Health system matters

IN 1978, 134 countries, 67 international organizations and many non-governmental organizations participated in an international conference at Alma-Ata, now Almaty, in Kazakhstan, and came up with the Declaration of Alma-Ata.

The declaration reaffirmed the World Health Organization (WHO) definition of health—a state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity. This argued that attainment of the highest possible level of health requires the action of socioeconomic sectors, in addition to the health sector.

The Alma-Ata declaration deemed inequity as unacceptable and health as a human right, thus called for "Health for All." From a limited perspective of service delivery—a world only of doctors and hospitals—health was now viewed as an outcome borne out of systematic actions from several actors and stakeholders. Just as it takes a village to raise a child, it takes a health system to ensure health for all.

The WHO defines a health system to consist of all organizations, people and actions whose primary intent is to promote, restore or maintain health. This includes efforts to influence socioeconomic determinants of health, as well as more direct health-improving activities. It is more than just public hospitals and health-care facilities delivering personal health services. It includes mothers taking care of their sick children, indigenous peoples seeking treatment from traditional healers, and private hospitals and health-care professionals, private and government health-insurance organizations. It includes the Department of Social Welfare and Development making vaccinations and facility-based deliveries as conditions for cash transfers and the Department of Education promoting oral hygiene and hand washing.

The World Bank (WB) states that individuals and organizations, whether public or private, who are regulators, recipients, purchasers, or providers of services and supplies, are all parts of the health system. These many parts are always inter-connected by the key functions of the health system, which are oversight of the whole health system, health-service provision and promotion, health financing, and management of health-related resources, such as pharmaceuticals, medical equipment and health information.

The attainment of health for all, or universal health coverage, thus requires transformation of all the parts of the health system. The WHO explains this as working on the six building blocks, which are as follows: improving health-service delivery; ensuring responsive health work force; setting up functional health-information systems; expanding access to essential medicines; appropriate health financing; and instituting strong leadership and governance.

Similarly, the WB talks about health-system control knobs, and that transformation of health systems would entail finding the right balance of up to where to move each of the control knobs. It means actions on the five control knobs of organization, financing, provider payment, regulation and persuasion.

Both frameworks are consistent with each other, as both challenges countries to do systematic reforms and not just piecemeal, silo-based and limited changes. Until countries start fully realizing that health system matters, the reforms will not be transformational.

In the next months, I will be describing how the Philippines and other countries in Southeast and East Asia and probably the rest of the world are reforming their respective health systems. We will look into how the Philippines and other countries are working to strengthen the building blocks and to find the appropriate mix of the control knobs.

We will look into where we are as to addressing the traditional public-health diseases of tuberculosis and malaria and the other emerging disease, such as dengue and HIV/AIDS. But beyond the usual number of cases, we will assess how various health-system interventions have contributed (or not) to addressing these public-health problems.

We will explore the role of the private sector—from hospitals to ambulatory health facilities, private physicians, pharmaceutical companies and health maintenance organizations in the reforms. We will delve into the role of development partners, bilateral and multilateral agencies in the reforms. We will discuss how public financing, be it from budget or health insurance, is changing behaviors and practices; look into how primary and preventive care and devolution are ensuring access and affordability of services; and many other stories of health system reforms.

Alma Ata correctly diagnosed that health for all needs changes from all of us. And for us to attain the dream of "Health for All," we need all parts of the health system to be transformed.

(source: businessmirror.com.ph)