The mixed health systems syndrome.

Global health appears to be undergoing a gradual shift in focus away from diseases towards systems. This is partly a response to the difficulties that disease-specific global health initiatives have experienced in meeting individual programme targets and internationally agreed benchmarks, in spite of significant increases in development assistance over the past decade. 1 It is also a response to the fiscal constraints caused by the global financial crisis, which has created an environment in which governments and development partners are not only striving to secure resources for development but are also focusing attention on improving returns on spending by strengthening poorly functioning public systems. As a result, there has been increased attention on health systems by major global health initiatives, the governments of the Group of Eight (G8) high-income countries, private foundations, new international partnerships and the World Health Organization (WHO). The latter is demonstrated in particular by its recent resurrection of primary health care. 2 The diversity in design of health systems around the world, complicated by the interconnectedness of health systems with the country's body politic, must be considered in any effort to strengthen health systems. Notwithstanding the many differences, health care in a majority of low-and middle-income countries is delivered by a mixed health system – defined as a health system in which out-of-pocket payments and market provision of services predominate as a means of financing and providing services in an environment where publicly-financed government health delivery coexists with privately-financed market delivery. 3 This perspective hypothesizes that poor performance is due to interplay between three factors in the mixed health system: (i) insufficient state funding for health; (ii) a regulatory environment that enables the private sector to deliver social services without an appropriate regulatory framework; and (iii) lack of transparency in gover-nance. This triad of determinants acts together to compromise the quality of public services and defeat the equity objective in several ways (see figure at: http://heartfile.org/mhhs1.htm). Most low-and low middle-income countries spend less than US$ 34 per capita annually on health, the amount considered essential by WHO to secure basic health services. All of the 42 low-income countries (as defined by The World Bank) spend less than US$ 34 per capita on health, except Zambia which spends US$ 35 (see figure at: http://heartfile.org/mhhs2.htm). Among the low to middle-income countries, the following spend less than Pakistan have populations greater than 100 million. Low levels of public financing …