House of Commons - Strengthening Health Systems in Developing Countries

Strengthening Health Systems in Developing Countries - International Development Committee Contents

4 Foundations of strong health systems

40. The WHO has identified six key building blocks of an effective health system: services, workforce, information, commodities, finance and governance.[106] This structure has been criticised as neglecting preventative measures, inter-dependencies between the blocks, and the importance of system-wide processes.[107] The WHO acknowledges that "the building blocks alone do not constitute a system, any more than a pile of bricks constitutes a functioning building".[108] Although DFID endorses the building blocks, it claims to account for such concerns in its work already.[109] The evidence we received on particular elements of health systems focused on governance, finance, workforces, and community and public health.

Governance and finance

GOVERNANCE

41. Our witnesses told us that effective health systems governance comprises efficient and accountable decision-making processes and the creation of incentives to support the achievement of objectives.[110] Dr Kalipso Chalkidou used the example of NICE International assisting the government of India with small changes to health insurance system governance such as improvements in administrative forms, contracts and records of conflicts of interest on decision-making committees. Though these were basic steps, they were "a necessary condition" for creating a more effective system.[111] Dr Dina Balabanova and Professor Martin McKee of the London School of Hygiene and Tropical Medicine told us that, while "there is no simple blueprint for a strong health system", studies of countries that had achieved significant health improvements identified "several critical factors underlying success, all intrinsically related to governance".[112]

42. DFID provided a case study of its governance work in Northern Nigeria, which was intended to address organisational bottlenecks that were hindering the effective functioning of the system. Its interventions included the establishment of State Primary Health Care Boards, providing technical support to the National Primary Health Care Development Agency and facilitating improvements to information systems.[113]

43. Other witnesses told us that DFID had tended to pay insufficient attention to strengthening leadership and governance.[114] NICE International wrote that "messier governance strengthening and institutional capacity-building initiatives", which were often dependent on "local politics and context", tended to be neglected.[115] Dr Kalipso Chalkidou added that DFID's governance work suffered from being "diluted down" through a lack of interest on the part of outcome-focused multilaterals.[116]

44. Improving the governance of decentralised health systems could be particularly problematic.[117] In its recent report on child mortality, ICAI highlighted the risks posed to DFID's HSS work in Kenya by the ongoing process of devolution in that country, which saw 65 per cent of the 2013-14 health budget managed locally. ICAI said that the risk of local authorities failing to spend this money on health was high, and noted the political incentive to prioritise highly visible items, such as hospitals, ambulances and bed net distributions, for funding. ICAI warned that devolution was even more challenging for GAVI and the Global Fund, which rely on government systems and do not have the capacity or presence to engage with local authorities.[118]

45. It can be difficult to quantify the effects of governance programmes and therefore to demonstrate tangible results. We were told that this has contributed to the perceived inadequate expenditure on governance.[119] Dr Andrew Cassels countered that, though DFID tended to communicate the successes its of programmes through health outcomes, debate on the NHS is dominated by discussion of systems indictors such as waiting times or geographical disparities in provision.[120]

FINANCE

46. An effective health financing system raises adequate funds for health, ensuring that people can use services and are not impoverished by paying for them. It also provides incentives for the system to operate more efficiently.[121]

47. Finance and governance are closely related issues: sufficient revenue must be raised to support a health system, and health ministries must make the political case for money to be spent on health and HSS rather than other priorities.[122] DFID described health systems finance as "essentially a very political issue".[123] Dr Fiona Samuels of the Overseas Development Institute (ODI) and Dr Dina Balabanova of the London School of Hygeine and Tropical Medicine told us that:

124

48. We heard concerns that generous disease-specific development financing has promoted a culture of reliance on donors.[125] This hypothesis is supported by poor progress by most African governments on the target, set out in the 2001 Abuja Declaration, to spend at least 15 per cent of annual government budgets on health. Of 50 African Union countries for which WHO data are available, just six met the target in 2012.[126]

