Every day, patients across all nationalities and socio-economic strata put their trust in hospitals to deliver a happy and healthy baby, a fighting chance against cancer, or a comfortable and respectful place to spend one’s last days with family and friends.
But too often, hospitals in low- and middle-income countries are failing to make good on those promises, and their deficiencies are jeopardizing the global movement for universal health coverage.
In some ways, the role of hospitals in national health systems is more important than ever. The global burden of disease is quickly shifting away from infectious diseases and toward chronic conditions, even in the poorest countries, prompting the global health community to shift how we finance and organize health systems. Vertical disease programs are falling out of favor as global health leaders emphasize the importance of nimble, integrated systems equipped to tackle everything from malaria to trauma, and childbirth to diabetes management. And those systems (hospitals included) are only as good as the people they serve — hence the global focus on ensuring equitable access to care through the roll out and expansion of UHC.
So what happened to hospitals? While they are essential in meeting the shifting needs of emerging economy health systems, they are completely missing from the global health agenda. Ever since the 1978 Alma Ata Declaration, global health dogma has prioritized primary care expansion and public health interventions — and often for good reason. Where health services were essentially nonexistent, those interventions paid big dividends at relatively low cost.
However, decades of investment have helped to pick this low-hanging fruit, and it’s now undeniable that many patients’ medical needs cannot be met through primary care alone. Community health workers can’t remove an appendix; peer educators can't administer an MRI. Patients with complicated or acute maladies instead must seek care in neglected, decaying hospitals — and it is these patients that ultimately pay the price for decades of policy-level neglect.
For patients, an unexpected hospital stay can be the difference between financial solvency and catastrophe. In India, 40 percent of families must sell assets or take on debt to pay the bills of a hospital admission, and 63 percent of those households fall into poverty as result. In Thailand, a hospitalization almost doubles a household’s risk of catastrophic health spending, even with the expansion of UHC since 2001. Meanwhile, governments devote huge and sometimes growing shares of their total health expenditure to inefficient hospitals, sometimes as much as 70 percent of national health budgets.
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Policy-level neglect of hospitals is not just costly for low- and middle-income countries — it can also be deadly. Across 26 facilities in eight low- and middle-income countries, a 2012 BMJ study found that one in 50 admissions ended in the patient’s preventable death — not from the original condition, but instead as a result of obvious hospital errors. Just in the past few months, the world has witnessed the disastrous consequences of hospital neglect in Guinea, Liberia and Sierra Leone, where facilities were underresourced, understaffed, and entirely unequipped to manage the Ebola epidemic.
So how can the global health community begin to right this ship? Certainly it won’t happen overnight. “Hospitals” as a group are diverse and immensely complex institutions — and so are the broader health systems in which they sit. Still, it’s way past time to put hospitals back on the global health agenda, and there are two concrete steps we can take today to help get them back in fighting shape.
1. At the country-level, policymakers and representatives of international organizations and donor countries need to embrace hospitals as one essential element of the domestic health system, and directly support efforts to strengthen them. Such support, whether financial or technical, is sorely needed. Donors could start with efforts to improve data collection and analysis, to benchmark performance, and to help foster coordination and integration across the continuum of care.
2. We need to help hospitals help themselves. Even where hospital managers and governments seek to improve hospital performance, they find few resources to help move them past their current rut. Our suggestion is a one-stop-shop global knowledge exchange platform for data and technical support on what works in hospital finance and management. We call it the Global Hospitals Collaborative and believe it could fill an essential (and currently very empty niche) in the global health ecosystem.
Healthy people means healthy hospitals. If we care about population health, ignoring the role of hospitals in health systems is no longer an option.
Healthy Means is an online conversation hosted by Devex in partnership with Concern Worldwide, Gavi, GlaxoSmithKline, International Federation of Pharmaceutical Manufacturers & Associations, International Federation of Red Cross and Red Crescent Societies, Johnson & Johnson and the United Nations Population Fund to showcase new ideas and ways we can work together to expand health care and live better lives.