World Health Systems: Challenges and Perspectives, Second Edition

By Bruce Fried

New in the fourth edition:

An update on the changes to Medicare coverage, including adding means testing on optional coverage for beneficiaries A new discussion of the legislation the current administration would like to implement for universal healthcare coverage A new focus on the quality-of-care debate and pay-for-performance incentives New requirements for not-for-profit hospitals to report services provided in order to validate their tax status An update on managed care and how universal coverage could change payment and delivery Updated information on biomedical research and the debate on whether the United States will remain a leader on this effort A new discussion of the effects of the current economic downturn on healthcare An updated discussion on the status of the healthcare workforce and how nursing and possible physician shortages will affect our system A discussion on healthcare expenditures and the estimated 47 million people who are currently uninsured A master bibliography has been created and is now located at the back of the book Updated glossary and acronym list

• Language: English
• Publisher: Health Administration Press
• Release date: Aug 24, 2012
• ISBN: 9781567935516

Book preview

Contributors

PREFACE

Health systems play an increasingly central role in every country, but perceptions of health systems are mixed. On the one hand, they are viewed as an essential feature of modern society and a key component of a country's safety net. Health systems may be also viewed as inefficient, wasteful, and a major driver of budget crises. Increasingly, health systems are arenas within which ideological battles are carried out, often between those who believe in healthcare as a right and others who view health services as a commodity whose distribution should be guided more by the market than by government intervention. Like many politically charged debates, the views of each side are often misconstrued, often with deliberate political intent. Even among players in the health sector, there is ongoing debate about how scarce health resources should be deployed. This second edition of World Health Systems settles no ideological arguments; rather, it presents information about health systems in what we believe is a dispassionate manner.

In this edition of World Health Systems, the core chapters in Part I have been strengthened, expanded, and redefined to enable the reader to acquire a broader understanding of the central issues in health systems. Part I includes core concepts about health systems that we see as relatively stable over time. For example, all health systems need to have financing mechanisms and regulation—as discussed in Chapters 3 and 4. Information is also presented about core issues and concepts common to all health systems, including points of debate about the role of a health system and the impact of a variety of internal and external factors.

Part II contains profiles of the health systems in 25 countries. In most cases, these have been written by authors from each country. The authors have been careful to present information in an objective manner. Readers may, however, disagree with specific speculation or conclusions about the future of a health system. We see this as healthy and characteristic of the alternative ways in which health system trends may be interpreted in each country. If there is a common set of values guiding the authors, it is the premise set forth by the World Health Organization, which has established that health systems should seek to achieve four sets of goals: quality health services, accessibility of services, financial protection to individuals from the costs of illness and treatment, and efficiency. The extent to which achieving these goals is the role of government versus the markets is treated as a variable rather than an intrinsic value.

In the description of each health system in Part II, we and the authors acknowledge the dynamic nature of health systems. A change in government, a financial crisis, an epidemic, or armed conflict can cause changes in disease patterns and a realignment of the health system. In light of this, the authors have been encouraged to impart information about the country and health system that can help the reader understand the evolution of the health system—how it got to its current state—and well-substantiated projections of alternative and likely future trajectories of the health system. The reader is encouraged to view the country profiles as a foundation for understanding each country's health system and to use this information as a basis for understanding current changes that may be taking place in the health system.

In Part II, we have included examples of health systems in low-, middle-, and high-income countries. However, students of health systems should appreciate the uniqueness of each health system and the distinctive forces that caused a health system to evolve in a particular way. While we have sought to include a representative set of countries, the reader should be aware that there are vast differences between countries within each income category; generalizations within income category are misleading. Health systems evolve from a complex interacting mix of social, cultural, political, economic, and historical forces. For those interested in examining additional health systems, we recommend using a framework similar to that used in the health system descriptions in this volume. Of critical importance, however, is that any useful analysis of a health system—including projections about the future direction of a health system—must consider the broader context of the country and the unique history and forces that resulted in the system's current state. The authors in this book have attempted to provide this essential contextual background.

For instructors who use this book in the classroom, instructor's resources can be requested by writing to [e-mail]. Included in the instructor's resources are a sample course syllabus and selected class assignments, an extended reference list, and a PowerPoint presentation for each of the six introductory chapters.

Bruce J. Fried

Laura M. Gaydos

January 2012

INTRODUCTION

Part I of World Health Systems synthesizes a range of issues affecting all health systems. Discussion focuses on the epidemiology of global health, health system components, and numerous issues associated with health system reform and strengthening. This foundation will provide the reader with basic information about health systems as well as a context for understanding the 25 health systems discussed in Part II .

The goal of all health systems is to improve the health of the population. Central to designing and evaluating health systems is understanding the basic features of population health, factors affecting population health, and the multiple ways in which health status in a population is measured. In Chapter 1, Laura M. Gaydos summarizes the complex trends in health status and disease patterns in the world and the multiple factors that affect the health of the population. Particular attention is given to the role of poverty and economic development as important determinants of population health. Gaydos pays particular attention to the multiple approaches used to measure health status and disability in a population. The epidemiological and demographic transitions help the reader understand and interpret trends in disease patterns and changes in the global burden of disease.

In Chapter 2, Meredith Kimball and Bruce J. Fried provide alternative perspectives on how to define and measure the effectiveness of health systems, which has important implications for reforming health systems and evaluating their performance. Researchers and organizations have developed frameworks for defining the scope, purpose, and functions of a health system. The World Health Organization's (WHO) building blocks concept of the structure and goals of health systems has proven to be a robust descriptive and analytic model. The key features of this model—as well as other analytic models that take different perspectives on health systems—are summarized in Chapter 2.

