Continuity and good management are key to better health outcomes in poor countries

BMJ 2011; 343 doi: (Published 18 October 2011) Cite this as: BMJ 2011;343:d6702
  1. Jacqui Wise
  1. 1London

Vision and long term planning, together with effective managers and continuity, have enabled some poor countries to achieve better health outcomes than others with similar incomes, says a new report.

The report follows up an influential report from the Rockefeller Foundation published in 1985. The earlier report found that Sri Lanka, Costa Rica, China, and the Indian state of Kerala achieved levels of health similar to those seen in richer countries but at much lower cost.

The new report, put together by a team from the London School of Hygiene and Tropical Medicine, revisits these four places and also assesses five other states or countries—Bangladesh, Ethiopia, Kyrgyzstan, Tamil Nadu in India, and Thailand—all of which have made substantial improvements in health and access to essential services. These improvements resulted from strengthened health systems but also factors beyond the health system, such as levels of literacy, road infrastructure, and political openness, the report says.

One of its authors, Dina Balabanova, senior lecturer in health policy and health systems at the London School of Hygiene and Tropical Medicine, told the BMJ: “One of the key factors linked with success was the vision of the government combined with people who could implement this vision. In Thailand, for example, they have had successive five year national plans that follow up on each other. And in Kyrgyzstan there is a law forbidding the firing of technocrats who implement health policy, so there is much greater continuity.”

Another key issue was taking context into account so that health policies are relevant to the country. In Bangladesh, for example, where the culture is for babies to be delivered at home, there has been a big improvement in maternal mortality despite the percentage of home deliveries staying the same. This was achieved partly through the use of skilled birth attendants at home deliveries but also through investment in roads so that women needing to get to hospital in an obstetric emergency were able to do so.

Tamil Nadu has made great progress in improving maternal, newborn, and child health, performing consistently above the Indian national average. It has a stable bureaucracy and effective managers who have ensured continuity. The state has also trained and deployed village health nurses to serve rural communities more rapidly than in most other parts of India.

“Tamil Nadu is the only state in India with dedicated public health workers who are specifically trained,” said Dr Balabanova.

The report warns, however, that it cannot be assumed that these five places will sustain their achievements in the face of emerging challenges. Of the four in the original report, only Sri Lanka and Costa Rica have managed to do so. In China some earlier achievements have been reversed because of growing income inequalities and the dismantling of many community based services.

Looking ahead to the next 25 years, Dr Balabanova is cautious: “Non-communicable diseases will be the next challenge for these countries. Their current systems will also have to adapt to dealing with increasing urbanisation.”

Components of an effective health system

A health system is successful when it:

  • Has vision and long term strategies and effective institutions to implement the strategies

  • Takes into account the constraints imposed by keeping to a particular line of development

  • Builds consensus at a societal level

  • Allows flexibility and autonomy in decision making

  • Is resilient and learns from experiences

  • Is in harmony with cultural and population preferences

  • Achieves synergies among sectors and actors

  • Is open to dialogue and collaboration between public and private sectors.


Cite this as: BMJ 2011;343:d6702


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