CHALLENGES, OBSTACLES AND PROBLEMS
According to WHO’s framework for assessing the health system governance (WHO/ EMRO, 2012), the analytical framework is based around the following governance principles:
- strategic vision;
- participation and consensus orientation;
- rule of law;
- equity and inclusiveness;
- effectiveness and efficiency;
- information and intelligence; and
In the case of most OIC countries, national policies and strategies are not regularly updated. Information and data for policy formulation and strategic planning are inadequate. Outdated legislation, lack of enforcement of public health regulations and a widely unregulated private sector leave consumers unprotected. Some member countries receive external assistance, yet donor coordination and aid effectiveness continue to be challenges, despite the fact that most have endorsed the Paris Declaration on Aid Effectiveness (WHO/ EMRO, 2012).
Decentralization of health governance remained ineffective in many member countries (WHO/ EMRO, 2012). Among others, the reasons for this include: wavering political commitment, resistance from higher tiers to redistribute authority and responsibility; lack of clarity in the decision making space awarded to the peripheral level, lack of training and capacity building programmes; and absence of a federal/national level entity to coordinate essential functions, such as developing consensus on national policies, sector regulation and donor coordination.
Access to primary health care services is still a serious challenge in many OIC countries due to inadequate or lack of health infrastructure, physical inaccessibility and insecurity accompanied by the high out-of-pocket spending and/or inadequate health workforce. Estimations show that access deficit in social health protection reaches as much as 90% of total population in some member countries- especially in Africa (ILO, 2008).
These member countries are at different stages of implementing an essential package of health services. So far, they have not met optimal quality standards provided for in the treatment protocols and guidelines. Hospital bed to population ratio ranges from 3 to 12 per 10,000 population. Hospitals consume more than 50% of the total government health expenditures (WHO/ EMRO, 2012).
Financial affordability and low quality of health services are the main challenges in most OIC countries in which access deficit in social health protection is below 40% of total population (WHO/ EMRO, 2012) .
The most important challenges in primary health care relate to quality, utilization and responsiveness to the changing disease burden and specific needs of ageing population.
In some countries, many of the services are delivered through the private sector, largely unregulated. Hospital bed to population ratio is mostly higher than the OIC average of 12 per 10,000 population, but lower than the world average of 29 per 10,000 population.
In the area of hospital care, challenges affecting performance include limited coordination with other tiers of the health system, under-funding and increasing dependency on user fees, dysfunctional referral systems, and inadequate management of resources.
Despite encouraging progress in some countries, many countries have not yet developed national accreditation programmes as a means of improving the quality of care delivered to patients (WHO/ EMRO, 2012).
Health financing is a critical component of health care systems. Globally, health care is financed by a mixture of tax-based financing, social health insurance, private health insurance, out-of-pocket spending and external contributions (aid and donations etc.). The relative share of these sources in total health expenditures has many implications for access, equity and financial sustainability of health care services.
In 2010, while accounting for 22.8% of world total population, total health expenditure of the OIC countries accounted only for 3.5% of total world health spending (US$ 227.2 billion). The average per capita health expenditure in OIC countries was US$ 147 in 2010, compared to US$ 5,276 in developed countries.
Regarding government expenditure on health as percentage of general government budget, the OIC countries, as a group, earmark only 8.9% of their general budget for health, compared to 18.5% in developed countries and 16% in the world.
In the OIC countries, 57% of total health expenditure comes from general government sources and 36% is out-of-pocket, compared to 65% and 14%, respectively in developed countries. Comparatively, out-of-pocket payments in the OIC countries, with regard to share in total health expenditure, doubled the world average in 2010.
Low government health spending in OIC countries is not merely due to public financial constraints but is also an indicator on low priority given to health. General government expenditure in most countries of the OIC accounts for a relatively high share of their gross domestic product (GDP), indicating available fiscal space for increasing spending on health.
Universal health coverage is difficult to achieve if general government health spending as a percentage of GDP is below 4%. So far only five OIC member countries have reached this level of spending. Although donors play a significant role in financing the health sector in countries in complex emergencies, external resources for health are often unpredictable and in many circumstances are ineffectively channelled to their final use.