Sufficient and sustainable financing is central to the success of all health systems. In Chapter 3, Lydia Ogden addresses fundamental issues in health system organization and financing. Ogden applies the Roemer typology of health systems, which arrays health systems along the two dimensions of national wealth and the degree of government involvement in health system financing and delivery. She addresses the complex question of variations across and within countries in public spending on health services. Among other questions is the central issue of how health systems are financed, and she draws on frameworks developed by Roemer and others in developing a conceptual understanding of the role of governments and private markets in financing health services. This issue is critical because it focuses so intensively on the debate ensuing in many countries about public versus private financing. The debate is ongoing, and evidence concerning the optimal public–private mix is complicated by economic conditions, health disparities, cultural and historical concerns, and a host of other factors.

Regulation is a required element in health systems, regardless of the type of health system, ownership of facilities, or sources of financing. Inadequate regulation—or poor enforcement of regulations—can inhibit the achievement of health system goals and may be a threat to quality of care and patient safety. In Chapter 4, Dean Harris explains the roles and purposes of regulation in health systems, with particular attention given to regulations related to medical professionals, health facilities, and health insurance plans.

Health system strengthening faces particular challenges in low- and middle-income countries. In Chapter 5, Kimberley Geissler and Darwin Young use the WHO building blocks approach to health systems to identify specific strategies and opportunities for innovative approaches to improving health and health systems in low- and middle-income countries. They contend that for health system strengthening efforts to be successful and sustainable, multiple factors must be addressed: innovative financing mechanisms, accountability, transparency, and support for infrastructure development.

As the reader will see, the 25 countries profiled in this book all have undergone or are currently in the process of reforming their health systems. In chapter 6, Thomas C. Ricketts examines the process of health reform. Discussion focuses on the multiple reasons countries initiate reform efforts and the multiple goals pursued by these efforts. Using examples from Germany, China, the United Kingdom, and other countries, Ricketts shows the great range in goals, driving forces, and processes of health system reform over the past century.

Laura M. Gaydos

The State of Health in the World

Global health conditions improved more in the past 60 years than in all of the years before. Worldwide, life expectancy has risen to an average of 66.12 years (CIA 2009) and death rates have declined, especially among young children (World Bank 2010). In the wealthiest countries, average life expectancy climbed from roughly 67 years in 1950 to 78.8 years in 2007; in the developing countries, life expectancy jumped from 40 to 64 years. Even in the least developed regions, such as sub-Saharan Africa, average life expectancy climbed from 36 to 52 years in 1998; however, the prevalence of HIV/AIDS has since reduced life expectancy to 47 years, compared with estimates of 62 years without the presence of AIDS (AVERT 2011). Another exception to these positive regional trends occurred in the transitional economies of the former Soviet Union, where life expectancy for men declined to 1980 levels in all 12 republics, reaching a low of 57.7 years in the Russian Federation in 1994 (WHO 1996). Today, Russian life expectancy has reached 68 years but remains low, at 61.8 for Russian men (World Bank 2010). Major strides have also been made in reducing child mortality. As recently as 1950, 287 children out of every 1,000 born in the developing countries would die before reaching age 5; by 2008, that number had dropped to 67 out of every 1,000 (World Bank 2010).

Yet this incredible progress should not mask the fact that health conditions remain dismal in many parts of the world, and huge disparities exist between the richest and the poorest countries and, indeed, between the rich and the poor within the same country or even the same city. For example, in sub-Saharan Africa, the child mortality rate is still 167 per 1,000 live births, compared with 6 per 1,000 in developed nations (UNICEF 2007).

Poverty and Health Status

Despite dramatic global economic growth, almost half of the world's population—3 billion people—live in extreme poverty on less than $2.50 per day. At least 80 percent of the world's population lives on less than $10 per day (Chen and Ravallion 2008).

Poverty not only increases the risk of poor health and the vulnerability of people, it also has serious implications for the delivery of effective healthcare, including reduced demand for services, lack of continuity or compliance in medical treatment, and increased transmission of infectious diseases.

Poverty is not just a lack of money. It generally includes the following elements: inadequate income; lack of education, knowledge, and skill; poor health status and lack of access to healthcare; poor housing; lack of access to safe water and sanitation; insufficient food and nutrition; and lack of control over the reproductive process.

In the lowest-GDP (gross domestic product) countries, a special effort is needed to enhance the health status of their populations and to reduce the gap with respect to the industrialized world and even to other developing countries. Swaziland—a country that has been ravaged by the HIV/AIDS epidemic—has a life expectancy of roughly 32 years, which is the lowest in the world; it is less than half that of Japan, which boasts the highest life expectancy worldwide at nearly 82.6 years (CIA 2009). These figures confirm a blatant inequality. In fact, average life expectancy in the low-GDP countries is about 56 percent of that in the United States and other industrialized nations (UNDESA 2009). Similarly, although huge improvements in child survival have been made, it must be noted that more than 15 percent of children born in the low-GDP countries will die before reaching age 5 (in Afghanistan, nearly 26 percent of children will die); in the richest countries, less than 1 percent will (UNDESA 2009). Nearly 80 percent of under-5 mortality occurred in sub-Saharan Africa and South Asia (UNICEF 2011b).

In addition to child deaths, the lifetime risk of maternal deaths in the world is 1 out of 140. This risk jumps astronomically to 1 in 37 in the low-GDP countries, compared with 1 in 4,300 in the developed nations (UNICEF 2011a).

According to a 2007 UNICEF study,

[a] review of recent evidence shows that while a number of middle-income countries have made progress in reducing maternal deaths, less progress has been achieved in low-income countries, particularly in sub-Saharan Africa. Across the developing world, maternal mortality levels remain too high, with more than 500,000 women dying every year as a result of complications during pregnancy and childbirth. About half of these deaths occur in sub-Saharan Africa, and about one third occur in South Asia—the two regions together account for about 85 percent of all maternal deaths. In sub-Saharan Africa, a woman's lifetime risk of maternal death is a staggering 1 in 22, compared with 1 in 8,000 in industrialized countries.

An excessively large gap is observed with regard to children's and women's health in the low-GDP countries: The average mortality rates of children under 5 and of mothers are at least 10 and 30 times as high, respectively, as the corresponding rates in industrialized countries (UNICEF 2011a).

