Developing countries
Health policy making in developing countries is increasingly being envisaged as a stewardship
process concerned with attaining trust and legitimacy between a government and its people
towards the improvement of the welfare of populations. Health policy today involves multiple
actors and an increased role by global and international agencies. Increased investment in the
context of the Millennium Development Goals is also placing greater attention on good national
and international governance. Particular attention is being paid to governance of the new breed of
vertical programmes. This approach has demonstrated benefits for the specific diseases being
tackled, yet it threatens other programmes and the capacity of local authorities to meet broad
health needs. Developing country governments should set clear priorities on the basis of health
needs and infrastructure capacity as well as on sound ethical guidance that help achieve
maximum improvement in health in return for minimum expenditure.
Comprehensive national health accounts is an important policy tool to track health spending from
all sources. Performance assessment can support policy making in monitoring and evaluating
attainment of critical outcomes and the efficiency of the health system in a way that allows
comparison over time and across systems. Particular attention is being given to financing
healthcare for the more than 1.3 billion rural poor and informal sector workers in developing
countries without financial protection against the catastrophic costs of healthcare. Success with
these and other innovations will depend on solving the multiple challenges facing the health
workforce. Relying on public–private mix of services to address health infrastructure faces the
question of the capacity by government to develop contracts, set prices, and monitor and
supervise private providers.
It is not always easy to reconcile efficiency and equity in health policy. Equity should be a
primary concern for sustainable policy making, and tools are available to trace the extent to
which investments at national levels benefit the poor and needy. In many respects, health policy
in developing countries is all about the encouragement of innovation and the scaling-up of life-
saving technologies and systems. Access to knowledge and technology has accounted for a high
proportion in the decline in mortality rates. New strategies for organizing health research systems
can contribute to make evidence-based policy a reality in developing countries.
Although the quantity rather than quality of health services has been the focus
historically in developing countries, ample evidence suggests that quality of
care (or the lack of it) must be at the center of every discussion about better
health. The following examples are illustrative: In one study evaluating
pediatric care in Papua New Guinea, 69 percent of health center workers
reported that they checked for only two of the four examination criteria for
pneumonia cases. Only 24 percent of these workers were able to indicate
correct treatment for malaria. When clinical encounters were observed at aid
posts, providers met minimal examination criteria in only 1 percent of cases
Elements of Quality
Quality comprises three elements:
Structure refers to stable, material characteristics (infrastructure, tools,
technology) and the resources of the organizations that provide care and
the financing of care (levels of funding, staffing, payment schemes,
incentives).
Process is the interaction between caregivers and patients during which
structural inputs from the health care system are transformed into health
outcomes.
Outcomes can be measured in terms of health status, deaths, or disability-
adjusted life years—a measure that encompasses the morbidity and
mortality of patients or groups of patients. Outcomes also include patient
satisfaction or patient responsiveness to the health care system (WHO
2000).
Quality of Care in Developing Countries
The process of providing care in developing countries is often poor and varies
widely. A large body of evidence from industrial countries consistently shows
variations in process, and these findings have transformed how quality of care is
perceived (McGlynn and others 2003). A 2002 study found that physicians
complied with evidence-based guidelines for at least 80 percent of patients in
only 8 of 306 U.S. hospital regions (Wennberg, Fisher, and Skinner 2002). It is
important to note that these variations appear to be independent of access to
care or cost of care: Neither greater supply nor higher spending resulted in
better care or better survival. Studies from developing countries show similar
results. For example, care in tertiary and teaching hospitals and care provided
by specialists may be better than care for the same cases in primary care
facilities and by generalists (Walker, Ashley, and Hayes 1988).
One explanation for variation and low-quality care in the developing world is
lack of resources. Limited data indicate, however, that high-quality care can be
provided even in environments with severely constrained resources. A study in
Jamaica, which used a cross-sectional analysis of government-run primary care
clinics, showed that better process alone was linked to significantly greater
birthweight (Peabody, Gertler, and Liebowitz 1998). A study in Indonesia
attributed 60 percent of all perinatal deaths to poor process and only 37 percent
to economic constraints (Supratikto and others 2002).
Cross-system or cross-national comparisons provide the best examples of the
great variation in clinical practice in developing countries. In one seven-country
study, researchers directly observing clinical practice found that 75 percent of
cases were not adequately diagnosed, treated, or monitored and that
inappropriate treatment with antibiotics, fluids, feeding, or oxygen occurred in
61 percent of cases (Nolan and others 2001). Another study compared providers'
knowledge and practice in California and FYR Macedonia, using vignettes to
adjust for case-mix severity. Although the quality of the overall or aggregate
process was lower in FYR Macedonia, a poor country, the top 5 percent of
Macedonian doctors performed as well as or better than the average
The healthcare sector is drastically underfunded in the least developed countries, and the vast
majority of these countries are unable to provide basic healthcare to the public.
Problems
Lack of an improved water source
Hundreds of millions of people in sub Saharan Africa and Southern Asia especially, mostly
living in rural areas, rely on water from local streams and rivers, which is often contaminated
with disease spreading parasites, which are ingested and then cause diarrhoea – resulting in
hundreds of thousands of death each year from the resulting malnutrition and dehydration.
