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Viewpoint (January 2004)

Author:  Professor Marc Roberts, Professor of Political Economy, Department of Health Policy and Management, Harvard University, School of Public Health, Harvard University 

After a decade of interest in and concern about health sector reform on the part of the international community, attention now seems to be shifting. The new focus is all on highly specific, quantifiable targets-eliminating polio and measles, achieving various indicators specified by the Millennium Development Goals, and the new "three by five" HIV program.  Even on 
the delivery system side, a focus on producing added human resources has replaced older health sector reform concerns like creating new social insurance schemes or revised payment systems, reorganizing public hospitals or improving the quality of private ambulatory care.

In some ways, such a shift is understandable. The older health sector reform agenda all too often proved to be more difficult to put in place and less reliable in producing better performance than some of its early advocates anticipated. Political leaders lost heart in the face of determined opposition from entrenched interest groups. A lack of administrative capacity and managerial skill made it harder to go from plans on paper to actually changing patterns of provider behavior. Resource limits, a lack of reliable data and in some cases a general lack of government legitimacy, all these have undermined various reform efforts.

But the new focus on highly specific goals carries within it the seeds of its own failure if renewed attention is not paid to increasing the capacity of health systems to deliver high quality services efficiently and effectively. Who will provide the care to reduce the under 5 mortality rates that are highlighted by the MGD's? What institutions will do the testing, counseling and clinical care that will allow the "there by five" program to truly improve the health status of those with HIV? How will these providers be trained, paid and organized? How will these new care activities be financed and what quality regulation will be put in place to insure that such care is delivered appropriately? How will patients, citizens and consumers be educated and mobilized to make effective use of the services? All these questions must be answered, and they are just the questions that have long concerned those involved in the process of health sector reform.

We have learned from past "campaigns" that an uncritical focus on narrow goals can distort the performance of a nation's health care system (and actually lower its overall health status). Those responsible for a nation's health care systems management and planning need to maintain a broad and critical perspective on overall policy and resource allocation. Leadership at the national and sub-national level needs to be empowered to interact with the donor community in ways that recognize local expertise on everything from social customs to epidemiological patterns. Such leadership needs to be a respected voice for the legitimacy (indeed inevitability) of local values and local political processes.

These realizations lie behind the design of the curriculum in the World Bank Institute's Flagship Course on Health Sector Reform and Sustainable Financing. They are also embodied in the new volume key faculty from the course have just produced (Getting Health Reform Right: A Guide To Improving Performance and Equity, Oxford, 2003). Leaders at a country level need to have a set of vital analytical skills and a knowledge of relevant international experience-to go with their local expertise. Only then will the efforts they make to achieve various performance targets be undertaken with the kind of breadth and depth that will produce long lasting results. Targets and goals are not alternatives to a concern with reform. Rather they are just one way to more sharply formulate the ends that the hard and difficult work of health sector reform should aim to achieve.

Professor Marc Roberts 


Further Reading

  • Reich, M. "The Political Economy of Health Transitions In the Third World," in Chen et. al. eds. Health and Social Change in International Perspective, Harvard School of Public Health, Boston, MA 1994. 
  • Hsiao, W.C. What Should Macroeconomists Know About Health Care Policy, IMF Working Paper no. 136, Washington, D.C. 1995.  
  • Mills, A. and Broomberg, J., Experiences of Contracting an Overview of the Literature, W.H.O., Geneva 1998.  
  • Feldman, P. and Roberts, M. "Magic Bullets or Seven Card Stud: Understanding Health Care Regulation" in Gordon, R. (ed.) Issues in Health Care Regulation, McGraw Hill, New York 1980.  


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