The main reasons of the inefficiency of health financing in most OIC countries include inappropriate skills mix, problems of procurement, and use of inappropriate technology in the delivery of health services. In some member countries, important sources of inefficiency relate to imbalances in health workforce production and utilization, in addition to disproportionate spending on curative and hospital care compared to preventive and primary care.
Furthermore, the absence of strategic purchasing approaches and performance-linked provider payment mechanism has led to significant inefficiencies in the use of health resources (WHO, 2010a).
Reinforcing health information systems, including civil registration, risk factor and morbidity monitoring and health system performance is another challenge that has to be considered by the national health authorities in OIC countries.
Health information systems are generally inadequate in terms of reporting quality and timeliness. There is duplication and fragmentation of data collection and lack of rigorous validation within different programmes.
Not all member countries have credible registration of births and deaths, and most of them do not report complete and accurate causes of death. Information disaggregated by age, gender, location and/or socioeconomic status is not available in most countries due to scarcity of trained human resources in Epidemiology and health information systems (WHO, 2011a).
In some member countries, mostly the least developed ones, there are gaps in the components of the health information system, which include resources, indicators, data sources, data management, information products and information use. In addition, the legislative and regulatory framework required to ensure a functioning health information system is sometimes lacking.
Resources (such as personnel, finance, information and communication technology) are scarce and coordination is often inadequate, resulting in fragmented and weak data collection systems, both facility-and-population-based, that ultimately produce low quality information products related to health risks, morbidity, mortality and intervention coverage.
Although some countries with health information system produce useful and relevant information products, major gaps still exist and quality is often a major concern. Evidence has shown that in countries having complete registration of births and deaths, the quality of cause-of-death statistics produced by the current systems requires major improvement.
Population surveys are conducted sporadically, some do not use standardize methodologies, thus not comparable, and some are conducted by multiple agencies with little joint planning and coordination leading to duplication and ineffective use of data for policy development and evaluation.
Median Availability of Selected Generic Medicines
In the OIC countries, for which the relevant data are available, the median availability of selected generic medicines for public health sector ranged between 3.3% and 96.7% (with an overall average of 41.4%).
Similarly, for the private health sector, the OIC countries represented a heterogeneous structure, with the median availability ranging from 13.6% to 98.2% (with an overall average of 66.5%).
Among the OIC sub-regions, the median availability of generics is very low in some of the MENA and SSA countries as well as the EAP countries.
Medicines are crucial ingredient for the safe and effective prevention and treatment of illness and diseases. It is, therefore, essential to have an easy and a timely access to them. Medicines must be accessible in acceptable quantities however, as mentioned above; this is not the case in most OIC countries.
Around half of the increase in annual expenditure of ministries of health is consumed on health technologies yet a high percentage of population lacks regular access to quality essential medicines and other products in countries like Afghanistan, Djibouti, Pakistan, Somalia and Yemen (WHO/EMRO, 2012).
Another major challenge for these countries is the lack of regulation of vaccines and other biological products, particularly those used in the private sector. Health technology management is affected by system‐wide weaknesses, such as limited financial resources and lack of production. Moreover, medicines procured as branded medicines are, on average, 2.9 times higher in price than the generic equivalent.
Efficient systems for quality assurance and surveillance do not exist in many OIC countries and sale of counterfeit medicines is a major problem. Over 90% of medical products in OIC countries are imported, and irrational use is widespread.
In the absence of government policies or capacity to regulate, markets are mainly supply‐driven, which partially explains why major investments made in procurement are wasted on inappropriate medical products.
The availability of essential medicines in the public sector is limited due to insufficient resources and inefficient distribution and procurement. Therefore, private sector becomes the main provider of the medicine for the patient. However, they charge more.
During the period 2003-2009, and due to higher manufacturers’ prices, high mark-ups, taxes and tariffs, the median consumer price ratio of selected generic medicines in private sector was three times more than the price ratio in public sector in the OIC countries.
According to the 2011 WHO Millennium Development Goal (MDG) report, promoting the use of generic medicines may be a solution for this problem because originator brand medicines generally cost much more than their generic equivalent.
Health infrastructures are the formal and enduring structures which protect and enhance health. Their main goal is to control the communicable and non-communicable disease as well as protecting the health of mothers and children.
