What is required is an index that would summarize the impact of specific health problems in terms of disease, disability, and premature death. Early attempts to develop a summary index were based on the calculation of the number of useful days of life lost from premature death (mortality) and from disability (morbidity) (Ghana Health Assessment Project Team 1981). This approach was further refined to a new measure, the disability-adjusted life year (DALY) which combines losses from death and disability but also makes allowance for:
a discount rate, so that future years of healthy life are valued at progressively lower level)
age weights, so that years lost at different ages are given different values (Murray 1994a,c).
The WHO and the World Bank collaborated in a venture to measure the global burden of disease (Murray and Lopez 1996). Individual countries are being encouraged to measure their national burden of disease. Measurement of burden of disease using DALYs is proving a valuable tool but is rather a complex operation, particularly difficult in developing countries that lack reliable data about the frequency and distribution of various health problems. In such situations, estimates of DALYs are based on extrapolations from limited studies and rough approximations. However, attempts to calculate the national burden of disease draw attention to gaps in information that can be filled by improvements in the national health information systems. The DALY is proving a useful tool but more work is required to refine and simplify it (Morrow and Bryant 1995; Hyder et al. 1998) (Table 2).
Table 2 Global pattern of burden of disease in countries by income
The DALY is used to:
rank diseases and conditions by the burden of disease;
estimate the cost-effectiveness of interventions by comparing the cost of averting a DALY.
Cost-effectiveness analysis enable policy-makers to compare different interventions for the same condition and select the interventions that give the largest gain in DALYs per unit cost (Murray 1994a). It also allows comparison of diseases and conditions by the availability of cost-effective interventions. It may provide clues on how modifications of interventions could make them more cost-effective.
National health accounts
Previously, policy-makers concentrated mainly on spending within the public sector, ignoring private spending through insurance, corporate arrangements, employees’ schemes, and out-of-pocket expenditure. Health economists now obtain a more comprehensive view of health expenditures by compiling national health accounts. These analyses attempt to obtain an overview of health spending from all sources—public and private, corporate and personal—into comprehensive health accounts. The results affect the choices made within the public sector but also influence the public role in providing guidelines to the private sector and communities on the most cost-effective uses of their personal expenditure. The basic analysis consists of a matrix of elements as follows:
the columns of the matrix list all sources of health spending—both public sources (taxation and national social insurance) and private sources including employment-based schemes, privately financed insurance, and out-of-pocket expenditure;
the rows of the matrix show the distribution of expenditure for personal health care, public health and environmental sanitation services, and administration.
Disaggregating the items in the columns and rows generates more elaborate analyses, providing more detailed information about sources and spending. Thus, the analyses could show variations over time, by geography, by population subgroups, or any other variable that is relevant to policy-making (Berman 1997).
Financing health care
The wide margin between the public resources for health and the demands and expectations of the population is a common challenge to health authorities in developing countries. Governments should ensure that there is an adequate level of financing from public and private sources to develop and sustain the essential components of the health services. In some of the more advanced developing countries which have enjoyed economic boom in recent years, the health services have grown and are meeting many of the public demands. In the poorer nations, especially those that have experienced marked economic decline, there is increasing pressure on public spending for health and other social sectors. Macroeconomic policies advocated by the International Monetary Fund and other funding agencies have forced many governments to trim public spending on health and to reassess the allocation of their limited resources.
Under these circumstances, policy-makers are exploring approaches to increase the resources available for health, allocate the limited resources to target priority conditions and groups, and promote equity. Specifically, governments are endeavouring to:
develop income-generating schemes
promote supplementary sources of finance, for example privately financed insurance schemes.
In the least developed countries, it is critically important to increase the financial resources if the health sector is to provide basic essential services. In the more advanced middle-income countries, the main issue is how to organize and manage a prepay system that is efficient and fair. In the high-income developing countries, the absolute quantity of funds is not the critical factor, rather it is often a question of using resources in the most cost-effective manner and promoting equity.
