Health care comprises a continuum from home-based, self-administered treatment to highly specialized intervention dependent on professionals with many years of training and a heavy capital investment. In principle, the role of the health system planner is to balance the many separate components of the system to optimize the magnitude and distribution of health benefits, subject to a variety of constraints such as budgetary levels, geography, and human resources capacity. While recognizing that other paradigms are possible and valid, we generally adopt this optimization perspective in our discussions because it combines broad social (including user) and political dimensions with systematic economic principles when decisions are made in a competitive, resource-constrained environment. Following such logic, it should be possible to define the place, purpose, and size of the district hospital sector within a balanced system of care for any particular setting.
Although this view is theoretically appealing, the world of real health systems that have evolved under different historical and political pressures is somewhat different. This perspective does, nevertheless, suggest some common principles involved in defining the optimum balance of care even within groupings as diverse as "developing countries." Two further points are worth considering:
First, although the focus of this chapter is the district hospital, crucial links exist with many other aspects of the health system. Choices made in relation to hospitals are likely to affect the whole health system and vice versa. For example, programs to improve peripheral clinic referrals of women with high-risk pregnancies may result in a paradoxical decline in the quality of care if critical human and other resources are inadequate at the hospital level. Thus, the picture of public district hospitals as underused, inefficient, and providing poor quality care (Barnum and Kutzin 1993) may reflect deficiencies in the entire health system as well as at the hospital level.
Second, optimizing the health system configuration is an active, continuing process that must often proceed incrementally, ideally tackling problems in order of priority. An optimal balance is not likely to be achieved naturally through neglect or reliance on market mechanisms.
Hospitals are major consumers of health budgets. However, there is a paucity of good evidence—even in industrial countries—on their effect (McKee and Healy 2002), whereas the body of theory and opinion on their role is wide. This chapter can serve as only an introduction to topics that include, among others, the political and social value of hospitals and their essential role in integrated health systems (Sachs 2001; Van Leberghe, de Bethune, and de Brouwere 1997; WHO 1999; World Bank 1993). The chapter first introduces basic concepts relevant to district hospitals that may affect their role and performance and a description of possible core services (see figure 65.1). For discussions of the evidence justifying inclusion of an intervention or process as a core service at this level of care, the reader is referred to disease- and service-specific chapters. Although recently attempts have been made to refine definitions of performance (WHO 2000b), the term is used in a general sense, referring to processes and outcomes that contribute to improved levels and distribution of health. The chapter then summarizes currently available economic data on hospital care, focusing where possible on the district level and acknowledging the difficulty in generalizing findings from one setting to another. An illustration follows of some of the factors that threaten district hospitals' performance, indicating the broad range of influences to which they are subject. Finally, possible strategies for improving performance are proposed, focusing on cross-cutting interventions, and highlight areas where current knowledge is inadequate and research is urgently needed.