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Strengthening Health Systems in Developing Countries

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Strengthening Health Systems in Developing Countries House of Commons International Development Committee Strengthening Health Systems in Developing Countries Fifth Report of Session 2014–15 Report, together with formal minutes Ordered by the House of Commons to be printed 2 September 2014 HC 246 Published on 12 September 2014 by authority of the House of Commons London: The Stationery Office Limited £0.00 International Development Committee The International Development Committee is appointed by the House of Commons to examine the expenditure, administration, and policy of the Office of the Secretary of State for International Development Committee. Current membership Rt Hon Sir Malcolm Bruce MP (Liberal Democrat, Gordon) (Chair) Hugh Bayley MP (Labour, York Central) Fiona Bruce MP (Conservative, Congleton) Sir Tony Cunningham MP (Labour, Workington) Fabian Hamilton MP (Labour, Leeds North East) Pauline Latham OBE MP (Conservative, Mid Derbyshire) Jeremy Lefroy MP (Conservative, Stafford) Sir Peter Luff MP (Conservative, Mid Worcestershire) Mr Michael McCann MP (Labour, East Kilbride, Strathaven and Lesmahagow) Fiona O’Donnell MP (Labour, East Lothian) Chris White MP (Conservative, Warwick and Leamington) The following member was also a member of the committee during the parliament: Mr Russell Brown MP (Labour, Dumfries, Galloway) Richard Burden MP (Labour, Birmingham, Northfield) Mr James Clappison MP (Conservative, Hertsmere) Mr Sam Gyimah MP (Conservative, East Surrey) Richard Harrington MP (Conservative, Watford) Alison McGovern MP (Labour, Wirral South) Ann McKechin MP (Labour, Glasgow North) Mark Pritchard MP (Conservative, The Wrekin) Anas Sarwar MP (Labour, Glasgow Central) Powers The committee is one of the departmental select committees, the powers of which are set out in House of Commons Standing Orders, principally in SO No 152. These are available on the internet via www.parliament.uk. Publication Committee reports are published on the Committee’s website at www.parliament.uk/indcom and by The Stationary Office by Order of the House. Evidence relating to this report is published on the Committee’s website at Strengthening health systems in developing countries Committee staff The current staff of the Committee are Dr David Harrison (Clerk), Chloe Challender (Senior Adviser), Louise Whitley (Committee Specialist), Adam Mellows-Facer (Committee Specialist) Richard Ratcliffe (Committee Specialist) Anita Fuki (Senior Committee Assistant), Paul Hampson, (Committee Support Assistant) and Hannah Pearce (Media Officer). Contacts All correspondence should be addressed to the Clerk of the International Development Committee, House of Commons, 7 Millbank, London SW1P 3JA. The telephone number for general enquiries is 020 7219 1223; the Committee’s email address is [email protected] Strengthening health systems in developing countries 1 Contents Report Page Summary 3 1 Introduction 5 2 DFID’s health systems work 7 Expenditure 7 Bilateral programmes 8 International partners 9 Multilaterals 9 Other donors 10 Gap-filling and coordination 10 3 Information and accountability 13 Expenditure and performance indicators 13 DFID 13 International partners 14 Research 16 4 Foundations of strong health systems 17 Governance and finance 17 Governance 17 Finance 18 Workforces and community health 21 Health workforces 21 Community health workers 23 Community care and public health 24 5 Making better use of NHS expertise 28 Health Partnership Scheme and volunteering overseas 28 Management and finance skills 30 6 DFID leadership 31 Leadership in systems strengthening 31 Post-2015 development goals and universal health coverage 32 Conclusions and recommendations 34 Formal Minutes 38 Witnesses 39 Published written evidence 40 List of Reports from the Committee during the current Parliament 42 Strengthening health systems in developing countries 3 Summary Better health is a basic human right and an end in itself. A healthy population is also essential to development. Recent years have seen some rapid improvements in health partly driven by the Millennium Development Goals and the large international funds set up to accelerate progress towards them. However, these improvements have at times been achieved despite the poor state of health systems in many developing countries. Stronger health systems will be required to ensure efficiency, tackle growing challenges such as non- communicable diseases and progress towards self-sufficiency. DFID has long had a good reputation for health system strengthening and this is reflected in its own work. But DFID now relies on international partners, which do not all share this reputation, in an increasing number of countries and to manage an ever-greater proportion of its