Many countries that previously offered health services at no cost or at highly subsidized rates are now imposing fees on users at the point of delivery. The aim is to generate additional income for use by the public sector, to enable the public sector to redistribute resources in favour of the poor, and to achieve increasing self-reliance for sustainable community health programmes.
Mobilizing additional resources for health
The main objective of user fees is to generate resources that can be used to expand the quantity and improve the quality of health services. These schemes are designed not only to recover some of the costs involved in providing the services but also to focus public resources on top priorities. In favour of user fees is the observation that free health services selectively subsidize the more affluent members of society. This is particularly true for curative services in hospitals. The share of hospitals in total public recurrent expenditure in many developing countries ranges from 40 to 80 per cent, but only a small unrepresentative section of the population, the urban élite, benefits directly from these hospital services (Barnum and Kutzin 1993) (Fig. 4).
Fig. 4 The share of hospitals in total public recurrent expenditure.
Redistribution of resources
User charges enable the public sector to reallocate the resources by withdrawing subsidies from those who can afford to pay and redirecting the savings to expand cost-effective public health services to the poor. The imposition of charges is based on the evidence from studies on health accounts that people already spend a considerable amount of private resources in paying for health care (Shaw and Griffin 1995).
User fees have also been designed to promote self-reliance and make community health programmes sustainable. At the primary health care level, this manifests as charges for medications with a small profit margin that can be used to support local health services (Gbedonou et al. 1994; Diallo et al. 1996; Anderson 1998).
The imposition of user fees remains a contentious issue. The advocates of this policy claim that it is a progressive measure that promotes equity. Their analyses suggest that the public sector can derive additional revenue from clients who are willing and able to pay. The additional income can be used to improve the quality of services and to subsidize poor people who are exempted from payment (World Bank 1994; Shaw and Griffin 1995). Noting the sharp decline in the utilization of services when user fees are introduced, other workers regard such schemes as a regressive policy that further widens the gap between the rich and the poor (Ekwempu et al. 1990). Some of the concerns about equity can be met by carefully designed exemptions for certain people and for specific services.
Many lessons are being learnt in the development of these schemes. People seem more willing to pay if they perceive an improvement in the quality of services. Local institutions can deliver these improved services if they are able to retain some of the income generated from user fees. A major challenge is the administration of cost recovery schemes and the management of services to reflect the increased income.
Risk sharing through privately financed health insurance
The promotion of self-financed insurance schemes is a complementary policy; it is designed to make it easier for those who can afford to pay to share the risk, thereby protecting individuals and families against the effects of catastrophic illness or accident. The availability of personal insurance schemes facilitates the operation of cost recovery schemes in hospitals. Private insurance schemes would also promote the development of the private providers of hospital and other health services thereby reducing the pressure on public institutions.
In summary, the policy direction for financing health care in many developing countries is to ensure that those who can afford to pay cover health costs from their own resources. This enables the public sector to focus resources on top priority health issues and to target selectively the needs of the poor.
The crisis in the health sector has induced governments in many developing countries to review the relationship of the public sector to the private sector. Specifically, policy-makers are exploring mechanisms to promote complementary involvement of the private sector in particular with regard to the delivery of health care and the provision of medical supplies. The WHO now strongly supports the promotion of public–private partnerships with the caveat that such partnerships should be mutually beneficial and must always benefit health (WHO 1998a,b).
Public–private partnerships in health-care delivery
The non-profit private sector—non-governmental organizations and religious-based medical missions—provides a variety of health services; often they target populations that are poorly served by the public sector and people with special needs such as leprosy and HIV/AIDS. Such services usually have the reputation of being very efficient; they are highly appreciated by the public who would use the fee-based services from non-governmental organizations in preference to the free services offered by the public sector.
Another important source of health care are employment-related health schemes which provide health care for workers and their families. The employer may finance the cost of care by reimbursing their workers’ medical expenses, or they may provide health care through company-based services or by contracting such services from private providers.
Relationships of the public sector with the for-profit private services have been more tentative but are now being encouraged. Now that many governments have abandoned the goal of providing comprehensive health care to the entire population, new policy directions favour the promotion of the private sector as providers of curative services to affluent sections of the population. For those who receive care from the private sector, the role of the government is to protect public interest by regulating the services and setting minimal standards for care. The fostering of private health insurance schemes facilitates the growth of the private sector by enhancing the ability to pay private providers.
