Safeguarding the continued existence of humanity requires building societies that cause minimal disruptions of the essential planetary systems that support life. While major successes have been achieved in improving health in recent decades, threats from the environment may undermine these gains, particularly among vulnerable populations and communities. In this article, we review the rationale for governments to invest in environmental Common Goods for Health (CGH) and identify functions that qualify as such, including interventions to improve air quality, develop sustainable food systems, preserve biodiversity, reduce greenhouse gas emissions, and encourage carbon sinks. Exploratory empirical analyses reveal that public spending on environmental goods does not crowd out public spending on health. Additionally, we find that improved governance is associated with better performance in environmental health outcomes, while the degrees of people's participation in the political system together with voice and accountability are positively associated with performance in ambient air quality and biodiversity/habitat. We provide a list of functions that should be prioritized by governments across different sectors, and present preliminary costing of environmental CGH. As shown by the costing estimates presented here, these actions need not be especially expensive. Indeed, they are potentially cost-saving. The paper concludes with case examples of national governments that have successfully prioritized and financed environmental CGH. Because societal preferences may vary across time, government leaders seeking to protect the health of future generations must look beyond electoral cycles to enact policies that protect the environment and finance environmental CGH.
An analysis of population coverage of hypertension treatment services can be used to make inferences about the performance of primary care services within health systems. Malaysia, an upper middle-income country, has a well-established primary care system but one that favors rural populations and provision of services for maternal and child health and infectious diseases. Demographic factors including rapid aging, urbanization, as well as lifestyle changes characteristic of a modernizing society have led to an increase in noncommunicable diseases, including hypertension. In this article, we used data from a nationally representative household health survey to develop service coverage indicators for hypertension screening and treatment services. The age-standardized prevalence of hypertension was estimated to be 33.9% (95% confidence interval [CI], 33.9, 33.9). Only 39.0% (95% CI, 37.5, 40.6) of adults with hypertension had been diagnosed by a medical practitioner, 35.7% had been on treatment, and 9.6% had blood pressure controlled under treatment. The diagnosis, treatment, and controlled treatment coverage were higher for older persons compared to younger persons. There were no differences in the diagnosis and treatment coverage between urban and rural areas and between ethnic groups. However, controlled treatment coverage was higher among Chinese and those living in urban areas. Our findings suggest that primary care services in Malaysia may need to intensify health education activities to promote screening services. There is also a need to reprioritize activities to provide regular community health screening of adults and increase access to affordable primary care services, especially in the urban areas.
Health system reforms across high- and middle-income countries often involve changes to public hospital governance. Corporatization is one such reform, in which public sector hospitals are granted greater functional independence while remaining publicly owned. In theory, this can improve public hospital efficiency, while retaining a public service ethos. However, the extent to which efficiency gains are realized and public purpose is maintained depends on policy choices about governance and payment systems. We present a case study of Malaysia's National Heart Institute (IJN), which was created in 1992 by corporatization of one department in a large public hospital. The aim of the paper is to examine whether IJN has achieved the goals for which it was created, and if so, whether it provides a potential model for further reforms in Malaysia and other similar health systems. Using a combination of document analysis and key informant interviews, we examine key governance, health financing and payment, and equity issues. For governance, we highlight the choice to have IJN owned by and answerable to a Ministry of Finance (MOF) holding company and MOF-appointed board, rather than the Ministry of Health (MOH). On financing and payment, we analyze the implications of IJN's combined role as fee-for-service provider to MOH as well as provider of care to private patients. For equity, we analyze the targeting of IJN care across publicly-referred and private patients. These issues demonstrate unresolved tensions between IJN's objectives and public service goals. As an institutional innovation that has endured for 28 years and grown dramatically in size and revenue, IJN's trajectory offers critical insights on the relevance of the hybrid public-private models for hospitals in Malaysia as well as in other middle-income countries. While IJN appears to have achieved its goal of establishing itself as a commercially viable, publicly owned center of clinical excellence in Malaysia, the value for money and equity of the services it provides to the Ministry of Health remain unclear. IJN is accountable to a small Ministry of Finance holding company, which means that detailed information required to evaluate these critical questions is not published. The case of IJN highlights that corporatization cannot achieve its stated goals of efficiency, innovation, and equity in isolation; rather it must be supported by broader reforms, including of health financing, payment, governance, and transparency, in order to ensure that autonomous hospitals improve quality and provide efficient care in an equitable way.
Abstract-Progress toward universal health coverage (UHC) requires making difficult trade-offs. In this journal, Dr. Margaret Chan, the World Health Organization (WHO) Director-General, has endorsed the principles for making such decisions put forward by the WHO Consultative Group on Equity and UHC. These principles include maximizing population health, priority for the worse off, and shielding people from health-related financial risks. But how should one apply these principles in particular cases, and how should one adjudicate between them when their demands conflict? This article by some members of the Consultative Group and a diverse group of health policy professionals addresses these questions. It considers three stylized versions of actual policy dilemmas. Each of these cases pertains to one of the three key dimensions of progress toward UHC: which services to cover first, which populations to prioritize for coverage, and how to move from out-of-pocket expenditures to prepayment with pooling of funds. Our cases are simplified to highlight common trade-offs. Though we make specific recommendations, our primary aim is to demonstrate both the form and substance of the reasoning involved in striking a fair balance between competing interests on the road to UHC.
Community engagement describes a complex political process with dynamic negotiation and renegotiation of power and authority between providers and recipients of health care in order to achieve a shared goal of universal health care coverage. Though examples exist of community engagement projects, there is very little guidance on how to implement and embed community engagement as a concerted, integrated, strategic, and sustained component of health systems. Through a series of case studies, this article explores the factors that enable community engagement particularly with a direct impact on health systems.
This paper explores whether middle-income Asian countries are reorienting their health services in response to non-communicable diseases (NCDs). Malaysia, Sri Lanka, and Thailand were selected as case studies of Asian societies experiencing rapid increases both in NCDs and an aging population. While NCD programs, especially those related to diabetes and stroke, are well-established in Thailand, health services struggle to respond to increasing numbers of people with chronic health problems. Health services at all levels must plan ahead for more patients with chronic and often multiple conditions who require better integrated health care.