Background
a mother caring for a sick child at home; private providers; behaviour change programmes; vector-control campaigns; health insurance organizations; occupational health and safety legislation. It includes inter-sectoral action by health staff, for example, encouraging the ministry of education to promote female education, a well-known determinant of better health [1].
Conceptual framework
Methods
Search strategy: Identification of databases and relevant articles
Article selection process
Data collection and charting
Collating, summarizing and reporting the results
Human resources
Finances
Infrastructure and supplies
Knowledge and information
Leadership and governance
Service delivery
Context and population
Principles and values
Locating countries along the HDI
Results
What kind of research has been conducted on HS challenges since 2000?
Where has this research been conducted, in which health sectors and on which populations?
HDI category | Country | n. | % |
---|---|---|---|
Low HDI | Pakistan | 6 | 20.7 |
Nigeria | 3 | 10.3 | |
Papua and New Guinea | 3 | 10.3 | |
Ethiopia | 2 | 6.9 | |
Kenya | 2 | 6.9 | |
Malawi | 2 | 6.9 | |
Uganda | 2 | 6.9 | |
All articles | 29 | 100 | |
Medium HDI | India | 8 | 28.6 |
South Africa | 7 | 25.0 | |
Zambia | 3 | 10.7 | |
Bangladesh | 2 | 7.1 | |
Ghana | 2 | 7.1 | |
All articles | 28 | 100 | |
High HDI | China | 16 | 34.8 |
Malaysia | 4 | 8.7 | |
Brazil | 3 | 6.5 | |
Iran | 3 | 6.5 | |
All articles | 46 | 100 | |
Very high HDI | United States | 72 | 47.7 |
Canada | 18 | 11.9 | |
Australia | 17 | 11.3 | |
All articles | 151 | 100 |
Health sectors | n. | % |
---|---|---|
Acute care | 1 | 0.8 |
Addiction | 1 | 0.8 |
Cancer care | 7 | 5.5 |
Community clinics | 3 | 2.3 |
Dental health | 7 | 5.5 |
Disaster medicine | 1 | 0.8 |
Home care and long-term care | 6 | 4.7 |
Infectious diseases | 15 | 11.7 |
Maternal and infant health | 10 | 7.8 |
Mental health | 33 | 25.8 |
Non-communicable diseases | 12 | 9.4 |
Palliative and end of life care | 3 | 2.3 |
Pediatrics | 2 | 1.6 |
Primary healthcare | 14 | 10.9 |
Public health | 9 | 7.0 |
Sexual and reproductive health | 3 | 2.3 |
Rehabilitation | 1 | 0.8 |
Total | 128 | 100 |
Target populations | n. | % |
---|---|---|
Children and adolescents | 15 | 15.3 |
Elderly people | 18 | 18.4 |
Immigrants and refugees | 9 | 9.2 |
Low socioeconomic status populations | 7 | 7.1 |
People with chronic diseases | 3 | 3.1 |
Groups with specific health issues | 11 | 11.2 |
Poor urban, rural and remote areas | 16 | 16.3 |
Post war and disaster areas | 2 | 2.0 |
Visible and ethnic minorities | 15 | 15.3 |
Women | 2 | 2.0 |
Total | 98 | 100 |
What types of HS challenge have been documented by investigators?
Human resources
Overall, human resources are not sufficient and are unequally distributed in the different geographical areas of [Brazil]. The number of psychiatric nurses is insufficient in all geographical areas of the country. Psychologists outnumber psychiatrists in all regions of the country. The distribution of human resources between urban and rural areas is also disproportionate [20].
The low level of 0.9 physicians per 1000 population has seriously constrained the capacity in meeting the population’s needs in Malaysia. The movement of doctors to private hospitals further exacerbated the manpower shortage in public hospitals. Consequently, one-third of the total number of physicians who remain in the public sector struggle to provide services for two-thirds of the total number of hospital beds in the country [21].
Finances
The most serious issue in Japan’s current healthcare system is the management of rising national health expenditure associated with the aging of the population. Unless appropriate countermeasures are taken, national healthcare expenditure is projected to increase from 33 trillion yen in 2006 to 56 trillion yen —a 1.7-fold increase— 19 years later in 2025 [22].