49. Domestic investment in the health sector can yield positive results. Rwanda, the country in Africa with the highest proportion of government expenditure allocated to health, has seen significant improvements in health outcomes and has been making progress towards self-sustainability by focusing on strengthening its health system and investing in health professionals.[127] Dr David Evans, Director of Health Systems Governance and Financing, WHO, told us that developing country governments should be expected to do more to raise revenue and allocate it to health.[128] The Minister told us that there were challenges in convincing governments that it was their responsibility to ensure public services were provided and that investment in health was good value for money.[129]

50. We asked the Minister whether DFID used local parliamentarians as advocates for health system expenditure and reform. She expressed reservations that parliamentarians in many developing countries did not have as strong a link to their constituencies as in the UK system. While DFID had parliamentary strengthening programmes focused on finance and audit, she was unaware of any health-specific interventions.[130]

51. The Malaria Consortium argued that "long-term sustainable change will never be achieved without increased support for countries to develop their own sources of health financing".[131] Health Poverty Action agreed that enabling countries to collect taxes and tackle tax evasion should be an urgent priority, though Crown Agents stressed that such work needed to be properly integrated with HSS programmes.[132] Improved revenue collection was necessary, but not sufficient, for greater domestic spending on health.[133]

52. Funding allocated to health is often poorly spent.[134] We were told that there is extensive evidence that resources are not efficiently allocated and that far more could be achieved with the same funding by employing more effective priority-setting mechanisms. NICE International referred to "ad hoc decision-making on budgets, driven more by inertia and interest groups than science, ethics, and the public interest".[135] We heard of funding for "high-cost, low-impact interventions when low-cost, high-impact options are underfunded" and public subsidies for treatments considered not to be cost-effective in the world's wealthiest countries.[136] For example, Avastin, a breast cancer treatment deemed not to be value for money in the UK, is routinely offered in Colombia, whereas screening for cervical cancer is not.[137] Oxfam was critical of the Affordable Medicines Facility Initiative, which involves the sale of malaria treatment in grocery shops, funded by DFID and partners through the Global Fund. They argued this was counter-productive as it led to sales of medicine without proper diagnosis or contact with health professionals and suggested it indicated that value for money principles were not being applied across all DFID spending.[138]

53. DFID has taken some innovative approaches to health system finance. With DFID support, the World Bank has been trialling results-based financing in Argentina, Burundi and Rwanda whereby project financing and disbursements are explicitly linked to pre-agreed results. The World Bank argued this has increased accountability, reduced inefficiency and achieved impressive outcomes.[139] Others praised DFID for its inventive voucher programmes for reproductive health in Malawi, Pakistan and Rwanda; and for subsidising private health insurance schemes for the poor in Ghana, Kenya and Nigeria.[140] We were told that DFID's approach to interventions in health systems financing is pragmatic, not always arguing in favour of tax-funded systems like the NHS but adapting to local circumstances.[141] However, it may underestimate the international appetite for UK systems governance and finance advice based on the NHS experience.[142] We consider this further in chapter 5.

54. The lack of progress by many African governments on the health expenditure commitment in the 2001 Abuja declaration is very worrying. It suggests a culture of reliance on aid that is irreconcilable with ultimate self-reliance. DFID aid should never be a blank cheque. We recommend that, as well as making the positive case for expenditure on health systems, DFID work with developing country governments to agree medium-term aid plans based on concordance with the Abuja target and fund accordingly, taking a tough line with governments which are unwilling to take responsibility for the long-term health of their own populations. We also recommend that DFID make better use of local parliamentarians and medical professionals as advocates for prioritising expenditure on health systems over other demands.

55. Health systems governance and finance are complex political issues. The outcomes of intervention in these areas tend to be uncertain and expenditure on them can be harder to sell to electorates, donors and developing country governments. DFID's international partners, given their narrower objectives, are also less likely to be involved. However, health systems governance and finance are vital to properly functioning and ultimately self-sustaining health systems. DFID must lead the way on strengthening them, including making the case for such interventions to sceptics at home and abroad.