Exhibit 1.1 shows basic indicators for developing nations; Exhibit 1.2 compares these figures with those of the more developed, wealthier nations.

As expected, among those countries facing high levels of poverty, one can see higher infant and child mortality rates, substantially lower life expectancies, and other diminished health indicators. Most notable is the magnitude of the differences in health status between the wealthy and impoverished nations.

Since 1990, the United Nations Development Programme has employed a Human Development Index (HDI), which serves as a scale for its annual development report. HDI scores are between 0 and 1, with scores closer to 1 demonstrating higher levels of development. The HDI accounts for the following:

Life expectancy at birth

Knowledge (adult literacy rate)

Standard of living (GDP)

Developing nations, not surprisingly, have overall lower scores on the HDI scale. Large portions of the populations of developing countries do not have access to necessities, such as healthcare and safe water, and this leads to a plethora of diseases that, although they are not exclusive to developing nations, often define mortality in these countries. Ninety percent of the 1.3 billion people who live in absolute poverty reside in South Asia, sub-Saharan Africa, and China.

Human Development Index (HDI)

Created by the United Nations Development Programme, HDI measures life expectancy at birth, adult literacy rate, and gross domestic product. HDI scores are between 0 and 1, with scores closer to 1 demonstrating higher levels of development.

Poverty and Disability

Despite all their benefits, mortality figures do not capture the huge burden of sickness and disability caused by diseases that do not result in death but still prevent adults from working, keep children out of school, and generally slow economic and social development. Statistics on morbidity, which is the measure of disease incidence, are even harder to come by than mortality numbers.

Disability-adjusted life year (DALY)

A metric that combines losses from premature death (defined as the difference between the actual age of death and life expectancy) and loss of healthy life that results from disability.

Disability-Adjusted Life Years (DALYs)

Over the years, various investigators have attempted to overcome these limitations by developing new metrics that factor in disability or quality of life along with mortality. One such measure is the disability-adjusted life year (DALY). DALYs combine losses from premature death (defined as the difference between the actual age of death and the life expectancy at that age, and loss of healthy life that results from disability. In simple terms, a DALY strives to tally the complete burden that a particular disease exacts. Key elements to consider include the age at which the disease or disability occurs, how long its effects linger, and its impact on quality of life. Losing one's sight at age seven, for instance, is a greater loss than losing one's sight at 67. Similarly, a bout of acute illness that is over quickly carries less weight in the DALY calculation than an illness, such as persistent worm infections, that leaves lingering weakness.

Examined from this perspective—which considers not just premature death but disability as well—the huge toll of ill health in developing countries stands out even more starkly. Nearly nine-tenths of the global burden of disease occurs in developing regions where only one-tenth of global health expenditures occur. As Exhibit 1.3 illustrates, the burden of ill health in Africa and Southeast Asia is nearly five times that found in the richest countries and regions.

When measured with DALYs, communicable diseases are the single most important cause of ill health globally, accounting for 44 percent of the total, with respiratory infections and diarrheal diseases heading the list (WHO 2008a). DALYs also underscore the disproportionate burden of ill health borne by the world's children. Children under age 15 account for almost half of all DALYs worldwide. Exhibit 1.4 further illustrates comparisons between mortality and DALYs.

The Epidemiological Transition

Until recently, it was widely assumed that, with increasing economic growth, the developing countries would follow the same paths as Europe and North America and experience what has become known as the epidemiological transition; this term refers to a change in the type of diseases and illnesses experienced within a society. Changes in mortality structure are the principal outcome indicator by which the epidemiological transition is assessed.

Humankind has undergone multiple epidemiological transitions, beginning with a cultural shift from a foraging to an agricultural society that led to the development of new diseases, including zoonotic infections that resulted from the domestication of animals.

The first modern epidemiological transition resulted from the development of urban centers. Early in their history, large urban settlements began to experience problems involving waste disposal and contaminated water and food sources. Communicable diseases such as cholera, which is transmitted by contaminated water, became problematic. Viral diseases, such as measles, mumps, and smallpox, threatened epidemic proportions as the close urban living quarters allowed for repeated and multiple exposures.

With industrialization came an even greater environmental and social transformation. City dwellers were forced to contend with industrial waste and polluted water and air. Slums arose in industrial cities and became focal points for poverty and the spread of disease. Epidemics of smallpox, typhus, diphtheria, measles, and yellow fever were well documented. Tuberculosis and respiratory diseases, such as pneumonia and bronchitis, were even more serious problems, and they were exacerbated by harsh working situations and crowded living conditions.

The next part of this chapter focuses on the second epidemiological transition, which involved the rise of chronic and degenerative diseases, and the third transition, which was a re-emergence of infectious diseases with antibiotic resistance.

Epidemiological transition

A change in the type of diseases and illnesses experienced within a society.

The Second Epidemiological Transition: The Rise of Chronic and Degenerative Diseases

The second epidemiological transition was the shift from acute infectious diseases to chronic, noninfectious, degenerative diseases. The increasing prevalence of these diseases is related to an increase in longevity. Cultural advances result in a larger percentage of individuals reaching the oldest age segment of the population. Simultaneously, the technological advances that have allowed for increased longevity can also lead to environmental concerns that threaten health, and these advances arguably lead to new chronic diagnoses. Interestingly, within developing countries, many of the chronic diseases first appear in the wealthier segments of the population or in those segments with greater access to Western products and practices.

With increasing developments in technology, medicine, and science, a better understanding of the source of infectious disease arose, followed by an increased ability to control these diseases. The development of immunizations resulted in the control of many infections and the eradication of many diseases, such as smallpox. The decrease in infectious diseases and the subsequent reduction in infant mortality have resulted in greater life expectancy at birth. In addition, longevity has increased for adults, and this has resulted in an increase in chronic and degenerative diseases.