Infrastructure and supplies
Despite considerable investment in public infrastructure, poorer, rural areas [in South Africa] generally have more frequent stock-outs of key medical supplies, less access to diagnostic test facilities, emergency transport and various clinical equipment, and less basic infrastructure [23].
Knowledge and information
Even as research discoveries inform evidence-based practices, implementation remains suboptimal, and consequently, major gaps between evidence and practice persist. Large studies of healthcare delivery show that only about half (55%) of U.S. citizens receive necessary care; and, fewer than half of physician practices incorporate recommended processes of care. This is not a failure of knowledge; it is a failure to create a process by which new knowledge is applied and incorporated into daily practices [25].
Although there have been some significant advancements, Australia still lags behind the UK and New Zealand in having a comprehensive approach to improving chronic disease management in general practice. This is in part due to the lack of systematic based guidelines through audit and incentives [26].
Leadership and governance
Although lack of fiscal resources often impedes development of services for young adults, the main impediments are separation of child and adult mental HSs, a lack of leadership and a lack of prioritisation of this age group, often the result of disconnected commissioning structures whereby services for children and young people, which are often relatively small in size, ‘lose out’ against a larger and more numerous range of services for adults [17].
District governments have had little experience with such responsibilities in the past and although it makes perfectly good sense to encourage local decision-making in relation to priority-setting and resource utilization, limited capacity – for governance, planning and implementation and evaluation of programmes – raise serious issue. Pakistan’s health system fails to hold individuals and organizations accountable for their actions [29].
Stakeholders [in Japan] agree on the movement toward more community-oriented mental health, but questions remain on how, how fast, and how far to take the reform measures. […] Family and consumers should be involved from the beginning of the planning process, not because their involvement is politically correct but because only they know the real needs [30].
We have trained voluntary treatment partners for [Directly Observed therapy, Short Course for tuberculosis in Papua and New Guinea] and the model has produced good success... A similar approach may be successful with [antiretroviral therapy] [31].
Service delivery
Financial barriers to access also influence health service use [in South Africa]. Increases in perceived payments difficulties for people with low income may reflect the costs of transport or worsening household economic conditions. There are also specific concerns about affordability problems at the hospital level. The rapid cost spiral in medical schemes has continued unabated since the 1980s and has made insurance increasingly unaffordable [23].
Several [African] countries’ health systems have a weak organisational structure, which leads to uncoordinated activities at all levels of care. The collapse of primary and secondary health facilities has put serious pressure on tertiary health facilities that are not optimally prepared [32].
Discharge planning for homeless patients is difficult [in the U.S.]. Homeless patients were said to be medically stable to leave the hospital, but still in need of basic medical care that is not available in shelters or on the street. Other participants said that hospital discharge may be delayed if an appropriate place is not available, and length of hospital stay would be longer. Hospital staff members are obligated to discharge patients who are medically stable, but shelter staff are unable to provide medical care for recuperation [35].
Context and population
[Women] reported that healthcare providers often defined women with disabilities solely in terms of their disabling condition. Women said they often felt depersonalized by and burdensome to healthcare providers. They described encountering negative judgments about their sexual and reproductive choices; they found it difficult to advocate for their children with providers who did not support their decisions to have children. Women frequently reported that providers did not suggest pelvic examinations or mammograms and that if the women pursued such screening, they encountered difficulty finding experienced providers and accessible facilities [36].
The aging of the population not only increases national healthcare expenditures, but also puts Japan’s universal medical insurance system on the verge of crisis and collapse [22].
Principles and values
In Transitional economies (e.g., China, Mongolia, Vietnam, Laos, Cambodia) with the collapse of central planning and the lack of new redistributive mechanisms for health care provision and finances, uneven development between geographical areas and disparities among population groups are highly accentuated. In newly industrialized economies there are widening disparities in resource utilization and the quality of care between the public and the private sectors [37].
To what extent do the challenges reported in the scientific literature vary across countries?