Workforces and community health

HEALTH WORKFORCES

56. We were told that "trained, supported, motivated and employed" staff were necessary for any successful health intervention.[143] For example, skilled care before, during and after childbirth can be the difference between life and death, yet only 46 per cent of women in low-income countries benefit from it.[144] Witnesses argued that the fundamental problem was a "numbers game" and the global shortage of health workers was a barrier to achieving national and international health aims.[145] This chimed with our experience on our recent visit to Sierra Leone, where we heard that a shortage of doctors, nurses and midwives was a major obstacle to health system improvement.[146] We heard that a scarcity of specialist expertise was a major obstacle to tackling conditions such as neglected tropical diseases. The Global Health Workforce Alliance (GWHA) estimates that more than seven million additional health workers are required to deliver basic services to all, a deficit that could rise to 13 million by 2035 because of projected population growth.[147]

57. Wealthy countries, including the UK, have a history of undermining the health systems of some of the poorest countries through the recruitment of their doctors and nurses.[148] An NHS Code of Practice, which states that "international recruitment of healthcare professionals should not prejudice the healthcare systems of developing countries",[149] was introduced in 2001 and a Global Code of Practice was adopted by the World Health Assembly in 2010.[150]

58. Health worker migration to the UK from outside the EU has declined in recent years, though this trend may in part be due to a cyclical, and reversible, fall in demand.[151] We heard concerns that there is insufficient collaboration between DFID and the Department of Health on workforce planning and that the ban on active recruitment from developing countries does not cover the private sector, including care homes.[152] Health Poverty Action argued that source countries should receive some form of restitution should their health workers be recruited by UK employers, though they acknowledged that further work would be required to ascertain how this might happen in practice.[153]

59. The Minister highlighted the Medical Training Initiative, under which a small number of overseas doctors undertake two years' training in the UK before returning to their home country, as an example of good practice.[154] However, we were told that the Government could do more to promote such schemes and that there could be problems obtaining visas for visiting trainee doctors.[155] Lord Crisp drew attention to the success of specialist incountry medical training in Zambia, arguing that there was high demand for such schemes and DFID could do much more to support them.[156] Dr John Howard of the Academy of Medical Royal Colleges told us that while there was a lot of potential in incountry training, many existing local programmes were very weak.[157] As it was, a shortage of affordable medical training was creating a bottleneck in some countries, meaning there were too few adequately trained medical professionals to keep up with increases in public access to health services.[158]

60. The staffing of the UK health sector should not be at the expense of health systems in developing countries. We recommend DFID work with the Department of Health to review its approach to the UK recruitment of health workers from overseas. This review should consider options for compensating source country systems, promoting training schemes that involve a temporary stay in the UK, and strengthening local programmes to enable more medical training to take place in-country.

61. DFID is currently reviewing its approach to human resources for health (HRH).[159] Currently, it does not monitor how much it spends on HRH and does not have any HRH targets or performance measures, precluding effective evaluation. We were told that insufficient evidence of the best ways to strengthen health workforces hampers DFID's work and limits its leverage in encouraging its international partners to prioritise HRH.[160] Witnesses called for DFID to have a more ambitious and comprehensive HRH strategy and to be more vocal in pushing for a global HRH strategy under the auspices of the GHWA.[161]

62. Doctors, nurses and other health professionals are at the centre of any wellfunctioning health system. We are concerned that DFID does not know how much it spends on human resources for health and or have means of monitoring its performance. We recommend that DFID's review of its approach to human resources for health extends to an ambitious strategy which would set an example of best practice to international partners.

COMMUNITY HEALTH WORKERS

63. DFID noted that its training of health staff had "focussed particularly on community health workers and skilled birth attendants", resulting in an additional 2.75 million births having a skilled attendant over the past three years.[162] Community health workers (CHWs), with limited training, can play an important role in delivering primary care, from prevention and health promotion to diagnosis and basic treatment.[163]

Box 2: The Health Extension Programme in Ethiopia

In Ethiopia, DFID support to the health budget has enabled over 30,000 Community Health Workers (CHWs), known as Health Extension Workers (HEWs), to be trained. Health services are now available to rural communities that did not previously have access. Primary care coverage has increased to 93 per cent, close to universal coverage, from 77 per cent in 2005 and 30 per cent in 1991.[164] Provision of preventative health care and basic treatment for conditions such as malaria, diarrhoea and pneumonia by HEWs has been credited for rapid improvements in health outcomes, including Ethiopia's achievement of its child mortality Millennium Development Goal.[165] Many other countries are now looking to use the Ethiopian model in developing their own CHW programmes.[166]

