Solutions in Low-Capacity Environments
Developing countries possess a range of capacities to improve the functioning of their health systems, but one group of countries faces the greatest constraints to doing so. Analyses undertaken for the Commission on Macroeconomics and Health used the framework presented in table 3.2 to understand the dimensions of the constraints problem in 79 low-income countries. Using proxies for the various types and levels of constraints—gross domestic product per capita, female literacy rate, number of nurses per population ratio, diphtheria-pertussis-tetanus immunization coverage, access to health services, control of corruption, and government effectiveness—countries can be classified as more or less constrained. Table 3.3 shows key indicators for the most constrained and other countries.
[Table .]
The most constrained group has significantly worse health indicators and much worse access to health resources. For example, countries in this group have almost twice the infant mortality rate and more than twice the maternal mortality rate of other countries but only one-sixth as many nurses. In absolute terms, the most constrained group represents a relatively small share of the total population of countries analyzed and consists, for the most part, of small countries (more than half have populations of less than 10 million) in Sub-Saharan Africa.
The key question in relation to improving health outcomes is what financing and delivery strategy might work best in these settings. Should it take the form of a limited number of programs, each addressing one or a few diseases? Or should efforts be devoted to building up the basic health service infrastructure on which targeted efforts to address specific health problems can then be built? Given the lack of evidence, providing guidance is difficult, and the chapters in this book present different views. Chapter 63 firmly dismisses the option of bypassing organized health services altogether in the poorest countries and promoting the delivery of child health interventions directly to households through, for example, community-based projects dispensing antimalarials or antibiotics. It argues that, though this approach may be a short-term solution, successes using it largely occur in small-scale pilots with strong managerial backup. Chapter 56 suggests that in the poorest societies basic preventive services should be introduced first—especially immunization, access to basic drugs, and management of the most severe threats to health such as emergency care for traffic injuries. At slightly higher levels of development, the introduction of community-based activities may be cost-effective if coverage by the formal health service is poor. Both chapters imply that the issue is not which approach to use but how to phase approaches and use a mix that depends on the intervention and the local context. Accomplishing this requires not only service delivery capacity but also management capacity to plan and evaluate the mix of approaches and make adjustments over time.
Molyneux (2004) suggests that disease control programs can be used to build capacity for the long term and that, with time, such programs can become more advisory and less managerial. For example, in Pakistan, primary health care was built on the experience of TB and leprosy clinics. In China, the vertical programs for disease control purchased time from health service operational staff members, thereby ensuring that funds flowed into the health service infrastructure (Dean Jamison, personal communication, 2004). In seven countries in southern Africa, a successful combined strategy for measles immunization started with a single, nationwide catch-up campaign in which mobile teams vaccinated all children in a particular age group (Levine 2004), an action that can sharply reduce the spread of the virus. Routine services were used to continue measles immunization but with a follow-up campaign three to four years later to prevent the number of susceptible cases from rising to the level required for transmission. Over five years, measles virtually disappeared from southern Africa. However, maintaining this achievement requires that routine services be able to reach more than 80 percent coverage, a level many countries find hard to sustain. Moreover, in low-capacity environments, campaigns can divert attention and resources from routine primary health care services. Schreuder and Kostermans (2001) indicate that this problem occurred in southern Africa, particularly with respect to diverting scarce management capacity, implying that reducing deaths from one cause may risk worsening services for other diseases and conditions.
Victora and others (2004) suggest that the most appropriate mix of vertical and horizontal approaches depends on the human and financial resources available, the urgency with which results need to be achieved, the existing organization of health services, and the natural development of programs over time. Within a horizontal approach, the weaker the health system setting is, the more important the provision of good technical and management backup will be to service delivery. The authors ascribe some of the difficulties that integrated management of infant and childhood illness (IMCI) faced in several countries to the absence of full-time IMCI coordinators, operational plans, and specific budget lines. They suggest that, when health systems are extremely weak, vertical programs may be required; however, as health systems strengthen, financing and delivery strategies can become less vertical and more horizontal and less selective and more integrated.
