Strengthening Health Systems in Developing Countries

Many statements such as the Alma Ata Declaration¹ and Millennium Development Goals,² have called on the global community to commit to addressing global health inequities that especially affect poor countries. There has been an increase in resources from donors to combat global epidemics, including the Global Fund for AIDS, Tuberculosis, and Malaria, the President’s Emergency Fund for AIDS Relief (PEPFAR), the Clinton Foundation, and the Bill and Melinda Gates Foundation. However, despite this increase in resources, the need for an increased investment in the expansion of health programs is essential, and treatment expansion efforts have been slowed by insufficient health infrastructure.^3–7

Health worker shortages and weak health systems have led to a lack of preventive and curative health care services and health promotion programs, making it unlikely the world’s poorest countries can achieve the Millennium Development Goals.^8,9 Global climate change will have a disproportionate effect on health in developing countries, and strengthening health infrastructure is crucial for effective climate change adaptation. The American Public Health Association (APHA) recognizes that health systems encompass curative, preventive, promotion, and rehabilitative health care services and that health is defined broadly under the World Health Organization (WHO) definition as a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.

The health systems in countries throughout the developing world suffer from insufficient financial and human resources, limited institutional capacity and infrastructure, weak health information systems, lack of comprehensiveness, embedded inequity and discrimination in availability of services, absence of community participation, lack of transparency and accountability, and a need for management capacity building.^10–12 WHO estimates that 4 million additional doctors, nurses, midwives, and support workers are needed globally to be able to provide 80% of essential care,¹³ and a continued source of the depletion of human resources in developing countries is the international recruitment of health professionals to the United States and other industrialized countries.¹⁴

APHA seeks the development of health systems grounded in the human right to the highest attainable standard of health.¹⁵ To be consistent with the right to the highest attainable standard of health, health systems must be effective, integrated, and evidence based, embracing activities to promote health, prevent disease, and offer diagnosis and treatment; be based on principles of comprehensiveness, coordination, equity, quality, nondiscrimination, transparency, participation, and accountability to prevent corruption; and ensure that the poorest and most vulnerable members of society have effective access to the services and programs the health system offers. In 2006, the United Nations Human Rights Council adopted a resolution asking the Special Rapporteur on the Right to Health to identify key features of an effective, integrated, and accessible health system from the viewpoint of the right to the highest attainable standard of health.¹⁶

National health systems receive resources and technical assistance from many different nongovernmental (NGO) and donor programs and projects with varied priorities and demands, placing pressure on health ministries to favor vertical programs and to respond to short-term goals.^17–19 Although many vertical programs have made important gains, ensuring funding for overall health system strengthening is critical.²⁰

International NGOs can exacerbate the weakening of national health systems through their project activities by diverting health workers, managers, and leaders away from the public sector and creating parallel structures to government services that tend to worsen the isolation of communities from formal health systems.^21,22 Several concerned NGOs have drafted a code of conduct for international NGOs that offers guidance to strengthen health systems.²³

International financial institutions have historically played a role in limiting public-sector spending on health in developing countries with the imposition of structural adjustment programs.²⁴ Research and studies have concluded that the International Monetary Fund’s fiscal and monetary policies designed to reduce inflation and deficits and balance developing countries’ budgets²⁵ are overly restrictive and have constrained national budgets and health sector budgets at unnecessarily low levels at a time when such budgets need to be increased.²⁶

The Paris Declaration for Aid Effectiveness calls for donors to support and scale up effective programs and projects by strengthening the host country’s development strategies and health system operational procedures.²⁷ It is important that signatories, including the US government, be accountable for their foreign assistance.

