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Inadequate healthcare systems in low-income nations contribute significantly to their poor health outcomes. Doing better, however, will require difficult reforms that not only deal with resource limits, but also with the political, managerial and technical factors that inhibit service delivery. Helping with that will require the international community to shift its focus to longer time horizons and less glamorous reform priorities.
Poverty itself is detrimental to nutrition, living conditions, clean water supply and sanitation. Moreover, the poorest governments cannot afford even inexpensive and effective interventions, such as immunizations and basic primary care. International donations and aid have been expanding recently, and must continue to do so. But increasing inputs to poor countries—whether drugs, staff training or money—will not improve health unless the systems using those resources are strengthened significantly. And that means addressing the interconnected political, managerial and organizational weaknesses of those systems, a reality which will require three other essential steps.
Foster political reform: When poor nations’ political leaders tolerate (or support) patterns of public sector corruption and patronage, they significantly undermine service delivery. Interested stakeholders (such as drug companies) can also exert pressures that hinder effective policymaking. Reforms that enhance political competition, accountability and responsiveness are therefore steps in the right direction. They are not a panacea: political competition can produce populist irresponsibility. Nevertheless, improving health systems requires a shift in focus from patronage to better customer service—and leaders who have reasons to make such efforts.
Improve management: Managers appointed through patronage and corruption generally lack the training, incentives, motivation and authority to make public healthcare systems work effectively. They often lack even the most basic clinical and financial information required to track and improve performance. As a result, the workers they supervise become cynical and unmotivated; theft, demands for bribes and absenteeism become commonplace.
Better management could significantly improve the performance of most public systems, even within the limits of their existing resources. This, however, will require radical changes in managers’ selection, training, incentives and authority. Where such changes are not possible politically, it may be sensible to shift some functions to quasi-autonomous public agencies that are freed of some legal constraints and political interference, or even to contract with the private sector to carry out certain tasks.
Expand knowledge to improve policymaking: Research on and understanding of effective health sector policies in low- and middle-income countries is surprisingly limited. Case reports often involve more advocacy than science. Critical compilations of the available evidence, like those done for clinical medicine, could be quite helpful.
If the international community is to help poor nations provide better healthcare, it has to do more than send over drugs (which are often stolen) or build health centers (that remain unstaffed and unused). Programs need to be better coordinated. Nations need to respond to long-term, often unglamorous needs (like management training and research on the effectiveness of alternative program designs) that do not provide attractive “photo ops.” They also need to continue to push for democratization, even in countries whose “strong men” support their economic interests or geo-political ambitions. We do not know all we need to know to improve healthcare in poor counties, but we do know enough to do much better than we are doing now.
Vast regional differences exist in spending as a percentage of GDP around the world. In addition to regional averages, this map includes snapshots for a sampling of nations.
© 2010 Scientific American,
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