7. Pillars of the Health System

Information, Surveillance, and Research

The importance of collecting, processing, and using data in the campaign to improve health cannot be stressed enough.¹ As noted in chapter 1, much of the progress in extending and improving the quality of human life is due to technical progress, including advances in knowledge about diseases and about appropriate, cost-effective responses. To the extent that the generation and application of information and knowledge can be facilitated and become more systematic, accelerating progress in improving human health and eliminating health inequities should be possible.

Information and Surveillance

Health sector decision makers—whether health care workers in small clinics, managers of major hospitals, directors of drug safety, local political officeholders, or ministers of health—ask a number of questions that must serve as the starting point for any discussion of information. For example, is the recent surge in flu cases the beginning of a new epidemic? Are we reaching 90 percent of children under five with the recommended vaccines? What are likely to be the major causes of death in the next 10 to 20 years? What social behaviors are contributing the most to the spread of STIs? Where is the public sector's health expenditure going? What interventions are effective against a particular disease? Are more cost-effective methods available?

". . . fewer than half of all births and only a third of all deaths are reported to national registration systems."

The information for answering such questions generally comes from the following six major sources:

• Vital events registration provides data on births and deaths, as well as on marriages, divorces, and migrations. The data on births, deaths, and migration are particularly critical for good health policy analysis, as without them tracking the population and calculating such basic indicators as disease incidence rates are impossible. However, these basic data are poorly recorded in most of the world: fewer than half of all births and only a third of all deaths are reported to national registration systems.

• Health service statistics comprise information on consultations by patients, services provided, and diagnoses. Health facilities routinely gather much of this information for local use, but it is rarely collected in standardized formats or reported to a national health database. Health service statistics are fundamental to managing public health services, identifying health trends, and allocating resources efficiently.

• Public health surveillance comprises a wide range of efforts to track and respond to disease trends. One common approach is to identify a list of notifiable diseases that health care providers are required to report to national authorities, generally infectious diseases that might be rare, but that require an immediate response. In another kind of surveillance known as sentinel surveillance, samples of health care providers or facilities agree to report all cases of particular conditions. This kind of arrangement is good for large public health programs, but is not effective at detecting rare or new health threats. Surveillance can be based on health care providers reporting cases with particular symptoms or laboratory tests with particular diagnoses. In general, surveillance works best when a wide range of sources are integrated in a system that includes detection, monitoring, analysis, and response.

• Census data that are accurate and collected regularly provide the basis for calculating important ratios and designing reliable samples.

• Household surveys are an effective way to obtain information about population demographics, social characteristics, and dynamics on a regular basis between censuses. They can also be expanded to gather important information about behaviors or particular health conditions.

• Resource tracking involves measuring and managing human resources, facilities, commodities, and finances. It relies on a variety of reporting methods and data collection efforts. Collecting information about health care professionals generally requires more than tracking public health sector employment to include activities by health care professionals with private practices. Similarly, financial flows in the health system cannot be fully understood without combining public budget information with data on private health spending, including out-of-pocket spending on consultations and drugs, health insurance premiums, and pharmaceutical research and development expenditures.

"Health service statistics are fundamental to managing public health services, identifying health trends, and allocating resources efficiently."

Timeliness and appropriate reporting intervals are important for all data collection systems. Surveillance for outbreaks of infectious epidemics needs to be rapid and constant to provide early warning. By contrast, surveillance for changes in behavioral risk factors may merit longer intervals.

"Surveillance for outbreaks of infectious epidemics needs to be rapid and constant . . . [but] surveillance for changes in behavioral risk factors may merit longer intervals."

When building health information systems, seeking highly detailed information on health status and health services at every possible site is tempting, but this does not necessarily yield data that are reliable and amenable to analysis. A sample of preselected sites that are reliable in relation to the accuracy and completeness of the information gathered can often provide better data than haphazard attempts at universal reporting. If an appropriate sampling method has been used to select these sites, the information they provide will permit accurate extrapolations to the population at large. Many countries have therefore started to improve their vital registration systems by focusing on a sample of preselected districts to provide good quality data for national analyses and decision making, while at the same time working to expand and improve vital event registration in other districts so that the system will eventually be universal.

