Transformational trends confounding the South Asian health systems

Already overwhelmed by the burden of communicable diseases, the health systems in South Asia face six global and regional transformational trends, which pose opportunities, challenges and threats. These six trends discussed in the paper are: (i) economic growth and globalization; (ii) technological changes; (iii) labor market changes; (iv) private sector growth; (v) demographic changes; and (vi) epidemiological changes. These trends have created dual challenges for the health systems in South Asia: (i) to achieve the Millennium Development Goals (MDGs) relating to child and maternal health, and communicable diseases and (ii) to deal with the emerging challenges posed by the six transformational trends.The paper suggests and proposes the use of the transformational trends framework to investigate the various opportunities and challenges, and to design effective policy responses. The capacities and resources of the governments in the region are already stretched by legacy challenges posed by communicable diseases. Hence, effective responses to new challenges will need flexible and innovative approaches including partnership with private sector, civil society, and regional cooperation. The opportunities from the trends are more likely to benefit the richer sections of the society. Therefore, pro-poor measures are necessary to ensure inclusive development.     

Epidemiological Transition and the Double Burden of Disease in Accra,Ghana

It has long been recognized that as societies modernize, they experience significant changes in their patterns of health and disease. Despite rapid modernization across the globe, there are relatively few detailed case studies of changes in health and disease within specific countries especially for sub-Saharan African countries. This paper presents evidence to illustrate the nature and speed of the epidemiological transition in Accra, Ghana’s capital city. As the most urbanized and modernized Ghanaian city, and as the national center of multidisciplinary research since becoming state capital in 1877, Accra constitutes an important case study for understanding the epidemiological transition in African cities. We review multidisciplinary research on culture, development, health, and disease in Accra since the late nineteenth century, as well as relevant work on Ghana’s socio-economic and demographic changes and burden of chronic disease. Our review indicates that the epidemiological transition in Accra reflects a protracted polarized model. A “protracted” double burden of infectious and chronic disease constitutes major causes of morbidity and mortality. This double burden is polarized across social class. While wealthy communities experience higher risk of chronic diseases, poor communities experience higher risk of infectious diseases and a double burden of infectious and chronic diseases. Urbanization, urban poverty and globalization are key factors in the transition. We explore the structures and processes of these factors and consider the implications for the epidemiological transition in other African cities.     

Health sector reform: making health development sustainable

Health sector reform is underway or under consideration.in countries throughout the world and at all levels of income. This paper presents an overview of key concepts and approaches to health sector reform in developing countries. Reform implies sustained, purposeful, and fundamental changes in the health sector. While it is difficult to define precisely what constitutes a true reform, there is widespread consensus that reform is a process of change involving the what, who, and how of health sector action. Health is increasingly included as an important goal of national development. It can make development more sustainable. The paper outlines some general and specific health sector reform strategies that can contribute to sustainable development for countries at all levels of income, although the strategies will differ in content and emphasis. Health sector reform should be based on an holistic view of the health sector. The paper presents two frameworks to aid in reform design: one highlighting the linkages between different institutional actors in the health sector; the second addressing linkages across different functional areas of reform action. In order to develop and carry out reform, information and analysis is needed. A variety of practical tools now available for this purpose are discussed, encompassing all the different areas of action. While tool development should continue, reform proponents already have much to work with. Given global interest, the importance of health sector reform in development strategies, and significant existing knowledge and experience, country level analysis and action should proceed vigorously.     

Economic impact of animal diseases on production systems in South America: case studies]

The authors discuss the relative importance of the livestock sector in South America, in developing countries and in countries world-wide. The development of animal health services is highlighted and the new challenges which these services must meet, with respect to the restructuring of international trade, are described. The economic impact of animal diseases and of disease control is evaluated by taking a regional approach and by analysing production systems. A classification of production systems is accompanied by case studies on the economics of animal health. Emphasis is placed on national control programmes, diseases which affect reproduction, parasitic diseases and mastitis, with particular reference to the livestock sector of Colombia. The authors suggest that integrated livestock development programmes include the management of animal health and production information. A change of attitude is also recommended with greater participation of those involved. The need to co-ordinate sustained research initiatives is stressed.     

