In a refreshing and necessary change from the last decade’s focus on more money, the 2010 World Health Report —released yesterday by the WHO—focuses part of its attention on the problem of health system inefficiencies, estimating that 20% to 40% of all health spending ($1.5 trillion USD) is currently wasted. The report indicates that this level of waste—a combined result of poorly used inputs and corruption/fraud—is of similar magnitude in both poor and wealthy countries. Although these numbers are merely illustrative (based on specific country studies or systematic reviews and extrapolated to entire groups of countries), the evidence does suggest that the technical efficiency problem is huge. If you add the problems of allocative efficiency to the mix—that countries and their donor partners are not fully financing the set of interventions that would maximize health given the budget constraint—the report makes a convincing case that there is much that governments and donors could do to free up resources for better health.
The report’s recommendations for the international community relate to aid effectiveness (national health plans, predictability, unified reporting requirements), but the international community could be more pro-active. Here are three ideas:
- Clearly define measures of inefficiency in health systems, include them as part of the WHO’s core indicators, and track them in future World Health Reports. The 2000 Report proposed one metric of (in)efficiency and the 2010 Report uses others, so it’s difficult to know how things are changing over time. Deciding on a set of easy-to-understand, consistent definitions of technical and allocative efficiency indicators would help policymakers measure progress in their own countries, identify and cost possible solutions in their national health strategies, and orient donor spending accordingly.
- Measure the results of health system strengthening using efficiency measures. New money in global health is destined for health systems strengthening (HSS) —both the U.S. Global Health Initiative and the Health Systems Funding Platform (IHP+) boarded this train. But difficulties remain in defining the expected results from these investments, given their indirect connection to service coverage and health outcomes. Efficiency measures are the missing link between inputs and outputs/outcomes. If you care about health systems strengthening to improve maternal health, for example, you will want to know whether the mix of interventions selected for public financing is the one that will maximize maternal health outcomes, whether the inputs purchased or deployed are used efficiently (i.e., the report describes low capacity utilization in hospitals in Ghana, Nigeria, and Pakistan), and finally whether the provision apparatus is efficient at producing coverage of key services.
- Use aid to support and monitor efficiency-improving institutions and processes. Institutions such as the UK’s National Institute for Health and Clinical Excellence (NICE) and Thailand’s Health Intervention and Technology Assessment Program (HITAP) are drivers of efficiency improvements in their respective health systems and demonstrate that the difficult political economy of priority-setting is not insurmountable. While not every country will have the resources to set up a HITAP or a NICE, providing technical assistance and financial (and moral) support to establish and expand similar public funding allocation processes in developing countries—that could be tracked by civil society—may represent a global or at least, a regional public good. Civil society monitoring of provision and expenditure is probably a better, more sustainable solution to identifying corruption, waste, and mismanagement than cutting off the public sector from aid anytime an irregularity is detected.
Suggestions for additional or different actions are welcome, or thoughts on what obstacles still need to be overcome in the development of a more effective response.
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