For this purpose, the number of health posts as well as the number of health centres per person is very informative when evaluating the countries’ health infrastructure.
WHO defines health posts as either community centres or health environments with a very limited number of beds and limited curative and preventive care resources normally assisted by health workers.
In 2010, the average number of public and private health posts in OIC countries, for which the data are available, was 12.75 per 100,000 population; a level which is quite lower than the world average of 22.07 and the average of the developed countries of 46.59.
Similarly, the average number of public and private health centres was 5.98 per 100,000 population; a level which was lower than the world average of 7.11 and the average of the other developing countries of 7.56 (WHO, 2012a).
The main obstacle is the availability of adequate and efficient public health systems. Even the lowest priced generic products and health services may not be afforded by the poorest portion of the population. It is, therefore, very crucial to ensure the availability of essential medicines and health infrastructure at no cost to provide access for all.
Health Technology Policy
Having a national health technology (medical device) policy can help in guaranteeing the best use of resources according to the unique needs of the population.
Around 58.5% of the OIC countries (24 out of 41 countries), for which the data are available in 2010, did not have a national health technology (medical device) policy. Such a ratio is quite high compared to the developed countries average of 44.8% and the world average of 52%.
However, 84.4% of these OIC countries had responsible units in their Ministries of Health for the management of medical devices. Such a rate was well above the world average of 72.8% in 2010.
This situation indicates that although many OIC countries had units responsible for the management of medical devices, they do not have national medical device policy which simply implies that these units in the Ministry of Health are not efficient.
In other words, concepts such as health technology assessment and management have yet to be recognized by the national health planners in many OIC countries.
With regards to health technology policy, the productivity, itself, is an important problem. The units in the Ministries of Health need to be trained to provide national medical device policy. Organization and classification are other obstacles.
In 2010, 63.6% of the OIC countries (28 out of 44 countries for which the data are available) did not have a list of medical devices required for clinical procedures, high burden disease management or public health emergencies. Misuse and medical errors associated with health technologies are other major concerns.
Many OIC countries are still facing considerable challenges with respect to quantity, diversity and competency of the health workforce.
Out of the 57 countries with a critical shortage of health workers in the world, 30 are OIC member countries. In these countries, the average health workforce density is around 10 per 10,000 population; a rate which is well below the benchmark of 23 per 10,000 population.
Health workforce shortages are especially serious in member countries located in the regions of SA and SSA regions. Much of this is due to: insufficient measures at entry, in particular lack of preparation of the workforce through strategic investment in education and effective recruitment practices; inadequate workforce performance due to poor management practices in the public and private sectors; and problems at exit, in particular lack of policies for managing migration and attrition to reduce wasteful loss of human resources.
Underpinning these are serious challenges relating to governance, stakeholders coordination, and information and evidence for decision-making, all of which need strengthening.
The limited access to an adequately trained health workforce, particularly in rural and underserved urban areas, is the single most important factor in the inability to ensure access to essential health services and achieve the Millennium Development Goals.
Health workforce development is facing serious challenges in the domains of planning, production, deployment/retention and governance. Effective use of the limited pool of locally produced human resources for health requires strengthening of workforce management, supportive work environment, training and capacity building, better productivity and effective approaches to retain staff.
The quality of educational programmes is questionable due to declining support to the higher education institutions. The inability to prioritize investment in the production of a suitable workforce mix, including community level health workers, which meets population health needs and is sustainable, is an important challenge for workforce development in these countries.
Only 15 OIC countries have relatively higher health workforce density ratios, ranging from 23 to 59 per 10,000 population. Although many of these countries have higher workforce density ratios compared to the world average, several challenges are still exist. The most important challenge is the inability of the system to coordinate and optimize production, deployment and productivity.
While the production capacity is adequate in many countries, the health system, in some countries, has limited capacity to absorb the workforce it produces.
Concerns about the quality and consistency of standards and social accountability of higher education institutions necessitate efforts to establish national accreditation programmes in most of these countries.
According to WHO, health services are the most visible part of any health system both to users and to the general public.