Drugs and supplies
Drugs, vaccines, and other supplies take up a high proportion of public resources in the health services of developing countries. The WHO and other international agencies are assisting governments to improve their drug policies, and the procurement and management of pharmaceuticals through essential drug programmes. The goal is to ensure reliable availability of consistent supplies of basic remedies so that health institutions can consistently deliver cost-effective treatments. In collaboration with industry, governments are encouraged to select a list of the most cost-effective medicaments using inexpensive generic products as far as possible (WHO 1998b).
The high cost of some new drugs and vaccines limits the access of developing countries. For example, poor developing countries cannot afford to provide the expensive triple therapy for the management of HIV/AIDS nor can they introduce the Haemophilus influenzae and hepatitis B vaccines into their routine immunization programmes. New international initiatives, such as the Global Alliance for Vaccines and Immunization, aim to assist poor countries to have access to vaccines.
Previously, policy-making was based largely on intuitive opinions of experts but were not always backed by sound knowledge and objective analysis. There is now increasing pressure to make decisions on the basis of sound scientific knowledge. Evidence-based decision-making requires that relevant information be collected and analysed, and that essential research be conducted to elucidate issues.
Developing countries are paying increasing attention to the role of research in policy-making. Following the report of an independent Commission for Health Research for Development (1990), developing countries are being encouraged to improve the management of health research in support of their health services. The Commission recommended that each country should adopt the principles of Essential National Health Research as a strategy for planning, prioritizing, and managing national health research. The goal of Essential National Health Research is health development on the basis of social justice and equity; its content is the full range of biomedical and clinical research, as well as epidemiological, social, and economic studies (Table 3). Its mode of operation is inclusiveness, involving all stakeholders—research scientists, policy-makers and programme managers, and other representatives of civil society (Task Force on Health Research for Development 1991).
Table 3 A simple classification of health research
At the global level, there is concern that market-driven research and development effort largely ignores the needs of the poor. Only 10 per cent of 50 to 60 billion American dollars that is spent every year for health research is used for research on the health problems of 90 per cent of the world’s people. A new entity, the Global Forum for Health Research (1999) has drawn attention to the ’10/90′ disequilibrium, and in collaboration with the WHO, the World Bank, private foundations, the pharmaceutical industry, non-governmental organizations, and other stakeholders, is seeking solutions to the problem. The central objective of the Global Forum is to help correct the 10/90 gap and focus research efforts on diseases representing the heaviest burden on the world’s health, by improving the allocation of research funds and by facilitating the collaboration among partners both in the public and private sectors. One of the initiatives of the Forum is the Alliance for Health Policy and Systems Research. Following on studies initiated by the Ad Hoc Committee on Health Research Relating to Future Intervention Options (1996), the Global Forum is developing analytical tools for defining priorities for global health research. The Ad Hoc Committee introduced a five-step process in priority setting for health research as follows (Table 4).
Table 4 A practical framework for setting priorities in health research
What is the burden of the disease/risk factor?
Why does the burden of disease persist? What are the determinants?
What is the present level of knowledge?
How cost-effective could future interventions be?
What are the resource flows for that disease/risk factor?
The research priorities are also derived from an analysis of the relative share of the burden that can or cannot be averted with existing technologies (Fig. 5):
averted with current mix of interventions and population coverage
avertable with improved efficiency
avertable with existing but not cost-effective interventions
cannot be averted with existing interventions.
Fig. 5 Analysing the burden of a health problem to identify research needs. (Sources: Barnum and Kutzin 1993; Ad Hoc Committee on Health Research Relating to Future Intervention Options 1996.)
International organizations and foreign donors
The WHO is recognized as the leading agency for health within the United Nations system. In recent years, other international agencies have increased their involvement in the health sector. UNICEF, through its child survival programme, provides massive input into the health sector often in collaboration with the WHO. Other United Nations agencies like the United Nations Fund for Population Action, the International Labour Organization, and the Food and Agricultural Organization have relevant programmes involving specific aspects of the health sector. Through its lending programme, the World Bank has now become the largest source of external finance for the health sector and has stimulated countries to develop more efficient and cost-effective health programmes.
