Health Care Systems in Low- and Middle-Income Countries

Abstract

O ver the past 10 years, debates on global health have paid in-creasing attention to the importance of health care systems, which encom-pass the institutions, organizations, and resources (physical, financial, and human) assembled to deliver health care services that meet population needs. It has become especially important to emphasize health care systems in low-and middle-income countries because of the substantial external funding provided for disease-specific programs, especially for drugs and medical supplies, and the relative under-funding of the broader health care infrastructures in these countries. 1 A function ing health care system is fundamental to the achievement of universal coverage for health care, which has been the focus of recent statements by advocacy groups and other organizations around the globe, including a declaration by the United Nations in 2012. 2 Recent analyses have drawn attention to the weaknesses of health care systems in low-and middle-income countries. For example, in the 75 countries that account for more than 95% of maternal and child deaths, the median proportion of births attended by a skilled health worker is only 62% (range, 10 to 100%), and women without money or coverage for this service are much less likely to receive it than are women with the means to pay for it. 3 Lack of financial protection for the costs of health care means that approximately 100 million people are pushed below the poverty line each year by payments for health care, 4 and many more will not seek care because they lack the necessary funds. In response to such deficiencies in the health care system, a number of countries and their partners in development have been introducing new approaches to financ-ing, organizing, and delivering health care. This article briefly reviews the main weaknesses of health care systems in low-and middle-income countries, lists the most common responses to those weaknesses, and then presents three of the most popular responses for further review. These responses, which have attracted consid-erable controversy, involve the questions of whether to pay for health care through general taxation or contributory insurance funds to improve financial protection for specific sections of the population, whether to use financial incentives to in-crease health care utilization and improve health care quality, and whether to make use of private entities to extend the reach of the health care system. This review draws on what is now quite an extensive literature on the deficien-cies of health care systems 1 and on the Health Systems Evidence database. 5 How-ever, the poor quality and uneven coverage of evidence on the strengthening of health care systems means that evidence of deficiencies is stronger than evidence of remedies. Moreover, the specific circumstances of individual countries strongly influence both decisions about which approaches might be relevant and their suc-cess, so any generalizations made from health systems research in particular coun-tries must be carefully considered. 6 It is unlikely that there is one single blueprint global health n engl j med 370;6 nejm.org february 6, 2014 553 for an ideal health care system design or a magic bullet that will automatically remedy deficiencies. The strengthening of health care systems in low-and middle-income countries must be seen as a long-term developmental process. He a lth C a r e Sys tem Cons tr a ints a nd R esponses A framework for categorizing the constraints on health care systems 7 was originally developed in 2001 for the Commission on Macroeconomics and Health of the World Health Organization and has been widely applied since then. This frame-work has the merit of looking at systems both horizontally (e.g., assessing each level to deter-mine all the elements needed for effective service delivery) and vertically (e.g., accounting for the support functions of the higher levels in a sys-tem). Table 1 lists six levels that exist within any health care system, from the community level to the global level; the main constraints of the sys-tem at each level; and the main responses to these constraints. Three issues drawn from these responses have been selected for detailed consid-eration below. These issues have been selected for several reasons. They involve critical functions of the health care system (i.e., financing and health care delivery), receive considerable prominence in inter-national debates on how to strengthen the health care system, and have been evaluated somewhat more rigorously than other issues. General Taxation vs. Contributory Insurance