Expanding access to priority health interventions: A framework for understanding the contraints to scaling up


The level of funding of basic health services in many low and middle-income countries is woefully inadequate. The Commission on Macroeconomics and Health recently recommended a dramatic increase in funding for a set of key interventions that will significantly improve the health of the poor in a relatively short time period. Money, however, is not the only constraint to improving health status in such environments. A range of other constraints will influence the success of efforts to scale-up. Some of these can be \"bought off\" with additional funds; others may, for example, lie outside the influence of Ministries of Health, require cross-sectoral action, or be rooted in characteristics of the social and political system that are fixed over the time horizon being considered. The range of constraints that operates in a specific setting, together with their severity, will influence the choice of strategy for delivering specific health interventions and the pace at which scaling up can be achieved. The first part of this paper sets out a framework for analysing the range and intensity of constraints faced by countries that are engaged in such a scaling up effort. A typology is proposed which is based on three dimensions: the level at which a constraint operates from community/household level through health service delivery, health policy, central government and environmental factors); the nature of the constraint, using a production function approach inputs, technologies, and socio-political environment); and the degree to which a constraint can be \"bought out\", or relaxed through money alone. We show how such a typology can be used to classify countries in terms of the constraints they face. We then discuss how this classification can inform the choice of strategies for scaling up in specific contexts, the identification of the types of support that may be required, and the costs involved. In the later part of the paper we introduce the six accompanying papers.


Journal of International Development (2003) 15 (1) 1-14 [doi: 10.1002/jid.963]

Published 12 September 2006