TABLE 9-1 Health System Constraints with Potential Disease-Specific and Health System Responses

Constraint Disease-Specific Response Health-System Response
Financial inaccessibility: inability to pay, informal fees Permit exemptions or reduce prices for focal diseases Develop risk pooling strategies
Service Delivery
Physical inaccessibility: distance to facility Provide outreach for focal diseases Reconsider plans for long-term capital investment and planning for facilities
Poor quality of care among providers in the private sector Provide trainings for private-sector providers Develop systems for accreditation and regulation
Inappropriately skilled staff Implement continuous education and training workshops aimed at developing skills in focal diseases Review basic medical and nursing training curricula to ensure basic training includes necessary and appropriate skills
Poorly motivated staff Offer financial incentives to reward delivery of priority services Institute appropriate performance review systems, create greater clarity around performance roles and expectations, review salary structures and promotion procedures
Leadership and Governance
Weak planning and management Provide continuous education and training workshops aimed at developing planning and management skills Restructure ministries of health, recruit and develop a cadre of dedicated managers
Lack of intersectoral action and partnership Create special disease-focused cross-sectoral committees and task forces at the national level Build systems of local government that incorporate representatives from health, education, and agriculture and that promote accountability of local governance structures to the people

SOURCE: Adapted from Travis et al., 2004.


As part of the current Institute of Medicine (IOM) evaluation of PEPFAR, Congress mandated an assessment of PEPFAR’s effects on health systems, “including on the financing and management of health systems

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