expenditure. We recommend that DFID reviews in each country whether its funding arrangements enable its health systems strengthening objectives to be met. Assessing the effectiveness and value for money of health system strengthening work by DFID and its international partners is more difficult than it ought to be. Expenditure and performance figures are not published and the research base is inadequate. This must change. We also recommend DFID takes the lead in system governance and finance, and publishes a new strategy on health workforces. The UK has one of the best health systems in the world, but DFID makes only limited use of it. We call on DFID to work with the NHS in expanding volunteering schemes for doctors and nurses and making more use of NHS finance and management skills. Finally, we urge DFID to demonstrate global leadership worthy of its health systems expertise. It should be a vocal champion of system strengthening and seek to influence its international partners to prioritise it in their work. It looks likely that universal health coverage will be a target in the global post-2015 development goals, providing a chance to increase international focus on system strengthening. DFID must grasp this opportunity. Strengthening health systems in developing countries 5 1 Introduction 1. The enjoyment of the highest attainable standard of health is an end in itself and, according to the World Health Organization (WHO) constitution, a basic human right.1 A healthy population is also fundamental to societal development and economic growth.2 Recent years have seen some rapid improvements in health outcomes in developing countries: malaria incidence and the number of new cases of HIV have each fallen by around one-third since the turn of the century and the global child mortality rate has halved since 1990.3 Nevertheless, there is widespread concern that many developing country health systems remain weak. The UK Department for International Development (DFID) argues that, though outcomes can be improved rapidly in the short run through disease-specific “vertical” interventions, health system strengthening (HSS)4 is essential for long-term efficiency, sustainability and, ultimately, a future without aid. 5 Box 1: Vertical and horizontal Health interventions that seek to target particular diseases, such as HIV or malaria, or population groups, such as mothers or young children, are sometimes known as “vertical” programmes. They can be crudely distinguished from “horizontal” programmes, which aim to achieve better health outcomes by making improvements across all conditions or population groups, often through strengthening underlying health systems. In reality, many programmes include both vertical and horizontal elements. 2. A global United Nations survey in 2013 found that better healthcare ranked second behind education as the highest public priority. In Africa, improved healthcare was the single most important concern.6 A good health system delivers high quality services when and where people need them. The public expect a healthy environment, with access to clean water and nutritious food, information about how to stay healthy, preventative care such as immunisation, local access to advice and basic treatment, a system of referral to more specialist care and provision for emergencies. They can reasonably expect such services to be provided regardless of their social background, without resulting in impoverishment and preferably free at the point of use, and taking into account their preferences about their care.7 3. We were told that HSS was now of particular importance because the “quick wins” from scaling up vertical interventions in major communicable diseases and child and maternal 1 World Health Organization, Constitution of the World Health Organization, October 2006, p1 2 DFID, Health position paper: delivering health results, July 2013, pp4-5 3 World Health Organization Factsheet 290, Millennium Development Goals (MDGs), May 2014 4 The World Health Organization defines health systems strengthening as “[i] the process of identifying and implementing the changes in policy and practice in a country’s health system, so that the country can respond better to its health and health system challenges; [ii] any array of initiatives and strategies that improves one or more of the functions of the health system and that leads to better health through improvements in access, coverage, quality, or efficiency”. See http://www.who.int/healthsystems/hss_glossary/en/. 5 HSS19 [DFID] 6 United Nations, My World, the United Nations Global survey for a better world: summary of results, March 2013 7 World Health Organization Factsheet, Key components of a well-functioning health system, May 2010 6 Strengthening health systems in developing countries health have largely been exhausted.8 Furthermore,
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