Poor Sanitation
This is responsible for the spread of diarrhoeal diseases – living in close proximity to open
sewers full of human and animal waste products exposes one to a host of disease pathogens
Malnutrition
Nearly a billion people in the world are malnourished – this is one of the leading causes of
child mortality.
Underdeveloped public health services
In the developed world there is 1 doctor for every 520 people, in the developing world there
is one doctor for every 15 000 people. In rural areas, hospitals are spread so far apart that
pregnant women often find it a practical impossibility to get to one for child birth.
War and Conflict
Some countries, most notably Somalia and Afghanistan, are currently in conflict – obviously
this increases the likelihood of people getting injured and puts additional strain on a countries
economic and health care resources.
Poverty
All of the above are ultimately linked to underlying poverty – as emphasised by Hans
Rosling in his various videos.
Patriarchy and Traditional values
Modernisation Theorists emphasise the internal cultural values of developing countries
that can act as barriers to improving life expectancy etc.
Patriarchal traditions may prevent money being spent on training midwives and
providing maternity resources which could help reduce deaths in pregnancy
Patriarchy and religious values may prevent contraception use – which is linked to the
spread of HIV in Sub Saharan Africa
Environmental Factors
Jeffrey Sachs also points out that Environmental Factors also play a role –
simply put, Mosquitos, which spread Malaria, responsible for 5% of deaths in
low income countries, are especially partial to the conditions in parts of sub-
Saharan Africa.
Some developing countries have developed health care programmes at the most peripheral
level to meet the health and development needs of the deprived populations. Each
experience has followed a particular approach. China uses mass education programmes and
“barefoot doctors” to deliver primary health services. Tanzania has instituted massive rural
population re-location efforts to facilitate delivering health care and other government-
sponsored development service. By subordinating health care per se to the related fields of
agriculture, water supply and housing, projects in India have encouraged village acceptance
of primary health care. Venezuela and Iran have excellent referral systems working up from
local levels to highly specialized hospitals. Cuba, through political reform, has extended
coverage to nearly all of its population. In Niger voluntary workers help keep costs at a
minimum. In Sudan, a National Health Programme has been adopted.
Recent analyses have drawn attention to the weaknesses of health care systems in
low- and middle-income countries. For example, in the 75 countries that account for
more than 95% of maternal and child deaths, the median proportion of births
attended by a skilled health worker is only 62% (range, 10 to 100%), and women
without money or coverage for this service are much less likely to receive it than are
women with the means to pay for it.3 Lack of financial protection for the costs of
health care means that approximately 100 million people are pushed below the
poverty line each year by payments for health care, 4 and many more will not seek
care because they lack the necessary funds.
In developing countries, the average citizen doesn’t have full access to
health care at all times. By the word ‘access’, I mean medical services are
easily delivered, convenient, and affordable. Health coverage has been an
idea since the 1880s when it was first proposed by the German
government. Since then, countries have adopted the concept of offering
their citizens adequate, subsidised health service once they fall ill. One of
the biggest challenges that face developing countries in achieving UHC is
their leadership. Health finds itself at the bottom of government priorities,
particularly with regard to financial support, human resources and reform
ideas. There is great disparity in the availability of health services between
urban and rural areas. The distances patients must travel to reach
efficient health facilities is another major obstacle.
What are the major healthcare challenges worldwide?
Above all, it is a question of meeting people’s expectations. Whether in Paris or Bamako, we all want the same thing
for ourselves and our families when it comes to healthcare: we want access to quality and affordable care, close to
home. What seems normal to us in France thanks, in part, to the Social Security system, can be very difficult to
obtain elsewhere. Many people in poor countries do not even have access to basic healthcare. This may be because
they have to pay for it themselves, or they live too far away from a healthcare center.
Centers do not always have water or electricity; the doctors may not be available every day, or there are no
medicines on hand, and so on. The priority is to improve conditions and shore up healthcare systems in the poorest
countries.
The Ebola epidemic was able to spread in Guinea five years ago and in the Democratic Republic of Congo today
because of their inadequate healthcare systems. When a person arrives at a clinic to get treatment, not only are they
not treated, but they also contaminate the people around them.
There is a correlation between these inadequacies and the countries’ levels of poverty and the state of their
infrastructure. The WHO estimates that 22 countries need to rebuild the very foundations of their healthcare
systems: from equipment and medicines to human resources and governance. In middle-income countries, the
situation is better and the focus is more on adapting healthcare systems to new needs.
How can overseas development aid address these challenges?
The healthcare sector is drastically underfunded in the least developed countries, and the vast majority of these
countries are unable to provide basic healthcare to the public. The problem is getting worse in areas such as
the Sahel, where government spending on maintaining public security is increasing at the expense of healthcare,
amongst other things. This is why the sector is highly dependent on international aid. And this situation is not going
to get any better in the coming years.
Development assistance is a relatively effective tool to remedy the problem. Often aid is provided more for
programs that target a disease or group of diseases, and is delivered by multilateral bodies (such as the Global
Fund to Fight AIDS, Tuberculosis and Malaria). These programs have their advantages: they are efficient in their
field and make it easy to measure the impacts—in terms of numbers of children vaccinated, for instance, and deaths
prevented.
