It’s Time to Transform Community Health Systems
It’s Time to Transform Community Health Systems
With less than 1000 days until the Millennium Development Goals expire, the process for setting post-2015 goals continues to ramp up. We take this opportunity to reflect on the current state of community health systems in low- and middle-income countries and consider how the post-2015 agenda could reshape them—perhaps dramatically.
Community health systems today
Integration moves ahead
Poor and rural communities in low- and middle-income countries are leaving behind the “one clinic, one service” approach. So-called vertical programs, which organized resources according to single health conditions, created a patchwork of health services at the community level. You could get HIV care from one provider, but would have to go down the hall, down the street, or often much farther to get maternal health care or malaria care.
Recently, efforts have accelerated towards a more comprehensive, primary care model of service delivery. For example, MSH has helped train and equip health centers in Tanzania in diagnosing and treating pediatric tuberculosis, with support from USAID. The expanded services most likely saved the life of Makasi, a little boy whose grandmother brought him to a local health center where his TB was effectively diagnosed and treated. Since his symptoms weren’t easily identifiable as TB, a freestanding TB clinic wouldn’t have helped him.
Another form of integration involves using the platforms that vertical programs have created. We’ve written about Mildred Akinyi in Uganda, whose routine visit for HIV care was expanded to include a cervical cancer screening. The screening found a precancerous growth, but Mildred was successfully referred for treatment.
These examples show the benefits of building out existing platforms. Vertical programs rapidly scaled up capacity to address urgent problems like HIV, maternal and child mortality. But today, it’s necessary to integrate these services and others, moving towards a primary care model that can provide most needed services in one place. It saves clinic visits for patients and can avoid missed diagnoses. It’s a vehicle for attracting and retaining patients for the long term, and boosting primary care can greatly increase community engagement and ownership of the health system.
Communities organize for better coverage
Services don’t mean much when you can’t afford them. In many communities, services must be paid for out of pocket. Lacking the protection of health insurance or similar mechanisms, the toll of getting sick can be devastating: 150 million people around the world experience financial catastrophe from health costs every year. 100 million of them fall into poverty.
Rwanda is an example of a country that has used community-based health insurance (CBHI) to pool risk and identify those who need subsidized services. Eugenie is a widow who suffered from a renal tumor. Even under CBHI, she was unable to afford the 10% copay for her care. Finally, however, with revised policies with and an improved database, CBHI was the mechanism that could deliver care to Eugenie for free. She was successfully treated for the tumor.
Health service availability
Access to services requires a qualified, motivated workforce. To scale up services around HIV and other conditions, health systems have innovated ways of maximizing the resources they’ve already got. MSH has been involved with performance-based financing in many settings, creating incentives for providers to deliver high-quality care. It has been effective at jump-starting health services in post-conflict settings and improving them. We have trained community health workers all over the world, vastly expanding health systems’ reach.
In many places, the first place you go when you’re sick is to a local shop—where you’re likely to get the wrong medicines, in the wrong doses, at a high price. With funding from the Bill and Melinda Gates Foundation, MSH helped Tanzania’s government pioneer community health shops where trained professionals give you the right medicines. The shops are a novel step towards broader health coverage. What’s more, they foster entrepreneurship and empowerment among the newly-trained shop owners, 90 percent of whom are women.
The next phase of community health systems
Today’s efforts to integrate services are crucial in settings where services have been scattered. The game-changer, though, is to implement a true primary care system that provides a comprehensive package of health services in every community. When resources are thin, the basic package can focus on low-cost, high-impact services that address the majority of preventable deaths. Progressively the health system can deepen the services provided by the basic package.
This model isn’t new—the foundational concepts are familiar from the Primary Health Care movement of the 1970s—but with the end of the vertical era, the timing is right.
We can already see the growing burden of chronic diseases—primarily heart and lung disease, cancers and diabetes. These have surpassed other causes as the leading causes of death worldwide. In low and middle income countries, their burden is growing, easily on pace to surpass infectious diseases as the top killers. Yet in these countries, diagnosis and treatment lag far behind. Rather than creating another vertical delivery system for these services, a strong primary care system can fold high-impact interventions for chronic diseases into patients’ ongoing care.
Financial protection and health for all
As the World Bank’s Adam Wagstaff argued at a recent Harvard event, the problem in weak health systems isn’t simply lack of coverage. Almost everyone is covered: if you can afford to pay out of pocket, you can receive the services. The real issue is whether everyone has got the necessary financial protection that makes care affordable.
Risk pooling and public subsidies have been the blueprint for success stories like Rwanda. Risk pooling involves upfront costs and administrative costs and subsidies can be expensive—but as developing economies, especially in sub-Saharan Africa, continue to grow steadily, domestic funding and private investment will be on the table (even as development assistance levels off or begins to decline).
Widespread financial protection against health care costs has consistently proven to improve quality of life. Everyone, in every community, should have this opportunity at a healthy life. For chronic diseases in particular, adding basic screening and treatment to the primary care package will be a major step. But to really close the gap between rich and poor countries, financial protection for major procedures—like Eugenie’s surgery—will be essential.
UHC and the post-2015 agenda
This type of overhaul carries upfront costs, but the payoff is clear: transformative change for the worst-off. Multiple groups, including MSH, have recommended universal health coverage (UHC) as an overarching health goal for the Post-MDG framework. The UHC concept, defined as a system which provides all people the health services they need without financial hardship, creates all the right incentives for integrated primary care services and financial protection mechanisms. It’s a worthy vision for the future, but it’s not just an aspirational goal—it’s linked to the numerous examples, from Mexico to Thailand to Ghana, of low-to-middle income countries which have successfully reorganized their health systems and created a playbook for others. These success stories offer a picture of the better health that communities around the world should not only expect in the future, but demand in the Post-2015 engagement process.
Gloria Sangiwa, MD, is Management Sciences for Health’s global technical lead for chronic non-communicable diseases and the director of technical quality and innovation in MSH’s Center for Health Services. Jonathan (Jon) Jay, JD, MA, is a senior writer at MSH.