Nutritional transition and non-communicable diet-related chronic diseases in developing countries

It is increasingly recognized that developing countries are undergoing an epidemiologic transition similar to that which occurred in industrialized countries in previous centuries. While infectious diseases are still the main cause of morbidity and mortality, there is a marked increase in chronic non-communicable diseases, particularly in the most advanced developing countries, and these diseases are expected to take the lead in a decade or two. Most of these diseases, above all coronary heart diseases, stroke and diabetes, are related to diet and lifestyles, for example tobacco and alcohol consumption. As a matter of fact, these societies are also facing a growing epidemic of overweight and obesity, due to the frequent energetic imbalance between energy-dense food consumption and reduced daily physical expenditure. This health transition, favoured by demographic changes towards aging populations, is occurring at an increased pace in urban societies widely exposed to the modernization of lifestyle, sedentary occupation, and to lipid- and sugar-rich food, often poor in fibre and micronutrients. Increased world access to cheaper vegetable oil is thought to have triggered off this accelerated and generalized trend, though animal food, rich in saturated fat, and imported or locally-made industrialized food also play a role. While increased national and household incomes facilitate the initial change, as the transition advances poor people progressively become the main victims, as has been observed in the more advanced developing countries. Metabolic imprinting due to intra-uterine and infant malnutrition, which are still common in these societies, is also thought to play a significant role in the increase in the expression of insulin resistance, obesity and chronic diseases when these children are exposed to abundant food and modern lifestyle, later in life. Treatment and secondary prevention of nutrition-related chronic diseases and associated disabilities have an ever rising cost in industrialized countries, which is far beyond the means of the still fragile economies of developing countries. This double burden of infectious diseases and undernutrition that still exist, and of non-communicable diseases and overnutrition represents a threat to the frequently unprepared health care services in developing countries. There is a clear need to focus health policies on the prevention of chronic diseases through primary health care services, the use of mass media for communication and education about healthy nutrition and lifestyle, and the adaptation of public policies. Nutritionists must also adapt to this changing nutritional situation which may result in apparently contradictory nutritional status findings within societies if not even within households.     

Research on health transition in Africa: time for action

With rapidly increasing globalization, trends towards unhealthy diets, obesity, sedentary lifestyles and unhealthy habits are resulting in an increased worldwide burden of chronic non-communicable diseases (NCDs). In Africa this means that health systems face the challenge of an increasing burden of NCDs and of continuing high morbidity and mortality from communicable diseases. This health transition represents an enormous challenge to Africa as the region with the least resources for an effective response. Whereas previous epidemics, including HIV, have caught Africa unprepared, the opportunity now arises to take the advancing wave of health transition in Africa seriously. Health research has a key role to play in meeting health and development goals, and must be responsive to changing disease patterns, such as health transition. There is an urgent need for research on health transition in Africa to enable countries to respond effectively to rapidly changing health needs.     

Environmental health impacts associated with rapid urbanisation in South Africa.

There is an urgent need for epidemiological assessments of environmental factors associated with rapid urbanisation in developing countries. Unlike the process in developed countries, urbanisation in the developing world is often associated with urban poverty, particularly on the periphery of the city where informal settlement areas develop. Population growth rates in these areas are frequently higher than in the city itself, and access to basic environmental amenities is frequently lacking. In Africa, ill-health conditions associated with rapid urbanisation, such as diarrhoea and acute respiratory infections, continue to be major causes of childhood deaths. An account is given of research being conducted in South Africa to address such problems, as well as problems related to inner-city decay, such as childhood lead exposure. There is a critical need for better inter-sectoral co-ordination between the health sector and other sectors such as housing and planning, in preventing negative health impacts associated with rapid urbanisation in the future.     

