A new study led by the London School of Hygiene & Tropical Medicine “Good health at low cost – 25 years on” concludes that countries with relatively low income can make big improvements to the health of their populations by adopting a winning formula for strengthening health systems. Countries studied were Bangladesh, Ethiopia, Kyrgyzstan, Tamil Nadu (India) and Thailand.
The report picks up where a 1985 Rockefeller Foundation report left off, which found that Sri Lanka, Costa Rica, China and the Indian state of Kerala achieved levels of health comparable to those of wealthier countries.
To mark the 25th anniversary of the original Good Health at low cost report, the LSHTM-led team returned to the original research questions and found that today’s study countries have made substantial improvements in health and access to essential services beyond what might be expected on the basis of their income level.
WHCC Health Innovations recently asked project participants Tracey Koehlmoos, PhD, Programme Head, Health & Family Planning Systems Programme, International Centre for Diarrhoeal Disease Research, Bangladesh and Dina Balabanova, Senior Lecturer, Health Systems/Policy, Department of Global Health & Development, LSHTM about the study:
Much has changed in health care delivery in the past 25 year, particularly with the emergence of new technologies that did not exist in the late 1980s. How much has a widespread embracing of technology affected the success of the heath systems you studied?
Less so than the embracing and wide-spread distribution of high technology, high cost treatment across developing countries, particularly Bangladesh. What we see is the strengthening of means to bring low technology, low cost solutions to the population. Examples of this will be improvements in means of family planning like door step delivery or increases in the uptake of childhood immunization. In Bangladesh we specifically benefitted from the door to door scale up of Oral Rehydration Solution (ORS) and now are trying to build up on that success by scaling up zinc. The manufacturing of the product is done locally through a technology transfer but the use of the product is easy, the intervention is sold over the counter, and the cost is minimal; however, zinc for childhood diarrhea can save upward of 50,000 child lives per year in Bangladesh alone.
In Bangladesh, many people live off the power grid, yet mobile phone access is tremendous and use of phones is very inexpensive. Thus, we are seeing more and more of a combination of low tech and high tech solutions, such as the use of mobile phones to remind women to have their depo provera injections and we just completed extensive testing of the use of mobile phones to enable skilled birth attendants to engage with pregnant women in the villages and to receive guidance from physicians when women are delivering.
The research shows Bangladesh, Ethiopia, Kyrgystan, Tamil Nadu, India and Thailand have outpaced other countries with similar income levels. Is there a particular country among these that has shown the most substantial improvement in the past quarter of a century?
The study countries have made substantial improvements in health and access to essential services beyond what might be expected on the basis of their income level. Each of the study countries has achieved improvements in different areas reflecting their specific contexts (in terms of disease burdens, health system setup and resources). The advances are both in terms of health indicators and in access to health care.
Bangladesh and Tamil Nadu have among the longest life expectancies for men and women in their regions.Bangladesh has achieved huge improvements in maternal mortality, known internationally as the ‘Bangladesh miracle’. Ethiopiahas gone from being one of the worst performers in under-5 mortality to outperforming neighbouring Tanzania and Uganda. Thailand, a country that has achieved all the health MDGs, has now adopted MDG+, a set of targets that go well beyond the internationally agreed goals.
All countries have made large advances in access to key services responding to population needs. Bangladesh now provides almost universal access to vaccination services, as measured by the percentage of children under 1 year of age who receive BCG (a vaccine against tuberculosis). This increased from 2% in 1985 to 99% in 2009. Ethiopia scaled up the innovative Health Extension Programme, seeking to reduce geographical barriers to care. As a result between 2004 and 2008, the percentage of births with a skilled attendant doubled, and the percentage of women receiving antenatal care and of infants fully immunized increased by over 50%. Thailand and Kyrgyzstan have achieved universal health care coverage through expansion of health insurance schemes.
Many of these positive trends were sustained or accelerated over long periods of time.
If a high income population is not necessarily a prerequisite for a successful health care system, is there one driving factor that appears to be essential?
The book identifies government leadership as being critical in achieving progress. In each study country there were strong individuals who had a vision of where they wanted the health system to be and the ability to inspire those around them to get the job done. This included charismatic political leaders, inspirational and influential health sector and health care professionals and talented and committed technocrats, although leadership and vision alone would not have been as effective without the presence of strong institutions that were resilient in the face of political and societal changes and that retained institutional memory.
Another aspect of leadership was the ability to seize a window of opportunity. Economic and political shocks and other external events can also catalyse health systems change and lead to the creation of new capacities and learning. This ultimately promotes health system strengthening.
Government leadership has also been manifested in inter-sectoral action, combining policies and programmes that strengthen health systems with efforts to improve literacy levels, road infrastructure and political openness that can improve health more effectively.
The research concludes that piecemeal approaches to health care challenges ultimately do not have a long-lasting substantial impact. Why is this?
The research demonstrates that only comprehensive and long term approaches to improving health systems and constant monitoring of the target outcomes will work. Continuity, including stable, professionalised bureaucracies, is a staple ingredient in building effective health systems. This process requires time, ability to prioritise and sustained effort.
For example, the Manas and Manas Taalimi programmes inKyrgyzstancovered a 15-year period surviving three major political upheavals as well as a series of economic shocks, providing continuity for the health system. Thailand had a long succession of 5 year plans.Bangladesh has demonstrated strong political commitment to health and despite rapid changes in the political landscape many health policies have been sustained for significant periods of time.
Are there plans to leverage the findings of the porter to encourage other countries to adopt similar strategies?
The book seeks to stimulate debate among international and national health actors and advocates about the need to keep building strong health systems on the policy agenda of governments and donors. The book cautions that even countries currently seen as success stories are vulnerable to global economic shocks and increasing urbanisation, a growing private sector and an upsurge in non-communicable diseases. It suggests that both learning from the past and new approaches are required to adapt health systems
The book and forthcoming activities on the project website (
), Twitter (@healthatlowcost and @dinabalabanova), aim to catalyse dialogue, enable sharing of knowledge and inform action at national and international level. Drawing on the study countries and further country experience, we will continue to make the case that success is possible even at relatively low level of resources despite facing multiple economic, political and social challenges. The book reinforces the key goal of theRio declaration: to address broad determinants of health, while emphasizing that health systems remain more important in improving health than ever before.