April 2013 SciDev Net; Despite much effort and some progress, many low- and middle-income countries (LMICs) are struggling to improve the health of their populations and are missing the targets of the health-related Millennium Development Goals (MDGs).
For the most part, global agencies supporting these countries are injecting funds into a few priority programmes, such as malaria control. There appears to be an underlying rationale — implicit or explicit — that it is either not important or too difficult to attempt to resolve the weaknesses of the health systems within which these programmes then operate.
But a country’s health system is an essential base that supports all health programmes. History suggests that, apart from special cases where the nature of a disease makes eradication feasible (suchas smallpox), insulating health programmes from their context and the systems in which they function does not lead to sustainable success.
No quick fixes
One example is the failure to replicate in Sub-Saharan Africa the eradication of malaria in North America and parts of Europe. Weak health systems are among the reasons why efforts have failed.
And some of the problems for polio eradiation in the most challenging regions seem to be related to contexts and systems rather than technical procedures.
Sometimes, ‘strengthening health systems’ is added as a secondary objective when it is recognised that these selective or ‘vertical’ programmes do indeed rest on weak health systems.
But actions are often of the ‘quick fix’ variety. Buying and distributing cars, renovating health centres or donating some computers are typical of ‘strengthening’ approaches by international development partners and donors, private foundations and even country governments.
Providing these often desperately needed inputs is not bad in itself. But to label them as ‘systems strengthening’ shows a fundamental lack of understanding of the nature of health systems
The complex nature of health systems means they can only be fully understood by appreciating the relationships and connections among their parts.
Health systems are constantly self-organising and adapting, based on experience. Intervening in one part of the system will almost always have ripple effects — so a quick fix can become part of the next generation of problems.
An example is Ghana’s introduction of an allowance for additional duty hours as a response to low salaries for health workers. The result was almost a decade of industrial unrest and escalating bills. And eventually, the comprehensive salary reform that decision-makers tried to avoid had to be introduced.
Side-stepping weak health systems is like picking low-hanging fruit: as it is harvested, the more obvious it becomes that higher branches are bending under the burden of un-harvested crop.
I remember my frustration as a district medical officer that mass campaigns for childhood immunisation were leading to wide swings in coverage from year to year, rather than a sustained high level of coverage. It was only after integrating immunisation into routine services and investing in strengthening these systems that we began to document a steady, slow rise towards the goal of 80 per cent coverage.
Following the money
Countries are responsible for developing their own health systems, and rightly so. But governments of poor, donor-dependent countries are influenced by their financiers.
Much as the financial support is needed, large amounts of funding for disease priorities can sometimes so dwarf a poorer country’s own financing mechanisms that investment in health systems can be overpowered by disease-specific priorities.
For example, a relatively well-funded HIV/AIDS programme may attract considerable human and other resources to maintain its targets — such that a woman with HIV who survives a pregnancy by taking the latest antiretroviral drugs may die because of a lack of midwives or emergency obstetric services.
Balancing the priorities
Admittedly, LMICs do not have enough resources, even with aid, to deal with all priorities for strengthening health systems. But, several decades of experience with the selective approach suggests that it is not the solution, either.
To move forward, a third way is needed: a two-pronged approach that addresses health systems issues in their own right alongside the specific programmes that rest on this common foundation.
As a first step, global health agencies could agree to pool a certain percentage of their funds in joint programmes to strengthen the health systems that are undermining goals in many countries. Ideally, every dollar that goes to a selective intervention should be matched by a dollar on systems strengthening.
Simply increasing funding will not necessarily strengthen health systems — other capacities, such as science and leadership are also necessary. But finding a way to develop health systems will help balance priorities locally to improve global health. Let us look for that third alternative now.