64. Results UK told us that CHWs "can effectively deliver high quality health interventions to improve health outcomes to at least the level of other trained professionals". They can act as an important link between formal health structures and primary care provision in the community, assist in tracking patients and encourage communities to participate in preventative activities.[167] Witnesses suggested that CHW programmes should be scaled-up and that DFID should both champion CHWs and support their integration into national health strategies.[168]

65. The REACHOUT Consortium noted that "close-to-community" programmes "are increasingly being initiated and scaled up in response to the human resources for health crisis", but expressed concern at the lack of evidence on how best to support such programmes.[169] Dr Julian Lob-Levyt warned that CHWs "have been seen as magic bullets for under-funded and poor-performing health services", but that they required sophisticated integration with other services.[170] Oxfam stressed the importance of complementing CHWs with a system of referral to more expert care, a point reiterated by Angela Spilsbury of DFID.[171] Simon Wright of Action for Global Health said that CHW schemes had not resulted in falling neonatal mortality as CHWs were not able to deal with complications and expressed concern that such programmes were further examples of "quick wins" being chased.[172] Lord Crisp told us that many countries had more urgent demand for the training of high-level specialists.[173]

66. Community health workers can be an important part of a developing health system. They provide flexibility and enable programmes to be scaled-up very quickly. However, they should not be seen as an easy remedy for all health system problems, nor as a substitute for properly trained and specialist health professionals. As in other areas, DFID would benefit from sounder monitoring and a better evidence base in assessing the role to be played by community health workers in individual countries.

COMMUNITY CARE AND PUBLIC HEALTH

67. We received a large volume of evidence supporting a greater focus on community and decentralised health service provision, beyond that which can be offered by CHWs. Dr Dina Balabanova and Professor Martin McKee noted that system strengthening tended to focus on formal and government structures, which accounted for a small proportion of healthcare in many countries.[174] The International HIV/AIDS Alliance noted that "grassroots community organisations deliver a substantial share of health services" in many countries and that they could be important in reaching the most marginalised population groups.[175]

68. Action for Global Health stressed the importance of community engagement in improving preventative public health services and addressing the wider determinants of good health such as WASH (water, sanitation and hygiene).[176] The WHO defines public health as "all organised measures to prevent disease, promote health, and prolong life among the population as a whole", adding that "its activities aim to provide conditions in which people can be healthy and focus on entire populations, not on individual patients or diseases".[177] DFID claimed to take a "public health approach" to HSS, arguing that the provision of preventative services was an important factor in improving both health outcomes and system efficiency.[178] However, Dr John Howard feared that "public health has almost been forgotten" and was insufficiently integrated with other programmes.[179] In 2012, DFID found that there was potential for efficiency gains by better aligning its WASH and health programmes.[180]

Box 3: Trachoma elimination

The UK Coalition against Neglected Tropical Diseases told us that a coordinated health systems approach was vital to a SAFE (Surgery, Antibiotics, Facial cleanliness, Environment) strategy to eliminate blinding trachoma by 2020:

"Surgical interventions, antibiotic distribution and health promotion activities need to be delivered through a health system in order to reach trachoma endemic communities. However, many trachoma-endemic countries have a weak health system with even weaker primary healthcare, as well as little capacity to work across ministries and sectors to deliver components such as water, sanitation and hygiene. The current momentum in reinvigorating primary healthcare with integration of eye care and health system strengthening, provides a real opportunity in the drive towards trachoma elimination."

Currently, only 13 per cent of people receive the treatment they require for this disease.[181]

69. One possible explanation for the poor integration of preventative care in HSS work is that the standard models of HSS, such as the WHO's six building blocks, do not explicitly include public health. This could lead to separate preventative and curative programmes and institutions.[182] We were also told that HSS tends to be associated with ensuring access to services rather than public health campaigns.[183] In our recent Report, Disability and Development, we expressed reservations that DFID underestimates the importance of preventative care in its health budget.[184] The balance of evidence to this inquiry added to those concerns.