Generally, these external agencies operate independently of each other but there have been some attempts at co-ordination and collaboration. UNICEF and the WHO have established mechanisms of collaboration including such formal mechanisms as the Task Force for Child Survival. The WHO also sometimes executes health programmes on behalf of other external agencies. A more ambitious attempt at interagency collaboration is the United Nations AIDS programme; six United Nations agencies jointly manage this programme for the global control of the HIV/AIDS epidemic.
A number of bilateral donor agencies have also expanded their involvement in the health sector. Some of these aid agencies now fund and support health programmes as part of their development assistance programme. The bilateral programmes vary considerably in their content, duration, and interaction with other external agencies. Some of them narrowly focus on the specific interest of the donor countries, for example family planning. There is, however, a new move to achieve more effective co-ordination of external aid through the mechanism of sectorwide expenditure planning. The idea is to develop a national programme, based on national priorities and funded from national resources supplemented by donor aid. All participating donors subscribe to the national plan and contribute their donation to a common basket.
The existing gross inequality in the health status of the people particularly between developed and developing countries as well as within countries is politically, socially and economically unacceptable and is, therefore, of common concern to all countries.
Declaration of Alma-Ata (WHO 1978)
Although equity in health is intuitively understood to reflect a sense of fairness and justice, the term is used to refer to related but non-identical concepts covering three main issues:
health status of families, communities, and population groups
allocation of resources
access to and utilization of services.
Inequalities in health status occur commonly and are regarded as prima-facie evidence of inequities in the health-care system. Significant inequalities in health status are found even in the most affluent developed countries, with long traditions of national health services that are designed to provide universal coverage. (Black et al. 1998; Pollock 1999). A consistent finding is the strong association between poverty and poor health status as defined by such indicators as the expectation of life, the incidence of acute diseases and injuries, and the prevalence of chronic diseases and disabilities (Gwatkin 2000). This consistent association of poverty with poor health strengthens the case in favour of programmes for the alleviation of poverty as important strategies for health promotion.
Allocation of resources
Equity is also examined in terms of the allocation of resources to different sections of the population. On moral and ethical grounds, the objective of allocative equity is for public resources to be shared out in a fair manner (Taipale 1999). The simplest formula would be a uniform per capita allocation. However, if large differences in health status already exist, an equal allocation would tend to perpetuate the inequalities. It can be argued that it is the responsibility of governments to perform a redistributive function by allocating resources from the more affluent sector of society to meet the needs of lower-income individuals and families, so-called ‘vertical equity’.
Access and utilization
Another view of equity is that everyone should have an equal opportunity of receiving care. This so-called ‘horizontal equity’ proposes that individuals in like situations should be treated in like manner. Access is often defined in terms of the availability of services and its geographical coverage but experience has shown that the potential access, that is the services are within geographical range, does not necessarily correspond to real access as measured by the utilization of services.
Marked disparities are often found in the geographical distribution of health facilities: between regions, between urban and rural areas, between rural areas, and within urban areas (Phillips 1990). The differential ratios of people per facility—hospital beds, nurses, and doctors—are used to measure the disparities. The distribution of health centres and other institutions in relation to the population—how far people have to travel to reach such facilities—are also used to indicate the uneven distribution of resources.
Optimization of equity
Optimization of equity requires conscious attention to a number of important issues:
allocation of resources
monitoring of equity.
The political commitment of the government is the essential basis for promoting equity in health (Feachem 2000). The objective of equity in health fits well with the political philosophy in welfare states that have the clear goal of providing universal coverage of comprehensive health care for the entire population from birth to death. In such countries, the question is not whether the state should embrace equity in health but how to achieve this goal in practice. The situation is more difficult where the political outlook is dominated by free-market ideas, individual entrepreneurship, and market forces.
