Elsevier

The Lancet

Volume 382, Issue 9897, 21–27 September 2013, Pages 1060-1069
The Lancet

Health Policy
Redefining global health-care delivery

https://doi.org/10.1016/S0140-6736(13)61047-8Get rights and content

Summary

Initiatives to address the unmet needs of those facing both poverty and serious illness have expanded significantly over the past decade. But many of them are designed in an ad-hoc manner to address one health problem among many; they are too rarely assessed; best practices spread slowly. When assessments of delivery do occur, they are often narrow studies of the cost-effectiveness of a single intervention rather than the complex set of them required to deliver value to patients and their families. We propose a framework for global health-care delivery and evaluation by considering efforts to introduce HIV/AIDS care to resource-poor settings. The framework introduces the notion of care delivery value chains that apply a systems-level analysis to the complex processes and interventions that must occur, across a health-care system and over time, to deliver high-value care for patients with HIV/AIDS and cooccurring conditions, from tuberculosis to malnutrition. To deliver value, vertical or stand-alone projects must be integrated into shared delivery infrastructure so that personnel and facilities are used wisely and economies of scale reaped. Two other integrative processes are necessary for delivering and assessing value in global health: one is the alignment of delivery with local context by incorporating knowledge of both barriers to good outcomes (from poor nutrition to a lack of water and sanitation) and broader social and economic determinants of health and wellbeing (jobs, housing, physical infrastructure). The second is the use of effective investments in care delivery to promote equitable economic development, especially for those struggling against poverty and high burdens of disease. We close by reporting our own shared experience of seeking to move towards a science of delivery by harnessing research and training to understand and improve care delivery.

Introduction

Global health as an endeavour has expanded strikingly over the past two decades and offers great promise to improve lives in resource-poor settings. Broad public interest in the health and wellbeing of people in the developing world, and of poor and marginalised individuals in advanced economies, has grown. Complex diseases recently held to be untreatable, and thus universally fatal in such settings, are tackled with increasing success. Scholarly work on or relevant to global health is also growing rapidly. Funded research is on the rise, focusing principally on basic-science discovery, the development of new clinical resources (preventive, diagnostic, and therapeutic), and more recently evaluation of particular interventions. This focus on technological solutions is a source of great optimism and consistent with the flow of funds that has supported career advancement in academic medicine and in science for the better part of a century. In our view, however, the biggest obstacle facing global health is a failure of delivery. The gritty business of actually delivering health care in developing countries has not attracted much academic interest, even though improving capacity to deliver care in these settings will save lives, leverage substantial and growing philanthropic support of global health, and increase returns on existing and new investments in both discovery and development of new resources.

Knowledge about the delivery of health care to the poor is highly fragmented around narrow topics reflecting funding streams; the design of programmes in the field is often ad hoc, and there are few mechanisms to capture what practitioners learn in the field and thereby add to a shared store of knowledge about effective care delivery in settings of privation. What scant attention to research and teaching of health-care delivery exists is focused on specific questions about particular interventions (eg, the feasibility of administration of a vaccine, and its cost-effectiveness) rather than on the broader systems and conditions. These bottlenecks and barriers—ranging from problems in supply-chain management to an absence of trained personnel to questions of how components of a health system best fit together—are rooted in rapidly changing social context, as opposed to unalterable circumstance, and thus amenable to improvement. All too often, and especially in settings of poverty and social inequality, systems-level improvement does not occur. The price of failing to improve delivery is a worsening of health disparities both local and global. In many such settings, advances in health technologies benefit largely a minority well served by existing health systems.

The present article is a call to harness existing resources and dedicate new ones to the issues of global health-care delivery. We define this term, and the new endeavour it describes, in relation to the existing specialties of health care, global health care, and health-care delivery systems.

Health care is almost too familiar a concept to require definition, but here we emphasise its inclusiveness: the profession of health care includes many subspecialties of clinical medicine (from surgery to mental health, delivered by a broad range of professionals), public health, sanitary and nutritional support, and health infrastructure.

Global health care is understood to mean the provision of a limited set of health services to underserved populations in resource-poor areas of the world. Although this pursuit was for decades termed “international health”, its aspirations limited sharply because of scant resources, we take the term “global” to indicate applicability to the human species as a whole.

By health-care delivery we mean the effective provision of services to people with diseases for which proven therapies exist. This provision is always local. It does a sick person no good to be living in a country with world-class health-care facilities if financial, social, or geographical obstacles render those facilities inaccessible. Rational, inclusive efforts to bring high-quality diagnostic and clinical services within ready reach of populations previously considered (by purveyors of such services or by those setting health policy) too remote, too “backward,” or too poor to make use of them. Considerations of equity and justice, though not always explicitly acknowledged, have a powerful role in expanding access to health services (prevention, diagnosis, and care) to those in great need of them. We here advocate study and improvement of such efforts, and provide clinical, economic, political and moral justifications for the endeavour we call global health-care delivery.

We also believe that this new specialty of global health delivery will lead to innovations that could improve care delivery and outcomes in developed countries, including our own. We will illustrate by drawing on lessons learned in responding to AIDS.

Section snippets

Reconceiving delivery, reimagining global health

The prevailing goal of global health has been to increase access to goods and services that might improve health outcomes. Access to care is not only crucial in view of acute needs; health care planners are under a moral imperative to address disparities in access to life-saving preventives, such as vaccines, and to care for afflictions new and old. But experience since the Alma-Ata Declaration of 1978, with its slogan of “health care for all”, teaches us to look beyond facile notions of ready

A strategic approach to global health delivery

A strategic framework for global health delivery aims to define the core principles that underpin a high-value delivery system and its component parts. It provides a common structure and language to use in accumulating knowledge about delivery. It informs value-based system design, management structures, and operational best practices to be disseminated among those responsible for managing health-care systems as well as to funders and regulatory bodies evaluating new and existing programmes. By

An action research and policy agenda

Many individual elements we have described will be familiar to global health scholars and practitioners. Many lessons have been learned in discrete areas. What we lack is a true field. We need a clearing-house for information about programme design, best practices, lessons learned, synergies, policy constraints, environmental determinants, and other elements of global health-care delivery. In an age of information, the collection of data can run seamlessly from bedside to seminar room and back

Conclusions

Interest in improving health-care delivery for the world's poorest inhabitants is greater than ever. There is a pressing need to define a field of global health delivery and, in so doing, improve health outcomes among those who do not yet enjoy ready access to high-value health care. The future of this field lies in bringing new disciplines, perspectives, and methodologies to bear, including management, anthropology, sociology, epidemiology, and economics and health policy, integrated into

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