Sick Systems – can we achieve RBM and MDG Goals?

The Magazine of the East African has featured a story on “Ailing Reforms,” after reviewing an evaluation of World Bank Efforts to improve health, nutrition and population (HNP) programs. “According to the watchdog, Independent Evaluation Group, while two-thirds of the Bank’s health projects between 1997 and 2007 achieved their development objectives, one-third, mostly in Africa, did not. ‘Overly complicated project designs and weak government capacity contributed to low outcomes,’ Martha Ainsworth, lead author of the report, told the media.”One example of reform, user fees to aid in cost recovery, were found not to have the desired effect.  We have seen this with Antenatal Care in Nigeria’s southeastern Akwa Ibom State where card fees at local government clinics have resulted in less than 20% of pregnant women seeking care, and consequently services to prevent malaria in pregnancy, at these facilities, despite the good compliment of well trained staff.

According to the Evaluation Group, “Contributing factors have been the increasing complexity of HNP operations, particularly in Africa but also in health-reform support to middle-income countries; inadequate risk assessment and mitigation; and weak monitoring and evaluation.” In particular, “Accountability of projects for delivering health results to the poor has been weak.”

The Evaluation Group’s report also offers an important lesson in health system capacity. “In an environment of scarce human resource capacity within the health system, care must be taken to balance the allocation of resources across health programs and budget lines, to ensure that large earmarked funds for specific diseases do not result in lower efficiencies or reduced care elsewhere in the health system.”

Two health systems experts with WHO, Kirigia and Barry, offer further insight into the challenges. They offer the following conclusions:

Effective public health interventions are available to curb the heavy disease burden in Africa. Unfortunately, health systems are too weak to efficiently and equitably deliver those interventions to people who need them, when and where needed. Fortunately, the health policy-makers know what actions ought to be implemented to strengthen health systems. However, it might not be possible to adequately implement those actions without a concerted and coordinated fight against corruption, sustained domestic and external investment in social sectors (e.g. health, education, water, sanitation), and enabling macroeconomic and political (i.e. internally secure) environment.

Kirigia and colleagues also shed light on why user fees may not work in their study of health financing in the African Region. They reported in the East African Medical Journal (2006 Sep; 83(9 Suppl): S1-28) that, “direct out-of-pocket expenditures constituted over 50% of the private health expenditure in 38 countries.” No wonder people don’t want to pay more in user fees!

One of the key reasons malaria eradication failed in the 1950s and ’60s was weak health systems that could not cope with the demands of sustained spraying operations.  Lack of financial, human resource, and political commitments to health systems can doom disease control efforts. Fifty years later, even though we have more malaria control options, we are again confronted with health systems challenges. Donors that don’t address and fund systems issues together with disease control priorities are only asking history to repeat itself.

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