Elsevier

The Lancet

Volume 381, Issue 9883, 15–21 June 2013, Pages 2118-2133
The Lancet

Health Policy
Good Health at Low Cost 25 years on: lessons for the future of health systems strengthening

https://doi.org/10.1016/S0140-6736(12)62000-5Get rights and content

Summary

In 1985, the Rockefeller Foundation published Good health at low cost to discuss why some countries or regions achieve better health and social outcomes than do others at a similar level of income and to show the role of political will and socially progressive policies. 25 years on, the Good Health at Low Cost project revisited these places but looked anew at Bangladesh, Ethiopia, Kyrgyzstan, Thailand, and the Indian state of Tamil Nadu, which have all either achieved substantial improvements in health or access to services or implemented innovative health policies relative to their neighbours. A series of comparative case studies (2009–11) looked at how and why each region accomplished these changes. Attributes of success included good governance and political commitment, effective bureaucracies that preserve institutional memory and can learn from experience, and the ability to innovate and adapt to resource limitations. Furthermore, the capacity to respond to population needs and build resilience into health systems in the face of political unrest, economic crises, and natural disasters was important. Transport infrastructure, female empowerment, and education also played a part. Health systems are complex and no simple recipe exists for success. Yet in the countries and regions studied, progress has been assisted by institutional stability, with continuity of reforms despite political and economic turmoil, learning lessons from experience, seizing windows of opportunity, and ensuring sensitivity to context. These experiences show that improvements in health can still be achieved in countries with relatively few resources, though strategic investment is necessary to address new challenges such as complex chronic diseases and growing population expectations.

Introduction

Why do some countries achieve better health outcomes than do others at similar levels of income? In 1985, the Rockefeller Foundation convened a meeting in Bellagio, Italy, to consider the experiences of four countries or regions seen as success stories: China, Costa Rica, Sri Lanka, and the state of Kerala in India. All had achieved substantially better health outcomes than other nations at similar levels of development. The result was a publication entitled Good health at low cost1 that not only dispelled the then widely believed myth that economic growth was necessary for health improvement but also identified specific factors associated with success. These were a commitment to equity, effective governance systems, and contextually appropriate programmes addressing the wider determinants of health. Politics also mattered, and every country or region was run by left-wing governments of various hues. 25 years later, the threats to health and the scope to respond are much more complex. Do the lessons of 25 years ago still apply?

In 2011, we revisited the original countries and regions and looked at five different places that were judged to have succeeded in either achieving long-term improvements in health and access to services or implementing innovative reforms relative to their neighbours (table).2 We used a conceptual framework (figure) to assess how access to health care and good health are affected by context (global and national), sector (public and private), and systems (health and non-health). The nature of the success varies; some have achieved substantial health gains whereas others have improved coverage or health system performance but are yet to see the full effect. Here, we review the experiences of Bangladesh (panel 1), Ethiopia (panel 2), Kyrgyzstan (panel 3), the Indian state of Tamil Nadu (panel 4), and Thailand (panel 5) and reflect on lessons they offer to other countries of low and middle income that are attempting to strengthen health systems in constrained or uncertain circumstances.

In 2009–11, we undertook a series of historical case studies to investigate how and why these five countries or regions made progress in health and access to care (panel 6). Our conceptual framework (figure) was based on existing published work65, 80, 81, 82 and was used to identify a comprehensive range of factors related to health systems, public provisioning (including social programmes such as literacy and female empowerment), and politics and values underpinning the public process. This framework included a mix of quantitative and qualitative methods.83 Findings were validated within and across countries. Our central study question was what determines achievement? Although the complexity of health systems, and the broader political systems in which they are embedded, means that no blueprint is available for producing a strong health system,75, 77 our approach meant we could identify common patterns plausibly linked to better health and health care of potential relevance beyond the countries studied.77 We describe here the main emerging themes focused on the health systems, with reference to topics related to other sectors and the wider context (panel 7).

Section snippets

Characteristics of well functioning health systems

Four characteristics linked to improvements in health and health care emerged from our analysis. The first was good governance and political commitment; the second was effective bureaucracies and institutions; the third factor was the ability to innovate, especially with respect to service delivery; and the final point was health system resilience (panel 8).

Good governance and political commitment

Governance underlies all health system functions80 in addition to broader social development,93 although the meaning of governance in relation to health systems is diverse and contested.94, 95 It includes the regulatory and managerial arrangements through which the health system operates, including how overall goals are set and monitored and how various components of the health system interact to achieve these goals. Governance also includes normative values (equity, transparency) and political

Effective bureaucracies and institutions

Development of sound policies and plans does not guarantee their effective implementation. In our study, functioning bureaucracies and institutions were deemed important for successful reforms. These organisations could be within the health sector (eg, ministries of health, district and subdistrict health institutions, or donor agencies) or outside it but whose operation influences the functioning of health systems (eg, other ministries, the media, or development non-governmental organisations

Innovation

All study countries showed innovation in various aspects of their health systems. Particular originality was seen in the workforce (which is a severe constraint in all countries), financing mechanisms, and means of delivering services.