Political commitment is also required to correct the inequities that result from discrimination on the basis of gender, race, ethnic group, and religion. Often, inequalities in health status reflect the marginalization of disadvantaged groups (Brockerhoff and Hewett 2000).
The plight of indigenous populations in the Americas and Australasia is a special case. There is much variation in the commitment of the national governments to promoting equal socio-economic and political status to the indigenous populations. In extreme cases, erosion of their human rights borders on genocide.
In weighing policy options, a good guideline would be to examine critically the expected impact of the selected option on equity. The formulation of health policies has to contend with a variety of pressures including the increasing demands of populations for more services, the desire to achieve maximal improvement in health of the populations served, and the need to contain costs. Reforms of the health sector aim at improving efficiency, effectiveness, cost-effectiveness, and equity. It is not always easy to reconcile these goals. For example, the delivery of care to the populations in remote areas is relatively expensive and less cost-effective than services to dense urban areas. However, in the interest of equity, health services should reach the underserved populations even in remote settings.
The impact of macroeconomic policies on health also deserves attention. For example, under pressure from the international finance agencies, some developing countries undertook Structural Adjustment Programmes and markedly reduced public investment in health and other social sectors. UNICEF and other agencies drew attention to the negative impact of the Structural Adjustment Programme on the health of children. In future, careful analysis and relevant research would be used to design macroeconomic policies that would not harm the health of vulnerable groups.
There is increasing recognition of the role of health policy and health systems research in identifying and solving problems on the planning and operation of health services. The Global Forum for Health Research, a new independent entity, focuses specifically on promoting health research with particular reference to the problems that affect the poor.
Allocation of resources
One aspect of equity is that the government should allocate financial resources fairly to the entire population. A simple demographic formula that allocates funds simply on population size may need to be adjusted to take note of the special needs of particular regions; otherwise, the uniform allocation may tend to perpetuate inequalities. Another source of inequity is the degree to which local authorities can raise additional funds through taxation and by retaining user fees. Again, the fact that the more affluent areas are able to raise much larger funds than the poorer areas may tend to widen the gap in the quantity and quality of health care.
Within the health budget, there is the difficult task of allocating resources to the needs of the various groups within the community (Castro-Leal et al. 2000; Makinen et al. 2000). With finite resources, even the most affluent nations have to accept limits to the services that the public sector can provide. Hence rationing is an inevitable feature of health planning. In the interests of equity and social justice, if economies have to be made, the burden should be fairly shared among various sectors of the community. Quantitative estimates of burden of disease and of the cost-effectiveness of various interventions help to rationalize the selection of priorities (Murray 1994a,b,c; Hyder et al. 1998). But a point is reached at which difficult choices cannot be made solely on the basis of objective measurements. At this stage, the debate must include philosophical and ethical considerations about the value of human life (Morrow and Bryant 1995).
The profound effects of socio-economic circumstances on health have been widely recognized. Social stratification as variously defined is also a prominent risk factor for ill health, reflecting the combined effects of income, education, and culture. The association between poverty and poor health is a consistent finding. The poor die young (Table 5) and their disease profile is largely dominated by communicable diseases, maternal and perinatal conditions, and nutritional deficiencies (Table 6). In developed countries, not only are they are at higher risk from the diseases of the poor but they also suffer more from the lifestyle health problems that are prominent in affluent communities—cancer, coronary heart disease, etc. Furthermore, with the increasing emphasis on free-market economy, the gap between rich and poor is widening. Improved quantity and quality of health care is necessary but not sufficient to correct and prevent inequities in health status associated with poverty and social deprivation.
Table 5 Comparing some health indicators of the poor versus the better off in selected countries
Table 6 Distribution of deaths by cause in different population groups (1990)
Discrimination against females is a global phenomenon but it varies in its intensity in different parts of the world. It extends through the entire lifecycle, ranging from selective abortion of females, discrimination in quality of health care for infants and children, access to education, and salary differentials based on gender. Discriminatory practices have direct and indirect effects on the health of women. It is often an underlying or aggravating factor in the frequency, severity, and outcome of some specific health problems. For example, poverty is a common cause of malnutrition in women in some parts of the world; not only does it predispose them to anaemia and other health problems but it also limits their access to health care. A common finding is the association between female education and various health indicators for themselves and their children (Cleland and Van Ginneken 1989; Harrison 1997).
