HSPH experts highlight the importance of social values, politics, organization,
and economic considerations to health system reform in a new book, Getting
Health Reform Right: A Guide to Improving Performance and Equity.
Published by Oxford University Press, the uniquely multidisciplinary "repair
manual" takes reformers step by step through the complexities of
patching up and replacing broken systems.
world is littered with failed reform efforts," observes Marc
J. Roberts, one of the quartet and a professor of political economy
and health policy. But given the enormous needs, notes his colleague,
professor of population and international health economics, "We have
no choice but to do better."
what the United States spends to stay healthy--about $1.5 trillion a year,
more than any other nation--this country ranked 37th among Western nations
in one 2000 World Health Organization report that factored in quality
and disparities in care among the insured and uninsured. When you consider
that 2.8 billion people--more than half the population of all developing
countries--live on less than $2 a day, you get an inkling of how little
people in, say, Tanzania or Honduras have to spend on medical care, let
alone prevention. If a wealthy, stable country like the U.S. can't provide
good health services to all its citizens, what can resource-poor countries
hope to accomplish?
functioning health systems prevent many nations from sharing the benefits
of development with their own populations, and even from moving forward
economically. That fact was acknowledged by 189 countries of the United
Nations in a pact to cut world poverty in half by 2015 known as the Millennium
Development Goals (MDG). In the wake of the MDG plan, wealthy nations
have begun providing funds, technology, and training to help developing
countries raise their levels of health, along with literacy, gender equality,
and environmental quality. As one might expect, Harvard University--and
particularly HSPH--is deeply involved in research and training to advance
technologies have been developed in the last 40 years for both preventing
and curing disease, the four professors say. At hand are not only diagnostic
and therapeutic tools, but also data-management, telemedicine, and surveillance
aids unimaginable to the last generation.
much of that technology isn't benefiting those who need it most, says
Hsiao, professor of economics. According to Michael
R. Reich, professor of international health, politics plays a critical
role in both maintaining and changing the status quo.
is against this backdrop that Berman, Hsiao, Reich, and Roberts have spent
much of the last decade hammering out principles that any developing country--or
even the U.S.--might follow when attempting to change the health-care
sector. Their experience includes consulting in countries from Colombia
to Kazakhstan. The four have also learned from teaching and listening
to participants in the Flagship Course on Health System Reform and Sustainable
Financing, a combined effort of HSPH and the World Bank Institute. More
than 4,700 health care leaders from 56 countries have participated since
the course began eight years ago.
are guidelines for would-be reformers, whose goals might range from creating
a new insurance system to outlining a financing scheme, changing how primary
care is delivered, or training the next generation of professionals for
clarify your goals and values.
health care system is a means," says Berman. "Reformers need
to think deeply about the ends." What are you trying to accomplish?
What are you willing to do to make it happen? Where do you draw the
easy to draft health policies that are both ethically sound and politically
feasible. Roberts demonstrated that dilemma to Flagship participants
with a pointed question concerning human-organ transplants. "If
rich people need organs and poor people are willing to give up theirs,
why not let them?" he challenged a room full of policy makers last
abound. If you charge for medical care, you won't reach the poorest
patients. Increase police interdiction of drug use as a means to halt
the spread of HIV, and you risk infringing upon civil liberties.
Diagnose the root problem--honestly.
identified a problem that needs fixing--such as limited immunizations
among your country's poorest citizens--work backwards, the authors advise.
State the situation, then back down the diagnostic tree until you get
to the problem's root. Is it rising health care costs? Limited capacity
to pay? Scarce human resources? General distrust of government? Political
corruption or instability? Perhaps instead it's geographic constraints,
poverty, an overflow of counterfeit drugs into the country, a lack of
education, or a poor understanding of basic public health practices.
Build health systems, not just medical systems.
the monumental task of keeping a poor population healthy, a country
must have backbone--a strong, broad-based ("horizontal") health
care infrastructure, heavy on prevention, with adequately funded and
staffed primary care, sanitation, nutrition, and education systems.
That takes money, training, and a large-scale commitment to promoting
technologies and expertise, you need health care systems, not just medical
systems, Berman says. It won't do to ship the latest imaging tools to
areas without electrical power. It's not enough to open clinics if you
don't have trained, motivated people to staff them.
says Hsiao, many of the most visible, best-funded programs are so-called
"vertical" ones-- focus on rescue work, responding to an epidemic,
a natural disaster, or a single, persistent disease, such as malaria.
But "vertical programs have difficulty being effective when the
infrastructure is not there to deliver services," Hsiao says.
of dollars are poured into vertical programs, but "when donors
pull out, these programs often fail," Hsiao warns. That's why Hsiao,
Berman, Reich, and Roberts stress building infrastructures based on
long-term planning, analysis, and evaluation. They want a safety net
to be there when the rescue workers go home.