Many of the diseases of the second transition share common factors related to human adaptation, including diet, activity level, mental stress, behavioral practices, and environmental pollution. For example, the industrialization and commercialization of food often results in malnutrition. Obesity, which is another form of malnutrition, is a direct result of an increasingly sedentary lifestyle in conjunction with higher caloric intakes.

Chronic diseases are a recent factor in human morbidity, indicating a strong environmental factor in disease etiology. Although biological factors, such as genetics, are clearly important in determining who succumbs to disease, genetics alone cannot explain the widespread changes seen in the second epidemiological transition.

The Third Epidemiological Transition: Re-emergence of Infectious Diseases

The third epidemiological transition is marked by the emergence of new infectious diseases, which have the potential for a global impact. This transition is a result of an interaction of social, demographic, and environmental changes that have resulted in the adaptation and genetic mutation of the microbe; international commerce and travel, technological change, the breakdown of public health measures, and other factors have influenced this change. Ecological issues, such as agricultural development projects, dams, deforestation, floods, droughts, and climatic changes, are believed to have caused the emergence of diseases such as hantavirus and possibly HIV and AIDS.

The catalyst driving the re-emergence of many diseases is ecological change that brings humans into contact with pathogens. The development of antibiotic resistance in any pathogen is the result of medical and agricultural practices. Antibiotics have been used indiscriminately and inappropriately, resulting in multidrug-resistant strains of bacteria that infect a large number of patients (Mayo Clinic 2011). Similarly, agricultural uses of antibiotics, such as supplementation of animal feed, have become more prevalent; there is debate about whether this may lead to antibiotic resistance in humans.

The Demographic Transition

The demographic transition model seeks to explain the transformation of countries from agricultural to industrial societies. The model approximates occurrences in Western Europe and to some extent the experience of most developed nations. In high-income countries, this transition began in the eighteenth century and continues today; low-income countries are still in the midst of earlier stages in the model.

As countries become developed and industrialized, they experience declines in death rates followed by declines in birth rates. As a result, nations move from rapid population growth to slow growth, then to zero growth, and finally to a reduction in population; this is the essence of the demographic transition model. Demographers have observed that this transition takes place in four distinct stages:

Preindustrial stage. In this first stage, when the economy is underdeveloped, both birth and death rates are high. High birth rates are attributed to such factors as early marriages and religious and social customs; death rates are high due to poor diet, ill health, and the absence of medical facilities. As a result, population growth is slow in the preindustrial stage.

Transitional stage. In this second stage, which typically occurs shortly after industrialization, national and per capita incomes rise because of the implementation of development programs. The standard of living is high, health and sanitary conditions improve, and diseases are controlled. Consequently, the death rate falls, but the birth rate continues to be high. Population growth is high, and a population explosion results.

Industrial stage. The third stage of the transition occurs as industrialization becomes widespread. When development reaches an advanced stage, many changes occur in the economic and social structures. People understand the benefits of family planning, and they deliberately restrict the size of their families. Restriction of family size is equated with higher standards of living, so birth and death rates are low at this stage. The advanced countries of the world are now in this stage.

Postindustrial stage. The fourth and final stage occurs when birth rates decline even further to equal the death rate, thus causing the rate of population growth to reach zero. The birth rate eventually falls below the death rate, and total population size slowly decreases.

The formal demographic transition theory had only four stages; however, some theorists now suggest that a fifth stage is needed to represent nations with sub-replacement fertility levels. The higher-GDP countries in Europe and North America—as well as Japan, Australia, and New Zealand—are growing by less than 1 percent annually. Population growth rates are negative in many European countries, including Russia (–0.5 percent), Estonia (–0.4 percent), Hungary (–0.3 percent), and Ukraine (–0.8 percent) (PRB 2010).

Exhibit 1.5 provides a graphic representation of the demographic transition (stages 1 through 4).

Demographic transition

A model that explains the transformation of countries from agricultural to industrial societies. As countries become developed and industrialized, they experience declines in death rates followed by declines in birth rates. As a result, nations move from rapid population growth to slow growth, then to zero growth, and finally to a reduction in population.

Developing Nations and the Demographic Transition

Many developing nations are currently in the transitional stage, sometimes called the demographic trap because it is a dangerous stage from the perspective of population growth. An estimated 17 percent of the world's current population—more than 67 nations—are in this stage, leading to record increases in population size (WHO 1998).

One example of a region that is in this demographic trap is sub-Saharan Africa, which has experienced nearly constant fertility rates coupled with a decrease in death rates because of longer life expectancy. Mortality has decreased without a corresponding change in fertility, which has led to a population explosion in this region that is mirrored worldwide.

It is worth noting that the demographic transition theory may be less applicable to less economically developed countries. The theory was validated primarily in Europe, Japan, and North America, where demographic data cover several centuries. However, high-quality demographic data for most low-GDP countries did not become widely available until the mid-twentieth century (Lee 2003). The demographic transition model does not account for recent phenomena such as AIDS, which has become the leading source of mortality in many developing areas of the world. Disturbing trends in waterborne bacterial infant mortality are occurring in countries such as Malawi, Sudan, and Nigeria, where progress in the demographic transition clearly stopped and reversed between 1975 and 2005 (Population Action International 2006). Therefore, although the demographic transition model is a useful tool for analysis, it should not be viewed as the set path of progression for all developing nations.

Diseases of Poverty

The diseases of poverty are typically acute ailments caused by poor nutrition, environment, and lack of access to appropriate care. Whereas wealthier nations frequently treat and prevent these diseases with ease, in impoverished nations these diseases often present issues of life and death.

In the poorest nations, child health is of primary concern; children's less-developed bodies are more prone to the diseases themselves and to the underlying causes of these diseases that keep children from developing fully functional immune systems and other natural defenses.

Infant and Child Mortality

In 1955, 21 million children under age 5 died worldwide; in 2008, about 8.8 million died (down from 12.5 million in 1990). This number is expected to drop to 5 million for 2025, when the world population is projected to reach 8 billion. Under-5 mortality rates per 1,000 live births for 1955, 1990, and 2010 are 210, 90, and 57, respectively (UNICEF 20011b).

