The enduring – and fresh – lessons of Good Health at Low Cost

Why do some countries achieve better health and social outcomes than others at a similar level of income? What factors drive improvements in the health system and access to primary health care? These were some of the key questions that led to the publication almost four decades ago of one of the most seminal works in global health, Good Health at Low Cost.

Originally published by the Rockefeller Foundation in 1985, a follow-up edition called Good Health at Low Cost 25 Years On was released in 2011 that featured new case studies from Bangladesh, Ethiopia, Kyrgyzstan, Thailand, and the Indian state of Tamil Nadu, which had all recorded significant improvements in health services or access compared to nearby countries.

According to the researchers, these successes could be traced back to good governance and political commitment; effective bureaucracies that can learn from experience; and the ability to innovate and adapt to resource limitations. They also found that the ability to respond to population needs and build resilience into health systems in the face of crises were vital, and that transportation infrastructure, female empowerment, and education, were also factors. Good Health at Low Cost and the follow-up edition also highlighted the importance of the social determinants of health, permanently altering the conversation on health policies.

We spoke with one of the co-authors Good Health At Low Cost 25 Years On, Professor Dina Balabanova, Professor of Health Systems and Policy in the Department of Global Health and Development at the London School of Hygiene and Tropical Medicine about whether the Good Health at Low Cost team had fresh insights regarding catalyzing improvements in health outcomes, in light of the COVID pandemic.

Exemplar News: The question that kicked off Good Health at Low Cost more than three decades ago was “Why do some countries achieve better health outcomes than do others at similar levels of income?” How has the answer changed since 1985 and your follow-up research in 2013 and, now, with the research you're conducting with Exemplars on primary healthcare?

Professor Balabanova: A lot of the drivers of success we highlighted in Good Health at Low Cost are things we still talk about and they often appear quite obvious. It is now widely accepted that vision, good governance, having multi-actor approaches, effectively collaborating, community engagement, innovative investment in portfolios of policies and interventions, having a systemic approach is critical. These are things we think about when talking about a good, effective, equitable health system. So all of these still hold. Since then we've learned about other key factors that we should also be looking at now.

One of these is the importance of embedding policies and interventions into community structures. Of course, one of the key tenets of primary health care is that it should be owned by the community. They should be co-producers. In the book, we did talk about that, but I think we looked at community structures as effective partners that can facilitate implementation of policies designed often at national level, not as co-creators. We didn't look at them as people and structures who hold power. They hold the power because they could choose to use or not use services and they could shape how the services operate. That's really important. Our approach in Good Health at Low Cost was a little bit top-down, and I think intentionally. We really wanted to stress the point about governance and stewardship. The fact that somebody needs to be in charge, somebody needs to know what is going on in every part of the system – this is often the government or the government working in coalition with other influential actors including donors and civil society organizations and media. I think this idea is much more accepted now, and we really should look at the community more in terms of its power and how we can harness that.

The second big area I would like to highlight is resilience. Very often, people talk about resilience as synonymous with effective health systems. I would like to distinguish these two concepts and emphasize that we need both. This is something we learned not just with COVID response, but before that, in the course of the Ebola response. Another important point is continuity and sequencing. I think we have learned that successful policies evolve and adapt while maintaining a consistent thread in their core. We need to reconcile continuity with the need to constantly change and adapt policies to changing contexts and use different transformational opportunities for example as shown with the example of China. These are windows of opportunity. Regarding sequencing, the question is often – where do you start? What direction do you follow? And how do you sustain progress but also take advantage of opportunities and counter challenges such as epidemics and changing disease profiles and political landscapes? That's really a policy-relevant question for many countries who are planning health care system reform and transformation.

Finally, when we examined progress toward better health and equity in Good Health at Low Cost, we talked about progress as if it was a linear pathway. We did recognize the detours, that some countries experience temporary setbacks, crises and change of direction in terms of key policies. But I think we’ve learned a lot more since then. After Ebola, after COVID-19, we are more aware of the volatility and how there is this constant cycle of new threats, but also opportunities. Interestingly, in the book, we said, 'OK, we know what to do about maternal and child health, infectious disease. We have good models and consistent evidence on how relatively low cost strategies underpinned by effective leadership and political support work. Now we have to turn to noncommunicable diseases, that's a more complex problem.' Beyond that, we are seeing that we have dual burdens of infectious diseases and noncommunicable diseases, in the context of climate change, migration, economic and political crises. These are compounded threats, and we need new tools. The responses will be much more challenging. That's why understanding the windows of opportunity is critical so we can have test-cases of solutions that work.

Exemplars News: GHLC identified a number of factors in public health successes in lower-resourced countries, including a commitment to equity, effective governance systems, and contextually appropriate programs addressing the wider determinants of health. Do these lessons still apply?

Professor Balabanova: Building on what I talked about, governance continues to be critical. But when we think about governance, we have to think more about the bottom-up approaches and staying close to the frontline of service delivery. This is about understanding the reality of what people experience when seeking care despite the existence of formal policies. Bottom-up governing structures are often outside the health system. What is happening outside the health system, in the community, is often critical. Community structures, political structures, kinship structures, elite networks and all sorts of social-political networks drive progress. They influence how the health system operates. Very often, you cannot implement quality improvements if these are not accepted by the community and supported by powerful networks including influential informal leaders and elites. Very often, there is political pressure to demonstrate results often co-existent with patronage networks. There is an informal consensus in the community about how things are done. My observation is that key people in key roles and policy designers and implementers need to do in-depth mapping to understand who holds the power in reality. Are they political leaders? Are they informal leaders with some formal powers (e.g. in health committees and other structures), Are these religious leaders? We find very often it's local politicians who are connected to villages or communities. It's really important to understand who should be involved in this co-creation process. This engagement with local structures, we believe, will strengthen health system resilience. It will also improve the legitimacy of different policies. As I said, system strengthening is about investing and improving the structures, but it's also about resilience. How do you bounce back after shocks? You cannot separate one from another, they are different aspects of the system strengthening operational and equitable systems.

