Health Systems
(Note: This reading reflection paper was written in the second half of 2020 as part of an Introduction to Global Health course)
The readings this week shows the importance of national health systems. According to Skolnick (2020), “the goal of a health system should be the attainment of universal health coverage (UHC). UHC is health provided in a “cost-efficient a manner as possible, in fairly distributed ways, with particular attention to the marginalized members of society.” To attain UHC, the health system must ensure that “all people have access to an agreed set of at least basic healthcare services either for free or at such low cost that it does not constrain access or cause hardship.” The way the components and personnel within a health system interact and are coordinated impact on the ability of the health system to provide UHC. Therefore, the roles assigned to the public; private, for-profit; private, not-for-profit; and NGO sectors and how those roles are paid for is critical to the success of health systems.
Drobac, P. et al. (2013) highlights two cases where the health system rebounded in the aftermath of great catastrophe — Rwanda after the genocide in 1994 and Haiti after the earthquake in 2010. In Rwanda, the transparency and accountability within the health system helped programs succeed and attract more investments. There was a “clear national development plan that promoted coordination among donors and implementing partners,” development strategies aimed at reducing inequalities, and infrastructural and educational investments in rural communities that were initially neglected. Like colonial West Africa, despite Haiti to the French economy, France’s investment in health care infrastructure was negligible. Overall, Drobac, P. et al (2013) show how history shapes political and health systems and how responsive governments can steer the direction back on a positive track.
Result based evaluations and Pay for performance are two incentive-based systems that improved performance of actors within a health system. However, in some contexts where Pay for performance was instituted, there was evidence of health personnel cheating the system, “falsifying patient records, or refusing to dispense medication to prevent stock outs.” The “lack of computer-based bookkeeping, accountants, and trained civil servants” contributed to this. The accompagnateur model used by Partners in Health in Haiti where neighbors were assigned to their HIV positive neighbors, so they are committed to their ART regimen reduced significantly patient viral loads.
Kim, J. Y. (2013) statement that “only states can guarantee rights, including the right to health,” seems too flattering of states. Although Kim, J. Y. (2013) explains further saying, “democratic governments are generally more accountable to their citizens than non-state health care providers are to those they serve” and that NGOs because they are accountable to funders can cut services when funders no longer provide funding or provide vertical interventions, I am of the opinion that states cannot guarantee rights independently. Therefore, states alone cannot guarantee rights, but can “integrate and coordinate the efforts of diverse health providers to ensure that care is delivered efficiently and effectively and equitably throughout the country.”
Questions
· When performance-based evaluation data is being falsified, can triangulation — looking for additional or confirmatory data — help? For example, doing patient satisfaction surveys in addition to hospital records data. Which kinds of triangulation would work, inexpensive and be corruption free? Can mystery shopping be of any help here or be sustainable long term?
· Isn’t the accompaniment model too expensive, would any other non-personnel intensive system with follow up calls have been equally effective Wasn’t privacy a concern for HIV patients? How was confidentiality and curious wondering neighbors connecting the dots addressed?