8. Health and health services
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Disease control programmes have the potential to impact massively on the disease burden. Influencing sexual behaviour to prevent HIV/AIDS, treatment compliance for tuberculosis, rapid treatment for malaria, reaching children to immunise them against measles, use of oral rehydration to prevent dehydration from diarrhoea and early identification and treatment of pneumonia are all within our grasp. Programmes and initiatives such as the International Partnership Against Aids in Africa, Stop TB, Roll Back Malaria, the Integrated Management of Childhood Illnesses, and Making Pregnancy Safer are all making a major contribution. However, overall success to date has been limited, because the overall effort has not been of sufficient scale to impact at the level desired. The concept of disease control is commonly erroneously applied only to communicable diseases. The potential for effective prevention and control programmes to impact on non-communicable diseases, such as chronic obstructive airways disease, diabetes, hypertension, myocardial infarction, epilepsy and blindness is similarly massive.
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Success in the reducing the disease burden requires more than disease control programmes. Besides sustainable economic, environmental and social development, countries also require a solid health care system, capacity for strategic support and effective mobilization of personal action and technological development to improve health.
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Effective health services are the backbone of health interventions, and have the potential to impact dramatically on health. To be effective, services need to be accessible and offer good quality care. This requires appropriate focus, equitable distribution, good organisation and sufficient resources (human, physical and supplies). Yet many countries are unable to secure or sustain their health services at the level required to make the desired impact to effectively support disease reduction. Governance and management weaknesses do continue to compromise the system but, however judiciously available money is spent, current funding levels are inadequate to allow for viable health systems.
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According to some estimates, total health spending in the least developed countries averages US$ 13 per capita per annum and US$ 24 in other developing countries. This is well below what is required, even to sustain basic health services. This compromises the ability of countries to retain sufficient numbers of capable and committed health workers and to afford and ensure supply chains and even affordable generic drugs, particularly so in more remote and unstable areas. The continuing loss of health professionals from developing countries compromises services, and results in a waste of the investment made in their education.
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Coverage of health services in sub-Saharan Africa and other countries with a GDP less than or equal to US$ 1200 is 44% for DOTS for TB, 2% for malaria prevention, 27% for malaria care, 35% for acute respiratory infections (ARIs), 60% for measles immunisation, 45% for skilled birth attendants, 20% for smoking control, and below 10% for most components of HIV prevention and care. In consequence, many conditions that are treated in the developed world are death sentences for the worlds poor. The HIV/AIDS epidemic has made this contrast more striking than ever.
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Some of the pathways through which insecure health services worsen health are illustrated in Box 2 below.
| Box 2: Examples of how insecure health services worsen health |
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Whether a person is suffering from a genital discharge that, untreated, increases manifold the risk of contracting HIV, a chronic cough which could indicate tuberculosis, a high fever that could signal (resistant) malaria, or shortness of breath that may be pneumonia, access to health care is imperative to reduce death, suffering and to avoid the spread of infection, directly or indirectly. The reality for many of the world’s poor is that there is no accessible service and, even where there is access, the health worker may not be capable of accurately diagnosing or treating their condition. Essential drugs and supplies required for treatment and care are commonly not available. They may also be unable to effect referrals to hospital in emergencies, such as for women in obstructed labour. Adherence to therapy for chronic diseases, such as tuberculosis, is particularly difficult in a weak health system, rendering treatment ineffective and leading to drug resistance. It is in this context that the lack of consistent care for non-communicable diseases, such as diabetes and asthma, add to the death toll, while uncontrolled epilepsy and untreated mental health problems add to morbidity. The effect of the epidemiological transition, often driven by lifestyle changes imposed on the poor, albeit hidden beneath the burden of communicable disease, should not be underestimated. Disease prevention and health promotion measures, such as immunization and contraception are also impeded by ineffective health systems. In addition, people are not enabled to take action to protect and improve their health, nor to intervene early through simple measures such as oral rehydration to prevent diarrhoea deaths, as the health service has not been able to achieve a sufficient level of health literacy in communities. Thus, although poverty is at the root of much ill-health, poor health services add dramatically to disease burden and death.
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The lack of sufficient strategic support capacity for health system development is shown by the dearth and impoverishment of centres of excellence in the developing world. Health research capacity is also underdeveloped, and even accounting for contributions from developed countries, 90% of the world’s research goes into less than 10% percent of its health problems.
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The potential for technological development to advance disease control is not realised. A key reason for this is that the commercial opportunity is not good enough. So, although there are important new initiatives, there is slow progress for more effective drugs for the treatment of malaria, tuberculosis and sleeping sickness (trypanosomiasis) and for vaccines against the strains of pneumococci, rotavirus, shigella and meningococcus causing disease in the developing world.10
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There is much that individuals and families can do to improve their own health, as illustrated in Box 3 below. This potential for reducing disease is not realised, as not enough is done to empower individuals and communities to take action to improve their own health – nor is it done in a manner that enhances dignity and consciousness. Exploitative advertising is a counter-force, which not only needs to be controlled, but whose power to use the media needs to be emulated in pursuit of health.
| Box 3: Examples of actions that families can take to improve their health |
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A drop of chlorine in a litre of water and hand washing with soap can prevent cholera and many cases of diarrhoea, while the early use of home-made oral rehydration solutions can prevent death from dehydration. Use of insecticide-impregnated materials helps prevent malaria and use of condoms, AIDS. Lifestyle changes, such as healthier eating patterns and not smoking could impact on disease, while seeking health care early for children with fast breathing, a cough and a hot body would reduce deaths from pneumonia.
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The inequity in burden of disease and of development opportunities is mirrored by health services often not being evenly spread between and within countries. As the poorest and most marginalized people and those displaced by war and other emergencies are especially vulnerable and bear a disproportionate burden of disease, if the aim is to massively reduce disease burden, then health care should be skewed towards them. Yet, the inverse is generally true.
Footnote
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The pneumococcus causes pneumonia, the rotavirus and shigella cause diarrhoea and the meningococcus causes meningitis.
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