The APHA supports the Paris Declaration principles and appreciates the effort by its signatories to support governments in developing countries and to fund the priorities defined by local actors.²⁷ The APHA recognizes that global health donors, such as the Global Fund for AIDS, Tuberculosis, and Malaria, have begun to implement specific policies and funding procedures to emphasize health system strengthening.²⁸

The International Health Partnership launched in September of 2007 is a pact between donor and recipient countries, international health agencies, and foundations aimed at strengthening national health systems, ensuring better coordination among donors and addressing the problem of disparate projects, and providing long-term, predictable financing to countries.²⁹

The World Organization of Family Doctors; Global Health through Education, Training and Service; the Network: Towards Unity for Health; the European Forum for Primary Care; and others are calling for 15% of the budgets of vertical disease-oriented programs to be invested in strengthening primary health care systems by 2015 and to increasing this percentage over time.^30,31

Therefore, APHA
Encourages the US government to support and finance initiatives that are explicitly aimed at building the capacity of health systems in developing countries to address prevention, promotion, and curative health care needs, such as the proposed African Health Capacity Investment Act.³²

Urges international NGOs to sign on to Code of Conduct for Health System Strengthening in Developing Countries²³ coordinated by Action Aid International USA, Health Alliance International, Health GAP, Partners in Health, and Physicians for Human Rights, that calls for NGOs to engage in hiring practices that ensure long-term health system sustainability; enact employee compensation practices that strengthen the public sector; pledge to create and maintain human resources training and support systems that are good for the countries where they work; minimize the NGO management burden for Ministries; support Ministries of Health as they engage with communities; advocate for policies which promote and support the public sector.

Recommends that international NGOs include capacity building and strengthening of national and local health systems in their projects to ensure long-term sustainability after project periods end.^33,34 

Encourages genuine partnerships with affected countries to strengthen health system capacity, using the example of the Emergency Human Resources Programme in Malawi as an example of a national government-led response to the national human resource crisis.³⁵

Recommends that donors commit support to ministries of health and universities to develop national workforce plans, acknowledging that these entities are responsible for organizing appropriately staffed health care delivery systems, and expanding and strengthening the workforce pipeline with an appropriate mix of adequately trained health care professionals.

Urges donors, recipient countries, WHO, and other entities involved in health system development to use criteria based on the highest attainable standard of health in planning, developing, and assessing progress in the development of health systems.

Urges donors, recipient countries, WHO, and other entities involved in health system development to implement the following eight core elements of primary health care outlined in the Alma Ata declaration: (1) education concerning prevailing health problems and the methods of preventing and controlling them; (2) promotion of food supply and proper nutrition; (3) an adequate supply of safe water and basic sanitation; (4) maternal and child health care, including family planning; (5) immunization against the major infectious diseases; (6) prevention and control of locally endemic diseases; (7) appropriate treatment of common diseases and injuries; and (8) provision of essential drugs,¹ and

Urges the International Monetary Fund to alter its current fiscal and monetary policies that have prevented developing country governments from adequately expanding health system capacity and national health workforces, and to officially change its policy positions on the restrictiveness of these policies in future loan programs to allow countries the freedom to adopt options that allow for increased public spending and health budgets in particular and to widely publicize such policy changes to finance ministries and IMF staff.

Encourages organizations and donors to support African countries in expanding their health budgets by signing on to the Abuja Declaration on HIV/AIDS, Tuberculosis, and other related infectious diseases,³⁶ which calls for the lifting of all tariff and economic barriers to access to funding of AIDS related activities and for African governments to devote at least 15% of their annual national budgets to improving the health sector.

Urges the US government to adhere to the principles of ownership, harmonization, alignment, results, and mutual accountability it endorsed in the Paris Declaration²⁷ and contribute to strengthening host countries’ development strategies and health system frameworks, as well as contribute to defining standards of performance and accountability in improving health services and programs.

Recommends that the US government, foundations, and other donors increase substantially the resources dedicated to strengthening primary health care as the foundation of health systems in developing countries.