Similar to child mortality, the world infant mortality rate declined from 126 per 100,000 in 1960 to 45 in 2008 (UNICEF 2010). Infant mortality is linked to several predictive correlates, including the following:

Birth order

Economic conditions

Ethnicity and culture

Low birth weight (often resulting from premature birth)

Maternal age

Maternal education

Gender

These correlates have a large impact in the prenatal period, during which a fetus may not receive the proper medical care and nutrition needed to develop fully. In fact, more than half of all infant deaths take place within the first few days of life, largely because of inadequate care for the mother during pregnancy and childbirth (WHO 2000a). An entire international body of literature exists that discusses correlations between maternal education, age, and external cultural factors and prenatal care and proper nutrition.

Malnutrition

Each year, more than 11 million children die from the effects of disease and inadequate nutrition. In some countries, more than 1 in 5 children die before they reach their fifth birthday, and many of those who do survive are unable to grow and develop to their full potential.

Thirty-five percent of all under-5 deaths are associated with malnutrition (Black et al. 2008). Additionally, approximately 27 percent (168 million) of children under age 5 are underweight, which increases their risk of mortality from infectious illnesses, such as diarrhea and pneumonia (Rice et al. 2000) and may result in poor cognitive development and neurological impairment. In adulthood, they are at an increased risk for cardiovascular disease, high blood pressure, obstructed lung disease, diabetes, high cholesterol concentrations, and renal damage (WHO 2000b).

Protein energy malnutrition (PEM) affects more than a third of the world's children, with a range of underweight children from 8 percent in the region with the least PEM (South America) to 60 percent in the poorest region (Southeast Asia). PEM is caused by a combination of insufficient food intake and infectious diseases, and it is closely related to insufficient knowledge, poor sanitation, poverty, and insufficient access to medical care. PEM and other dietary deficiencies of vitamins and minerals can lead to learning disabilities, mental retardation, poor health, low work capacity, blindness, and premature death.

Micronutrient malnutrition, which affects at least 2 billion people of all ages, refers primarily to an insufficient dietary intake of iodine, iron, and vitamin A. Some functional consequences of the micronutrient deficiencies are described in Exhibit 1.6.

Infection—particularly frequent or persistent diarrhea, pneumonia, measles, or malaria—undermines nutritional status. Poor feeding practices that contribute to malnutrition include inadequate breastfeeding, offering the wrong foods, giving food in insufficient quantities, and not ensuring that a child eats her share. For these and other reasons, malnourished children are more vulnerable to disease.

Protein energy malnutrition (PEM)

A nutritional deficiency caused by insufficient food intake and infectious diseases; closely related to insufficient knowledge, poor sanitation, poverty, and insufficient access to medical care.

Micronutrient malnutrition

An insufficient dietary intake of iodine, iron, and vitamin A.

Food Safety

In addition to malnutrition, food contamination is one of the most widespread health problems today, and it is an important cause of reduced economic productivity. Hundreds of millions of people, particularly infants and children, suffer from diseases caused by contaminated food and water sources. In industrialized countries, up to 30 percent of the population suffers from foodborne diseases each year. While less well documented, developing countries bear the brunt of the problem because of a wide range of foodborne diseases, including those caused by parasites. The high prevalence of diarrheal diseases in many developing countries suggests major underlying food safety problems (WHO 2007a).

Acute Respiratory Infections

Acute respiratory infections are estimated to be the leading cause of death for all age groups in developing nations (WHO 2008b). According to the World Health Organization (WHO), most young children worldwide have from four to eight episodes of respiratory infection per year, and most of these episodes are self-limiting infections of the upper respiratory tract. However, the incidence of acute lower respiratory infections, particularly pneumonia, is high in developing countries because of the many individual and environmental factors that heighten the risk of developing these conditions, especially low birth weight, poor nutrition, low income, and indoor air pollution. About 2.94 million people in the poorest nations die from these infections each year, mostly as a result of pneumonia (WHO 2008b).

Control of acute respiratory infections is difficult because many of the causal agents are airborne. Some diseases, such as measles, can be reduced through immunization. Immunization against pneumonia, however, is difficult because 83 different serotypes are known, and each is immunologically unique.

Beyond specific disease-causing agents, exposure to certain ambient air pollutants (e.g., sulfur dioxide and particulate matter) causes severe respiratory problems throughout the world. Road traffic emissions of lead and nitrogen oxides and other air pollutants from localized sources are also often encountered. In the indoor environment, exposure to nitrogen oxides, volatile organic compounds, and tobacco smoke have significant effects on human health and comfort (WHO 2000c).

Diarrheal Disease

Another 2 million children in developing countries die each year from diarrheal diseases, making these diseases the second highest killer of children under 5 worldwide. Diarrhea can, in most cases, be prevented and treated. Basic causes of diarrhea include toxins, allergies, lactose intolerance, and malaria. However, by far the most common causes of diarrheas in children are pathogens ingested through contaminated food or water, particularly in developing countries.

The immediate result of acute diarrheal disease is dehydration. Loss of approximately 5 percent of body weight through dehydration can typically be tolerated, although this may be accompanied by symptoms such as lightheadedness from a drop in blood pressure. A loss of 10 percent of body weight, as is often seen in children in developing countries, can produce real danger with possibilities of shock, kidney failure, and death.

The introduction of oral rehydration therapy (ORT) in recent years has proved effective, is relatively simple and inexpensive, and has saved perhaps millions of pediatric lives. ORT replaces lost fluids orally rather than intravenously, and it works regardless of which agent caused the episode because it counteracts the resulting dehydration rather than the cause.

However, no treatment, including ORT, is perfect. In addition to relatively minor side effects such as increased stool production, ORT does require access to certain resources such as clean, safe water. Although water may seem like a feasible resource, in many nations clean, safe water is costly and out of reach of those most in need. Consequently, many children in need of ORT do not truly have access.