70. Other witnesses said it was important not to over-rely on decentralised provision. Dr Julian LobLevyt emphasised the importance of integrated, national services and cautioned against establishing clinics to be run by external organisations in isolation from the wider health system.[185] We were also warned that there was a risk of undermining national health systems through decentralisation, which could "reduce people's expectation that their Government is going to be accountable for the delivery of their healthcare".[186]

71. Writing about the ongoing Ebola epidemic in Sierra Leone, Matthew Clark of the Welbodi Partnership said that the health system was undermined by a lack of trust, stemming from an absence of both transparency about how donor funds are spent and a means of holding to account those in charge.[187] The Tony Blair Faith Foundation told us that community and faith organisations were often trusted by local populations and could be used to encourage greater use of health services.[188] Under-provision is sometimes attributable to low demand for healthcare, or the difficulties in reaching facilities, as well as under-supply.[189] In Zambia, church provision of health services is supported by the government, well-integrated with the rest of the system and is more effective as a result.[190]

72. We received in evidence several examples of cultural and informational barriers to system strengthening. A scorecard scheme in Afghanistan, designed to understand the needs and concerns of local people, revealed that patients thought they were only receiving familiar basic painkillers because the drugs they were given were similar small white tablets.[191] We were told the story of a health centre in Uganda that was closed because the manager had taken his sick mother to visit the witchdoctor.[192] We also heard that, in Sierra Leone, community volunteer drug distributors had been successful in both improving awareness of neglected tropical diseases and combating discrimination against suffers of such illnesses.[193]

73. Some barriers to health service access affect particular social groups. We were told that indigenous Guatemalan women had maternal mortality rates three-times the national average, partly reflecting exclusion from decision-making processes, language barriers and discrimination.[194] The International HIV/AIDS Alliance said that there had been a global increase in discrimination against lesbian, gay, bisexual, and transgender people, including recent laws against homosexuality in India and Nigeria, which manifested in unequal access to services. They argued that this threatened progress in HSS and called on DFID's health programmes to be accompanied by a broader strategy of strengthening communities and defending human rights.[195] In our 2012 Report on Violence against Woman and Girls, we noted both that abuse acted as an obstacle to use of health services and that the health sector could be better used to help tackle violence and its consequences.[196] In its 2013 Health Position Paper, DFID similarly identified factors such as the low and unequal status of women and girls, and early or forced marriage as limiting access to healthcare.[197]

74. Community services and public health are important parts of an effective and efficient health system. There can be a tendency, driven partly by standard health system models, to focus on curative care in formal national systems. We heard concerns that DFID sometimes falls into this trap. It is too hard to assess whether this is the case. We recommend that, in publishing the disaggregated data recommended earlier in this Report, DFID prioritise community services and public health.

75. DFID rightly identifies factors ranging from superstition and mistrust of formal health systems to discrimination and violence against women and girls as obstacles to improving healthcare. We recommend that DFID press its international partners, including national governments, to tackle unacceptable cultural barriers to access to health services.

106 World Health Organization, Everybody's business: strengthening health systems to improve health outcomes: WHO's framework for action, 2007, p3 Back

107 HSS5 [Options Consultancy Ltd], HSS11 [The Open University] and HSS28 [Royal College of General Practitioners] Back

108 World Health Organization, Systems thinking for health systems strengthening, 2009, p31 Back

109 HSS19 [DFID] Back

110 Q24 [Dr Andrew Cassels] and Q29 [Dr David Evans] Back

111 Q92 [Dr Kalipso Chalkidou] Back

112 HSS16 [Dr Dina Balabanova and Prof Martin McKee] Back

113 HSS19 [DFID] Back

114 HSS1 [Malaria Consortium] and HSS20 [Crown Agents] Back

115 HSS2 [NICE International] Back

116 Q60 [Dr Kalipso Chalkidou] Back

117 HSS5 [Options Consultancy Ltd] Back