The health sector must provide the leadership for mobilizing intersectoral action to achieve these three objectives:
policies and programmes to alleviate poverty and social deprivation
ensuring that people have the basic requirements for maintaining good health—food, safe and adequate water supply, sanitation, and housing
guaranteeing access to affordable health care.
Decentralized health services need to devise mechanisms for obtaining informed opinions from the whole community through credible representatives of civil society. The involvement of communities in decisions that affect their health care is widely recommended: it does not often work effectively in practice. Even in developed countries, the communities are often unable to participate effectively in decision-making because:
authorities may not consult them
they lack relevant information
the society may not be well organized.
Lack of consultation Health officials often make key decisions about health care with minimal consultation with the public. Decisions about priorities for allocation of resources are often handed down without informed participation of the client communities.
Lack of information The public often lack information that would enable them to make informed judgements about health-care issues. Often this is because the technical information and their significance are not presented in language that would inform the lay public. Occasionally, there is deliberate suppression of information by government officials, for example there is a tendency to cover up information about outbreaks of infectious diseases like cholera, HIV/AIDS, etc. Some governments invoke Official Secrets Acts and claims about sovereign rights and national security to justify their suppression of health information. Access to health information should be recognized as a human right (Lucas 1992).
Lack of effective organization of society Even in developed countries where the lay public is relatively sophisticated, the civil society is poorly organized with regard to health issues. Public opinion about health is often stage managed by vociferous single-issue lobbyists and by sensational reports in the tabloid press. In modern societies, a variety of special groups maintain watching briefs on specific issues of interest to them—cruelty to animals or to children, protection of the environment, of wildlife, of birds, etc. Such groups collect and disseminate information, lobby governments, and engage in advocacy. Health care does not usually attract such strong lobbies from the lay public. The public response tends to be ad hoc and episodic rather than being well considered and systematic. Furthermore, there is usually no effective leadership and representation of the civil society to provide credible representation of the public. When consultations take place, the powerful elite, the politically influential, and other privileged groups tend to dominate the debate drowning the quieter voices of the poor, the disadvantaged, and marginalized groups.
In order to design services that are equitable and to monitor performance of health services, each health authority needs an appropriate management information system which must include measuring inequalities in health status and inequities in access to health care. The data-collecting instruments must be designed to take note of groups and subgroups especially vulnerable groups whose access to services is restricted by geographical, economic, social, and cultural factors. It should include the usual demographic indicators of age, sex, and marital status, as well as socio-economic indicators like race, ethnic origin, occupation, residence, and other social variables (Rosen 1999).
Special studies aimed at probing aspects of the operation of the health services with particular reference to the issue of equity, can usefully supplement routinely collected data. The studies should be designed not only to inform the debate on specific issues but also to provide clues about feasible solutions to the identified problems (Gakidou et al. 2000; Wagstaff 2000).
Monitoring and evaluation
The health system should include mechanisms for monitoring equity objectively. Interest in measuring equity has generated some useful tools and some valuable experience is accumulating. In the first instance, monitoring equity is the responsibility of health authorities at each level of care. They must build into their service sensitive indicators that would inform them of their performance with regard to equity and access to care.
In addition to such internal processes, it would be valuable to commission independent reviews of equity within the health system by groups outside the health departments. Another option would be to assign responsibility for a national equity watch to a local non-governmental organization.
With its strong commitment to this goal of equity and its accumulated knowledge and experience, the WHO may provide useful guidance to the national programme. Because some of the issues involved are politically sensitive, many governments would not welcome the direct involvement of external agencies in the review process.
