Chapter 7: Health Systems: principled integrated care
Pro-equity health systems: government's central role
If a key responsibility of the health system is to narrow health equity gaps -- a fundamental principle of primary health care -- then a criterion for evaluating strategies in workforce development, health information, financing strategies and other areas must be the degree to which these strategies are pro-equity.
The mutual reinforcement of poverty and ill-health is increasingly well understood, and there is growing evidence of how unequally and inequitably resources, efforts and outcomes are distributed. Benefit incidence studies consistently show that people living in poverty receive less than a proportional share of public funding for health, relative to the better-off (51,55). Income is not the only relevant factor. Poverty is fundamentally a condition in which individuals lack the capacities required to satisfy their needs, fulfil their aspirations and participate fully in society (56). Hence, the lack of political empowerment and education are factors in the exclusion of people from health care. Gender, racial and ethnic discrimination contribute significantly to inequities in health and in access to health care services.
Policies that improve a country's aggregate health indicators are not necessarily fair or pro-equity. Where countries have succeeded in improving health outcomes and reducing inequity, health system development policies have had to "swim against the tide", explicitly countering the bias to serve the better-off first (57,60). Whatever the specific configuration of a country's health sector, effective stewardship of the whole health sector by the government -- including supervision, monitoring and enforcement of health policies -- is vital, if pro-equity outcomes are to be achieved (61).
Patterns of inequitable access to care
Pro-equity health care strategies will vary by context. The key difference concerns the pattern of inequitable access to care, which takes three distinct forms. In the poorest countries, the pattern can be characterized as mass deprivation -- the majority of the population has equivalent but deficient access to health care services while a small privileged class finds ways to obtain the care it needs. In somewhat better-off countries, such inequities can be described as queuing -- general access to health services is better, but middle-income and upper-income groups benefit most, while poorer groups must wait for a "trickle down" effect. In some countries, inequities take the form of exclusion whereby the majority of the population has reasonable access to services, but a poor minority of the population is deprived. These patterns can be visualized by considering the percentage of births that occur in a health facility (as a proxy for general access to health services) by income quintile (see Figure 7.3).
The manner in which systems based on primary health care develop will vary across these differing contexts. In some cases, programmes targeted at specific population groups are urgently needed to achieve pro-equity outcomes. In other instances, broad strengthening of the whole system is the priority. These two approaches can also be combined.
In countries characterized by exclusion, targeting will probably be needed to combat social inequality and inequality in access to health services. Such a strategy might apply to middle-income and low-income countries such as Chile and Uzbekistan, but it is also appropriate in wealthier countries in which marginal populations remain excluded from otherwise universal services because of discrimination by race, ethnicity or gender, income poverty, or social stigmatization. Progress will not take place without government action, either through the provision or payment of services, or the design of appropriate incentives to the nongovernmental sector. Examples of targeting include recent efforts in Chile and New Zealand to make health services more culturally appropriate and accessible to indigenous populations (62), as well as an Australian programme to strengthen primary health care among the indigenous people of the Tiwi Islands (see Box 7.8).
Box 7.8 Community health reforms in the Tiwi Islands
The remote Tiwi Islands are located 60 km north of the Australian coast in the Arafura Sea, with a population of over 2000 consisting mainly of indigenous people. Unemployment is high and housing conditions are generally of low quality. Very high rates of chronic conditions have been recorded, especially diabetes and renal and respiratory tract conditions. In 1997, the Australian Commonwealth and Territory governments negotiated with the community-based Tiwi Council to reform existing primary health care services, through a Coordinated Care Trial with four broad objectives:
- to achieve Tiwi community control of health services, through the establishment of an area health board to administer pooled health sector funds;
- to improve the effectiveness of preventive measures based on local participation in community programmes;
- to improve the quality and effectiveness of health services, through the use of increased resources for a mix of primary coordinated care and population-based health services;
- to improve the standard of care according to best practice guidelines and protocols.
The trial ran for three years. Health outcomes could not be measured in this short phase, but process measures of success were achieved (63), including:
- community control, by the establishment of the Tiwi Health Board, which now determines health policy and expenditures;
- increased community awareness of health issues among Tiwi islanders, and greater community input into service delivery;
- improved prevention services, especially those tackling urgent local problems;
- increased number and improved quality of primary health services;
- reduction in avoidable hospitalization.
Three types of targeting strategies have been commonly used: direct, characteristic and self-targeting. They are not mutually exclusive and are, in fact, often employed in combination. Direct targeting seeks to provide benefits only to the poor. One approach is to waive the cost of care for individuals who cannot afford to pay. Implementing this strategy requires means testing (assessment of the patient's financial capability). Waivers reliant on means testing demand substantial administrative capacity. Governments can also make direct conditional cash transfers to poor families to reward household behaviour change, such as bringing children to health centres for regular check-ups. Again, this requires considerable institutional capacity. In parts of Latin America, such approaches have increased participation in preventive health care (64).