Standardization will also enhance the value of data collection efforts. Setting common standards for data collection facilitates recording, communicating, and analyzing information. It also permits more efficient training and hardware and software development. For example, the U.S. Centers for Disease Control and Prevention developed standards for automatic reporting of diagnostic laboratory results for notifiable diseases and disseminated related software that is used in many countries. The key in such initiatives is to develop standards in an open process, engaging other countries and international agencies both to improve the standards and to encourage widespread adoption.

Technology is reshaping and expanding methods for collecting, storing, and processing information. For example, cheaper, faster, and simpler techniques for obtaining and analyzing tissue samples permit diagnosing diseases and collecting epidemiological information in a much wider range of places and circumstances than was previously possible, and new communication technologies allow the rapid transmission of newly collected data if the requisite hardware and skilled staff are available to use them properly.

Indeed, DCP2 argues that the principal barriers to improving information systems in low- and middle-income countries have less to do with the technologies and more to do with the required investments in training and coordinating people. The expertise required to operate and use an effective health information system goes beyond knowledge of survey design, sampling, hardware, and software to include skills required for management, medical research, and field epidemiology and knowledge of such fields as economics and sociology. International initiatives can play a valuable role in developing such expertise. For example, the U.S. Centers for Disease Control and Prevention and WHO coordinate a program to train field epidemiologists in more than 30 countries.

"The successful containment of SARS, for which no cure or vaccine is yet available, is attributable to the organized work of competent, dedicated health workers with access to good communications . . ."

In controlling disease, examples of specific instances underscore the importance of having skilled people supported by good communication. The severe acute respiratory syndrome (SARS) epidemic broke out in China in November 2002 and spread to Canada, Hong Kong (China), Vietnam, Singapore, and other countries within five months. Success in controlling this first new pandemic disease of the 21st century depended on a combination of open collaboration among scientists and politicians of many countries and the rapid and accurate communication of surveillance data within and among countries. The global pandemic ended in July 2003 after more than 8,000 patients in 26 countries and 5 continents had been affected and 774 deaths had been confirmed. The successful containment of SARS, for which no cure or vaccine is yet available, is attributable to the organized work of competent, dedicated health workers with access to good communications (see DCP2, chapter 53, for more details).

To be effective, health information has to be integrated in ways that facilitate analysis and are linked to responses and actions. For example, WHO's Regional Office in Africa is working with a number of countries to link epidemiological and laboratory data to decision making under an integrated disease population surveillance strategy that successfully responded to the health threat of Ebola in Uganda (box 7.1). Surveillance in the Philippines regularly detects outbreaks including cholera and typhoid (box 7.2). More recently, the type A H5N1 avian influenza threat in Southeast Asia is under very close scrutiny by several countries and the WHO and plans are being developed for its containment of a new pandemic should inter-human spread begin.

Finally, health information systems cannot be established and operated without funds. A good, comprehensive information system can cost as little as US$3 per person in certain countries, but even these limited financial resource requirements may be prohibitive in low-income countries where the entire public health budget is of a similar order of magnitude (table 7.1). Fortunately, many international programs have recognized this problem and are financing health information activities as components of loans and grants.

"A good, comprehensive information system can cost as little as US$3 per person . . ."

Health information is also valuable in improving the efficiency of health services. For example, a study in rural Mali found that the cost of childhood immunization programs in areas covered by community-based information systems was only US$1.47 per child, compared with US$2.79 per child for areas without such systems. Similarly, in South Africa's Eastern Cape Province, improved pharmaceutical tracking and management reduced situations where facilities ran out of essential drugs by 39 percent, improving treatment for thousands of patients by improving access to required medications.

". . . in rural Mali . . . the cost of childhood immunization programs in areas covered by community-based information systems was only US$1.47 per child, compared with US$2.79 per child for areas without such systems."

The Tanzania Essential Health Interventions Program (TEHIP) provides evidence on the cost-effectiveness of health information systems. This program provided training to health care workers and managers in the use of information to determine priorities and better manage existing interventions (box 7.3). TEHIP cost approximately US$0.80 per person in the districts where it was implemented. Looking only at the resulting reduction in mortality among children under five, the program cost US$68.50 per DALY averted. Because adults' health also improved and morbidity declined, a fuller accounting would have shown the health information system initiative to be even more cost-effective.

Research and Development

Health information systems must be useful to decision makers if they are to influence clinical choices, health system management, and public policy. However, they also need to furnish information and generate questions for the fundamental research that generates new understanding of disease; improved techniques for prevention, diagnosis, and treatment; and better methods for delivering and organizing health care services.