In 2002, the WHO introduced an improved oral rehydration salts (ORS) formula, which decreased stool production and resulted in less vomiting and need for intravenous hydration. The formula reduces the severity and duration of acute diarrheal illness. The WHO estimates the formula could prevent 14,000 deaths and save $7.1 million for every 1 million diarrhea episodes (USAID 2009). WHO estimates some 50 million children have been saved thanks to the mixture, which costs only 30 cents per dose. In 2004, WHO and the United Nations Children's Fund (UNICEF) recommended the use of zinc treatment with ORS as a two-pronged approach to treatment of diarrhea.

Oral rehydration therapy

A simple and inexpensive treatment that replaces lost fluids orally rather than intravenously; it works regardless of which agent caused the episode because it counteracts the resulting dehydration rather than the cause.

Adult Illness and Poverty

The standard international health framework discusses illness in poorer countries in terms of communicable and reproductive diseases. As with child health, adults in developing and impoverished nations have long been believed to suffer most often from the following diseases:

Diarrheal disease

Tuberculosis

Malaria

Venereal diseases

Respiratory infections

Maternal and perinatal illness

HIV and AIDS

The causal factors associated with these illnesses are the same for adults as for children, including lack of safe drinking water and food, poor sanitation, poor housing conditions, malnutrition, chronic parasitic infections, and lack of effective curative measures.

Higher mortality rates among the poor may also result from noncommunicable diseases. The specific determinants of these differences are not always evident, but poor nutrition, stress, indoor air pollution (in select countries), smoking, and workplace hazards are important factors for consideration. Access to effective medical care is also likely to have a significant impact on mortality from noncommunicable diseases.

Health Problems of Affluence

In contrast with developing and poor nations, the more affluent, developed nations of the world have largely conquered communicable and reproductive diseases with medical science. That is not to say that no communicable and reproductive diseases exist in wealthier nations, but these health problems are secondary causes of morbidity and mortality.

In wealthy nations, major sources of morbidity and mortality result from chronic and noncommunicable diseases. Many of these diseases are related to lifestyle, such as increased lung cancer because of smoking or high rates of cardiovascular disease that result from obesity and lack of exercise.

Common diseases among wealthy, developed nations include the following:

Arthritis

Cancer

Cardiovascular disease

Diabetes

Hypertension

Note that these are not diseases that result from malnutrition or lack of access to health services; they may be related to excesses in personal lifestyle or may simply be due to increased longevity, which causes the body to become more susceptible to such conditions.

Similarly, because these diseases are not caused by a single contaminant or pathogen, medical treatment often focuses on management of these diseases rather than their cure. Consequently, the wealthy nations of the world have populations with substantial chronic disease prevalence and, therefore, continual healthcare needs. These needs may seem less extreme than those present in the poorer countries, but the resources required to treat diseases of affluence are significant.

The Changing World Scene

As epidemiological transitions progress on a more global level, similar changes are observed among specific nations and societies. Among developing nations, the more traditional frameworks for evaluating health needs in poverty-stricken nations no longer hold strictly true to form. Although impoverished nations largely have not improved their economic standing, the people of these nations are beginning to develop the diseases of affluence in addition to the diseases of poverty.

Most low- and middle-income countries are already facing a double burden of disease. They suffer a backlog of common infections, malnutrition, and reproductive health problems. At the same time, without having addressed these challenges, they have to cope with the emerging problems represented by noncommunicable diseases, heart disease, cancer, new infections, and injuries.

What is causing this addition of new diseases in less wealthy nations? Development seems to be the primary factor. Economic development, as touted by organizations such as the World Bank and the United Nations Development Programme, has many positive consequences. However, economic development also brings to less developed nations the modern determinants of health, which arise primarily from changes in behavior and from the hazards of new and imperfectly understood technology. As the wealthier nations of the world reach out to help developing nations grow and become civilized, both positive and negative influences are introduced. Among the negative influences involved is the introduction of unhealthy habits.

Tobacco Use

The causal relationships between tobacco usage and several noncommunicable diseases, such as lung cancer and emphysema, are well established. Smoking may also have an impact on cardiac health, premature and complicated births, and many other health problems. Although tobacco consumption in developed nations has been on the decline (largely because of increased public health efforts designed to inform people about the dangers of the drug), the reverse is true in developing nations for several reasons.

First, antismoking campaigns essentially do not exist in less wealthy countries, so the public health effects of public awareness are virtually nonexistent. Second, in less wealthy nations, few if any restrictions are placed on advertising, resulting in unchecked, widespread campaigns that target the entire population. Third, low-GDP nations typically have no controls on the content of tobacco products. Therefore, although the percentage of tar used in cigarettes in wealthier nations has been consistently on the decline, tar levels in cigarettes in poorer nations remain very high. As a consequence of all these factors, the wealthier nations have introduced a vice to developing nations that is not coupled with any of the controls that are often taken for granted in the higher-income countries.

The total number of tobacco-attributable deaths is projected to rise from 5.4 million in 2005 to 6.4 million in 2015 and to 8.3 million in 2030. Tobacco is projected to kill 50 percent more people in 2015 than HIV/AIDS and to be responsible for 10 percent of all deaths (WHO 2007b). According to the latest estimates, more than 80 percent of the 8.3 million deaths attributed to tobacco projected to the year 2030 will occur in low-income and middle-income countries (Mathers and Loncar 2006).

Alcohol Use

Ethyl alcohol, the active ingredient in all alcoholic drinks, is a toxic compound with addictive properties. Alcohol consumption may lead to a number of acute and chronic health problems in addition to possible mental health concerns. Alcohol can cause alcohol poisoning, acute gastritis, and suicidal behavior, and it may contribute to accidents. Long-term exposure to alcohol can also cause cirrhosis of the liver, stomach ulcers, diabetes, and fetal alcohol syndrome. Alcohol dependency may also lead to a series of social and economic problems.

