Intro
Interventions are not generally provided as freestanding activities but are delivered in a variety of packages and through different levels of a health system.1 For this reason, this book—in addition to including the disease- and program-specific chapters—addresses not only the cost-effectiveness of levels of care, packages of care, and services but also the strengthening of the management of health systems as a whole.
Cost-effectiveness data reflect largely what can be achieved in a reasonably well-functioning health system. In that sense, they can be considered to represent potential cost-effectiveness and need to be supplemented with evidence and guidance on how health systems can be strengthened to provide interventions effectively, efficiently, and equitably. This argument is given added weight by evidence on inadequacies in the performance of health institutions in countries at all levels of development (Hensher 2001; Preker and Harding 2003). Hensher (2001) documents the extensive inefficiencies in low-and middle-income countries, including the following:
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failure to minimize the physical inputs used—for example, prescribing excessive quantities of drugs
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failure to use the mix of inputs that costs the least—for instance, allocating a high proportion of expenditure to staff salaries and only a small share to operating costs and maintenance
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failure to operate at the appropriate scale—for example, running extremely large hospitals that suffer from scale inefficiencies
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failure to pay staff enough to encourage good performance.
Hensher estimates that hospital inefficiencies could easily account for up to 10 percent of total health spending.
Such inefficiencies have two main causes. First, they may occur because decision makers lack incentives to behave efficiently; for example, their promotion chances may not depend on how well they perform in managing a hospital. Second, decision makers may be constrained in their ability to make efficient choices; for instance, they may lack knowledge or experience of what to do or political factors may affect whether they can dismiss underperforming staff members or determine which company they must buy drugs from. Evidence on the quality of care (chapter 70) demonstrates that health systems may not merely be inefficient in failing to minimize costs but may also fail to deliver effective care.
The extent of inequities is also a major concern. Recent analyses show that even when interventions are provided, the poorest members of society usually have the least access to them (Gwatkin and others 2000). In many countries, gaps in child mortality between the poor and the better off widened during the 1990s (World Bank 2004). Thus, health systems need to have the capacity not only to deliver interventions efficiently but also to sustain high levels of coverage, especially of the poorest and most vulnerable.
Awareness has grown that international targets, such as the Millennium Development Goals (MDGs) and the provision of antiretroviral treatment for HIV/AIDS patients cannot be achieved without the key elements of a functioning health system. The example of the reduction of maternal mortality in Sri Lanka (chapter 8) demonstrates the improvements in health outcomes that are possible once a basic platform of functioning health services is available on which targeted initiatives can build (Levine 2004).
Thus, the aim of this chapter is to review how health systems can be strengthened in differing country contexts to deliver interventions effectively, efficiently, and equitably. The chapter is mainly concerned with strengthening health services: issues in managing core public health functions are reviewed elsewhere (Khaleghian and Das Gupta 2004). Although the chapter seeks to draw valuable lessons from all parts of the world, it focuses on countries with the least capacity, especially the poorer countries in Sub-Saharan Africa and Asia.