References

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2. United Nations. End Poverty 2015. Millennium Development Goals. Available at: www.un.org/millenniumgoals. Accessed November 20, 2008.
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5. World Health Organization (WHO). Monitoring and Evaluation of Maternal and Newborn Health and Services at the District Level: Technical Consultation Meeting Report, December 5–8, 2006, Geneva, Switzerland: World Health Organization; 2006. Available at: http://whqlibdoc.who.int/hq/2007/WHO_MPS_07.04_eng.pdf. Accessed June 11, 2008.
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8. Pfeiffer J, Johnson W, Fort M, et al. Strengthening health systems in poor countries: a Code of Conduct for nongovernmental organizations.Strengthening health systems in poor countries: do we need an NGO code of conduct? AJPH. 2008;98(12):2134–2140.
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11. Institute of Medicine. PEPFAR Implementation: Progress and Promise. Washington, DC: National Academies Press; 2007.
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15. United Nations Committee on Economic, Social and Cultural Rights. General Comment 14: Right to the Highest Attainable Standard of Health. UN document E/C.12/2000/4. 2000. Available at: www.unhchr.ch/tbs/doc.nsf/(symbol)/E.C.12.2000.4.En. Accessed November 20, 2008.
16. Report is due out in the first half of 2008. [AQ: Please provide complete citation.]United Nations Human Rights Council. Report of the Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health, Paul Hunt. UN document A/HRC/7/11. 2008. Available at: http://daccessdds.un.org/doc/UNDOC/GEN/G08/105/03/PDF/G0810503.pdf?OpenElement. Accessed December 12, 2008.
17. Sanders, D. 2008. The Context and Implications of Global Health Initiatives with Particular Reference to Africa. Presentation at: Exchange and study program for Leading Chinese Health Academia Scholars to Thailand, 27th January – 2nd February 2008. 2008.Available at: www.who.int/healthsystems/reference_Africa.pdf. Accessed December 12, 2008. 
18. Vertical vs. Horizontal Approaches to global health challenges, My Global Fund Beta Web site. Available at: http://myglobalfund.org/forums/t/1006.aspx. Accessed November 20, 2008.
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20. Fifteen by 2015: Strengthening Primary Health Care in Developing Countries. Available at: www.15by15.org/wp-content/uploads/2008/01/background-15-by-2015-2.doc. Accessed November 20, 2008.
21. Farmer P. Challenging Orthodoxies in Health and Human Rights. Boston, Mass: American Public Health Association; 2006.
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24. American Public Health Association. APHA policy statement 2005-3. Expenditure ceilings imposed on poor countries must be lifted to achieve the Millennium Development Goals. Washington, DC: American Public Health Association; 2005. Available at: www.apha.org/advocacy/policy/policysearch/default.htm?id=1308. Accessed November 17, 2008.
25. Berkmen P. Precautionary Monetary and Fiscal Policies. February 2007. IMF Working Paper No. 07/30. Social Science Research Network. Available at: http://ssrn.com/abstract=964338. Accessed June 11, 2008.
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27. Paris Declaration on Aid Effectiveness. Ownership, Harmonization, Alignment, Results & Mutual Accountability. Paper presented at: Joint Progress Toward Enhanced Aid Effectiveness, Feb 28–Mar 2, 2005.
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29. Department for International Development. The International Health Partnership Launched Today. September 5, 2007. Available at: www.dfid.gov.uk/news/files/ihp/default.asp. Accessed January 11, 2008.
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31. De Maeseneer J, van Weel C, Egilman D, Mfenyana K, Kaufman A, Sewankambo N, Flinkenflögel M. Funding for primary health care in developing countries. BMJ. 2008;336:518–519.
32. African Health Capacity Investment Act of 2007 (HR 3812/S 805). Available at: www.govtrack.us/congress/bill.xpd?bill=s110–805. Accessed December 12, 2008. 
33. Koku Awoonor-Williams J, Feinglass ES, Tobey R, Vaughan-Smith MN, Nyonator FK, Jones TC. Bridging the gap between evidence-based innovation and national health-sector reform in Ghana. Stud Fam Plann. 2004;35:161–177.
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35. Palmer D. Tackling Malawi’s Human Resources Crisis. Reprod Health Matters. 2006;14(27), 27–39.
36. Heads of State and Government of the Organisation of African Unity. Abuja Declaration on HIV/AIDS, Tuberculosis, and other related infectious diseases. Summit in Abuja, Nigeria April 24–27, 2001. Available at: www.un.org/ga/aids/pdf/abuja_declaration.pdf. Accessed June 11, 2008.

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