The design and management of efficient health systems is one of the main challenges for developing countries in this century. The vast amount of information accumulated in recent decades provides valuable guidance to policy-makers. Not only must policy-making be knowledge based it must also be result oriented. Careful planning and skilled management can achieve good results even where financial resources are limited. The countries that have achieved good health at low cost challenge other countries to adapt and adopt relevant aspects of their policies. It is a painful irony that millions of children in developing countries are dying of diseases that can be controlled with simple, affordable interventions. Policy-makers must give high priority to strategies that will eliminate the major items of the unfinished agenda that still plague many developing countries. Many lives can be saved and much disability prevented by simple measures like boosting immunization programmes, ensuring access to adequate supplies of safe water and good sanitation, providing effective treatment for common childhood ailments, and ensuring skilled care during childbirth including emergency obstetric care. More daunting tasks include the pandemic of HIV/AIDS that is ravaging parts of the developing world but experience has shown that some progress can be made through the application of social and behavioural interventions without necessarily relying on expensive drugs or waiting for the promise of vaccines.
Ad Hoc Committee on Health Research Relating to Future Intervention Options (1996). Investing in health research and development. WHO, Geneva.
Andersen, E. (1998). Establishment of drug chests in commune health stations in Vietnam, Bamako Initiative.South-east Asian Journal of Tropical Medicine and Public Health, 29, 628–35.
Barnum, H. and Kutzin, J. (1993). Public hospitals in developing countries: resource use, cost, and financing. Johns Hopkins University Press, Baltimore, MD.
Berman, P.A. (ed.) (1995). Health sector reform in developing countries: making health development sustainable. Harvard University Press, Cambridge, MA.
Berman, P.A. (1997). National health accounts in developing countries: appropriate methods and recent applications. Health Economics, 6, 11–30.
Black, D., Morris, J.N., Smith, C., and Townsend, P. (1998). Better benefits for health: plan to implement the central recommendation of the Acheson Report. British Medical Journal, 318, 724–7.
Brockerhoff, M. and Hewett, P. (2000). Inequality of child mortality among ethnic groups in sub-Saharan Africa.Bulletin of the World Health Organization,78, 30–41.
Castro-Leal, F., Dayton, J., Demery, L., and Mehra, K. (2000). Public spending on health care in Africa: do the poor benefit?Bulletin of the World Health Organization, 78, 66–74.
Cleland, J. and Van Ginneken, J. (1989). Maternal schooling and childhood mortality.Journal of Biosocial Science, Supplement 10, 13–34.
Commission For Health Research For Development (1990).Health research: essential link to equity in development. Oxford University Press, New York.
Diallo, I., McKeown, S., and Wone, I. (1996). Bamako boost for primary care. World Health Forum, 17, 382–5.
Ekwempu, C.C., Maine, D., Olorukoba, M.B., Essien, E.S., and Kisseka, M.N. (1990). Structural adjustment and health in Africa. Lancet, 336, 56–7.
Feachem, R.G.A. (2000). Poverty and inequity: a proper focus for the new century. Bulletin of the World Health Organization, 78, 1.
Frenk, J., Bobadilla, J.-I., Sepulveda, J., and Lopez-Cervantes, M. (1989). Health transition in middle-income countries: new challenges for health care. Health Policy and Planning, 4, 29–39.
Gakidou, E.E., Murray, C.J.L., and Frenk, J. (2000). Defining and measuring health inequality: an approach based on the distribution of health expectancy. Bulletin of the World Health Organization, 78, 42–54.
Gbedonou, P., Moussa, Y., Floury, B., Josse, R., Ndiaye, J.M., and Diallo, S. (1994). The Bamako initiative: hope or illusion? Observations on the Benin experience. Sante, 4, 281–8.
Ghana Health Assessment Project Team (1981). A quantitative method of assessing the health impact of different diseases in less developed countries. International Journal of Epidemiology, 10, 73–80.
Global Forum for Health Research (1999). The 10/90 report on health research. Global Forum for Health Research, Geneva.
Gwatkin, D.R. (2000). Critical reflection: health inequalities and the health of the poor: what do we know? What can we do?Bulletin of the World Health Organization, 78, 3–18.
Harrison, K. (1997). The importance of the educated healthy woman in Africa.Lancet, 349, 588.
Hyder, A.A., Rotllant, G., and Morrow, R.H. (1998) Measuring the burden of disease: healthy life-years. American Journal of Public Health, 88, 196–202.
