New England Journal of Medicine
February 6, 2014  Vol. 370 No. 6
http://www.nejm.org/toc/nejm/medical-journal

Global Health
Health Care Systems in Low- and Middle-Income Countries
Anne Mills, D.H.S.A., Ph.D.
N Engl J Med 2014; 370:552-557 February 6, 2014 DOI: 10.1056/NEJMra1110897

Excerpt
Over the past 10 years, debates on global health have paid increasing attention to the importance of health care systems, which encompass the institutions, organizations, and resources (physical, financial, and human) assembled to deliver health care services that meet population needs. It has become especially important to emphasize health care systems in low- and middle-income countries because of the substantial external funding provided for disease-specific programs, especially for drugs and medical supplies, and the relative underfunding of the broader health care infrastructures in these countries.1 A functioning health care system is fundamental to the achievement of universal coverage for health care, which has been the focus of recent statements by advocacy groups and other organizations around the globe, including a declaration by the United Nations in 2012.2

Recent analyses have drawn attention to the weaknesses of health care systems in low- and middle-income countries. For example, in the 75 countries that account for more than 95% of maternal and child deaths, the median proportion of births attended by a skilled health worker is only 62% (range, 10 to 100%), and women without money or coverage for this service are much less likely to receive it than are women with the means to pay for it.3 Lack of financial protection for the costs of health care means that approximately 100 million people are pushed below the poverty line each year by payments for health care,4 and many more will not seek care because they lack the necessary funds.

In response to such deficiencies in the health care system, a number of countries and their partners in development have been introducing new approaches to financing, organizing, and delivering health care. This article briefly reviews the main weaknesses of health care systems in low- and middle-income countries, lists the most common responses to those weaknesses, and then presents three of the most popular responses for further review. These responses, which have attracted considerable controversy, involve the questions of whether to pay for health care through general taxation or contributory insurance funds to improve financial protection for specific sections of the population, whether to use financial incentives to increase health care utilization and improve health care quality, and whether to make use of private entities to extend the reach of the health care system.

This review draws on what is now quite an extensive literature on the deficiencies of health care systems1 and on the Health Systems Evidence database.5 However, the poor quality and uneven coverage of evidence on the strengthening of health care systems means that evidence of deficiencies is stronger than evidence of remedies. Moreover, the specific circumstances of individual countries strongly influence both decisions about which approaches might be relevant and their success, so any generalizations made from health systems research in particular countries must be carefully considered.6 It is unlikely that there is one single blueprint for an ideal health care system design or a magic bullet that will automatically remedy deficiencies. The strengthening of health care systems in low- and middle-income countries must be seen as a long-term developmental process….