Health System Constraints on the Delivery of Public and Personal Health Services
The challenge of scaling up services to meet the health-related MDGs and concerns that the multiple international efforts may overwhelm countries' fragile infrastructures have encouraged efforts to think systematically about health system constraints on achieving the MDGs, and the extent to which additional funding can readily and quickly improve services (Ranson, Hanson, and Mills 2003; Travis and others 2004). Weaknesses in service delivery—for example, at the health center level—may stem from problems at that level, such as staff shortages, or may be affected by factors higher up the system, such as a poor drug distribution system. Ranson and others (2003) therefore analyze constraints by five different levels: community and household, health services delivery, health sector policy and strategic management, public policies cutting across sectors, and environmental and contextual characteristics (see table 3.2).
[Table .]
At the community and household level, lack of demand can limit coverage. This lack may stem from cultural factors, such as low acceptability of immunization or prenatal care, but it may also result from financial and physical barriers to access. For example, estimates indicate that, in Niger, children under five average only 0.5 visits to a health provider per year, and in Bangladesh, only 8 percent of ill children were taken to a qualified provider (see chapter 63). Many barriers can be reduced by increasing accessibility, for example, by expanding the service infrastructure closer to communities. In Cameroon, Litvack and Bodart's (1993) study finds that a combination of user fees and improved quality, including a better drug supply and improved geographic access, led to increased use despite the user fees.
Low use may stem less from inaccessibility than from low quality at the level of health care delivery. Low quality can result from human resource shortages, limited incentives for the staff to provide good quality care, training inappropriate to local needs, poor drug supply systems, and lack of simple equipment such as that needed to measure blood pressure (Southern Africa Stroke Prevention Initiative Project Team 2004). In Tanzania, an analysis of the treatment-seeking decisions of those who later died from malaria showed that the great majority had preferred modern medicine, even for cerebral malaria, which according to a substantial body of evidence mothers view as a condition best treated by traditional healers (de Savigny and others 2004). Yet despite high rates of seeking modern medicine, malaria mortality remained high, whether because of delay in seeking treatment, poor quality care, or poor patient adherence. Treatment quality can be improved by increasing resources, although it may also demand change higher up the system; for example, better health worker performance may not be possible without reforming human resource management systems.
Performance at the third level, health sector policy and strategic management, can have a pervasive influence on performance at lower levels and is less easy to address through additional funding alone. Some improvements, such as orienting management more toward good performance and reduced corruption, may require a change in organizational culture or a change in structures—for instance, decentralizing authority or creating autonomous agencies. Such changes can be difficult and may take time to implement (Preker and Harding 2003). Other improvements require action outside the country—for example, a change in aid agency practices so that weak country management structures are not overloaded by multiple demands and reporting structures.
Finally, at the highest levels, broad multisectoral public policies and environmental and contextual characteristics set limits on what the health sector can change without help. For example, wage policies for the public sector health staff are usually set centrally and linked to overall levels of pay for the public sector. Even if funds are available, increasing the wages of only health staff members may not be possible.
At this highest level, constraints also reflect much broader institutional influences, as was demonstrated by recent analyses of the results of efforts to build state capacity in Africa. Levy's (2004) review points out that the results are mixed at best. For example, of all World Bank civil service reform projects completed by 1997, only 29 percent were rated as satisfactory by the operations evaluation department. Levy argues that a key reason for the limited success was an implicit presumption that the weakness of public administration was managerial and could be remedied through organizational change and financial support for technical advice, hardware, and training. However, public administrations are part of political institutions and of social, economic, and political interests more broadly, and they do not change readily or quickly. Nevertheless, windows of opportunity may open that drastically affect the chances of change within a few years. Consider the cases of Mozambique, Rwanda, and Uganda, all countries that experienced many years of conflict and economic collapse but that have since made significant progress in reforming government institutions and performance. Apart from those exceptional cases, Levy argues that the way forward for administrative reform is likely to be an incremental one.
In general, straightforward shortages of buildings, equipment, and drugs and a lack of specific skills on the part of health workers and managers can be addressed fairly rapidly with additional funding. Remedying staff shortages takes somewhat longer, especially if the education system is producing insufficient numbers of people with the qualifications needed to enter health training programs. The constraints most impervious to additional funding are likely to relate to broader systems and institutional deficiencies, such as a bureaucratic culture that does not reward good performance and political systems that ignore the voices of the poor. Long-term and carefully phased capacity building in the broadest sense, including political development and strengthened governance structures, is likely to be required to relax these constraints (Mills and others 2001).
