Academic journal article Bulletin of the World Health Organization

Organization of Ambulatory Care Provision: A Critical Determinant of Health System Performance in Developing Countries

Academic journal article Bulletin of the World Health Organization

Organization of Ambulatory Care Provision: A Critical Determinant of Health System Performance in Developing Countries

Article excerpt

Voir page 799 le resume en francais. En la pagina 800 figura un resumen en espanol.


The epidemiological transition in Western Europe in the early part of the twentieth century has largely been attributed to gains in living standards and changes in population behaviour. Much of this took place before many low-cost prevention and treatment technologies were available. Widespread access to basic health care has already greatly accelerated this transition for today's lower income nations.

Health care services deserve much of the credit for the sizeable gains in health status made in developing countries over the last few decades. Despite these gains, the performance of health care systems in developing countries still leaves much to be desired. There is ample evidence of sub-standard quality, maldistribution in terms of both types of services and beneficiaries, and high cost burdens on individuals and, in some cases, communities and nations.

Health care system reform strategies in developing countries have emphasized new methods for generating resources for health care and rational approaches, such as those based on disease burden and cost-effectiveness, for the allocation of resources in public programmes. The logic behind these reform strategies seems to be that if one can decide what are the best things for the health care system to do and raise enough money to pay for them, they will be done successfully. This ignores the widespread evidence of underused public services and extensive nongovernment provision, even of those interventions which have been chosen as government public health priorities.

The objective of this article is to focus attention on the organization of health care provision as a critical and under-appreciated determinant of successful health system policies. Better understanding of the organization of health care at a system level has significant implications for the design of strategies to improve system performance. It is argued that this hypothesis is particularly significant for the organization of personal ambulatory care provision in lower income countries. These providers are the source of most of the potential health gains and account for most of the financial burden of the current health care system in poorer countries. In many countries, personal ambulatory care provision is the most pluralistic and competitive part of the health care system and the least amenable to improvement solely from expanding public provision. The system-level organization of these services (macro organization as it is termed below) is poorly measured and understood. As a result, governments do not do enough of the things needed to improve system performance.

The article begins by presenting the case for the importance of ambulatory care provision in health care system performance. The concept of the macro organization of health care services is then introduced as a useful analytical category in the analysis of health care systems along with a review and critique of available information. The mechanisms through which macro organization affects system performance are then discussed. Diarrhoeal disease control programmes provide one example of the importance of understanding macro organization. The article concludes with a discussion of the implications of better analysis of macro organization for governmental reform efforts and some suggestions on the next steps for global data collection and analysis.

Importance of ambulatory care provision

Defining ambulatory care provision

The term "ambulatory care provision" refers to the individuals and organizations that deliver personal health care services on an outpatient basis. It is useful to contrast this concept with the related use of the terms "primary care" and "primary health care", both of which have been defined in various ways by observers of health care systems. The WHO definition, as found in the 1978 Declaration of Alma-Ata is well known (l). …

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