Better organized out-patient services could make the biggest immediate health gains for the poor in most of the world’s developing countries, according to an article in the June issue, just out, of The Bulletin of World Health Organization, which is devoted to health systems.

In low-income countries, most people turn to these services for the prevention or treatment of the most common diseases, including childhood diarrhoea, lower respiratory infection, tuberculosis, sexually transmitted diseases and acute malaria. These are among the top ten conditions responsible for the overall disease burden in developing countries: out-patient, or ambulatory, services deal with 80% of the disease burden caused by these conditions. Out-patient services also account for the largest share of total health expenditure in most developing countries.

The care provided, however, is often costly and substandard, and imposes a heavy financial burden on poor households.. One reason, says the author of the article, Professor Peter Berman of the Harvard School of Public Health, is that governments have been paying too little attention to the organization of these ambulatory health services. Yet, improving them through better financing, regulation and information is likely to be the best way of improving the performance of health systems in most developing nations.

"To do this wisely, much better information on primary care organization will be needed as well as more experience with diverse approaches to improve performance. This agenda has become even more pressing with growing global attention to more complex clinical problems such as reproductive health, integrated management of sick children, and treatment of HIV/AIDS," says Professor Berman.

"Over the last two decades the OECD countries have introduced exciting innovations in governance, incentives, organization, and information to improve public management of health care. Few of these innovations have migrated to lower income countries," he says.

The author is associate professor of international health economics, and director of the International Health Systems Group at Harvard.

How good is your health system?

Many countries, rich and poor, are struggling to assess how well their health systems are performing and how to make them perform better. But health systems are complex and have to a large extent defied precise evaluation. Murray and Frenk (pp. 717-731) present a conceptual framework that provides a road map to the essential components of a health system and should make the task of measuring its performance less daunting. The framework starts by marking out the system’s boundaries, that are based on its defining activity, i.e. actions (health actions) primarily intended to improve or maintain health. It then identifies the system’s main goals: better health, responsiveness to the population’s expectations and fair financing. Underpinning the entire workings of the system are four key functions-- "stewardship" (see next paragraph), financing, provision of services and generation of resources. The framework is still evolving but its potential as a policy-making tool is already illustrated in a comparative analysis of the performance of the health systems of all 191 WHO member states and published for the first time in the WHO’s World Health Report 2000.

Wanted—trusty steward

A new buzzword is doing the rounds of health and development circles—stewardship. Its meaning is not clear, though. On an ethical ladder, with management on the bottom rung and administration and governance on the next two rungs above it, stewardship would be at the top. Saltman and Ferroussier-Davis (pp. 732-739) explore the history of the concept—from the selfless servant of Biblical times who managed his master’s assets to the Muhtasib who regulated medical practice in pre-colonial Arab societies to the present-day Scandinavian model of the welfare state—and suggest that the term, which denotes a mix of pragmatism, efficiency, accountability, trust and regulation, could define a new role for the state in running a country’s health system. By extension, the WHO believes stewardship could apply to international organizations acting as "good agents" for national governments.

The woes of wealth

Life is not always a bed of roses for the healthy and wealthy. Hurst (pp. 751-760) looks at some of the problems facing health policy-makers in the 29 countries of the Organisation for Economic Co-operation and Development: an ageing population that makes disproportionately heavy demands on the health system; affluence that often goes hand-in-hand with an unhealthy lifestyle; hi-tech medicine that can perform "miracles" but is costly and raises popular expectations that governments cannot always fulfil. Moreover, OECD countries cover a wide range of wealth and health status, from Mexico and Turkey with a below-average health expenditure and an above-average infant mortality rate, to the United States, the top spender on health, but not necessarily with the best performing health system, not to mention the unemployed and poor population groups within countries. Some observers predict that with an expected further wave of hi-tech medicine coming over the horizon, many OECD governments will not be able to afford their publicly funded health care systems much longer. However, there is no sign that any countries with universal health insurance cover are about to abandon that prize. Everything points to a need for greater efficiency.

Managed chaos

In the United States nine out of ten employees are enrolled in a managed health care plan—a system whereby an insurer contracts with health providers (physicians, hospitals, etc.) to deliver to members enrolled in the plan a defined set of health care services at an agreed price. Introduced in the 1980s and 1990s to stem escalating health costs and to put some order into a fragmented health delivery scene, managed care has in recent years provoked criticism that it has not produced a fall in costs but rather in the quality of care provided. Sekhri (pp. 830-844) analyses the intricate web of managed care systems operating today in the United States and shows that managed care has slowed the growth of health care spending without lowering quality of care. Other countries, particularly those coping with a possibly unmanageable mix of public and private health delivery, might see in the United States’ experience elements they could apply to their own attempts at health reform.

For further information please contact Gregory Hartl, WHO Press Spokesperson, Geneva. Tel (+41 22) 791 4458, Fax (+41 22) 791 4858. E-mail: hartlg@who.int or Mr Thomson Prentice, WHO, Geneva, Tel (+41 22) 791 4224, e-mail prenticet@who.int All WHO Press Releases, Fact Sheets and Features can be obtained on Internet on the WHO home page http://www.who.int

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