Health services may be delivered in the home, the community, the workplace, or in health facilities. According to WHO’s classification, to evaluate the quality of health service delivery, there are three main indicators: (i) antenatal care coverage; (ii) the third dose of diphtheria, pertussis and tetanus coverage rate; (iii) the tuberculosis treatment success rate.
Antenatal Care Coverage
The availability of antenatal care coverage (ANCC) data is still a major concern in many OIC countries as well as in the rest of the world even though a lot of progress has been made during the last decade.
According to the latest available data during 2000-2010, around 80% of total pregnant women worldwide received antenatal checks up from a qualified health professional at least once during their pregnancy. Comparatively, ANCC rates in OIC countries remained lower than the world average.
Around 77% of total pregnant women in the OIC member countries benefitted from antenatal care services at least once during their pregnancy (WHO, 2012a).
At the OIC sub-regional level, member countries in ECA and MENA, except Yemen, registered ANCC rates that are higher than the OIC averages whereas the averages of SSA region remained below the OIC average. For the SA region, the data is even not available.
Antenatal care and counselling is the entry point to the formal health care system and provides a solid base to monitor and improve the mother-baby health by identifying and preventing/controlling antenatal complications at the earliest stage. It also ensures a normal pregnancy with delivery from a physiologically and psychologically healthy mother.
The third dose of combined Diphtheria-Tetanus-Pertussis (DTP3) immunization coverage has increased substantially in OIC countries during the last decade. The coverage rate increased to 83% in 2010 from 67% in 2000.
However, despite this significant improvement, DTP3 immunization coverage in OIC countries remained slightly below the world average of 85% and well below the average of the developed countries of 95%.
Coverage of DTP3 vaccination in the first year of life has been improved across the OIC regions where DTP3 coverage rates in LAC, ECA, MENA and EAP regions remained higher than the OIC average and the world average. In contrast, SSA is still seriously lagging behind coverage rate of 72.8% in 2010.
DTP3 coverage data are used to reflect the proportion of children protected against diphtheria, pertussis and tetanus, and to indicate performance of immunization services and the health system in general.
DTP3 is important in terms of vaccine preventable disease. The data shows that the higher DTP3 coverage rates the lower percentage of deaths from vaccine preventable disease among children.
The Smear Positive Treatment Success Rate
In 2009, the smear positive tuberculosis treatment success rate in OIC countries was 86%; a rate which was higher than the world average of 85%. Yet, OIC countries in SSA region and some of the MENA countries registered rates which are lower than the world average.
According to the United Nations (UN), the likelihood of treatment success rates can be affected by several reasons including the severity of disease (often related to the delay between onset of disease and the start of treatment), HIV infection, drug resistance, malnutrition and the support provided to the patient to ensure that he or she completes treatment.
Even if the treatment quality is high, reported success rates will only be high when the routine information system is functioning properly. The treatment success rate will also be affected whether the outcome of treatment is recorded for all patients or not, including those who transfer from one treatment facility to another.
There are several obstacles for OIC countries in terms of health service delivery.
First of all, the availability of data is a problem itself. Institutional and international collaboration in health and information services are important for capacity building and data gathering. Database for health data and statistics could be established to have better monitoring and assessment on the progress of health indicators.
Effective health service delivery also depends on having some key resources such as skilled labour, equipment, finance and information. The ways services organized and managed is also a key factor.
When we examine the OIC countries, even though they perform well in some cases as a group, the regional problems still occur. Particularly, actions should be taken across the SSA region.
In this manner, global partnerships as well as funding mechanisms should be given priority since they are available to sustain routine financial support and therefore strengthen services.
Finally, in low income countries, the management capacity/quality is another concern as was also proposed by the WHO. The managers attempting to scale up their services in unstable conditions are struggling with basic problems such as limited skills in basic accounting, managing drug stocks and the management of basic personnel.
It is therefore very important to prefer program specific or system-wide management systems within the health sector.
According to the WHO definition, equity is the absence of avoidable or remediable differences among groups of people, whether those groups are defined socially, economically, demographically, or geographically.
Health inequities therefore involve more than inequality with respect to health determinants, access to the resources needed to improve and maintain health or health outcomes. They also entail a failure to avoid or overcome inequalities that infringe on fairness and human rights norms.