Average alcohol consumption is increasing in most nations of the world. However, this increase is substantially larger among less wealthy nations. Alcohol consumption has led to numerous socioeconomic consequences in impoverished nations; one of the primary results is a decreased workforce due to chronic intoxication.

Intentional Violence: Suicide, Homicide, and Warfare

Suicide is a major cause of mortality in all countries. Worldwide, about a million suicides occur each year. Several psychological factors have an impact on suicidal tendencies, including social isolation, crises, depression, and alcoholism.

Suicide is a complex issue, and few effective preventive methods have been discovered. However, high socioeconomic status and community support seem to be highly correlated with the success of suicide prevention.

As with suicide, homicide is also related to a variety of social factors. However, homicide rates vary to a much larger degree across nations, possibly as a reflection of differences in culture and laws. Homicide rates are higher in most low-GDP nations than in their wealthier counterparts. Within developing countries, homicide rates also vary by numerous factors including gender (males have higher rates), income (the poor have higher rates), place of residence (rates are higher in urban areas), and ethnicity.

In addition, warfare kills and disables substantial portions of the populations of many low-GDP countries, especially in the Middle East, southern Africa, Central America, and Southeast Asia. Although accurate data are often difficult to obtain because of the nature of war and the less-developed tracking systems in low-GDP nations, warfare mortality is often caused by conflicts between criminal gangs and police agencies as well as conflicts among gangs themselves. Warfare of this sort is often tied to the ever-increasing presence of illicit drug trafficking.

Dietary Imbalance

As noted earlier, the major dietary problem in the developing world is lack of food. However, as nations develop, food supplies often increase, and diets change. Whereas the old diets of many lower-income nations, when adequate, typically included large amounts of carbohydrates (e.g., rice, polenta), soy or lentils, and perhaps some fish or meat, newer diets consist of more processed foods. These new diets are typically much higher in saturated fat and sodium and lower in simple fiber. Although the exact impact of diet on disease manifestation is still up for debate, considerable evidence links this more westernized diet with a number of chronic diseases, including hypertension and certain forms of cancer.

Changes in Physical Activity

It is well established that regular physical activity promotes greater health. Regular activity, whether occupational or recreational, leads to decreases in coronary heart disease and possibly decreased risk for stroke, cancer, and other diseases. In low-GDP countries, most people have enough activity in their daily lives to maintain a health benefit. In high-GDP countries, however, levels of activity have been on a steady decline because of conveniences such as automobiles and many other labor-saving devices. As countries mature and adopt many of these conveniences, the populations of these countries begin to face the same deficit of physical activity as is seen in wealthier nations.

Mortality and Automobiles

Automobile collisions are one of the major causes of adult mortality in the developing world, and about half a million deaths each year result from these types of accidents. In 1990, road traffic accidents were the ninth leading cause of disease burden; by 2020, they are expected to be the third leading cause (WHO 2008a). As the number of automobiles has increased in developing countries, the levels of associated morbidity and mortality have grown at alarming rates. Similarly, countries with high proportions of motorcycles and other unprotected vehicles (e.g., many countries in Southeast Asia) have even higher risks of driver and passenger injury from motor vehicle collisions.

Whereas in high-GDP nations the majority of accidents occur to people between the ages of 15 and 24, in low-GDP nations the majority of accidents occur to those over age 25. As vehicle ownership becomes more widespread, these demographics will likely begin to mirror those found in wealthier nations.

The Environment

As discussed previously in this chapter, contaminated drinking water, food, and indoor air are major causal factors of ill health in impoverished nations. Industrialization and modernization of many low-income countries have created new sources of clean water and food, but they have simultaneously produced increased pollution that may add to health problems unless adequate preventive measures are taken.

Air pollution is a growing problem in many poorer countries. The main sources of pollution vary among nations, but in general they are motor vehicles, power plants, industry, and residential heating and cooking devices. Pollution given off from these sources can damage the lungs and other organs. Such pollution likely also contributes to chronic diseases of the lungs, such as asthma.

Chemical contamination of food and water sources is also of growing concern in poorer nations. Many industries in low-income nations contaminate water through various production processes. When polluted waterways are used for drinking water, cooking, irrigation, or as a source of fish, these contaminants can cause severe health problems.

Food contamination is largely a problem of biological contamination (naturally occurring contaminants such as dangerous bacteria), but chemical contamination is also an issue. Poisoning outbreaks have occurred from contamination during food processing.

Depletion of the ozone layer and the greenhouse effect are also problems that affect low-income nations. As industry develops, these nations are adding to ozone depletion by using manufactured products.

Workplace Injuries

Deaths from workplace injuries are approximately ten times more likely in low-income nations than in wealthier nations. Injuries are common in agriculture, construction, transport, and the primary industries such as mining; all of these industries constitute important sources of employment in poorer countries.

Unlike the wealthier nations, the poorer nations of the world do not yet have organizations and regulatory agencies dedicated to improving workplace safety (e.g., the Occupational Safety and Health Administration in the United States). Without these types of organizations, accidents are more likely to occur. The effects of workplace hazards are substantial. Occupational injuries are estimated to kill more than 300,000 workers worldwide every year and to cause many more cases of disability (Concha-Barrientos et al. 2005) and these numbers are likely underestimated because of poor data reporting in many countries. These accidents result in increased healthcare costs, decreased productivity, and substantial morbidity and mortality.

Conclusion

What is the state of health in the world today? Clearly no definitive answer to this question exists. Although global health conditions improved more in the past half-century than in all of the years before, many improvements still must be made. A large proportion of the world's population faces dramatic poverty and illness. Even in the wealthier nations of the world, illness—albeit chronic rather than acute—is still present at substantially high levels.

How should these mounting challenges be handled? Perhaps health professionals need to re-evaluate approaches to healthcare around the world; perhaps new paradigms are needed. Healthcare professionals must continue to fight against the growing inequalities and deficiencies in health systems around the world.

