Chapter 7: Health Systems: principled integrated care
Principles in a systems perspective
This report reinforces an important conceptual shift towards the model of health systems based on primary health care. In a systems perspective, the potential conflict between primary health care as a discrete level of care and as an overall approach to responsive, equitable health service provision can be reconciled. This shift emphasizes that primary health care is integrated into a larger whole, and its principles will inform and guide the functioning of the overall system.
A health system based on primary health care will:
- build on the Alma-Ata principles of equity, universal access, community participation, and intersectoral approaches;
- take account of broader population health issues, reflecting and reinforcing public health functions;
- create the conditions for effective provision of services to poor and excluded groups;
- organize integrated and seamless care, linking prevention, acute care and chronic care across all components of the health system;
- continuously evaluate and strive to improve performance.
Intervention across the disease continuum is needed to achieve the comprehensive care envisaged by such a system. To deal with the increasing burden of chronic diseases, both noncommunicable and communicable, requires upstream health promotion and disease prevention in the community as well as downstream disease management within health care services. Two integrated health care models, the chronic care model and its extension -- WHO's innovative care for chronic conditions framework -- promote primary health care concepts: intersectoral partnerships, community participation and seamless population-based care. Evidence supports the use of these integrated models as a means of implementing primary health care principles, with demonstrated reduction in health care costs, lower use of health care services, and improved health status (6,9).
Linking expanded HIV/AIDS treatment and health care systems development is a crucial challenge. No blueprint exists, but valuable examples are emerging. Since May 2001, Médecins Sans Frontières has provided antiretroviral therapy for HIV/AIDS through primary health care centres in the township of Khayelitsha, South Africa (10). The delivery of HIV/AIDS treatment in a primary health care setting underscores the potential for integration of different types of care and begins to show how scaling up treatment could fit into -- and help drive -- an overall strengthening of health care systems based on primary health care principles. The Khayelitsha antiretroviral programme uses a nurse-based service model and relies on strong community mobilization for peer support. It has shown that HIV/AIDS treatment can be rolled out most effectively if:
- the entire health system is mobilized and HIV/AIDS treatment activities are integrated into the basic package of care;
- treatment services are decentralized to ensure coverage and community involvement;
- treatment and care are part of a "continuum of care" supported by a facility-linked home-based care system and a referral system.
The additional resources that must flow into countries' health sectors to support HIV/AIDS control efforts, including "3 by 5", can be used in ways that will strengthen health systems horizontally. Developing context-specific strategies to achieve this will be part of WHO's technical collaboration with countries. Similarly, if the recommendations of the Commission on Macroeconomics and Health for large increases in global investment in health are followed by the international community, the coming years will offer a crucial opportunity for development of health systems that are led by primary health care.
Enormous obstacles to the scale-up of health systems based on primary health care persist. In some countries, violent conflicts and other emergencies have seriously damaged health systems (see Box 7.3). Multiple forms of inefficiency undermine systems, such as government health expenditure disproportionately devoted to tertiary care and programmes that do not focus on a significant burden of disease (11). Lack of financial resources remains a fundamental problem. Total health expenditure is still less than US$ 15 per capita in almost 20% of WHO Member States. In many countries, especially the poorest, people in need of treatment for themselves or their families still pay for the bulk of health services out of pocket.
Box 7.3 Rebuilding Iraq's health sector
The Gulf War of 1991 and the economic sanctions marked the start of the decline of a health care delivery system that had been a model for the region during the 1980s. Health indicators dropped to levels comparable to some of the least developed countries: in 1996, infant, child, and maternal mortality rates were estimated at 100/1000, 120/1000, and 300/100 000 live births, respectively, a twofold increase over 1990 levels. The Oil for Food programme brought a relative improvement of the health of Iraqi people, although still far from pre-1990 levels. Health outcomes are now among the poorest in the region.
Iraq is below the regional average in terms of physicians to population (5.3 doctors per 10 000 population in 2002); there are too many specialists but too few primary health doctors and nurses. Following the 2003 war, the health infrastructure, which had suffered from years of disrepair, was further weakened by the widespread looting, inadequate electricity and water supply, and institutional instability.
The pre-2003 war health system was hospital-based and driven by curative care, and did not respond adequately to health needs. The challenge for Iraqi policy-makers and the donor community is to re-establish basic services in the short term while transforming the inefficient and inadequate health services to a system based on primary care, prevention, and evidence-based policy. The new system should tackle the disease burden faced by Iraq's people and be affordable within the available envelope of public finance.
Major challenges face the health sector: limited capacity of the Ministry of Health (and health directorates in governorates) to undertake essential public health functions; lack of a package of health services that includes catastrophic care in the event of emergency and diagnostic and laboratory facilities; external brain drain of human resources; lack of an information system for informed decisions at the policy and implementation levels; inadequate financial resources and unclear mechanisms for smooth flow of funds to meet the investment and operational costs of the system; and the need for improved coordination among all stakeholders in health to optimize donated resources.
Senior staff from the Ministry of Health, officials from the Coalition Provisional Authority, and representatives of organizations of the United Nations system, nongovernmental organizations and donors met in Baghdad in August 2003 to determine immediate and medium-term priorities to enable the health sector to provide health services that are accessible, equitable, affordable and of adequate quality.
Re-establishing the functioning of the health sector to pre-war levels requires funds for salaries and other priority recurrent expenditure. It is estimated that Iraq's financial requirements for health services in 2004 -- from government and donor sources -- will be in the order of US$ 0.8--1.6 billion (or US$ 33--66 per capita). Assuming a sustained and increasing income, the projections for the period 2004--2007 are in the range of US$ 3.7--7.8 billion, which at the end of the period translate into a per capita public expenditure of US$ 40--84. Forecasting economic performance, fiscal capacity and donors' willingness to sustain Iraq for the period 2004--2007, however, is an exercise fraught with difficulties.
All efforts to improve health care systems in developing countries must confront several main challenges: workforce development and retention; health information management; financing; and government stewardship within a pluralistic health landscape. The remaining sections of this chapter consider these topics. Systems face difficulties in numerous other areas as well, but all four of these problems demand urgent action in order to scale up the system to meet health targets. If constraints in these areas are not overcome, little progress will be made in improving access to care among the poorest.