Building resilience in the health system

Health systems are sometimes vulnerable to unexpected shocks, leading to growing interest in how to foster resilience.79, 124 Thailand and Ethiopia have recently been affected by large-scale natural disasters and have subsequently put in place systems to prepare for similar events in the future. Long experience with seasonal floods and cyclones has made Bangladesh a model of development for appropriate infrastructure and systems to coordinate emergency responses, such that recent natural

Cross-cutting lessons

Here, we have attempted to distil cross-cutting lessons from our analytical case studies of Tamil Nadu in India, Bangladesh, Kyrgyzstan, Thailand, and Ethiopia. Cross-country analysis of national or regional experience has value for identification of common themes, even if the detailed characteristics vary. Although we do not present a roadmap for success, our synthesis draws attention to health system and non-health system factors that seem to be important across our study countries for

References (128)

  • Economic survey of India, 2010–11

    (2010)
  • World population prospects: the 2010 revision

  • C Chandramouli

    Census of India 2011: provisional population totals, India series 1

    (2011)
  • World health statistics 2011

  • Sample registration system (SRS): SRS bulletin, vol 46 no 1

  • Maternal and child mortality and total fertility rates: sample registration system (SRS)

  • Bangladesh: maternal mortality and health care survey 2010—preliminary results

  • Special bulletin on maternal mortality in India, 2007–09

  • Population projections for India and states 2001–2026: report of the technical group on population projections constituted by the National Commission on Population

  • Report on progress towards implementation of the UN Declaration of Commitment on HIV/AIDS

  • HIV sentinel surveillance and HIV estimation in India 2007: a technical brief

  • KD Rao et al.

    HRH technical report 1: India's health workforce—size, composition and distribution

  • Statistical hand book 2011

    (2011)
  • National health accounts, country health information

  • National health accounts, India 2004–05

  • Issues in social protection, discussion paper 19: social health protection—an ILO strategy towards universal access to health care, a consultation

  • A Ibraimova et al.

    Kyrgyzstan: health system review

    Health Syst Transit

    (2011)
  • Annual policy notes, 1990–2005

    (1990–2005)
  • Bangladesh: demographic and health survey, 2007

  • Ethiopia demographic and health survey 2011: preliminary report

  • Kyrgyzstan: monitoring the situation of children and women—multiple indicator cluster survey, Kyrgyz Republic, 2006

  • National family health survey (NFHS-3), 2005–06, India: volume 1

  • Monitoring the situation of children and women: Thailand multiple indicator cluster survey, December 2005–February 2006—final report

  • National family health survey (NFHS-3), India, 2005–06: Tamil Nadu

  • AK Blood

    The cruel birth of Bangladesh

    (2002)
  • S Islam

    History of Bangladesh 1704–1971: vol 1, political history

    (1992)
  • WHO country cooperation strategy 2008–2013: Bangladesh

  • 11 health questions about the 11 SEAR countries

  • ME Chowdhury et al.

    Causes of maternal mortality decline in Matlab, Bangladesh

    J Health Popul Nutr

    (2009)
  • Bangladesh EPI coverage evaluation survey, 2009

    (2009)
  • List of local allopathic pharmaceutical manufacturers

    (2010)
  • J Sundewall et al.

    Theory and practice: a case study of coordination and ownership in the Bangladesh health SWAp

    Health Res Policy Syst

    (2006)
  • Z Chowdhury

    The politics of essential drugs: the making of a successful health strategy: lessons from Bangladesh

    (1996)
  • TP Koehlmoos

    Evidence aid and the disaster response in Pakistan and Haiti

    Cochrane Database Syst Rev

    (2010)
  • M Meredith

    The State of Africa: a history of fifty years of independence

    (2006)
  • Health and health related indicators

    (2008)
  • MS Sebastian et al.

    Efficiency of the health extension programme in Tigray, Ethiopia: a data envelopment analysis

    BMC Int Health Hum Rights

    (2010)
  • H Negusse et al.

    Initial community perspectives on the Health Service Extension Programme in Welkait, Ethiopia

    Hum Resour Health

    (2007)
  • Ethiopia: demographic and health survey, 2005

  • Ethiopia: building on progress—a plan for accelerated and sustained development to end poverty (PASDEP)

    (2006)
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