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Meredith Kimball and Bruce J. Fried

Introduction

Across the world, health systems vary dramatically in structure and organization, human resource capacity, financing, service delivery, and resource allocation. Though the demographic and disease profiles of high-income, middle-income, and low-income countries are converging, differences remain. However, every health system still has some common inherent, underlying components and functions. As nations attempt to reform their systems to improve health outcomes, reduce financial risk, and improve access to care, it is imperative to know what truly composes a health system. What are the inputs? What are the system goals, and how will progress be measured? Where should future investments be made?

The need for health system definition and measurement is even greater at a time when the international development community has shifted from vertical, disease-specific programs to health system strengthening initiatives. Some fear that the term health system will become just a buzzword and a container concept that is used to label very different interventions (Marchal, Cavalli, and Kegels 2009). However, the first international conference on health systems research was held in November 2010 in Montreux, Switzerland, signaling an increased desire to provide clarity to what has been a vague concept. This chapter seeks to highlight the existing frameworks that define health systems and to provide guidance for how to evaluate and improve the performance of such systems.

What Is a Health System?

The World Health Organization's (WHO) 2000 World Health Report, Health Systems: Improving Performance, defines a health system as all the activities whose primary purpose is to promote, restore or maintain health, a definition that is widely accepted today. This includes not only actions by those employed in the formal healthcare sector, those who care for the sick at home, traditional healers, lay health workers, and those who promote prevention and safe practices, but also even actions to improve environmental and road safety. The definition excludes activities whose primary focus is not heath (e.g., education), even though they may have secondary effects on health.

In the 2000 World Health Report, the WHO identified fundamental objectives of a healthcare system that have remained present even in more recent frameworks:

To improve health outcomes,

To ensure financial protection against catastrophic payments, and

To be responsive to population expectations.

By definition, a health system seeks to improve health outcomes, but to do so in a vacuum is not enough. It must also ensure that individuals and families are protected against financial hardship when seeking healthcare. The combination of unforeseen medical expenses and high levels of out-of-pocket spending can catapult families into poverty. This has resulted in a variety of innovative financing and insurance schemes, and it has led to major health system reforms around the world. Microcredit and microinsurance schemes evolve at a more local level, while national governments continue to test innovative demand-side reforms. The movement toward universal health coverage (UHC) is gaining increased traction at a global level, and with a push from the World Health Assembly (2011), more countries are committing to UHC.

The last major health system objective described by WHO is responsiveness, which describes the nonmedical component of healthcare—patient satisfaction. A successful health system must take into account the holistic patient experience and meet the expectations and desires of those whom it serves.

Taken alone, it is hard to disagree with this conceptual definition, but while it succeeds in its broad applicability, its lack of specificity translates into practical difficulties in measuring and identifying the components of a health system—information that is critical for system improvements. The 2000 World Health Report was the first time the WHO took an in-depth look at how to measure health systems’ performance, and since then it has continued to build on this foundation.

Health system

All organizations, people, and actions whose primary intent is to promote, restore, or maintain health.

Universal health coverage

A health system in which all residents have access to affordable, high-quality healthcare. This can be accomplished through a variety of different financing arrangements and may involve both the public and private sectors.

Overview of Existing Frameworks

A plethora of conceptual frameworks for health systems exists and, though this variety allows for increased country contextualization, the many options may result in confusion at the country level for how to organize nationwide system-strengthening efforts. Exhibit 2.1 illustrates the main components and functions of a number of such frameworks.

Evans's (1981) early definition of a health system relies on four principal actors: those being served by the system, the providers of care, third-party payers, and the government as regulator. Hurst (1991) extrapolates on Evans's organization and identifies seven major subsystems of care: three voluntary insurance schemes (private reimbursement, private contract, and private integrated model); three compulsory models (public reimbursement, public contract, and public integrated model); and out-of-pocket payments, a model which is still highly problematic in many low- and middle-income countries.

Both Frenk (1994) and Cassels (1995) see health sector reform through a lens of actors and relationships. Frenk sees change happening at four levels: systemic; programmatic; organizational; and instrumental, which addresses issues of equity, allocative efficiency, technical improvements, and policy changes. Cassels expands on this to include additional actors such as resource institutions, purchasers, other sectoral agencies, and population.

Hsiao's control knob framework centers on the idea that there are certain knobs that policymakers can use to affect change in the system, including financing, payment, macro-organization, regulation, and behavior (Roberts et al. 2003). Large reforms may take moving several knobs together, whereas small-scale changes may be brought about through the use of a single knob or lever.

Using a capacity framework, Mills and Ranson (2006) identify four key functions of a health system—regulation, financing, resource allocation, and provision—and the key actors responsible for linking these functions—government, populations, financing agents, and providers.

Since 2000, the WHO has offered a number of frameworks for defining health systems. The performance measurement framework contained in the 2000 World Health Report expands on the goals of the system to outline four critical functions: resource generation, financing, service provision, and stewardship. Most recently, the 2008 World Health Report, Primary Health Care: Now More Than Ever (WHO 2008), brought attention to four key policy areas: moving toward universal coverage to address inequalities, reorganizing health services around people's needs, integrating public health initiatives with primary healthcare, and re-engagement of the state through leadership reforms.

However, the WHO's 2007 Building Blocks Framework continues to be the most widely referenced conceptual model, serving as the basis for many conversations about health systems and system strengthening. These building blocks (service delivery; health workforce; information; medical products, vaccines, and technologies; financing; and leadership and governance) are illuminated in increased detail in the following section.

Additional frameworks continue to emerge, and recent efforts focus on finding the common threads and achieving a universal framing for health system reform (Shakarishvili et al. 2010).

WHO Building Blocks Framework

The Building Blocks Framework (Exhibit 2.2) includes the following major building blocks: service delivery; health workforce; information; medical products, vaccines, and technologies; financing; and leadership and governance. These building blocks drive access, coverage, quality, and safety and ultimately result in the fundamental objectives described in the 2000 World Health Report. An additional major outcome listed is improved efficiency, which speaks to the need to reduce waste in systems