Date Published: January 12, 2010
Publisher: Public Library of Science
Author(s): Julio Frenk
Abstract: In the second in a series of articles on the changing nature of global health institutions, Julio Frenk offers a framework to better understand national health systems and their role in global health.
Partial Text: Three circumstances make the present moment unique for global health. First, health has been increasingly recognized as a key element of sustainable economic development , global security, effective governance, and human rights promotion . Second, due to the growing perceived importance of health, unprecedented—albeit still insufficient—sums of funds are flowing into this sector . Third, there is a burst of new initiatives coming forth to strengthen national health systems as the core of the global health system and a fundamental strategy to achieve the health-related Millennium Development Goals.
The increasing interest in national health systems signals a positive shift. As funding for global health has grown during the past years, it has become increasingly clear that this is a necessary but not sufficient condition for progress. Resources should also be used effectively to produce the expected results. In a virtuous circle, those results will help to maintain the momentum of increased funding for health.
Part of the problem with the health systems debate is that too often it has adopted a reductionist perspective that ignores important aspects. Developing a more comprehensive view requires that we expand our thinking in four main directions.
Actually, we know that there are wide variations in performance by different health systems, even at the same level of income per capita and health expenditure. These variations are due to the influence of several determinants enclosed in the acronym LIST, which stands for leadership, institutions, systems design, and technologies. These determinants are enumerated in decreasing order of complexity, from the bottom up.
The present moment offers a unique opportunity to advance specific proposals on each of the four elements of health systems strengthening: greater access to life-saving technologies, improvements in critical subsystems, long-term investments in institution building, and leadership development. However, for these investments to be successful, they must be linked to concrete health outcomes. In this respect, global health requires a new way of thinking and acting in order to bridge the traditional divide between the “vertical” approach, focusing on technical interventions for specific disease priorities , and the “horizontal” approach, aimed at strengthening the overall structure and functions of the health system but without a clear sense of priorities. The solution is a truly “diagonal” approach, whereby explicit intervention priorities are used to drive improvements of the health system .