Conclusions
This chapter has sought to address the question of how health systems can be strengthened to deliver cost-effective and equitable interventions and services. Recent cross-country analysis on the association between health expenditure by government and health outcomes has suggested that the effectiveness of increased health expenditure depends heavily on governments adopting the right policies (World Bank 2004). What are the right policies, and what are effective implementation processes? The review in this chapter suggests that in many areas not enough is known to recommend particular approaches and also that recommendations need to be adapted to local contexts. Nonetheless, six key points can be identified in relation to improving health systems:
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Health systems face numerous constraints in low-income countries, but they are the basis for the long-term future of sustained health improvements. The health of the system must, therefore, be carefully considered whenever major new programs are put in place.
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If capacity constraints are such that a focused disease- or program-specific effort is desirable to address an urgent problem, the effort should be designed to contribute to the long-term system strengthening, rather than detracting from it. Countries must avoid having multiple vertical programs competing for limited human resources and managerial capacity. Over time, as horizontally organized services strengthen, the need for more vertical financing and delivery strategies will lessen.
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Reforms affecting organizational structures and human resource management are likely to play an important role in improved performance. However, emerging evidence suggests in most settings that changes are most likely to be successfully implemented if they are incremental and gradual rather than "big bang" reforms. Stability of policies and consistent implementation are also required.
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Linking financial incentives to performance, whether through contracts with health care providers or through performance-related pay, may bring rewards if careful monitoring is possible; however, evidence on the sustainability of such arrangements is lacking, and effective monitoring may require long-term external involvement. Evidence is needed on alternative approaches to improving performance.
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Organizational reforms must keep the goal of improved health outcomes, equity, and responsiveness in sight. Doing so requires paying special attention to users' demands, to primary care and first-level hospitals, to quality of care, and to technical backup for disease control programs.
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Capacity-strengthening efforts in most settings must encompass action at all levels, from increasing leadership of the ministry of health at the national level through strengthening support for peripheral levels.
The current body of knowledge represents a largely ad hoc and disjointed collection of facts, figures, and points of view. Making confident recommendations relevant to strengthening health system capacity is thus difficult. Although international financing is vital, countries need flexibility to develop solutions based on local assessments and experience and to progress at a pace commensurate with their situations. Sustained investment in analytical and operational research capacity is needed as part of program and systems support, to serve national priority setting and policy formulation.
Notes
1. The health system is understood to encompass all activities whose prime intent is to improve health.
