Today I attended the launch of a new book, sponsored by the Rockefeller Foundation at the London School for Hygiene and Tropical Medicine, that analyses why some countries achieve good health outcomes despite having low income status.
It is a sequel to a seminal study published 25 years ago, looking at China, Costa Rica, Kerala (an Indian state) and Sri Lanka, which found that investment in accessible and affordable community-oriented services was essential to ahcieve ‘good health at low cost’.
This book dedicates one chapter to reflect back on those same five countries, but takes a closer look at an additonal five: Bangladesh, Ethiopia, Kyrgystan, Tamil Nadu (India) and Thailand.
The book considers the wider social determinants of health. There is a consensus that the socio-economic root causes of poverty need to be tackled for sustainble and widespread reductions in health inequities.
This was asserted in the Alma Ata Declaration on Primary Health Care in 1978, then advanced with the valuable work done by Michael Marmott’s Commission on Social Determinants in 2008, followed by a resolution at the 62nd World Health Assembly in 2009 recommending ‘health in all policies’.
The launch of the book coincides with the World Health Organisation’s current conference on the social determinants of health, reviving the importance of integrated and multi-sectoral approaches.
Several common contributory factors are identified across the five focus countries:
- the capacity of individuals and institutions
- continuity (such as stable bureaucracies)
- context (e.g. income, beliefs, history)
- catalysts (i.e. seizing social or political windows of opportunity)
Robust and resilient systems
In addition to the wider context, the study finds that robust and resilient health systems are ever more important to facilitate improved health outcomes.
Given the changing contexts and new challenges facing many developing countries – such as urbanisation, the rise of the private sector, and the growing burden of non-communicable diseases – the health system has to be strong and flexible in order to adapt to evolving needs.
This book serves as an important reminder of the value of investing in the pillars of a health system – its workforce, financing, governance, supply systems, infrastructure and so on.
This is particularly pertinent in the current environment where we see donors moving towards more easily attributable investments and further away from longer-term systemic funding.
Some issues raised could do with further explanation, such as how does a country develop a resilient health system when there is rampant private sector growth? Having the capacity to establish strong regulatory capacity is easier said than done.
What impact does the health financing arrangement have on the resilience of the system? Where there are high out-of-pocket payments – such as in Bangladesh, where the financial burden falls on the patient, are the health outcomes at genuine ‘low cost’?
Call to action
What the book doesn’t do is provide a framework for how the lessons can be applied. Good governance, adequate institutional capacity and stablility are all contextually determined and take time to develop. The challenge is that there is no blueprint.
As Richard Horton stated, as chair of the launch event, this is a call to action for governments to take a comprehensive and multisectoral approach to ensure better health outcomes are achieved for all people in developing countries.