Characteristic targeting attempts to benefit particular groups of poor people based on specific attributes that cause further deprivation. Criteria can include geographical location, gender, ethnicity, particular diseases (for example, HIV/AIDS), or other factors. Self-targeting relies on the better-off to opt out of services perceived to be of low quality. Such services may involve greater waiting time or a poorer service environment.
Countries and areas characterized by the queuing pattern of inequitable health care access include Turkey and the wealthier states and provinces of China and India. In such settings, pro-equity policies have to find the right balance between efforts to build on and expand the existing institutions of health care, effectively reducing the barriers that lead to queuing, while identifying and targeting those groups that would otherwise be excluded without special attention. Again, active government participation is required.
In 2001, Thailand began a programme to extend universal health insurance coverage to those without access to health services. Under the new programme, dubbed the "30 baht health plan", people register as patients with local health care providers and can then obtain all needed medical care for a co-payment of 30 baht (about US$ 0.35). The system is financed jointly from taxes and contributions by workers and employers, while health care providers are reimbursed on a capitation basis. The programme is not without its problems, but still represents a bold effort to confront health inequities (65). Another successful attempt to expand coverage to the poor was the health insurance reform in Colombia in the mid-1990s. Between 1995 and 2001 the number of contributors to the mandatory health insurance system was expanded from 9.2 to 18.2 million people. At the same time, the system was reformed so as to explicitly cross-subsidize the poor and unemployed. In 1995, 3 million people benefited from these cross-subsidies; by 2001 their number had grown to 11 million. Thus, millions of non-contributing individuals gained access to roughly the same package of benefits as those who made the contributions, in the public or private facility of their choice, and in the same way as those more affluent citizens who regularly contribute (66,67).
Countries with mass deprivation represent the greatest challenge of all. In such countries, most of the population is deprived of health care, with only the richest able to buy it. To speak of "targeting" in such circumstances is not useful. The main effort is best characterized as "scaling up", meaning overall extension and strengthening of the health system. Countries in this category need rapid expansion of outreach and extension of primary care facilities and hospitals, along with increased investments in other sectors such as education, water and sanitation. Redressing geographical and rural--urban imbalances can often go a long way towards accelerating progress in these countries. But the limited scale of public resources also requires innovations that build on and support local and community participation and the activity of the nongovernmental sector, as implied by the principles of primary health care.
Some innovative approaches have succeeded in extending health care to poor people despite resource, infrastructure and workforce constraints. In its Expanded Programme on Immunization, Bangladesh for example, used outreach programmes in rural areas and enlisted the active nongovernmental sector for service provision in urban areas to effectively bridge both the infrastructure and human resource gap (68). Scaling up was combined with prioritizing service delivery to rural areas and the poor and, as a result, considerable advance was made in reducing infant mortality rates. However, this intervention could not be accompanied by a complementary increase in attended births as this requires a very different approach to service delivery -- infrastructure requirements are greater as are the required facility staff skills. Both of these necessitate substantial additional resources as well as the capacity to use them effectively. This underscores the point that, while responsible government stewardship is vital to pro-equity health improvement, major gains cannot be achieved in countries confronting mass deprivation without substantially increased international support.
The goal: universal access
An approach to the development of health care systems driven by primary health care must aim at universal access to quality health care services. Speeding the historical movement towards universal coverage will ensure that general health systems improvement does not mask -- or contribute to -- widening health inequalities.
There are many obstacles to this goal, including limitations in financial resources, education and skilled personnel. But strong stewardship plays a significant role in dealing with these constraints. How rapidly countries advance towards universal coverage depends on whether governments accept a situation in which health benefits gradually trickle down from the rich to the poor, or whether they accelerate actions to ensure a fair distribution of health care resources and benefits to all social groups.
Government stewardship, community involvement
Responsible health sector oversight and pro-equity commitments by the state are essential to building and maintaining health systems based on primary health care. However, governments must engage with and respond to communities in a two-way relationship if they are to perform their stewardship role effectively. Community involvement -- including the dimensions of participation, ownership and empowerment -- is a key demand-side component of the health system, necessary to promote accountability and effectiveness.
The Declaration of Alma-Ata acknowledged the importance of community involvement in defining health objectives and implementing strategies. The declaration affirmed that "people have the right and duty to participate individually and collectively in the planning and implementation of their health care" (3). However, the concept of community participation was not easy to put into practice. In some cases, such participation emerged as a crucial factor in improving the performance of health systems. At community-owned health centres in Mali, for example, the fact that communities paid the salaries of health centre staff led to dramatic changes in the way nurses related to their clients (69). In a Sudanese village, a community-driven project has generated income and strengthened social capital -- with positive implications for health (see Box 7.9). However, all too often "community participation" has been limited to setting up health committees that acted as vehicles for cost recovery. Indeed, in some countries in west Africa, the term "community participation", applied in the health field, became synonymous with "co-payment".
