20 May 2000
HEALTH MINISTERS ADDRESS THE MAJOR CHALLENGES FACING HEALTH SYSTEMS
What makes for a good health system? What makes a health system fair? How do we know if a health system is performing as well as it could? The World Health Assembly today considered the results of four roundtables here earlier this week in which ministers identified and discussed ways in which they are designing and strengthening their health systems to respond to the major challenges they face.
While health indicators have improved in most countries, the distribution of good health, both between countries and between population groups within countries, was noted to be far from equal; and in some cases the inequality is growing. The advantages of primary health care were re-emphasized as a fundamental way of building the networks needed to deliver care to the most vulnerable—often the most remote—population groups and offering an effective approach to addressing disparities between population groups.
As the major determinants of health, such as adequate housing, food supply and social security, usually lie beyond the jurisdiction of the health ministry, Ministers repeatedly noted that reforms of their health systems involve many "partner" ministries and agencies, including donor agencies.
While all agreed that health systems must be assessed in relation to the specific context of each country, the Ministers welcomed a new WHO framework for improving health system performance as a critical tool to help identify and shape changes required to improve their health systems.
"Whatever standard we apply, it is evident that health systems in some countries perform well, while other perform poorly. This is not just due to differences in income or expenditure: performance can vary markedly even in countries with similar levels of spending," noted Dr Gro Harlem Brundtland , WHO Director-General, in her message to the WHA. "The way health systems are designed, managed and financed affects people's lives and livelihoods. This new framework brings together the best evidence available to date. It demonstrates that despite the complexity of the topic and the limitations of the data, it is possible to obtain a reasonable approximation of the current situation, in a way that provides an exciting agenda for future work. This new framework will help policy-makers to make wise choices. Substantial gains are possible for all countries and the poor will be the principal beneficiaries."
The new WHO framework focuses on three key goals of health systems.
The World Health Report 2000, to be launched 21 June 2000, analyzes the key functions that health systems need to fulfil in attaining these goals. Four key functions are identified: providing services; generating the human and physical resources that make service delivery possible; raising and pooling the resources used to pay for health care; and most critically, the function of stewardship.
Ministers, in the roundtable discussions, defined their central stewardship (leadership and co-ordination) role to include:
Many difficulties in fulfilling the stewardship role were identified; including,
Financing was identified as a major issue in all countries; especially for developing countries where the national budget is small and there is little or no flexibility in allocating the proportion to be spent on health. Ministers agreed that a fair system can only be developed in relation to a country's specific circumstances and will vary according to such factors as a country's level of poverty, unemployment rate and ability to pay.
While many countries recognised the advantages of cost-sharing, the Ministers noted that introduction of a pre-payment schemes could face a number of obstacles; including: lack of the required experience or managerial capacity, lack of political will, potential conflict with government policies being implemented in other sectors, opposition by health providers and the public, as a result of lack of awareness of its benefits.
A major discussion centred on the desirability of competition among health care providers. Many Ministers noted that competition has lead to fragmentation and duplication of services, poor sharing of information and friction in competing for scarce resources. Concerns were raised that competition might block improved health system performance, which requires collaboration among all providers, both public and private, based on clearly defined priorities.
Generating human and physical resources
Acknowledging the vital importance of developing human resources if the quality of health service delivery is to be improved, the Ministers noted that hurdles include difficulties in recruitment and retention of staff, suboptimal distribution of staff functions, and inadequate staff training and education.
Decentralization of service provision, including overall authority, budgetary control and personnel management, was identified as a key factor in increasing access of the population to health care, particularly at district level. All agreed that evidence-based measures of performance should be used to decide on and to monitor clinical interventions.
Support from WHO
The Ministers identified ways in which WHO could support the development of health systems both globally and at a national level.
At a global level, WHO should:
At a national level, WHO should:
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