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Policy for the Health Sector : Issues and options
Setting clear prioritiesFocusing on programmatic interventionsDue to resource constraints, DMC governments and the Bank have to set clear investment priorities. It is simply not possible for the DMCs to do everything in the health sector, and a lack of focus increases the risks of poor management, inefficiency, and ineffectiveness. For prioritizing specific interventions, DMC governments and the Bank should consider a limited set of criteria: (i) the efficacy of the intervention and the quality of the evidence supporting it; (ii) the burden of disease prevented or cured by the intervention; (iii) the ease of implementation of the intervention taking into account both supply-side and demand-side factors; (iv) the cost and cost effectiveness of the intervention; and (v) equity considerations, i.e., its effect on the poor, women, and indigenous peoples. Based on these criteria, a series of high-priority interventions that all the Bank’s DMCs should fully invest in are listed in Appendix 3, Table A3.1. As an example of a high-priority intervention, immunization is clearly very effective and can prevent 72 to 98 percent of the diseases for which vaccines are currently being used. The scientific evidence supporting the effectiveness of the vaccines is impressive. Immunization also addresses diseases associated with a large burden of preventable disease among children in the Bank’s DMCs. It is also an intervention that is easy to implement in the field. The high levels of coverage achieved in the region indicate that DMC governments have the capacity to provide the service (supply-side issues) and indicate that parents willingly submit their children for vaccination (demand-side issues). In fact, immunization has been one of the easiest activities for which to mobilize community volunteers. Vaccination is also low cost, $15 per fully immunized child, and highly cost effective at $20 per case prevented, making it one of the most cost effective interventions available. Finally, vaccination addresses diseases that differentially affect poor people. For example, measles, which is highly contagious, is much more likely to spread in conditions of overcrowding and is more likely to be fatal among the malnourished. Given these considerations, and the positive externalities associated with it, immunization is clearly a high priority activity that should be publicly financed. The interventions listed in Appendix 3, Table A3.1, are services that all countries should ensure are delivered to their citizens. However, there are other interventions that may be good investments but have characteristics that make them less of a priority (see Appendix 3, Table A3.2). For example, improved weaning practices are potentially critical because it is a time when young children easily become malnourished. The problem is that there are few interventions for improving weaning that have been demonstrated to be effective and low cost. Investing in the health care systemIn addition to prioritizing programmatic interventions, investments in the health care system itself are required. Almost all the priority interventions listed in Appendix 3 require an effective system of health posts and health centers. However, PHC typically receives 30 percent or less of government health budgets. It also receives little managerial attention from ministries of health, partly reflecting the interests and knowledge of the doctors who are in top management positions. The result, in most of the DMCs, is that the health posts and health centers that constitute the infrastructure for delivering cost-effective PHC services to the poor, are underfinanced and lack managerial support. Thus, ensuring greater financing for health centers and health posts and improving the managerial capacity to support these peripheral facilities constitute urgent priorities. The health posts and health centers that constitute the infrastructure for delivering cost-effective PHC services to the poor, are underfinanced and lack managerial support.
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