In these countries, health systems are plagued by inadequate human, financial and infrastructural resources, poor governance, weak leadership and management and lack of service delivery models appropriate for specific health threats and burden of disease [39].
Health service delivery challenges along the HDI
Rampant and unnecessary utilisation of high-tech equipment and procedures abounds without due consideration for cost-effectiveness, efficacy and safety. In the developed economies, problems of rising costs due to the excessive consumption of high-tech medical care are persistent, especially when bills are paid by generous health care finances systems that offer incentives for providers to over-service [37].
Health technology is also considered a major cause of increased health spending, largely due to its improper use; its development and diffusion [in Spain] leads to an increase in indications for inappropriate medical and surgical procedures, unnecessary pharmaceutical prescriptions, or an increase in the population targeted for treatment [41].
The facilities surveyed in most cases are adequate in terms of size and layout, but usually grossly inadequate in terms of furnishings and utilities. Most buildings are dilapidated and need renovations. […] All the primary health centres have stock-out of drugs. The secondary however have all basic essential drugs like chloroquine, ampicillin, anaesthetics, etc. Most of the equipment are old and non-functional and need replacement. Maintenance culture is poor [42].
This system of health care finances encourages over-prescription, especially the prescription of more expensive items. According to a recent study involving 27 private and non-private physicians in Ho Chi Minh City, current prescription practice is characterized as excessive, inappropriate, and “unethical” [45].
Because of a largely nonexistent tax base, the current system is highly donor dependent which means the system is totally vulnerable. This sentiment was also echoed by development partners who also cited low government expenditure and largely ear-marked donor funding as key financial challenges [47].
Although financial barriers to care are the most important in keeping individuals and families from seeking necessary health care, there are other barriers also in the way and underutilization of care by patients who delay or forego necessary care because of financial or other barriers [48].
The geographic isolation and remoteness of [the First Nations] communities from larger urban centres has contributed to restricted access to health care and support services, and to the lack of services available in their communities [49].
Several factors particularly impede herder families’ ability to access basic health care services and life-saving medical treatment, including long distances to health services and lack of transportation; lack of money for health insurance; run-down hospitals, unqualified health personnel and lack of medical equipment; and high rates of referrals from primary to secondary/tertiary level of health care, which, in turn, are often inaccessible due to transportation and financial barriers [50].
The racial composition of the Mississippi physician population is not reflective of the racial composition of the patient population. This is a concern because patients report that they are most comfortable with a physician of their own race. A lack of diversity is also seen in the Mississippi physician human resources in respect to gender. While 25% of the nation’s physicians are female, one-half of that percentage (12–13%) is female in Mississippi [51].
Human resource challenges along the HDI
The absence of an adequately trained health-care human resources and the so-called brain drain of substantial numbers of trained professionals out of Africa is a major problem for cancer control in sub-Saharan Africa [32].
The growth of the private health sector has triggered the steady migration of senior doctors, specialists and experienced allied health professionals from the public sector to the more lucrative private healthcare sector [53].
The concern about the shortage of local personal support workers was expressed in every community […]. A number of study respondents commented on the community’s needs for increased, reliable professional health services. In particular, they noted a deficiency in home nursing services, with nursing care available only during regular working hours and not on the weekends. In some communities, the community health nurse might come once or twice a week, but only if she is not detained in some other community [49].
The first [issue that Japan has to face] is the small number of doctors and nurses per hospital bed as well as population. This is attributable to the fact that compared with Europe and the U.S., Japan has a larger number of beds per population but fewer doctors and nurses per capita [22].
The human resource problems appear to be exacerbated by the fact that the bulk of staff working in psychiatric units are not mental health professionals by training. It was emphasized that although there are exceptions, the majority of mental health workers are general health care nurses and medical practitioners. Professionals working in the psychiatric units are largely untrained in even basic mental health care [54].
A patient may be taking drugs that either offset or potentiate one another in deleterious ways. Problems of this sort are compounded when the initial medical diagnosis is inaccurate, an event made more likely when physicians have had no exposure to geriatrics during medical school training [55].