Indonesian heath care and the economic crisis: is managed care the needed reform?

The ramifications of the current economic crisis are being felt throughout Asia, but problems are particularly acute in Indonesia; in the midst of high inflation and unemployment the government is considering expanding managed care reform. In this paper, we discuss the impact of the recent economic crisis on the health sector in Indonesia, and analyze the potential for implementing effective reform following the managed care model. The health sector is discussed, highlighting pre-existing problems in the health care supply environment. The determinants of the economic crisis are summarized, and the broad impacts of the crisis to date on the health sector are assessed. Next the prospects for success of current managed-care reform proposals are examined in some detail: viability of expanded managed care reform measures are assessed in light of the continuing crisis and its likely impacts on the consumers and suppliers of health care. Analysis of the potential impact of the continuing crisis focuses on key participants in health care reform: households, the government, and private health care providers. In conclusion the potential viability of managed care appears poor, given the current economic, political, and institutional conditions and likely future impacts, and suggest some alternative reform measures.     

Globalization of the pharmaceutical industry and the growing dependency of developing countries: the case of Turkey.

In developing countries, the effect of globalization on the pharmaceutical sector has resulted in a decrease in exportation and domestic production, accompanied by an increase in importation of pharmaceuticals and a rise in prices and expenditures. As an example of a developing country, Turkey has been facing the long-standing and increasing pressure of global regulations placed on its pharmaceutical sector. This has led to an increasing dependency on multinational companies and a gradual deterioration of an already weakened domestic pharmaceutical sector. This case study of Turkey offers points to consider in the world of increasing globalization, as it offers lessons on ways of examining the effects of globalization on the pharmaceutical industry of developing countries.     

Public health in the new millennium

In the new millennium the world has become a ?global village?. Urbanization, economical imbalance, changing social structures and globalization resulting in ever-increasing interpenetration and interdependence between local, national and transnational events constitute the new operational field of public health. This article discusses the challenges and constraints faced by developing countries in its efforts to improve equity in health care. It is noted that the challenges include globalization; emergence of diseases and epidemics; privatization of health care; improving the quality of care; developing Healthy Public Policy; effective decentralization; and a focus on the poor, vulnerable and marginalized groups. In terms of the constraints, most notable is the disagreement between providers of individual care and practitioners of population-based medicine, and the noncontribution of public health research to public policy. In view of such, several recommendations are cited in order to overcome these challenges and constraints and in turn, achieve the goal of improving equity in health care. In this regard, the importance of health systems development including health sector reform in shaping the system and practice of public health in the new millennium is emphasized.     

Toward an analytical approach to health sector reform

An analytical approach to health sector reform requires definition of the objectives of the health sector. Although a multiplicity of objectives may be appealing, there are compelling analytical reasons for simplicity. It is argued that a health status maximization objective is a widely acceptable choice, which captures most of the important aspects of utility maximization of relevance for health sector reform. Equity can be addressed in the process of aggregating individual outcomes. The widely recognized need for health sector reform in developing countries constitutes, in itself, evidence of the market failures in the health sector. If the market worked, why would we need reform? Given an objective and a justification for reform, analysis should proceed to address measurement questions and intervention strategies. The disability-adjusted life year lost is proposed as a consistent and feasible measure of health. Based on an optimization model of health sector performance in Africa, the paper discusses interventions to improve allocative and technical efficiency. These are broadly characterized as interventions dealing with lack of knowledge and interventions dealing with institutional shortcomings. They lead to different approaches to health sector reform. The paper concludes that we now have a systematic analytical approach to reform, in which tools and methods for addressing information gaps are well developed and need to be more widely applied, while those addressing institutional failures still need further development and application.     

