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INTRODUCTION

The health of communities around the world is influenced not only by their disease burden, but by local, regional, and global health systems, which have a profound impact on health promotion and the response to health threats. A focus on health system strengthening has been noted as critical to achieving the goals of global health enabling effective implementation of services and ensuring their sustainability. This chapter describes the various components of health systems and their role in ensuring the health of individuals and populations. It also highlights the interconnectedness of each of the health system “building blocks” including: clinical service delivery, governance and leadership, health financing, human resources for health, laboratory systems, commodities and procurement systems, health information systems (HIS), and community engagement (see Fig. 21-1).

FIGURE 21-1

Health Systems and Evolving Global Priorities

CLINICAL SERVICES DELIVERY

The delivery of high-quality health services is essential to the performance of effective health systems. Health systems are responsible for delivering a broad range of diverse health services including: preventive services such as vaccination; maternal health services such as antenatal and delivery care; curative services such as surgery or management of infectious diseases; and chronic health services for long-term conditions such as HIV and chronic noncommunicable diseases.

The structure and focus of health service delivery is not monolithic, however. Depending on the country, or even the state or province, service delivery may be more generalized versus. more specialized; offered at different levels, such as in general practice or primary healthcare clinics versus referral hospitals; and via publicly versus privately funded and managed institutions. In many low- and middle- income countries (LMICs), decisions affecting the availability, type, level, and degree of specialization of clinical health services have been influenced by trends in thinking within international organizations, most notably the World Health Organization (WHO) and the World Bank (WB). The following section maps these trends over the past half-century and discusses their influence on clinical service delivery in LMICs.

Harnessing the Power of Medical Advances

In the two decades following World War II, there was great optimism that harnessing the power of various medical technologies—including new antibiotics, vaccines, and antimalarial drugs would dramatically improve the health of populations in LMICs. WHO and UNICEF, two of the most influential international health organizations at the time, initiated ambitious disease elimination campaigns that were largely premised on the efficacy of newly available medical technologies. Programs such as the Expanded Program on Immunization (EPI) worked to eradicate polio and eliminate measles and rubella. At the same time, many newly independent nations in Africa and Asia were enthusiastically embracing the idea of providing high-quality healthcare for their citizens, by seeking to establish teaching hospitals and nursing and medical schools modelled in some cases on those of former ...

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