Elsevier

The Lancet

Volume 364, Issue 9437, 4–10 September 2004, Pages 900-906
The Lancet

Public Health
Overcoming health-systems constraints to achieve the Millennium Development Goals

https://doi.org/10.1016/S0140-6736(04)16987-0Get rights and content

Summary

Effective interventions exist for many priority health problems in low income countries; prices are falling, and funds are increasing. However, progress towards agreed health goals remains slow. There is increasing consensus that stronger health systems are key to achieving improved health outcomes. There is much less agreement on quite how to strengthen them. Part of the challenge is to get existing and emerging knowledge about more (and less) effective strategies into practice. The evidence base also remains remarkably weak, partly because health-systems research has an image problem. The forthcoming Ministerial Summit on Health Research seeks to help define a learning agenda for health systems, so that by 2015, substantial progress will have been made to reducing the system constraints to achieving the MDGs.

Section snippets

Previous efforts to improve delivery of priority services

Many of the current global initiatives to achieve the health MDGs have strong service-specific or disease-specific foci (table 1). Service delivery arrangements are sometimes described in terms of vertical or horizontal approaches. Vertical approaches use planning, staffing, management, and financing systems that are separate from other services, whereas horizontal approaches work through existing health-system structures. In reality, in many low-income countries, few interventions are

Constraints currently faced by health systems

Table 2, which uses a framework developed by Hanson and colleagues,10 illustrates some of the major constraints to improving service delivery identified in reviews by major global health initiatives. A wide range of frameworks and instruments were used for these reviews; from short, structured checklists to detailed questionnaires and quantitative approaches to assessing barriers.10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20 The reviews largely focus on constraints within the government system,

Parallel approaches

As discussed above, programmes specific to a service or disease can work in more or less vertical ways to achieve their goals. For example, several global initiatives are concerned with making good quality pharmaceuticals available to health facilities in a timely and reliable manner. This goal might be achieved through development of new and parallel pharmaceutical procurement and distribution systems, or by strengthening the existing pharmaceutical management system to meet the needs of all

Taking a system-wide perspective

As we have discussed, the system barriers identified by specific initiatives and programmes are rarely unique to their own focal disease, and the discourse of some global initiatives (such as Stop TB and 3 by 5)16 emphasises their need to take heed of the broader health-system context, and to contribute to overall system strengthening. For example, service-specific or disease-specific programmes may work with human resource planners at the ministry of health to increase the supply of nurses

Accelerating achievement of MDGs through improved knowledge on how to strengthen health systems

Disease or service-specific strategies to strengthen health systems on their own are unlikely to bring about the improvements in health systems needed to achieve the MDGs. Similarly, use of an intervention-specific or disease-specific lens to define the research agenda for health policy and systems serves to generate much useful knowledge,26 but on its own is incomplete. Such an approach must be complemented by a substantial additional body of knowledge and action that takes the functioning of

Advancing the learning agenda

If the case for greater learning about health systems is so strong, then why does health policy and systems analysis fail to get more support? Two examples illustrate the extent of the problem. An analysis by the Alliance for Health Policy and Systems Research reported that health-system research may attract only 0·007% of total health expenditure in low income countries.32 And only 48 of WHO's 1100 collaborating centres report a health systems research and development focus (Panisset U,

References (34)

  • The Lancet

    Kickstarting the revolution in health systems research

    Lancet

    (2004)
  • A/RES/55/2: United Nations Millennium Declaration: resolution adopted by the General Assembly. 55/2. Sept 18,...
  • World Bank

    The Millennium Development Goals for health

    Rising to the challenges (draft)

    (2003)
  • MA Clemens et al.

    The trouble with the MDGs: confronting expectations of aid and development success: working paper number 40

    (2004)
  • LC Chen

    Harnessing the power of human resources for achieving the MDGs

    (2004)
  • WHO

    High-level forum on the health MDGs

    (2004)
  • Knowledge into action for child survival

    Lancet

    (2003)
  • WHO

    World Health Report 2004: changing history

    (2004)
  • Declaration of Alma-Ata. International conference on primary health care, Alma-Ata, USSR. September 6–12,...
  • JA Walsh et al.

    Selective primary health care: an interim strategy for disease control in developing countries

    N Engl J Med

    (1979)
  • K Hanson et al.

    Expanding access to priority health interventions: a framework for understanding the constraints to scaling-up

    J Int Dev

    (2003)
  • Atun RA, Lennox-Chhuggani N, Drobniewski F, Samyshkin YA, Coker RJ. A framework and toolkit for capturing the...
  • Atun RA, Samyshkin YA, Drobniewski F, et al. Health system barriers to sustainable tuberculosis control in the Russian...
  • A Soucat et al.

    Marginal budgeting for bottlenecks: a new costing and resources allocation practice to buy health results

    (2002)
  • L Freedman et al.

    Millennium project: interim report of task force 4 on child health and maternal health: United Nations Development Group

  • WHO department of child and adolescent health and development

    Progress Report May 2002–April 2003: multi-country evaluation of IMCI effectiveness, cost and impact (MCE): (WHO/FCH/CAH/03.5)

    (2003)
  • WHO

    Report on the meeting of the second ad hoc Committee on the TB epidemic: recommendations to stop TB partners

    (2003)
  • Cited by (0)

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