South African Mental Health Process Indicators

BACKGROUND: In post-apartheid South Africa the organisation and delivery of mental health care is undergoing significant change. With the heritage of an under-resourced, fragmented, racially inequitable service, heavily reliant on chronic custodial treatment in large centralised institutions, this change is long overdue. New policy has set out a vision for a community-based, comprehensive, integrated mental health service. In order to realise this vision a review is required of the way in which care is currently delivered, or the 'process' of mental health care. To date, no national research has been conducted regarding process of care indicators in South African mental health services. AIMS OF THE STUDY: This study documents four public sector mental health service process indicators in South Africa: bed occupancy rates, admission rates, average length of stay and default rates. METHODS: A questionnaire was distributed to provincial mental health co-ordinators, requesting numbers of occupied and available beds in psychiatric inpatient facilities, annual mental health admissions, average length of stay (ALOS), and default rate in ambulatory care settings. The information was supplemented by consultations with mental health co-ordinators in each of the 9 provinces. RESULTS: The national bed occupancy rate is 83% (range: 63-109%). The national annual rate of admission to psychiatric inpatient facilities is 150 per 100 000 population (range: 33-300). The national average length of admission is 219 days in psychiatric hospitals, 11 days in general regional hospitals and 7 days in general district hospitals. On average 11% of psychiatric patients who attend ambulatory care services on a monthly basis fail to keep their appointments. DISCUSSION: Although the national mean bed occupancy is compatible with international figures, there is considerable discrepancy between provinces, indicating both over- and under- utilisation of inpatient resources. Admission rates are low, relative to developed countries, though comparable to developing countries. Low admission rates are associated with a range of factors including inadequate service provision, unmet need, inaccessible services, cross-border flow between provinces and custodial patterns of care. There is evidence of long periods of admission relative to international settings. There is also considerable diversity between provinces, with certain institutions continuing to provide long term custodial patterns of care. Default rates are low relative to international settings and past reports default in South Africa. IMPLICATIONS FOR HEALTH POLICIES: In keeping with current policies there is an urgent need for local level evaluation and reform of chronic custodial care. The ongoing monitoring of process indicators is important in the transition to community-based mental health care. IMPLICATIONS FOR FURTHER RESEARCH: Limitations of the data, and problems of collecting information on mental health care within an integrated health system indicate the need for further research in this area. There is also a need for further research into unmet need for mental health care in South Africa.     

Public sector reform and demand for human resources for health (HRH)

This article considers some of the effects of health sector reform on human resources for health (HRH) in developing countries and countries in transition by examining the effect of fiscal reform and the introduction of decentralisation and market mechanisms to the health sector.     

The international community and the reconstruction of health care in South Eastern Europe

Today, with the aid of the international community [European Union (EU), World Bank (WB), World Health Organisation (WHO), United Nations Children's Fund (UNICEF), nongovernmental organisations (NGOs), Global Fund (GF), Stability Pact, etc.] the ministries of health in transitional countries in the South Eastern Europe (SEE) region are in the process of expanding the capacities and skills of the health workforce in order to achieve successful health care reform and accomplish necessary steps for EU integration. The aim of this paper is to review international community support to reconstruction of the health care in SEE countries, with main focus on the EU and WB donors and projects. Review was done on the basis of existing donor reports, Internet search (search of official Web sites and electronic databases, check of references from selected documents, and use of a generic Internet search engine) and authors’ experience from different health projects. The governments of SEE countries, in order to create an effective and efficient health system, overcame a period of transition and soon or later became ready for the process of EU integration, and began working on the following issues: rehabilitation, reconstruction and equipping of health facilities; developing a health strategy and policy documents; legislation and financing framework; building institutional, human resource and management capacity; health care sector reform; support to public health development and restructuring of the pharmaceutical sector. In many SEE countries, the capacity of the Ministry of Health and Health Insurance Fund was strengthened, and policy and strategy documents were drafted to guide reorganisation and reorientation of health care services. The public health system was strengthened. A family medicine model was introduced and developed in most countries. Development of enabling legislation mostly followed proposed changes in the health system. Although progress on several important fronts in achieving transition and progress in the rehabilitation health sector in SEE countries is significant, a lot remains to be done. Experience in some countries can be used to stimulate, motivate and encourage professionals throughout the civil service to grasp with both hands the opportunities for positive change.     

