The Health Systems Pyramid

BARBARA MCPAKE: Most health systems are designed to work like the pyramid illustrated here. At the base of the pyramid, the bulk of population needs are intended to be met by a large number of close-to-community providers, a combination of fixed facilities providing primary care to a population mainly living within 5 kilometres and services that reach directly into communities through mobile outreach and community-based providers. A proportion of health conditions require care beyond what close-to-community providers have been equipped and staffed to provide. And the common arrangement is that patients presenting with these conditions should be referred to a more central facility often called the district hospital.

A further proportion of health conditions require care beyond what the district hospital has been equipped and staffed to provide, and these might be referred to a regional or provincial hospital. And in turn, a very small proportion of all patients and conditions are intended ultimately to be referred to a national hospital, which in principle is equipped and staffed to manage those conditions, hence the sizes of the blocks of the pyramid represent several things– the number of facilities, lots of small facilities at the bottom, a single national referral hospital at the top, staff, lots of staff at the bottom with generalist comprehensive knowledge and skills capable of managing a large percentage of the disease burden, a few specialist staff at the top with specialist knowledge of relatively rare conditions, and the volume of patients and conditions being managed.

Clearly the critical principle of the health system pyramid is the referral system. It’s intended that patients initially present at their local facility, or through an outreach clinic, or community-based provider; are identified where appropriate as requiring upward referral and are able to access services at the next level when referred. There is also usually an intended principle of downward supervision and support from upper to lower tiers of the system.

The more specialist staff at each level of the system have in most professional education systems initially been trained as generalists and added specialist qualifications as their careers and training have progressed, hence staff at each successive level should have the technical knowledge to support those at the level below and should have the needed seniority for that support to be recognised and appreciated. Those two processes, referral and staff support, do work reasonably well in some health systems. But in many others, the difficulties in making those systems work are at the heart of health systems problems.

Staff support processes are often very poorly undertaken for a range of reasons, including an overload of clinical work at each level of the system that causes staff to prioritise the patients in front of them over those that are not, a lack of investment or resource availability for transport and logistics required to visit facilities at the level below, and weak incentives for more central staff to spend time on this activity. For example, it may be apparent to staff that this activity will not advance their careers or they might be able to earn additional money seeing patients either in public or private facilities, which they have to forego to travel to more remote locations in the tier below and support staff there.

Even where this kind of support is provided, it tends to be insufficiently supportive and is often more directed at fault finding. Lack of effective support for staff at the lower levels of the system undermines quality of care. Perhaps the even more critical difficulties arrive in the referral process though. Patients in need of referral are often not appropriately identified, and some of those who should not need referral might be referred. This could arise because of mistakes by health staff or because of resource shortage that implies that a condition that should, in principle, be managed at that level cannot be because of equipment failure, or medicine stock out, or because a facility has not been able to recruit enough staff.

Patients who are appropriately referred may not be able to reach the next level. And it’s often much further away, and there may be no support for transport or any ambulance service. And when these problems are endemic and patients anticipate that the care they need will not be available at their local facility or that they’re quite likely to need to travel first to the local facility and then to the higher level at their own expense, they rationally opt to seek care initially as far up the pyramid as they can manage.

They may even find that they have to pay fees twice at both levels of the system if they follow the expected route, but only once at the higher level if they go there directly. As a result, what often happens is that the pyramid is inverted. Patients present their conditions at the highest level of the system they can reach, which then deals with a much larger share of the total disease burden than intended. The close-to-community level loses credibility with both patients and staff, and health workers seek to work at the highest level of the system where they can find a job. Staff will want to work where patients want to seek care and where their role is respected.

This can be reinforced by strong economic incentives if health staff rely formally or informally on patient fees for additional income. The problems may initially have been triggered by resource shortfalls that caused poor equipment maintenance and renewal, drug stock outs, and initial staffing shortfalls, and lack of resources for transport and logistics in the supervision system. But the resulting inverted pyramid goes to reinforce those resource shortfalls at the lower levels of the system. If few patients use close-to-community providers, it’s difficult to justify increasing budgets and even more importantly financial disbursements at that level. If the system is even somewhat dependent on patient fees, patients care seeking choices shape where funding flows.

If only the higher levels of the system command the respect of the population and also of the professional staff who populate both the provider institutions and the institutions governing the system, such as the Ministry of Health, political support for financing the lower levels of the system will be weak. Hence the inverted pyramid is often an accurate depiction of the financing of the health system too. It often seems that everyone is happy with the inverting of the pyramid. Everyone agrees that good services can only be achieved in hospitals. The bulk of financing goes to support hospital care. Patients avoid primary care and present all their conditions to hospitals. It’s known as a hospital-based system, and many people can’t see a problem.

Why not leave well enough alone? Those people who can’t see a problem are usually those that succeed in accessing hospital care and by doing so receive a disproportionate share of the public subsidy provided to the health system. The voices of those who can’t access hospital care are usually more muted.

These people might not be able to get hospital services because they live too far away and can’t afford or access the transport needed because they can’t afford the formal or informal fees required to use hospital services, or because they have to wait in long queues or in long waiting lists while others succeed in jumping them through social or professional connections, informal payments, and even formal public-private mix arrangements that have that effect. Their voices are muted exactly because they are remote, poor, and poorly connected to those with power. And even when consulted, they’re likely to indicate that what they want is to access hospital services because their knowledge of close-to-community care is of an underfunded and poorer quality system.

But their problems in accessing hospital care reflect the fact that current funding of the health system does not stretch to hospital care for everyone. And with the issues of ageing populations, a growing burden of chronic illness, and a growing importance of integrated care for people suffering with multiple conditions, a hospital-based system cannot be sustainable even with growing health budgets and isn’t the best system for managing and preventing the current patterns of disease; even in Africa, where the epidemiological transition is still in its infancy, far less the patterns of disease in those regions where the transition is more advanced or the patterns of disease of the future projected to be characterised to an even greater extent by multiple coexisting chronic conditions.

Quite simply, a hospital-based health system is both unsustainable and ineffective in dealing with the contemporary and future burden of disease. Much of the challenge of health system development is concerned with turning the pyramid the right way up again.