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'Good health at low cost' 25 years on - what makes a successful health system?

Even countries with a relatively low income can make big improvements to the health of their populations (particularly visible in the area of maternal and child health) by adopting a winning formula for strengthening health systems, according to a new study led by the London School of Hygiene & Tropical Medicine. The research assessed the health systems of five countries (Bangladesh, Ethiopia, Kyrgyzstan, Tamil Nadu (India) and Thailand) that have achieved better health outcomes than neighbouring ones with similar incomes.

The researchers identified a set of common characteristics associated with success that have allowed the five study countries to make sustained progress towards achieving the Millennium Development Goals (MDGs), sometimes in the face of political uncertainty. Key success factors include: leadership by individuals with a commitment to health gain; capacity within the individuals and institutions necessary to design and implement health reform; continuity to provide the stability that is required for reforms to succeed; the ability to seize windows of opportunity; and the ability to take context into account in order to develop appropriate and relevant policies. The research has shown that piecemeal interventions, however sound by themselves, cannot improve health without long-term commitment and attention to health system building.

These conclusions emerge in 'Good health at low cost' 25 years on, published today. The book, edited by Dina Balabanova, Martin McKee and Anne Mills, brings together insights from a multi-country project involving researchers from institutions in Bangladesh, Ethiopia, Kyrgyzstan, Tamil Nadu (India) and Thailand. This new research takes a fresh look at a question originally asked a quarter of a century ago: why are some poor countries able to achieve better health outcomes than others at similar levels of income?

In 1985 the Rockefeller Foundation published an influential report entitled Good health at low cost which sought to shed light on this issue. The report found that Sri Lanka, Costa Rica, China and the Indian state of Kerala achieved levels of health comparable to those seen in wealthier countries, but at significantly lower levels of income, convincingly dispelling the myth that economic growth was a sufficient driver of development and better population health.

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, including:

  • Thailand has seen steep reductions in maternal mortality between 1960-1990 and the Indian State of Tamil Nadu, has maternal mortality rates which are less than half the Indian national average.
  • Ethiopia has gone from being one of the worst performers in under-5 mortality to outperforming neighbouring Tanzania and Uganda.
  • Bangladesh and Tamil Nadu have among the longest life expectancies for men and women in their regions.
  • Thailand, a country that has achieved all the health MDGs, has now adopted MDG+, a set of targets which go well beyond the internationally agreed goals.
  • Thailand and Kyrgyzstan have achieved universal health care coverage through expansion of health insurance schemes, unique among countries at their income level.

Dr Dina Balabanova, of the London School of Hygiene & Tropical Medicine, says: "Our study shows that the findings of the original 1985 report remain valid. However, strong health systems are becoming more important in improving health than ever before. New challenges, such as increasing urbanisation, a growing private sector and an upsurge in non-communicable diseases, suggest that we need a combination of learning from the past and new thinking if we are to adapt health systems to the challenges of the 21st century."

Hailonm Banteyerga, of the College of Social Sciences and Humanities, Addis Ababa

University, says: "It is clear that the relationship between health and non-health systems factors is complex but we hope that the information we have gathered from the Good health at low cost countries can provide useful lessons to other countries that are striving to improve health."

Contact: Paula Fentiman
London School of Hygiene & Tropical Medicine

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