Disease control priorities in developing countries: health policy responses to epidemiological change.

Health systems in developing countries are facing major challenges in the 1990s and beyond because of a growing epidemiological diversity as a consequence of rapid economic development and declining fertility. The infectious and parasitic diseases of childhood must remain a priority at the same time the chronic diseases among adults are emerging as a serious problem. Health policymakers must engage in undertaking an epidemiological and economic analysis of the major disease problems, evaluating the cost-effectiveness of alternative intervention strategies; designing health care delivery systems; and, choosing what governments can do through persuasion, taxation, regulation, and provision of services. The World Bank has commissioned studies of over two dozen diseases in developing countries which have confirmed the priority of child survival interventions and revealed that interventions for many neglected and emerging adult health problems have comparable cost-effectiveness. Most developing countries lack information about most major diseases among adults, reflecting lack of national capacities in epidemiological and economic analyses, health technology assessment, and environmental monitoring and control. There is a critical need for national and international investment in capacity building and essential national health research to build the base for health policies.     

A systematic review of air pollution as a risk factor for cardiovascular disease in South Asia: Limited evidence from India and Pakistan

Cardiovascular diseases (CVD) are major contributors to mortality and morbidity in South Asia. Chronic exposure to air pollution is an important risk factor for cardiovascular diseases, although the majority of studies to date have been conducted in developed countries. Both indoor and outdoor air pollution are growing problems in developing countries in South Asia yet the impact on rising rates of CVD in these regions has largely been ignored. We aimed to assess the evidence available regarding air pollution effects on CVD and CVD risk factors in lower income countries in South Asia. A literature search was conducted in PubMed and Web of Science. Our inclusion criteria included peer-reviewed, original, empirical articles published in English between the years 1990 and 2012, conducted in the World Bank South Asia region (Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan and Sri Lanka). This resulted in 30 articles. Nine articles met our inclusion criteria and were assessed for this systematic review. Most of the studies were cross-sectional and examined measured particulate matter effects on CVD outcomes and indicators. We observed a bias as nearly all of the studies were from India. Hypertension and CVD deaths were positively associated with higher particulate matter levels. Biomarkers of oxidative stress such as increased levels of P-selection expressing platelets, depleted superoxide dismutase and reactive oxygen species generation as well as elevated levels of inflammatory-related C-reactive protein, interleukin-6 and interleukin-8 were also positively associated with biomass use or elevated particulate matter levels. An important outcome of this investigation was the evidence suggesting important air pollution effects regarding CVD risk in South Asia. However, too few studies have been conducted. There is as an urgent need for longer term investigations using robust measures of air pollution with different population groups that include a wider range of air pollutants and outcomes, including early indicators of CVD. These regions are facing burdens from increasing urbanization, air pollution and populations, generally weaker health infrastructure, aging populations and increased incidence of non-communicable diseases, included CVD. The extent to which the problem of air pollution and CVD will impact these countries will depend largely on the information available to inform policy and programs, which are still lacking, political will as well as social and economic development.     

Changing health in China: re-evaluating the epidemiological transition model

This paper reviews the changing health situation in China, which has shown remarkable improvement in the 50 years since the founding of the People's Republic of China (PRC) in 1949. At first sight this improving health situation follows the classical epidemiological transition model. Just three decades ago health in China was characterised by high rates of infectious disease and early mortality (diseases of poverty) in a mainly peasant society. More recently infectious disease rates have decreased, with corresponding and extended morbidity and mortality associated with an aging population in a rapidly urbanising society. This process has given rise to new health problems, including chronic and degenerative diseases (diseases of affluence). Nonetheless, while there is some validity in the application of the epidemiological transition concept, further analysis demonstrates that China faces a new epidemiological phase, characterised by increasing life expectancy and diseases of affluence coupled with the emergence and re-emergence of infectious diseases. We demonstrate that China's state policy plays a major role in defining the parameters of health in a Chinese context. We conclude that, today, China is faced with a new set of health issues, including the impact of smoking, hypertension, the health effects of environmental pollution and the rise of HIV/AIDS; however, state policy remains vital to the health of China's vast population. The challenge for policy is to maintain health reform whilst tackling the problems associated with rapid urbanisation, widening social and spatial inequalities and the emergence of HIV/AIDS and other infectious diseases.     

