NEWS
IN FOCUS
Arguing the case for strengthening health systems
Dr Timothy Evans, Assistant Director-General for WHO's Evidence and Information for Policy cluster, in conversation with the Bulletin.
It's not always easy persuading governments that first they need to strengthen their health systems before they can effectively fight epidemics like HIV/AIDS, malaria and tuberculosis that are devastating their countries.
That was just one of the challenges Dr Timothy Evans took on when he became Assistant Director-General for the Evidence and Information for Policy cluster of WHO last year.
One of the first things the Canadian physician and economist did was to gather feedback on how effectively the cluster is addressing Member States' needs and how effectively his team works with WHO regions and other WHO departments.
Drawing on six years as Director of Health Equity at the Rockefeller Foundation, Dr Evans and his team have established good links with the regions and helped to put the need for stronger health systems more centrally on the global health agenda.
One year into the job, Dr Evans has given WHO's information strategy a new direction. "I think we are doing reasonably well," he told the Bulletin.
In this interview, Dr Evans talks about the challenges WHO faces in trying to strengthen health systems, which areas need urgent attention and why information has taken on an important significance in international public health.
Q: How has WHO's approach to strengthening health systems changed?
A: We surveyed our stakeholders in WHO departments, the regions and governments early on. This showed us where we should be headed and reflected a reaction to the direction under the previous leadership. They wanted WHO's Evidence and Information for Policy cluster to address the need for measurement, financing or human resources for health systems as opposed to writing a paper which provides a conceptual framework and rather vague policy prescription. We want to make this cluster's work even more relevant to country offices and the regions by working closely with them on a shared strategy.
Q: What are the main challenges involved in strengthening health systems?
A: At the moment we have tremendous duplication and distortion in health systems. This is our main challenge. We are focusing on understanding health sector reforms, like decentralization, and the effect of vertical or single-disease programmes because these have important implications for the functioning of health systems as a whole. Vertical programmes are doing vital work providing interventions which may save lives or prevent illness, but in order for the health system to deliver those interventions you must address the financing, human resources and information base of a health system.
It is more efficient to create a platform or model for this, rather than each priority programme reinventing its own financing, human resources and information system. For example, WHO is developing an HIV/AIDS health systems platform to fulfil this role.
Q: What is the most important policy that could improve health systems substantially?
A: Much more should be done to address the woefully inadequate health financing in many countries. At present it is primarily the consumer who is paying out-of-pocket for care, and ill-health has become one of the major drivers of poverty. It's more complex than not having enough money to go round.
In very poor countries with high disease burdens, they are spending about a fifth of what they need to spend. How do you get to those countries to expand expenditure five times. That's tricky and needs to be thought out.
Q: Has information in public health taken on a new significance in recent years and how is this reflected in WHO's work?
A: Global disease outbreaks, for example of SARS, have underscored the need for adequate surveillance systems. We've moved into an era of development in health based on outcomes and targets surrounding the Millennium Development Goals. More and more people want to know whether what you are doing is affecting the outcome and so you need information which can measure those outcomes to find out if you're making progress.
WHO has thousands of databases, we tend to be information rich but without a strong enough inventory of where the major gaps are. That is not simply about processing an individual data set but looking at where we are in good shape and where we are not.
One area where we are in bad shape is in the most fundamental of public health responsibilities: we still can't count births and deaths in countries with the highest levels of ill health.
Q: How do you assess your first year? Have you achieved the goals you set yourself?
A: This first year has been very enjoyable, a steep learning curve. This is a wonderful institution with a huge talent pool.
So far, we have redirected the strategy of the Evidence and Information for Policy cluster. We have a new structure, we have established good links with our regional colleagues and we are coming up with a health systems strategy for the Organization. We are working much better with the departments, particularly the priority disease departments, and we are having some impact on bringing health systems more centrally on the global health agenda, and so I think we are moving in the right direction.
It would always be nice if we could move faster, but sometimes we have to move with patience and particularly with a big institution like this it is important to bring people along with you. I think we are doing reasonably well.