1 Introduction
1. The enjoyment of the highest attainable standard
of health is an end in itself and, according to the World Health
Organization (WHO) constitution, a basic human right.[1]
A healthy population is also fundamental to societal development
and economic growth.[2]
Recent years have seen some rapid improvements in health outcomes
in developing countries: malaria incidence and the number of new
cases of HIV have each fallen by around one-third since the turn
of the century and the global child mortality rate has halved
since 1990.[3] Nevertheless,
there is widespread concern that many developing country health
systems remain weak. The UK Department for International Development
(DFID) argues that, though outcomes can be improved rapidly in
the short run through disease-specific "vertical" interventions,
health system strengthening (HSS)[4]
is essential for long-term efficiency, sustainability and, ultimately,
a future without aid. [5]
Box 1: Vertical and horizontal
Health interventions that seek to target particular
diseases, such as HIV or malaria, or population groups, such as
mothers or young children, are sometimes known as "vertical"
programmes. They can be crudely distinguished from "horizontal"
programmes, which aim to achieve better health outcomes by making
improvements across all conditions or population groups, often
through strengthening underlying health systems. In reality, many
programmes include both vertical and horizontal elements.
2. A global United Nations survey in 2013 found that
better healthcare ranked second behind education as the highest
public priority. In Africa, improved healthcare was the single
most important concern.[6]
A good health system delivers high quality services when and where
people need them. The public expect a healthy environment, with
access to clean water and nutritious food, information about how
to stay healthy, preventative care such as immunisation, local
access to advice and basic treatment, a system of referral to
more specialist care and provision for emergencies. They can reasonably
expect such services to be provided regardless of their social
background, without resulting in impoverishment and preferably
free at the point of use, and taking into account their preferences
about their care.[7]
3. We were told that HSS was now of particular importance
because the "quick wins" from scaling up vertical interventions
in major communicable diseases and child and maternal health have
largely been exhausted.[8]
Furthermore, system strengthening was required to maximise the
impact of unprecedented recent investment in areas such as tackling
neglected tropical diseases.[9]
Other witnesses stressed that HSS was essential to tackling growing
and persistent issues such as non-communicable diseases (NCDs),
ageing populations, mental health, conflict-affected regions and
under-provision in rural areas and urban slums.[10]
4. The devastating ongoing Ebola epidemic in West
Africa has served to emphasise the importance of establishing
strong health systems. The developing, but impressive, health
system we saw on our recent visit to Liberia has been completely
overwhelmed and DFID has recently committed extra funds to support
health systems in the region.[11]
The apparent hesitancy and lack of coordination in the international
response suggest that the global health system and emergency plans
have failed.[12] We will
publish a separate Report on Recovery and Development in Sierra
Leone and Liberia shortly.[13]
5. DFID has a long-held reputation as a world-leader
in HSS, and we heard praise for its current approach.[14]
However, concerns were expressed that a targetdriven mentality
has precluded sufficient focus on HSS and that a lack of information
has made evaluating HSS work difficult, especially where DFID
funds are channelled through multilaterals.[15]
These issues are considered in chapters 2 and 3. In chapter 4,
we examine DFID's performance in supporting improvements in important
components of health systems such as workforces, governance and
system finance. Chapter 5 assesses whether better use of the UK's
domestic health expertise could be made in international development.
Finally, we heard calls for DFID to show greater global leadership
on HSS and we consider these issues in chapter 6.
6. We received a substantial volume of informative
written evidence. We also took oral evidence from four panels
of HSS experts, including representatives of academia, NGOs, multilateral
organisations, the NHS and DFID. We are very grateful to everyone
who contributed. Our evidence focused on areas of key concern
in what was a broad topic for a short inquiry. This Report does
likewise.
1 World Health Organization, Constitution of the World Health Organization,
October 2006, p1 Back
2
DFID, Health position paper: delivering health results, July
2013, pp4-5 Back
3
World Health Organization Factsheet 290, Millennium Development Goals (MDGs),
May 2014 Back
4
The World Health Organization defines health systems strengthening
as "[i] the process of identifying and implementing the changes
in policy and practice in a country's health system, so that the
country can respond better to its health and health system challenges;
[ii] any array of initiatives and strategies that improves one
or more of the functions of the health system and that leads to
better health through improvements in access, coverage, quality,
or efficiency". See http://www.who.int/healthsystems/hss_glossary/en/. Back
5
HSS19 [DFID] Back
6
United Nations, My World, the United Nations Global survey for a better world: summary of results,
March 2013 Back
7
World Health Organization Factsheet, Key components of a well-functioning health system,
May 2010 Back
8
Q2 [Dr David Evans] Back
9
HSS40 [UK Coalition against Neglected Tropical Diseases] and
HSS37 [Sightsavers] Back
10
HSS44 [Dr Julian Lob-Levyt], HSS32 [Age International and HelpAge International],
HSS14 [Programme for Improving Mental Health Care [PRIME] University of Cape Town,
HSS35 [International Committee of the Red Cross], HSS19 [DFID]
and HSS45 [Dr David Evans] Back
11
DFID press release, Britain to extend assistance to combat Ebola in West Africa,
18 August 2014 Back
12
Financial Times, 19 August 2014, MSF criticises global response to Ebola crisis,
by William Wallis Back
13
International Development Committee, Sixth Report of Session
2014-15, Recovery and Development in Sierra Leone and Liberia,
forthcoming Back
14
HSS7 [London School of Hygiene and Tropical Medicine] Back
15
For example HSS2 [NICE International]. Along with other donors,
DFID channels a proportion of aid through international bodies
for use in or on behalf of aid recipient countries. These, including
large international funds such as the Global Fund to Fight AIDS,
Tuberculosis and Malaria, are abbreviated to "multilaterals"
in this Report. Aid channelled through multilaterals is regarded
as bilateral where DFID specifies the use and destination of the
funds Back
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