Syndicate content


Are all medical procedures, drugs good for the patient?

Patricio V. Marquez's picture

Also available in: РусскийPatients waiting at health center in Angola (credit: UN/Evan Schneider).

When healthcare professionals take the Hippocratic Oath, they promise to prescribe patients regimens based on their “ability and judgment” and to “never do harm to anyone”.

Although extraordinary progress in medical knowledge during the last 50 years, coupled with the development of new technologies, drugs and procedures, has improved health conditions and quality of life, it has also created an ever-growing quandary regarding which drugs, medical procedures, tests and treatments work best.

And for policy makers, administrators and health economists, the unrestrained acquisition and use of new medical technologies and procedures (e.g., open heart surgery to replace clogged arteries, ultrasound technology scanners to aid in the detection of heart disease, and life-saving antiretroviral drugs for HIV/AIDS) is increasing health expenditures in an era of fiscal deficits.

In many countries, I’ve see how ensuring value for money in a limited-resources environment is not only difficult but requires careful selection and funding of procedures and drugs. It also comes with serious political, economic and ethical implications—and with new drugs and technologies appearing every day, this challenge isn’t going away. What should countries do?

Humanizing health systems

Adam Wagstaff's picture

In 1960, I wouldn’t have been writing this blog post. For a start I was just a baby at the time. Second, we were several decades away from 1994 when Justin Hall – then a student at Swarthmore – would sit down and tap out the world’s first blog. Most importantly of all, though, according to Google’s ngram viewer, people didn’t write about health systems much in 1960 (see chart). Usage of the term in books took off only in the mid 1960s, waned in the 1980s, and then started rising again in the 1990s. This doesn’t look like a statistical artifact. Usage of the term “Nobel prize” has stayed relatively constant over the period, and while the term “health economics” has also trended upwards, the growth has been much slower. So “health systems” is a fairly new term – and it’s on the rise.

Click on this image to see a larger version.

Not everyone thinks that’s a good thing.

A New Mechanism for South-South Knowledge

Susana Carrillo's picture

In my previous blog entry, I mentioned the expected growing engagement between Brazil and Sub-Saharan African countries in 2012, to exchange knowledge and further economic and social development.

Putting Humpty Dumpty back together again

Cristian Baeza's picture

2012 is off to a sobering start for those of us in the global health community, against a backdrop of continuing global financial volatility coupled with complex reforms at the Global Fund to Fight AIDS, Tuberculosis and Malaria. New research from the Institute for Health Metrics and Evaluation (IMHE) shows a slowdown—and perhaps a plateauing—of the historical growth in global health funding to which we have been accustomed during the past decade. This new reality is, rightly, leading to questions about whether substantial—if not radical—changes are needed in the highly fragmented global health ecosystem. And yet, at the same time, there are signs of new initiatives.

I believe the slowdown in global health funding requires adjusting our expectations in the coming years. Last fall, after participating in a number of inspiring discussions during the UN General Assembly, I reflected about each one of the critical global health priorities to which we have all pledged our support in recent years: the Millennium Development Goals (MDGs) for nutrition, child and maternal health, and HIV/AIDS, TB, and malaria, as well as non-communicable diseases. It struck me that while most of these health interventions are destined to help the same mother or child, we have created very separate initiatives and institutions to deliver on each. We have been able to elevate the awareness and commitments for each of these priorities, but now the challenge is, like Humpty Dumpty, how do we now put them all back together again?

Reforming hospitals in East Asia — engagement by development partners wanted

Toomas Palu's picture

Health systems are under pressure in Asia. Epidemiological and demographic transitions are taking place much faster than in Europe and America, in the span of a single generation. With the transition comes the non-communicable disease (NCD) epidemic that requires more sophisticated and expensive interventions provided by hospitals, inpatient or outpatient. Rapid economic development in Asia has lifted millions out of poverty and raised peoples’ expectations for services. Between China, India, Thailand, Philippines, Indonesia and Vietnam, expansion of health insurance coverage during the last decade has reached an additional one billion people, making services more affordable and thus increasing demand. Advancing medical technology eagerly awaited by specialist doctors sitting on top of health professional hierarchies further expands possibilities for treatment. The middle class votes with their feet and takes their health problems to medical tourism meccas like those in Bangkok and Singapore, voiding their own countries of additional income to health care providers. Policymakers are scrambling to expand hospital capacity, boost the pay of health professionals, and encourage investment to meet the demand.   

But governments do not wait. They are exploring hospital autonomy, decentralization, user fees and private sector participation. These policies often pose risks that need to be mitigated by policies and institutional arrangements. For example, health care providers sometimes order unnecessary procedures to earn additional revenue, thanks to the powerful incentive of the fee-for-service payment mechanism and information asymmetry between the patient and health care provider. This can mean financial ruin for both the patient and new, relatively weak health insurance agencies.