Health research is a global endeavor. Countries are increasingly recognizing that their own health research efforts are enhanced through more interaction with researchers in other countries, studies with multiple sites, and teamwork and joint training. There are five chapters in DCP2 devoted to the fact that science, new product development, and analytic capacity are essential for economic and social progress. DCP2 argues that thinking of research as a national or local function makes little sense, and that a global health research system with a global agenda should be conceived instead.

DCP2 identifies areas for future research that require a wide range of tools, from field epidemiology to genomics and from the behavioral sciences to biochemistry. The research agendas discussed throughout DCP2 and summarized in chapter 5 include priorities that are already on the global health agenda and promising topics that should be added to it.

Infectious diseases dominate the priorities that are already on the global health agenda. Many of the research goals address HIV/AIDS, malaria, and TB. These involve research on the epidemiology and risk factors associated with these diseases, with the development of new or better diagnostics, vaccines, and treatments. They also entail research on behavior change and counseling programs and how best to extend effective interventions in low-income and institutionally weak contexts. The absence of a marked departure from previous research priorities for these conditions attests to the complexity of these diseases and their importance in the poorest countries.

Research into the basic science of existing infectious diseases and how they evolve is also necessary to prepare for and respond to emerging infectious diseases. Since 1970, 32 new infectious diseases have been reported, including hepatitis C, Legionnaires' disease, Ebola, Nipah virus, SARS, and particular strains of Avian flu and cholera. Concerns have also arisen about the possible use of infectious diseases for terrorism and warfare.

"Since 1970, 32 new infectious diseases have been reported . . ."

In addition to infectious diseases, another significant part of the global research agenda focuses on maternal and neonatal conditions, an area that necessarily includes significant attention to extending basic health care services. Research on the financing, provision, management, and delivery of health services is central to extending cost-effective interventions. Without progress in this area, meeting international health targets, such as the MDGs pertaining to reducing maternal and child mortality, will be impossible.

"Research on the financing, provision, management, and delivery of health services is central to extending cost-effective interventions."

Regarding priorities as they relate to developing countries that do not yet figure prominently on the global health research agenda, DCP2 emphasizes such conditions as CVD, neuropsychiatric disorders, obesity, diabetes, and cancers, which already cause a large and increasing share of the disease burden in developing regions. DCP2 identifies research priorities for these conditions that focus on gaining a better understanding of the causes of noncommunicable diseases, particularly the effect of diet, lifestyle, obesity, and consumption of tobacco and alcohol; the transfer of knowledge about effective interventions from one context where they have succeeded to other places; and the development of new approaches for managing chronic conditions such as diabetes and depression in ways that improve patients' quality of life and prevent or mitigate further deterioration of their health.

With the growth of basic knowledge of disease and health interventions, opportunities for studying how to adapt successful programs and policies to new contexts increase. For example, many of the successful interventions against noncommunicable diseases that have been developed in high-income countries appear to be feasible in low- and middle-income countries, yet differences in culture, resources, and institutions complicate the transfer of this knowledge. Research can bridge this gap and bring the benefits of these interventions to new places.

". . . many of the successful interventions against noncommunicable diseases that have been developed in high-income countries appear to be feasible in low- and middle-income countries, yet differences in culture, resources, and institutions complicate the transfer of this knowledge."

Finally, health care systems themselves are an important object of research. Identifying institutional arrangements that are more efficient at channeling resources into effective health interventions can reduce waste and improve health. Research may indicate better ways to train and motivate health care workers and design policies to retain highly skilled staff. It can also assess different ways of mobilizing and allocating public financial resources for health and enhance understanding of how incentives encourage or discourage medical innovation.

DCP2's broad review of global health problems indicates an increasing convergence of some health problems between rich and poor countries. Some of this convergence is due to today's more interdependent world, where the speed of travel and commerce implies that the outbreak of an infectious epidemic in one place is of concern to everyone, but it is also due to the shared burden of noncommunicable diseases and injuries. The benefits of research on these conditions cannot be confined by artificial borders, and findings in poor countries are as valuable as findings in richer ones.

Adoption of this global perspective on health research requires promoting and supporting scientific capacity in all countries, making innovative use of technology and institutions to share and build new knowledge, setting global priorities to guide investments in research and development, and supporting the freedom of scientific inquiry (box 7.4).