Targeting Resources
An important dimension of health system capacity that has not been considered explicitly so far, is the ability to ensure that resources are used in ways that meet health system objectives. As noted earlier, many health systems fail to perform as well as they might on effectiveness, efficiency, and equity criteria. This section addresses what policy instruments might be available to ensure that additional resources are used to the greatest effect, first at the systems level and then at the level of service delivery.
Systems-Level Mechanisms
At the systems level, tools available to decision makers include regulation and legislation, resource allocation formulas, and financial incentives.
Decision makers can use regulation and legislation to set minimum standards of care that insurance packages must cover, for instance. They can influence the availability of drugs by, for example, liberalizing prescribing and introducing accompanying measures to educate providers and users so as to increase the use of certain drugs that are safe to distribute on a large scale. One approach that has worked in Uganda is a social-marketing program making subsidized and clearly packaged drugs for sexually transmitted diseases available through the retail sector (Mills and others 2002).
In some settings, explicit rationing of the provision of care in the public and private sectors can be used to prioritize the most cost-effective interventions and limit the provision of less cost-effective ones. However, regulatory controls are unlikely to be effective in low-capacity settings and will simply encourage illicit activities. Moreover, explicit rationing requires a high degree of public acceptance and public involvement in the prioritization process. A more acceptable strategy in most settings is to constrain the overall public sector resource envelope in terms of staff, buildings, equipment, and drugs and to leave rationing decisions within the envelope to clinical discretion (Segall 2003). However, clinicians may implicitly ration services in inequitable ways—for example, on the basis of age or social status—and supplementary measures are likely to be needed to ensure that health workers do not discriminate against poorer and marginalized members of society.
Resource allocation formulas have an important role to play in the public sector in directing resources to underserved geographic areas and population groups and to underfunded programs (Musgrove 2004). Given the typical shortages of health workers in more remote areas, such formulas should include remote area allowances or allow for the higher costs of delivering services in such areas. A formula in Zambia, for example, used distance from the railway line as a proxy for remoteness.
A similar approach to ensuring that resources go where they are most needed is the "marginal budgeting for bottlenecks" approach of the World Bank (see chapter 9). This country-based planning and budgeting approach assesses health sector impediments to faster progress toward the MDGs, identifies ways to remove them, and estimates both the costs and the likely effects of their removal on MDG outcomes.
In targeting resources to specific programs, expansion of one area of health provision should not occur at the expense of another priority area. For example, where staff capacity and facilities are limited, targeting additional funding to TB case detection and treatment may simply take staff time away from child health. This problem of the systemwide effects of disease-specific programs was discussed earlier. Addressing this problem requires empowering a central body, such as a ministry of health or a regional or district health authority, to take an overall view of priorities so that resource conflicts can be resolved.
Even though financial incentives need to be used cautiously, they can be powerful tools for influencing providers' behavior, as indicated earlier. They can also be an important influence on users'behavior. Experience in South Africa and Uganda (box 3.7) suggests that, in some settings, removing or reducing user fees at the primary care level may be an important element in encouraging greater take-up of primary care. Further studies of the effects of fee removal are needed.
[Box 3.7]
Service-Level Mechanisms
At the service level, evidence suggests the value of providing a framework of resources and guidance within which managers and health workers can prioritize their efforts. The experience of the Tanzania Essential Health Interventions Program (chapter 54) highlights the health gains that a decentralized management structure can achieve when district managers are provided with the information, tools, and training to enable them to match services and additional resources with the local burden of disease. Berwick (2004) draws similar lessons from the experience of several highly successful projects in resource-poor settings: set clear aims and targets, use a team approach, build an infrastructure of human resources and data systems, engage with the policy environment, and develop simple approaches to rapid scaling up.
Patient education on major causes of ill health is also important to ensure that people know when to seek care (for example, in the case of childhood illness); understand their rights to various services and the official level of charges; and can make appropriate decisions about drug purchases. Patient charters may play a role in making explicit what patients have the right to expect from their health services and what level of service providers should achieve. Local policies on service provision need to relate to community preferences: if they do not, clients' confidence in the public health system will be undermined. One simple example is the pervasive view in some South African communities that public clinics water down medicines, thereby rendering them ineffective (Schneider and Palmer 2002). Indeed, generic medicines used by the public sector are often perceived as less effective than name brand drugs. Accurate public information is needed to counter that perception.
