In 2016, the world will move from a global commitment to the Millennium Development Goals (MDGs) to a focus on the much more ambitious and wide-ranging Sustainable Development Goals (SDGs). Whereas the health-related MDGs focused narrowly on particular diseases or conditions for select vulnerable groups, the SDGs are broader, calling (in SDG 3) for the global community to “ensure healthy lives and promote well-being for all at all ages.” As we take on this challenge, it is useful to reflect on what we have learned and what we will need to do differently to make substantial progress towards the SDGs.
For the past four decades, donors have mainly funded disease-specific programs and global discourse has focused on the need for better primary care. In combination, these have contributed to remarkable progress in meeting many of the MDG health targets, especially those relating to child mortality, HIV/AIDS, and malaria.
Targeted programs and a primary care focus have been less successful, however, in achieving some of the other MDGs — most notably in the areas of maternal and neonatal mortality. While many papers and conferences have been devoted to the topic of “health systems strengthening,” funding priorities and programmatic approaches have remained narrowly targeted on diseases, or on a single platform of delivery: primary care.
Role Of Hospitals And Integrated Primary Care
Public health, health promotion, prevention, and controlling risk factors through a broad range of policy interventions, both within and outside the health sector, must be an important focus in the era of SDGs. However, delivering on the broad and ambitious SDG 3 will require an expansion in thinking to encompass the quality and efficiency of accessible care across the continuum of services — from community outreach, to primary and specialty clinics, to hospitals, and back to home or sub-acute settings. Countries such as China and Thailand that achieved the MDGs by investing in health care services broadly, rather than focusing only on specific interventions, saw dramatic progress in the health status of their entire populations.
Within the continuum of care services, insufficient attention has been paid to access to high quality hospital services. In both low- and middle-income countries, hospital quality and safety has lagged; in 2009, 15.5 million disability-adjusted life years (DALYs) were lost due to in-hospital adverse events. Despite domestic resources in most countries being disproportionately allocated to hospital care, hospitals in many low-income countries are inaccessible or are in a dismal state. Even with comparatively large expenditures on hospitals versus other modes of delivery, total domestic health expenditures are often too low to provide a good quality health system. These conditions are exacerbated by ineffective spending and lack of management accountability.
As a consequence, public hospitals in these countries are often dilapidated, lacking a reliable water supply, sanitation, and electricity. Drugs and other supplies may be unavailable, equipment is frequently broken, and basic infection control is absent. This makes it difficult, if not impossible, for limited medical personnel to ensure good health outcomes.
We argue that for personal health services, which are the focus of this perspective, it is now timely to rebalance the global health discourse and focus on the integration of primary care with essential hospital services. A strong health system needs both.
The world has witnessed, particularly in Africa, a similar imbalance in the field of education. Indeed the education MDG, Goal 2, referred only to primary education. Secondary and especially higher education have been largely neglected, leaving once vibrant universities in sub-Saharan Africa to decay. Lacking appropriate investment in all levels of education, this imbalance has left a legacy of critical skilled workforce shortages, including within the health workforce. SDG 4 attempts to remedy this gap by calling for universal, equal, and affordable access to secondary and tertiary education.
Historically, hospitals—perhaps like seats of higher education—have been seen as cost-ineffective investments that divert needed resources from cost-effective primary interventions and disproportionately serve the better off. While it is true that in many countries hospital investments have been regressive with limited geographic and financial access for the poor, this need not be the case. By planning for varied levels of hospital services, expanding these services to underserved areas, and providing financial protection to access care, hospitals can be available for all those who need this level of care.
Maternal And Child Health
To achieve SDG 3, a comprehensive health care system strengthening approach that includes primary care, district hospitals, and specialty institutions is important for several reasons. First, to meet the unfinished maternal and child health goals of preventing maternal mortality and eliminating avoidable pre-term and neonatal deaths (SDG 3.1, 3.2), access to well-functioning hospital services is essential. While strong antenatal care and skilled birth attendants are critical, referral to effective emergency and intensive obstetric and neonatal care are equally necessary.
Second, the shift in the global burden of disease from acute infections to noncommunicable diseases (NCDs, SDG 3.4), and chronic infections, such as HIV/AIDS, necessitates a high-quality continuum of care to prevent avoidable death and permanent disability once a patient has contracted the disease. More than three fourths of global deaths from ischemic heart disease occur in low- and middle-income countries; in Africa, more deaths are attributable to cancers than HIV, malaria, and tuberculosis together. While public health and primary care play an important role in both the prevention and treatment of NCDs, a complete care continuum must include hospitals to fill the role that lower acuity platforms cannot perform.