I would add that there are two things that are really taking us beyond the original book. One is the need for people-centered approaches to health system strengthening. Again, we need to recognize that in many cases, well-designed health system interventions that seem to make sense given the health systems capacities, the uptake can be low and these interventions are inadequately sustained and valued. People are aware and understand what is there, but the demand remains low or people don't follow through with their treatment. They drop out, they interrupt and modify treatment (e.g. combining evidence based treatments with insufficiently tested privately provided and traditional and alternative treatments). I would like to emphasize that that's not just the case in low and middle-income countries, it is also the case in high-income countries, for some services. What we really recommend is a much sharper focus on the need for people-centered approaches. This means that health systems are not there to perpetuate themselves as institutions, they exist to serve the needs of the population and the societies at large, and enable providers to deliver the best possible care. Then the second aspect that is relatively new to the global health policy debates since the book was published, are the political drivers. These is incredibly important. In developing health policies, one needs to understand the local political priorities and local governance structures, the political networks that shape how the resources are distributed. Policy makers and implementers not only need to understand the leaders and how they connect to the population but engage in a dialogue and really take on board these relationships. This often entails stepping outside the health system and acting within the political landscape.

Exemplars News: How has our understanding of success factors been influenced by countries’ performance throughout COVID?

Professor Balabanova: This is a great question, and it is important to ask it right now. For us, our understanding of how health systems operate, and need to operate, has really changed after the Ebola outbreak. We started talking a lot more about resilience. We see a similar debate with the COVID-10 outbreak, but on a much larger scale. You really need to understand the process of how health systems operate, what are the institutional and socio-political drivers and know there will always be something – climate change, a disease outbreak and worsening trends, or conflict. The social system, of which the health system is one, experiences constant disruption, which could present an impetus for radical change. A good health system should be able to adapt, respond to the challenges and then transform. How do you recover but not return to the same level, bounce to a better level, and use this transformation opportunity? This cycle is what drives sustainability.

I also think our responses to Ebola and COVID demonstrate that you really have to implement a multi-sectoral approach and get everybody aligned. That's often difficult because the different sectors have diverse vertical horizontal structures and governance processes, and they form a complex matrix. The actors within each sector have complex relationships and the incentives for collaboration may be insufficient. This makes is hard to know where to intervene and how. It's not easy even in high-income countries to really incorporate this local perspective. We found [in our research in Sierra Leone] that very often, districts came up with really innovative solutions even before the interventions of international actors. Then, at some point, they had to almost stop and adapt to this big influx of money and resources. While funds are essential, they can sometimes stifle rather than promote local initiative. The fact is that you need to find a way to layer all these interventions occurring in different sectors and at different levels.

Exemplars News: The research also noted the importance of building capacity resilience into health systems in the face of political unrest, economic crises, and natural disasters. Has this become even more important in the age of COVID? And if so, how?

Professor Balabanova: If you look at the literature reviews chronologically, resilience became more spoken about during the Ebola outbreak, well before COVID. I think people realized that what has been achieved in certain countries is very fragile and vulnerable. We also need to ask how learnings are incorporated into the current health system. I think that's something that countries and donors and districts and national actors should think about: how to you draw on the legacy of shocks and crises? how do you create capacity for resilience? For example, in some situations, it is not just about training and deploying more health workers, it may involve something different, such as repurposing care for workers at very short notice and finding ways to connect and support them in the field. And you need some support structures to do that, often relying on rapport with local communities. You need supervision structures, you can't just train people and send them out. You need new ways of sharing information. With Ebola a lot of adaptations and innovation especially at district level, may not have been drawn upon after the crisis. I have the feeling that maybe that's not exactly what's going to happen after COVID as more people are more aware of the need to learn for the future.

Exemplars News: You noted in your research that there are some decisions that are “path dependent” meaning that once they are put in place, they are hard to undo. Do you think the COVID pandemic introduces an opportunity to revisit some of the historical design decisions?

Professor Balabanova: I think it's a complex question. It's yes and no. This idea of disruption is a really important idea and it often contradicts the strategies relying on gradual cumulative development. The disruption is ever present, we can't control it. I think it's incredibly important to understand this pandemic is a transformational moment and many actors and those using services and the societies, are really accepting new models of care, new ways of working across previously distinct health system structures, something that would never have occurred otherwise. The second thing I would like to emphasize is that crises may create social organizations and movements and accelerate demands for equity – in my view this is something that is here to stay and can create these critical junctures that lead to taking a different path. During the epidemic, there's been a lot of emphasis on the fact that people who are most marginalized, the poorest, they suffered the most and they have the worst access to care and the worst-case fatality. These outcomes and the lack of fairness has become much more visible and unacceptable for societies, and this may have affected the political process. I don’t think the world can go back on that because this is really path-dependent.