A development framework for promoting evidence-based policy action: drawing on experiences in Sri Lanka

Most developing countries have embarked on one form or another of 'health sector reform' as a result of the global trend for health and health care reform that has emerged during the past decade. One consequence is that the issue of health sector performance is moving higher on the agenda of many developing countries, and particularly that of the corporate performance of health sector staff. Along with this movement has come increased attention to strengthening evidence-based management decision-making. To date, studies on measuring health sector performance, have had little impact on developing country health systems and have been limited to explorations primarily at an operational level. However, there is a growing recognition that there is a need to strengthen the policy function of ministries and their ability to monitor policy impact. Sri Lanka is one country that has identified the need to strengthen policy at national level. Many developing countries, like Sri Lanka, are familiar with input, process and output dimensions of operational performance. However, most are not ready to engage in routine performance assessment that can strengthen policy processes at national level. This paper explores (1) the implication and the use of indicators to support evidence based policy decision-making, and (2) the complexity of doing so in Ministries of Health that are undergoing some form of health sector reform. The paper emphasizes that new forms of organizational support are required for performance management at policy level. A conceptual framework for managing the collection and use of performance evidence is developed, including proposals for the introduction of outcome indicators into that process. The paper concludes with recommendations on initiatives required to develop appropriate organizational and technical capacity to engage with performance management at policy level and for further research towards creating ministries of health as 'learning organizations' that can change and adapt with informed decisions.     

Policy analysis: an essential research tool for the introduction of vaccines in developing countries

To address the unacceptable levels of disease in developing countries and the lack of vaccines to address infectious diseases, the public sector has been expanding its funding for, and involvement in, vaccine research and development. The public sector is becoming a full participant in the spectrum of translational research taking candidates from the laboratory to use in national immunization programmes. As these programmes and the continuing work of the private sector achieve success, an extensive analysis of policy will be needed to support the introduction of vaccines. Based on the early experience with the introduction of hepatitis B vaccine in several developing countries, there is a defined framework for the introduction of vaccines. This framework lays out five essential overlapping and complementary elements of introduction of vaccines in developing countries. Each element requires a clear understanding of policy-related issues. There is a pressing need to include and expand policy analysis on a wide range of topics to ensure that the poor in developing countries can have access to the fruits of modern biotechnology.     

Self-help: What future role in health care for low and middle-income countries?

In the debate on 'Third options' for health care delivery in low- and middle-income countries it is proposed that self-help should play a larger role. Self-help is expected to contribute towards improving population health outcomes and reducing government health care expenditure. We review scope and limitations of self-help groups in Europe and South Asia and assess their potential role in health care within the context of health sector reform.Self-help groups are voluntary unions of peers, formed for mutual assistance in accomplishing a health-related purpose. In Europe, self-help groups developed out of dissatisfaction with a de-personalised health care system. They successfully complement existing social and health services but cannot be instrumentalized to improve health outcomes while reducing health expenditure.In South Asia, with its hierarchical society, instrumental approaches towards self-help prevail in Non-governmental Organizations and government. The utility of this approach is limited as self-help groups are unlikely to be sustainable and effective when steered from outside. Self-help groups are typical for individualistic societies with developed health care systems - they are less suitable for hierarchical societies with unmet demand for regulated health care. We conclude that self-help groups can help to achieve some degree of synergy between health care providers and users but cannot be prescribed to partially replace government health services in low-income countries, thereby reducing health care expenditure and ensuring equity in health care.