Box 7.9 Building partnerships for health in Sudan
The Sudanese Basic Development Needs (BDN) programme was introduced in 1998 in Kosha, a remote village in Northern State with a population of around 2500. A needs assessment survey undertaken there showed multiple social, economic and health problems. A great majority of households had no latrines and 99% of the population used water directly from the river. Many pregnant women suffered miscarriages perhaps because of the strain of carrying water. Poor sanitation and hygiene resulted in many health problems, especially diarrhoeal diseases, malnutrition and eye infections. Vaccination coverage for children and mothers was very low and there was little practice of family planning methods, although the fertility rate was among the highest in the country. Most of the people were extremely poor and unemployment was very high.
Shortly after the introduction of the BDN programme, significant changes were recorded in the lives of this population. The community itself has rehabilitated the health centre, financially supported the medical assistant, and adopted self-financed community health insurance through the community development fund. All households now have access to safe water indoors, and over 60% of houses have sanitary latrines. This has resulted in a marked improvement of health indicators and a reduction in common diseases (diarrhoea, acute respiratory infections, malaria and dysentery), increased coverage of vaccination and antenatal care, and a reduction in the malnutrition rate to less than 1%.
The participation of local people in these matters has produced other positive changes: the enrolment of girls and boys in school has increased and adults have also participated in informal literacy classes; a nursery school has been established; and the youth social club has been renovated. Moreover, a women's committee has been formed to initiate and support activities related to development of women's status. The income of a majority of families has greatly increased through the cultivation of vegetables and fruit trees, with the assistance of small loans from the village development committee. The village now has electricity, enabling the community to acquire television and satellite for evening entertainment. In addition to WHO, the community has managed to build strong partnerships with UNICEF, UNFPA, the Government of the Netherlands, the Canadian International Development Agency, local government and many nongovernmental organizations.
The success of Kosha village has inspired five neighbouring villages to organize themselves, without any intervention from the national programme. Two of these villages have already completed the baseline survey and the training of community organizations using their own resources. The population of Kosha village itself is confident that it can continue to make improvements in health and quality of life through sustained self-help and self-reliant interventions.
Recent years have seen a move away from narrow definitions of community and community participation (through health committees, for example) to a wider view based on the involvement of civil society organizations. Such organizations are highly diverse. They may manage or co-manage health facilities (as the Federation of Community Health Associations does in Mali), promote self-help and self-reliance, act as champions of forgotten or excluded groups (as in the case of organizations of people living with HIV/AIDS), or practise consumer protection (like Thailand's Consumer Foundation).
One of the key roles of civil society organizations is to hold health care providers as well as governments accountable for what they do and how they do it. Where civil society is active, organizations can monitor government policy choices and practise advocacy. As stewards of the health system, ministries of health are responsible for protecting citizens' health and ensuring that quality health care is delivered to all who need it. This requires making the best choices given the available evidence, and systematically privileging the public interest over other competing priorities. This responsibility ultimately rests with governments, even in a context of decentralization where lines of accountability may be blurred. Yet without mechanisms enabling people to hold officials accountable, stewardship may falter. To enable effective pressure for accountability, accurate information about health and health systems performance is required throughout civil society. Government should make such information public and accessible. The Mexican Secretariat of Health, for example, has published a comprehensive, user-friendly overview of the country's state of health and of the performance of the health system (70). Civil society groups themselves, in their watchdog function, also generate and share information for accountability. This has been the case with Thailand's National Forums for Health Care Reform (71).
When the right structures are in place, effective governance and vigorous community involvement support each other. Participatory budgeting in Porto Alegre, Brazil, offers an example of consensus building with the community in what is usually a mainstream government activity. Initiated in 1988, the process is now substantially consumer driven, with the implementing agency accountable to its clients. Matching expenditure allocations to needs expressed by the community has produced measurable improvements in access to social services (72).
Realizing genuine community involvement requires overcoming numerous obstacles. Two issues are particularly constraining. First, communities, especially poor rural ones, may be unaware of the mechanisms for involvement. Second, relatively wealthy and more influential social groups can often dominate political processes at community level, again particularly in rural areas. When the better-off are allowed to "represent" the whole community in planning and implementation discussions, relatively affluent groups can absorb benefits at the expense of poor groups. Both these patterns restrict the capacity of poor people to participate fully in processes designed to foster community involvement in the health system. Implementing policies to overcome these obstacles is a key aspect of government stewardship in health.