In most OIC member countries with high out-of-pocket spending on health services and/or inadequate health workforce, access to local health services is a great challenge.
Protection of population groups that are vulnerable or have specific needs is one of the strategic directions highlighted in the WHO Country Cooperative Strategy (CCS 2008-2013) document.
A special attention should be given to improve equity in access to care and targeting of particularly vulnerable segments of the population, such as pregnant women and new-born infants, or groups of population with specific needs: people with physical disabilities, older people, children, young people and adolescents.
In the absence of adequate social protection, financing of health care relies heavily on out-of-pocket spending and is thus a significant source of catastrophic health spending and impoverishment which will lead to inequity among different groups in the society. This has been one of the major obstacles to provide health services to the low income poor groups of the society in OIC countries.
While evidence to support decision-making is more abundant, clear policies are often deficient and the capacity to develop norms and standards and monitor progress needs considerable strengthening. A stronger culture of accountability, transparency and inclusiveness needs to be developed in decisions related to resource allocation and distribution.
Ministries of health in member countries such as Egypt, Iran, Iraq, Jordan, Lebanon, Libya, Morocco, Palestine, Syria, and Tunisia that face resource constraints did not succeed in developing effective regulations for the expanding for-profit private health sector (WHO/ EMRO, 2012).
In many of these countries, relevant legislation either does not exist or is obsolete and standards have not been updated. Many ministries of health are increasingly engaging with the non-state sector through formal contractual arrangements.
There are opportunities for improvement by ensuring that contracting is competitive, transparent, well monitored and achieves the desired results.
In countries such as Bahrain, Kuwait, Oman, Qatar, Saudi Arabia and United Arab Emirates where socio-economic development has progressed considerably over the past decades, supported by high income, the public sector is prominent and caters to most health care needs of the population.
Strategic plans for health are available in these countries. However, the focus of these plans is usually on infrastructure development and they lack a multi-sectoral approach to addressing priority health problems, such as non-communicable diseases.
National plans are biased towards curative care with less attention given to promotion and prevention. A significant challenge is the lack of responsiveness of the national health system to the needs of the large expatriate population in these countries.
Many OIC countries face complex emergencies and most health systems are not well-prepared to respond to these situations.
Shortcomings exist in collaboration, coordination and planning; communications and information exchange; education and training; legislation and regulation; and health system surge capacity (WHO/ EMRO, 2012).
WHO has a portal for core capacity development to monitor the countries’ progress in IHR. Overall, in 2010 and 2011, the data show human resources, chemical events and points of entry as the main areas of weakness in the reporting OIC countries that were having capacity scores below 50%.
Reports also highlight the delay in the development of national plans for implementation of the Regulations, the lack of national frameworks that cover the wide scope of the Regulations and the prevailing political instability in many of the OIC member countries.
MENA countries, in particular, need specific guidance and policy documents on all core capacities in relation to international health regulations (IHR) especially those related to the local potential hazards. In terms of preparedness, countries lack national preparedness plans based on an all-hazards approach.
Along with the need for a national central public health laboratory, many of the national veterinary and food services lack the necessary trained staff and equipment to confirm national priority diseases. Many countries also lack clear policy or guidance on the role of the private laboratory sector in reporting to the national surveillance system.
Because of the many overlaps in the functions of surveillance, response and preparedness for relevant hazards across line ministries, along with the lack of coherent strategy; coordination is inadequate; lacking uniform surveillance and response mechanisms.
Other major challenges faced since entry into force of the Regulations are:
· A lack of commitment in some countries to implementing activities related to the Regulations;
· The inability of some countries to maintain the considerable level of transparency required when assessing and verifying events that might be of national, regional and international concern;
· The lack of appropriate mechanisms to empower the role of national focal points (at least in low and some of the middle income countries);
· A lack of strong coordination among the various partners at regional and national levels, especially for zoonotic diseases and other potential hazards, such as food safety events, chemical events and radiation emergencies;
· The lack of quality management systems in laboratories in most countries with regard to the importance of such systems on the part of national authorities, and of tools and procedures to implement quality management systems at country level;
· The need to maintain strong surveillance and response systems and points of entry capacities;
· The insufficiency of human and financial resources related to laboratories and points of entry.