The Laundry List

Editors note on our Health & Development series:

The correlation between access to first-rate healthcare and least developed countries is striking.  That correlation is more than superficial.  Causality runs in both directions: poor health leads to poverty by constraining the ability to work while simultaneously requiring expensive treatment.  But poverty limits access to expensive care and therefore leads to poor health.  All of this is exacerbated in countries without strong healthcare institutions.  As a result, fighting poverty is as much about providing healthcare opportunities as it is about providing economic opportunities.  Our ongoing series on Health & Development this year will focus on how the world is dealing with these interactions.


Most experts agree that health systems in low-income and middle-income countries need improvement. That much is clear. What is not so obvious is what exactly those improvements look like or how they can be implemented.

As The Lancet Commission noted in its “Global Health 2035” report, low-income and middle-income countries are generally lacking in all of the major health systems functions, including “service delivery, health workers, drugs, information systems, governance, and financing.” This means that smart investment is needed in just about every realm of public health for the lower-income countries.

The implications of this are daunting.

The following laundry list is not nearly exhaustive, but it highlights the most pressing areas of reform in generally inefficient health systems. To start off, primary care facilities must be improved, which includes maximizing use of infrastructure by concentrating hospitals where they are most needed, as well as stocking each clinic with the appropriate medical supplies. Quality and responsiveness of care must be boosted, which can be done by training better doctors and nurses. Cost-effective renovations and programs must be introduced and implemented on a wide scale, reaching urban slums where overcrowding creates shortages of medical treatment, but also rural areas where healthcare is generally most outdated. Immunization campaigns and other preventative measures must be scaled up in sustainable fashion. Research and development facilities must be set up to allow sovereign nations to monitor their own epidemiology and promptly track the emergence of new outbreaks. And lastly, education about disease prevention, proper sanitation, and healthcare options must reach every level of society so that, should a person get ill, the community knows how to respond.

Of course, nearly all of these health system improvements come at a cost, with price tags that vary considerably in magnitude. Some interventions are relatively inexpensive, such as the Nepal National Vitamin A program, which distributes 2 Vitamin A capsules per year to at-risk children. Vitamin A deficiency is the leading cause of preventable childhood blindness and a major risk factor in childhood mortality. In 2000, approximately 1.4 million Nepalese children were reached at a cost of $1.25 each, resulting in an annual cost of $1.7 million. On the other hand, building one hospital in Kano, Nigeria with modern standards and diagnostic capabilities costs around $12 million, which accounts solely for the actual construction of the building, not for its future labor and maintenance costs. In the former case, the Nepalese government, with USAID’s help, made the investment to procure and disseminate Vitamin A capsules. In the latter case, the primary investment was made by “cement tycoon” Aliko Dangote.

Just as there are multiple areas of health systems that need to be addressed in lower income countries, there are also multiple financial players involved. Governments need the support of the private sector, international organizations, and NGOs to effectively address key health system disparities and finance the improvements. Outside sources should act as support systems for developing nations pursuing structural healthcare change, since they can provide much-needed knowledge and financial relief. Additionally, governments are not always primed to detect all of the geographic inequities in healthcare delivery; it is often left to NGOs and international organizations with more available surveillance capacity to target neglected populations and bring them to national attention.

But just as governments should look to external entities for support and specialized expertise, these external entities need to be committed to working cooperatively, not autocratically. After all, none of the laundry-list improvements in healthcare delivery can be implemented without domestic governance and domestic political will. This means that governments of low-income and middle-income countries with poor healthcare systems must first develop plans for improvement that target unique needs. Then donors should work within these country-specific plans, more as development partners than as domineering investors. It is this combined effort that allows a nation’s health system improvements to be specifically catered to the needs of its people.

All of this may seem overwhelming. Indeed, the intimidation factor of uprooting current health systems is one of the major stumbling blocks to comprehensive healthcare improvement in many developing nations. Julio Frenk, a leading figure in the field of public health, believes that in order to catalyze large-scale improvements, we must dispel two huge misconceptions about health systems: the “black box” and “black hole.” The “black box” misconception is that health systems are too complicated to fix through specific interventions. The “black hole” misconception is that no amount of money will be able to achieve this improved health system ideal.

It is true that no one has the answers to creating a perfect health system. But we are figuring it out. We are learning which interventions work and which do not, and through these discoveries, rapidly increasing the potential for optimal healthcare. No set template can be universally replicated when each nation has its own unique disease burden and demography. Yet while there is no blanket cure-all for health systems, there are patterns of success that are shared among the select nations that now set the highest standards of healthcare in the world. The key for developing nations now is to recognize these motifs and devise country-specific agendas to address them. There is no black box or black hole, only abundant room to grow and improve.

Image Credit: Batulechaur Health Post, Pokhara, Nepal by AusAID/Jim Holmes via Wikimedia Commons

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