4.

MEDICAL PRODUCTS, VACCINES AND TECHNOLOGIES

A well-functioning health system ensures equitable access to essential medical products, vaccines
and technologies of assured quality, safety, efficacy and cost-effectiveness, and their scientifically
sound and cost-effective use. To achieve these objectives, the following are needed:

• National policies, standards, guidelines and regulations that support policy;

• Information on prices, international trade agreements and capacity to set and negotiate prices;

• Reliable manufacturing practices and quality assessment of priority products;

• Procurement, supply, storage and distribution systems that minimize leakage and other waste;

• Support for rational use of essential medicines, commodities and equipment, through guidelines,
strategies to assure adherence, reduce resistance, maximize patient safety and training.

WHO has a strong track record in helping countries frame national policies. It promotes evidence-
based selection of medicines, vaccines and technologies by developing international standards,
norms and guidelines through WHO’s Expert Committees and consultation processes. WHO/UN pre-
qualification programmes for priority vaccines, medicines and diagnostics will be boosted
significantly by the establishment of UNITAID, the new international drug purchase facility. WHO
provides information on medicine and vaccine prices and supports the development of systems for
post-marketing surveillance. It promotes equitable access and rational use, for example, through
essential medicines lists, clinical guidelines, strategies to assure adherence and safety, training and
working with consumer organizations. It also supports technology assessments and policy
development.

5. SUSTAINABLE FINANCING AND SOCIAL PROTECTION

A good health financing system raises adequate funds for health, in ways that ensure people can use
needed services, and are protected from financial catastrophe or impoverishment associated with
having to pay for them. Health financing systems that achieve universal coverage in this way also
encourage the provision and use of an effective and efficient mix of personal and non-personal
services.

Three interrelated functions are involved in order to achieve this: the collection of revenues – from
households, companies or external agencies; the pooling of pre-paid revenues in ways that allow
risks to be shared – including decisions on benefit coverage and entitlement; and purchasing, or the
process by which interventions are selected and services are paid for or providers are paid. The
interaction between all three functions determines the effectiveness, efficiency and equity of health
financing systems.

Like all aspects of health system strengthening, changes in health financing must be tailored to the
history, institutions and traditions of each country. Most systems involve a mix of public and private
financing and public and private provision, and there is no one template for action. However,
important principles to guide any country’s approach to financing include:

• Raising additional funds where health needs are high, revenues insufficient, and where
accountability mechanisms can ensure transparent and effective use of resources;

• Reducing reliance on out-of-pocket payments where they are high, by moving towards
prepayment systems involving pooling of financial risks across population groups (taxation and the
various forms of health insurance are all forms of pre-payment);
• Taking additional steps, where needed, to improve social protection by ensuring the poor and
other vulnerable groups have access to needed services, and that paying for care does not result in
financial catastrophe;

• Improving efficiency of resource use by focusing on the appropriate mix of activities and
interventions to fund and inputs to purchase, aligning provider payment methods with
organizational arrangements for service providers and other incentives for efficient service provision
and use including contracting, strengthening financial and other relationships with the private sector
and addressing fragmentation of financing arrangements for different types of services;

• Promoting transparency and accountability in health financing systems;

• Improving generation of information on the health financing system and its policy use.

The most pressing challenge is to provide technical advice to the large number of countries seeking
support to develop their financing systems to move more quickly towards universal coverage. Key
global public goods produced by WHO include standardized tools and guidelines, for example, for
costing, cost-effectiveness analysis and national health accounts. In addition, WHO provides
information to countries and works with them to improve their own data collection and to
incorporate it into policy development, including analysis of health expenditures and catastrophic
spending. Emerging issues relate to using debt relief and medium-term expenditure frameworks to
raise more funds for health, and the need to collaborate with priority health programmes, many of
which are seeking to develop sustainable financing plans for their particular country-level activities.

6. LEADERSHIP AND GOVERNANCE

The leadership and governance of health systems, also called stewardship, is arguably the most
complex but critical building block of any health system. It is about the role of the government in
health and its relation to other actors whose activities impact on health. This involves overseeing
and guiding the whole health system, private as well as public, in order to protect the public interest.
It requires both political and technical action, because it involves reconciling competing demands for
limited resources, in changing circumstances, for example, with rising expectations, more pluralistic
societies, decentralization or a growing private sector. There is increased attention to corruption,
and calls for a more human rights based approach to health. There is no blueprint for effective
health leadership and governance. While ultimately it is the responsibility of government, this does
not mean all leadership and governance functions have to be carried out by central ministries of
health. Experience suggests that there are some key functions common to all health systems,
irrespective of how these are organized.

• Policy guidance. Formulating sector strategies and also specific technical policies; defining goals,
directions and spending priorities across services; identifying the roles of public, private and
voluntary actors and the role of civil society.

• Intelligence and oversight. Ensuring generation, analysis and use of intelligence on trends and
differentials in inputs, service access, coverage, safety; on responsiveness, financial protection and
health outcomes, especially for vulnerable groups; on the effects of policies and reforms; on the
political environment and opportunities for action; and on policy options.

• Collaboration and coalition building.Across sectors in government and with actors outside
government, including civil society, to influence action on key determinants of health and access to
health services; to generate support for public policies, and to keep the different parts connected -
so called ‘joined up government’.
• Regulation. Designing regulations and incentives and ensuring they are fairly enforced.

• System design. Ensuring a fit between strategy and structure and reducing duplication and
fragmentation.

• Accountability. Ensuring all health system actors are held publicly accountable. Transparency is
required to achieve real accountability.

An increasing range of instruments and institutions exist to carry out the range of functions required
for effective leadership and governance. Instruments include sector policies and medium-term
expenditure frameworks; standardised benefit packages; resource allocation formulae;
performancebased contracts; Patient’s Charters; explicit government commitments to non-
discrimination and public participation; public fee schedules. Institutions involved may include other
ministries, Parliaments and their committees, other levels of government, independent statutory
bodies such as professional councils, inspectorates and audit commissions, NGO ‘watch dogs’ and a
free media.

WHO’s tendency at present is to focus on the development of specific technical health policies. This
is important, but the added challenge for governments is to provide vision and direction for the
whole health system, and oversee implementation of agreed health policies through systems that
are faced with critical governance and stewardship challenges. These include: reconciling competing
demands for resources; working across government to promote health outcomes; managing growing
private sector provision; tackling corruption, responding to decentralization; engaging with an
increasingly vocal civil society, and a growing array of international health agencies. This is an area in
which WHO needs to enhance its capacity to support ministries of health.