Achieving long-lasting health outcomes through health systems development


By: Merrian Brooks*

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“This growth had enormous consequences. Death rates were high and far worse in cities than in the countryside. Smallpox, typhus and tuberculosis were endemic, and cholera alarmingly epidemic. Overcrowding combined with poor sanitation and often grinding poverty to leave many people vulnerable to the latest outbreak of anything nasty.” (Source)


This story is the beginning of the story of the history of health systems development in Britain. I find it very reminiscent of the current structural reasons for increased morbidity and mortality in many African countries. When learning about the history of medicine two stories were told to my classmates and I. Yes of course we learned peripherally about “quack medicine” where bloodletting and adjusting ‘humors’ was the norm, but mostly we learned about vaccines and sanitation. We learnt that cholera was a catalyst for modern public health practices and epidemiology. It emphasized the importance of clean sanitation, and was one of several diseases affecting those living in poverty the most. Vaccines on the other hand, we also learnt,  allowed the public health system to protect the masses from deadly or disabling disease through both direct protections to the patient and from herd immunity. We see then, that a disease and intervention specific (i.e. targeting a disease like malaria for example, or having a vaccine campaign) approach did have big impacts on transforming public health in Britain.

Using a disease and intervention specific approach has worked for some countries that have reached the millennium development goal 4, namely to: Reduce Child Mortality; Target 4.A:   lower child mortality by two thirds (2/3). I applaud countries like Ethiopia who were able to drastically reduce child mortality on a tight budget. According to a 2013 UNICEF report on child mortality, Malawi (72 percent), Liberia (71 percent), United Republic of Tanzania (69 percent), Ethiopia (69 percent), Niger (68 percent) and Eritrea (67 percent) all significantly reduced the childhood mortality rates. Ethiopia, for example, dropped its rates from an estimated 205 deaths per 1000 live births, to an estimated 64 deaths per 1000 live births between 1990 and 2013. This is amazing. UNICEF and the UN report that vitamin supplementation, access to immunizations, and increasing the number of trained health workers all contributed to these improvements. In other words, the world’s focus on disease specific interventions worked in some of the hardest hit countries, right?

But what is missing from the story is what happened after Cholera in Great Britain; that Public Health Acts in the mid-19th century, resulted in production of infrastructure and assignment of local medical officers. Britain’s health system, one that could support all future interventions, began to take shape and it is now one of the most sophisticated in the world. Ethiopia similarly reports “political will” and is much more specific about the changes it had to make to get such a drastic reduction in mortality. Dr. Kesetebirhan Admasu, the Federal Minister of Health of Ethiopia states “It is now clear that the key policy choices that we made in the health sector were the right ones.” One such policy choice was to hire 38,000 health workers and spread them to 15,000 posts. That is a significant financial investment on the part of the government, to not just reach a goal, but to grow a system. Access to health workers, and having nearby health posts are the fundamentals of any health system. Without them disease and intervention specific approaches result in small or short lived successes tied to the whims of different funding agencies.

Ethiopia had the will to invest the financial resources to invest in the lives of its citizens. But with structural adjustment programs (SAPs) and other austerity measures when have most Sub-Saharan African countries had a chance to build up this needed system? Even the World Health Organization (WHO) writes in their assessment of structural adjustment, “Studies have shown that SAPs policies have slowed down improvements in, or worsened, the health status of people in countries implementing them. The results reported include worse nutritional status of children, increased incidence of infectious diseases, and higher infant and maternal mortality rates.” In Africa, where despite the success of Ethiopia and others listed above, most countries are NOT on track (See Map) to meet the 4th development goal. We must reevaluate our current disease and intervention focused development model in order to promote more funding for general health systems, and public health infrastructure development.

We know that health systems are vitally needed in order to have sustainable health measures in sub-Saharan Africa. Oxfam and Paul Farmer in their responses to the Ebola outbreak discuss a lack of health systems development as the primary reason that Ebola has spread so extensively and has lasted so long. Instead of focusing on a particular disease like Britain did in the 1800s it would be prudent to instead focus on health systems development like they did shortly after the initial cholera response. In the United States we spend trillions of dollars on medical care much of which is spent by the government. In many countries throughout the world like in the USA government spends millions or billions of dollars and builds the health system with positive health outcomes are a result. We must give sub-Saharan African countries the freedom to build health systems and developmental infrastructure. Ethiopia was able to make many strides because their government committed to building strong health infrastructure. Instead of earmarking funds for a particular disease it would be better to support African countries by providing grants for clinic constructions, healthcare worker trainings, and other fundamentals needed for a  functioning  a healthcare system. In order to move beyond the short sited criteria of the millennium development goals we may find that health systems development helps us move to more robust longstanding health outcomes.

*Merrian Brooks is a regular Bokamoso contributor. Read her previous articles here.

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