Third, the global surgery agenda, recently elaborated by The Lancet Commission on Global Surgery and the Essential Surgery volume of the Disease Control Priorities, Third Edition, estimates that five billion people lack access to safe surgical care. Of the 44 essential surgical interventions, all except six take place in hospitals. Providing these interventions would avert 1.5 million deaths per year, between 6 percent and 7 percent of all avertable deaths for low- and middle-income countries — greater than the individual burdens of HIV, malaria, or tuberculosis.
Sixteen million avertable DALYs annually are attributable to road traffic injuries alone, the target of SDG 3.6. While preventing road traffic injuries will require much broader policy interventions, once an injury has occurred, good hospital care may make the difference between life and death. An estimated 1 million deaths could be avoided annually with basic trauma services alone, which require a functioning network that extends from the community to strong emergency services located in hospitals. Without surgical capacity scale-up, low- and middle-income countries will lose $12.3 trillion (2010 US$) in cumulative economic productivity between 2015 and 2030. Essential surgery exemplifies how hospitals can be a cost-effective delivery platform.
Universal Health Coverage
Fourth, universal health coverage (UHC), including providing financial protection against impoverishment from health expenditures (SDG 3.8), requires coverage of hospital care. Households experiencing hospitalization are much more likely to suffer catastrophic health expenditure. Any UHC package that is to achieve its objectives must include an appropriate continuum of care that includes coverage for hospital care.
Infectious Disease Epidemics
Finally, as the Ebola epidemic has shown, health systems in low-income countries are not equipped to handle the challenges of a serious infectious epidemic. While the extent of the epidemic could have been contained through a solid surveillance system, diseases like Ebola have a natural history that requires acute, often hospital-level care, despite best efforts to intervene early. Availability of good hospital care that could provide intravenous fluids, medications, blood products, aggressive electrolyte replacement, and sound isolation practices is one of the factors that contributed to the lower case fatality rates of Ebola outside Africa.
Moreover, Ebola is just one of many infectious diseases that can reach epidemic proportions without a strong continuum of care to effectively manage them, prevent death, and reduce transmission.
A Way Forward
Both countries and the international community need to develop and implement strategies to ensure that the continuum of care is available to all, irrespective of income and geography. In doing this, there is also an urgent need to greatly increase the effectiveness and quality of hospital care. While countries themselves will take the lead on this, there are four areas in which the international community can provide support.
Access to capital to rebuild crumbling facilities and build new facilities in underserved areas.
The total hospital infrastructure backlog is immense, across the developing world. The median number of hospital beds per 1,000 people in low- and middle-income countries are 0.7 and 1.4, respectively, compared with 5.6 in high-income countries. The World Bank, Regional Development Banks, and the new Asian Infrastructure Investment Bank can do much to help. In addition, wealthy countries can share their expertise in innovative models for financing public infrastructure.
Technical expertise and educational support to develop health care managers who can operate complex institutions efficiently and to high standards.
While shortages in clinical personnel have been well documented, the need for a qualified managerial workforce is a neglected human resources crisis in many countries. In 2006, the World Health Report identified improving managerial capacity in low- and middle-income countries as the highest priority for country leaders if they are to address any of the other pressing clinical human resource deficiencies successfully.
Technical guidance and resources to share international best practices for managing diseases and linking health care across the continuum of care services.
There are many models and tools to integrate services and provide cost-effective, patient-centered care in both high- and middle-income countries that can be innovatively adapted for use in low-resource settings.
Active policy debate and action to ensure that all those able to contribute to building, maintaining, and operating good quality hospitals are conscripted to the task and work in alignment with public policy goals.
In many countries, this requires a pro-active stance by government in forming partnerships with non-governmental providers, including faith-based organizations, not-for-profit providers, and for-profit operators. This organized and regulated plurality of provision, including large scale public financing of private provision, is the norm in nearly every rich country, but remains extremely rare in the developing world.
The SDGs call for health for all individuals, present and future. All platforms of care delivery are necessary for health system success, and none are individually sufficient. Building health systems with a long view—to sustainably preserve and attain health—requires an integrated approach where one platform supports, rather than competes with, another. Putting hospitals on the agenda alongside other platforms of care is not the whole solution, but it is a necessary part of the solution, if we are to have any likelihood of achieving the SDGs.