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Latin America: Putting a human face on health systems

Keith Hansen's picture

Latin America: Crying out for good health systems. Photo: Marie Chantal Messier

It takes a health system to raise a healthy child—or nation. And this is true here in Latin America or anywhere else in the world.

That’s the big message of a small video the Bank has recently launched, featuring an adorable animated newborn named Maya. In it, Maya cries profusely, many times, but her tears are not the sad consequence of disease or discomfort but of the baby feeling well. Maya’s are happy tears –the product of a healthy baby. You can follow her journey into adulthood on her own Facebook page

Do we really need a cartoon to tell us that health systems matter? In principle, no. Specialists from many disciplines have long recognized that only a well-designed health system can ensure that the right services and financial protection are available to everyone throughout the life cycle.

Working in piecemeal fashion simply misses too many needs and opportunities, and can even result in duplicative or conflicting activities.

But in practice, “health system strengthening” has proven a hard sell with the public. Over the past decade, the world has doubled down on its investment in fighting disease. This has brought bracing new momentum to the cause of global health.

Yet so far only a small share of the money or attention has gone to building better health systems. Why? One reason is simple metrics. It’s hard to count how many deaths or diseases you avert by improving a health system. By contrast, investing in specific inputs or illnesses seems to promise results that are clearer and more computable.

But the experience of the past decade has proven that even the most narrowly tailored investments depend on a strong underpinning health system to attain or sustain their potential. And strong systems will prove even more vital in the years ahead as countries increasingly confront non-communicable diseases, for which specific inputs are seldom relevant.

Another reason, I suspect, is marketing. As a brand, the word “system” admittedly leaves something to be desired. It sounds abstruse, lacks a human face, and may even remind people of their malfunctioning computers. So if the purse strings connect to the heartstrings, it’s no wonder “systems” hasn’t inspired the same following as more compassionate-sounding campaigns. (As a reminder that branding matters, consider what happened when “Patagonian toothfish” became “Chilean sea bass.”)

Yet few systems have greater positive human impact than health systems. This becomes apparent, for instance, every time:

  • A sensitive surveillance system helps nip a nascent epidemic in the bud
  • Good insurance coverage keeps health care from dropping during an economic slump 
  • Clear incentives motivate health workers to consistently do their best for clients
  • Strong health stewardship reduces rates of smoking, alcohol abuse, and salt intake


Maya is our way of putting a human face on a health system. Her happy journey from conception to healthy birth came about because dozens of different services and functions worked together in seamless synergy. She reminds us that a health system is about more than its individual parts.

It’s about the rules and relationships that make those parts fit and work in unison—with real and enduring results. That’s why over the past decade the World Bank has increasingly shifted its support to health in Latin America and the Caribbean toward strengthening health systems through results-based approaches.

We support country-owned and operated programs (not “World Bank projects”) in areas such as: 

  • expanding health insurance for the poor · strengthening the accountability of service providers 
  • bolstering public health systems to promote healthier behaviors 
  • integrating care systems from primary through tertiary levels


A results-based approach ties the flow of funds to specific achievements in coverage, quality, services, or other key milestones. Reviewing these results, rigorous evaluations have helped prove the multiplicative power of strengthening systems.

To take one example, a new approach to accountability in Argentina has substantially increased the number and quality of prenatal visits in poor provinces. As a result, infants in participating provinces have greatly improved survival, birth weight, and health at birth. This happened because the country’s new incentive system ensured the right things would happen at the right time—just as happened with Maya.

We may never have the tools to compute the exact impact of every health system improvement (although efforts are underway to improve our accuracy, as my colleague Cristian Baeza has blogged about.) But the experiences of Argentina and many other countries in the region have shown that while Maya herself may be a cartoon, the results she represents are anything but fictional.


Comments

Submitted by Alex on
...forgot the "corruption" ingredient, where not matter how much funding is available, (or channelled through the "appropriate authorithies"),communities/people are enjoying only a small fraction/percentage of this funds to get appropriate and basic health services. This "disease", corruption of course, is much greater that any other known disease in Latin America (Peru, Colombia, etc, etc, etc.)..!

Alex, many thanks for your contribution. Corruption is a problem everywhere, of course (not only in Latin America) and the more severe it is, the greater its impact on public services and their outcomes. That is another virtue of taking a health systems approach. By focusing attention on the relationships, incentives, and transparency of the system, it’s possible to change the conditions that enable corruption. Some interesting work is underway to figure out which aspects of governance are most important to better system performance. Have a look at this recent World Bank working paper by the always-thoughtful Bill Savedoff: http://bit.ly/healthgovernance

The point about the metrics is a good one, people measure what is easy, and when establishing efficiency and effectiveness targets look to those metrics. The old adage is "what gets measured gets managed". Unfortunately, in companies, and in health systems apparently, this distorts what is essentially a holistic entity. We would not pick isolated metrics to measure ourselves - "How are you today, Keith?" "I'm great, my blood pressure is 120/70!" Just because the blood pressure is good, doesn't mean there is no disease, or illness, or other problem which definitively would make us "not great". We exist as a whole, and need to be considered in the same way, otherwise things can get out of whack very quickly. Thanks!

Good point, David. It’s obviously important that we keep our eye on final outcomes, because they are the goal of the system. (Sometimes in the past “system reforms” were done without regard to whether they actually made things better.) But not all inputs that matter can be quantified, and not all the important links to outcomes are as simple as A causes B. As Einstein -- who knew a thing or two about causality -- said: "Not everything that can be counted counts, and not everything that counts can be counted."

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