Base your plan on your nation's unique history, culture, and needs.
no template that serves everyone, Berman says. Your reform strategy
must work with your country's infrastructure, culture, and norms.
how three countries approached the same problem and chose very different
solutions, Hsiao points to health-financing schemes drawn up by Poland,
China, and Vietnam. All three countries are in the process of migrating
from a central-planning to a market-driven economy, but at different
rates and along different paths.
has moved toward a decentralized social insurance system. China is creating
a system that combines individual health-savings accounts with catastrophic
insurance underwritten by the central government. Vietnam is experimenting
with several models of community financing of local medical care centers
that provide primary care and prevention.
Experts don't know everything.
pushed around by so-called reform "experts," Roberts says,
even if they're from Harvard. "A lot of experts only have one view.
To someone who has only a hammer, everything looks like a nail."
"We try to force our readers and students to reflect on their own
values, think about their own political strategies, and consider how
those dimensions get included in the economic and technical approaches
they will take."
Become a political animal.
is not kicked off by public health practitioners' careful analysis,
Berman says. Sometimes the catalyst is a nation's acute health care
needs following a natural disaster, civil war, or economic catastrophe.
More often, it's the product of some political force--"external
pressure, unhappy interest groups, or inspired leadership," he
book, the authors cite the example of Bangladesh. There, a new pharmaceutical
policy focusing on essential medicines for the poor was pushed through
by a military dictator shortly after he took over the country in 1983.
But it didn't happen through a transparent, open, or democratic process.
coup is by no means the best way to institute change, reformers must
realize that, in the end, all is bound by politics. Observe the difficulties
U.S. health reformers have had in extending health insurance to 43 million
uninsured people. In a nation that champions the individual and has
no ideological commitment to universal health care, the political obstacles
is not just a technical process," the HSPH four stress, "but
also a profoundly political matter.
reformers need to embrace,
not shun politics."
must reflect upon their values and plot their political strategies accordingly,
they write. Learn to manage the four P's--players, power, position,
and perception--because they will figure into every step of your implementation.
Expect to bargain, build partnerships, make new friends, and discourage
foes, if you hope to arrive at a win-win plan.
"The mixed success of reform efforts in developing countries is
largely due to the political challenges of implementing reform plans.
There's a major need for better and earlier political analysis, to help
shape proposals that are politically feasible."
is proud of Flagship alums who have managed their P's well to win trust
and build bridges. In India, he says, Flagship participants have "started
serious conversations" with government leaders about how and when
that country might move forward to develop a social insurance system.
progress in China as well, where Harvard has led an intense educational
effort. "Not only are we dealing with senior government officials,
we're training trainers at universities," Roberts says. "The
quality of the policy dialogue about the nature of choices and effective
reforms is much higher now than it was several years ago."
Just do it.
is better than none, so don't wait forever. Expect difficulty; it comes
with the territory.
Poland has been widely lauded for its efforts, although the country
ran into difficulties when it tried to decentralize following a transition
to democracy in the late 1990s. The government tried to get urban hubs
to assume fiscal responsibility for local hospitals. They did--until
they discovered what it cost. In short order, the burden fell back to
the central government.
points to Colombia as an encouraging case. In the 1990s, this nation
extended health insurance to over 65 percent of the population, including
many in poor urban areas, following peaceful democratic elections and
an oil-revenue boom that followed the passage of landmark legislation
for health care and pensions. Despite an expansion of Colombia's civil
war that brought economic and political instability, Colombia has upheld
the spirit and substance of its reform efforts.
change is not an enterprise for the impatient or faint-hearted, the
have a strategy, you must constantly refine it. The authors cite five
"control knobs" for every reform plan: financing, payment,
organization, regulation, and behavior (such as smoking). Fine-tune
the reform process by ratcheting up the appropriate control knobs, remembering
that in fixing one thing you may break another. The trick is to make
incremental changes in synch, to amplify successes and minimize failures.
Learn from your and others' mistakes
consequences of reform are difficult to predict," Berman warns.
Build evaluation tools into reform efforts from Day One.
Most nations follow the pattern we take when we learn to walk: Two steps
forward, one step backward.
on the other hand, has barely begun to walk. Though that country came
up with a new financing plan, Roberts explains, it took "whatever
revenues they collected and put them back into the non-functioning,
old system" of health care delivery.
Be proud of what you do.
reform isn't sexy work. No one expects to get rich or famous by leading
the charge for a new insurance plan or free immunization program. Few,
if any, will win prizes--or even a hearty thank you--for financing sanitation
systems. In fact, it's possible that reformers will not live long enough
to see their work bear fruit. Some will see their life's work wash away
in a tidal wave of one sort of mayhem or another.
are persistent may see monumental change--and improvements in the lives
of thousands, or millions, of people.
say HSPH's four,
Be prepared for anything--or nothing--to happen.
Hartman Cohen has written about science and health for Newsday
and other national publications. She is a regular contributor to HSPHs
newsletter, Harvard Public Health NOW.