Institute of Medicine (1992). Emerging infections: microbial threats to health in the United States. National Academy Press, Washington, DC.
Lucas, A.O. (1992). Public access to health information as a human right. Proceedings of the International Symposium on Public Health Surveillance. Morbidity and Mortality Weekly Report, 41, 77–8.
McCarthy, J. (1997). The conceptual framework of the PMM network.International Journal of Gynecology and Obstetrics, 59 (Supplement 2), S15–22.
McCarthy, J. and Maine, D. (1992). A framework for analyzing the determinants of maternal mortality.Studies in Family Planning, 23, 23–33.
Makinen, M., Waters, H., Rauch, M., et al. (2000). Inequalities in health care use and expenditures: empirical data from eight developing countries and countries in transition.Bulletin of the World Health Organization, 78, 55–65.
Morrow, R.H. and Bryant, J. (1995). Health policy approaches to measuring and valuing human life: conceptual and ethical issues.American Journal of Public Health, 85, 1356–60.
Murray, C.J. (1994a). Cost-effectiveness analysis and policy choices: investing in health systems. Bulletin of the World Health Organization, 72, 663–74.
Murray, C.J. (1994b). National health expenditures: a global analysis. Bulletin of the World Health Organization, 72, 623–37.
Murray, C.J. (1994c). Quantifying the burden of disease: the technical basis for disability-adjusted life years. Bulletin of the World Health Organization, 72, 429–45.
Murray, C.J.L. and Lopez, A.D. (ed.) (1996). The global burden of disease. A comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020. Global Burden of Disease and Injury Series, Vol. I. Harvard School of Public Health on behalf of the World Health Organization and the World Bank, Cambridge, MA.
Phillips, D.R. (1990). Health and health care in the third world. Longmans, Harlow.
Pollock, A.M. (1999). Devolution and health: challenges to Scotland and Wales. British Medical Journal, 319, 94–8.
Rosen, M. (1999). Data needs in studies on equity in health and access to care––ethical considerations.Acta Oncologica, 38, 71–5.
Shaw, R.P. and Griffin, C.P. (1995). Financing health care in sub-Saharan Africa through user fees and insurance. World Bank, Washington, DC.
Taipale, V. (1999). Ethics and allocation of health resources—the influence of poverty on health. Acta Oncologica, 38, 51–5.
Tarimo, E. (1991). Organizing and manging district health systems based on primary health care. WHO, Geneva.
Task Force on Health Research for Development (1991). Essential national health research. A strategy for action in health and human development. United Nations Development Programme, Geneva.
UNICEF (1999). The state of the world’s children 1998. UNICEF/Oxford University Press.
Wagstaff, A. (2000). Socioeconomic inequalities in child mortality: comparisons across nine developing countries. Bulletin of the World Health Organization, 78, 19–29.
Walsh, J.A. and Warren, K.S. (1979). Selective primary health care; an interim strategy for disease control in developing countries.New England Journal of Medicine, 301, 967–74.
Warren, K.S. (1988). Selectivity within primary health care. Social Science and Medicine, 26, 899–902.
WHO (World Health Organization) (1978). Declaration of Alma-Ata. Report of the International Conference on Primary Health Care. Alma-Ata, 6–12 September 1978. WHO, Geneva.
WHO (World Health Organization) (1987). Hospitals and health for all. Report of a WHO Expert Committee on the Role of Hospitals at the First Referral Level. Technical report series No. 744. WHO, Geneva.
WHO (World Health Organization) (1998a). Health for all in the twenty-first century. WHO, Geneva.
WHO (World Health Organization) (1998b). The use of essential drugs. Eighth report of the WHO Expert Committee. Tenth model list of essential drugs. Technical report series, No. 882. WHO, Geneva.
WHO (World Health Organization) (1999). The world health report 1999. Making a difference. WHO, Geneva.
World Bank (1993). World development report 1993: investing in health. Oxford University Press, New York.
World Bank (1994). Better health in Africa: experience and lessons learnt. World Bank, Washington, DC.