Despite these challenges, hospitals aren’t high on the international health development agenda, save a few initiatives to improve quality and provider payment reform.

Haiti: Saving lives of mothers and children with better healthcare

Marie Chantal Messier's picture

También disponible en Español

Photo: Anne Poulsen

The story of Nelta is not uncommon in present-day Haiti. A few months ago, she gave birth to her second child, Jasmine, at her modest home, in the town of Jacmel, 30 miles south of Port-au-Prince.

Unexpectedly, she went into labor when she was 7 months pregnant, but lived too far from the health center to be able to get there in time for delivery. Jasmine was born prematurely and with a low birth weight.

Ethics, values and health systems

Patricio V. Marquez's picture

It’s widely accepted nowadays that the ultimate goals of a health system are to improve the health conditions of the population; minimize the risk of impoverishment due to catastrophic health events; and increase the level of satisfaction of the citizens of a country with the quality of services received.

What kind of health system needs to be developed to achieve these goals?

Professor Uwe E. Reinhardt, a distinguished Princeton University health economist, urges us to focus on broader social goals, including the distributive ethic or moral values in a country.   In essence, this means that the “structural parameters” of a health system—financing health care, risk pooling to protect individuals from the cost of illness, producing and delivering health services, purchasing or commissioning health care on behalf of patients, stewardship and governance, and production and distribution of health care resources--should be determined by the shared ethic or moral values in a society.

As Professor Reinhardt points out, alternative “distributive social ethics” or “moral values” may offer three broad health care organization models to choose from:  (i) a one-tier system, where health care is a social good available to all on equal terms; (ii) a two-tiered system, where health care is a social good for all with exception of the rich; and (iii) a multi-tiered system, where health care is a private consumption good like other services such as food and housing.

So which one of these models should governments adopt, adapt and develop? Which model should international organizations recommend as part of policy dialogue with governments? Is there an appropriate “government” versus “private market” combination that should prevail in a health system?

Out-of-pocket in the Caucasus

Owen Smith's picture

I am partway through a trip to the countries of the South Caucasus (Armenia, Azerbaijan and Georgia), where winter is settling in—snow in Tbilisi and Yerevan, and a raw wind on Baku’s seafront.

It is a diverse region at the proverbial crossroads, but one common trait is a bleak health financing environment. All three countries rely on out-of-pocket (OOP) expenditures for about two-thirds of total health spending, well above their peer groups, including other countries of the former Soviet Union or middle-income countries around the world. As a result, the incidence of “impoverishing” and “catastrophic” health spending by households—both common indicators of financial protection—are among the highest in the world. Besides costing some households dearly, OOP expenditures also keep many others away from the hospital or clinic: Utilization rates are among the lowest in Europe and Central Asia.

How did the Caucasus become such OOP outliers? The proximate causes are clear enough: large formal or informal payments for health care and high prices and overconsumption of pharmaceuticals. Many of these issues, in turn, can be traced to low levels of government spending on health, around 1.8% of GDP in all three countries, roughly half the regional average. Health spending is low as a share of government budgets, as well. As a result, providers recover costs directly from patients, and can have more latitude to engage in rent-seeking in the absence of stronger pooling and purchasing mechanisms.

Brazil and Africa: Bridging the Atlantic

Susana Carrillo's picture

Linked in the distant past through colonial-era trade enterprises, Brazil and Africa are becoming close partners again. More than two centuries after establishing a slave trade route across the Atlantic, both regions are again re-engaging, this time to exchange knowledge and further economic and social development.

Sub-Saharan African countries are looking to replicate Brazil’s successes in boosting agricultural production and exports, and private investments, which have made Brazil a key economic player in the international arena. This is no coincidence. The world is going though rapid changes, resulting in a new financial architecture, with emerging economies and countries in the South increasingly participating and influencing global decisions.

The imperative of integrated health care delivery systems

Patricio V. Marquez's picture

DL-PH002 World Bank

In the past decade we have witnessed a noticeable zigzag internationally on how to improve health system performance. While some have advocated for the primacy of primary health care (reinforced by a major 2008 WHO report), others have stressed the importance of hospital autonomy initiatives.

This zigzag clearly illustrates another false dichotomy in the health sector that merits urgent revision. More and more, we’re recognizing why a cohesive and integrated health care delivery model needs to be in place to better organize and respond to the changing needs of the population, particularly given the raising importance of noncommunicable diseases and injuries as the main causes of death and disability worldwide. A recent report on NCDs in China demonstrates how the chronic nature of these conditions—different from acute episodes of ill health resulting from infectious diseases—demands a well-coordinated combination of hospital, ambulatory and physician response, in some cases over the lifetime of an individual.