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1 The Challenge of Health Systems in Global Health HIV Center Grand Rounds March 2009.

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Presentation on theme: "1 The Challenge of Health Systems in Global Health HIV Center Grand Rounds March 2009."— Presentation transcript:

1 1 The Challenge of Health Systems in Global Health HIV Center Grand Rounds March 2009

2 2 Today’s presentation The New Challenge in Global Health Following the money – the countries’ own The Rockefeller Foundation’s Strategy

3 3 1960's1990's End of Euro- colonialism End of the Cold War 2010's The Market Meltdown A brief history of Global Health Tropical Medicine International Health Global Health ? A New World Health ?  Colonial arrangements  Pioneer age/missions  Western tech experts  Parasitic diseases and anti- viral vaccines  Eradication campaigns  New UN member states  East-West geopolitical divide  International solidarity  Health as social construction  Primary Health Care for all (Alma Ata to Selective PHC)  Globalization: trade, markets, ICT  AIDS and MDGs  WHO joined by WB, NGOs  New Philanthropy & Funds  Public-private partnerships  Health Systems neglect

4 4 Increasing funding for health - ODA reaching 20 Bn a year

5 5...but no enough improvement in MDGs 4, 5

6 6 Nearly 10 million children die every year Source: “Where and why are 10 million children dying every year?” Black RE, Morris SS, Bryce J, Lancet 2003; 361: ) The new challenge in global health Most die from preventable causes because of weak health systems

7 7 Problems resulting from neglected health systems Quality Ignorance/misapplication of proven interventions Fatal mistakes Few provider incentive structures Lack of quality standards Access Limited availability of basic health services A global crisis in human resources for health Uneven availability of medicines and supplies HEALTH SYSTEMS Affordability High out-of-pocket expenditures Impoverishing catastrophic expenses Undeveloped health insurance

8 8 Healthcare in low-income countries is primarily funded OOP Source: WHO National Health Accounts, updated (<$825) ($825 - $3,255) ($3,256 - $10,065) ($10,066+)

9 9

10 10 Today’s presentation The New Challenge in Global Health Following the money – the countries’ own The Rockefeller Foundation’s Strategy

11 11 Following the Money Relation between spending and health offers important, sometimes counterintuitive insights Health financing – key “control knob” available to policy makers Health financing critical to improve:  Risk protection  Coverage of services - Health outcomes & Equity  Efficiency (and quality) of service delivery

12 12 Health Freakonomics There is some “right” level of health spending Trying to reach it in poor countries, while reigning on costs in rich countries Modern cost-effective interventions progressively wipe out disease As people grows healthier, age-adjusted health spending eventually declines

13 13 Health Freakonomics Countries’ GDP and total health expenditure (THE) are tightly correlated (r 2 =0.95). Global data suggest donor spending adds little or nothing to a recipient country’s THE, and research indicates that private sector spending compensates for changes in public budgets. THE rises faster than GDP as economies grow (income elasticity ≈ 1.1). With GDP growing globally at an unprecedented rate, we predict an economic transition of health, immune to cost control, that will bring great challenges and opportunities for health equity. It is important to note that THE does not correlate strongly with HS performance. For example, some poor countries, such as Vietnam and Kenya, achieve much better health outcomes than other countries in the region with the same GDP. These findings suggest that focusing on HS performance, not simply external funding for health products and services, can drive improvements in health outcomes for the poor.

14 14 Good Health at Low Cost Childhood (<5) mortality (per 1,000) R 2 = 0.58 GDP per capita ($US, PPP) Rwanda Kenya Poorer countries' health is worse off, in general......but poor countries vary widely in health outcomes And good health exists across a range of GDP ,00010,000100,000 Source: WHO/IMF 2005 It’s not just about the level of health spending, but how resources are used N=178 countries

15 15 What we don’t know is the ‘How?’ How do countries make tax-financing, public delivery work in low income settings? How do countries, with weak capacity, manage the public-private mix in financing effectively? How do countries expand social insurance to rural/poor populations? How do some countries achieve universal coverage and MDGs at low cost?

16 16 Countries’ total health spending strongly tied to GDP Strong link between countries' wealth and total health spending THE per capita ) [log] GDP per capita [log] R 2 = 0.95 “The First Law of Health Economics” Source: Jacques van der Gaag; WHO/IMF 2005 This relationship is largely unaffected by: Relative share of public / private spending External donor assistance (which may inadvertently crowd out spending elsewhere) N = 178

17 17 Public /Private Mix (2004 data) AIID Dependent Variable: Log Health Expenditures / capita Constant-3.60*** (0.000) Log GDP / capita 1.09*** (0.000) Public Expenditure Share (0.01) R-Squared0.96 N175 Jacques van der Gaag 2008

18 18 Country's total health spending strongly tied to GDP Strong link between countries' wealth and total health spending THE per capita ) [log] GDP per capita [log] R 2 = 0.95 “The First Law of Health Economics” Source: Jacques van der Gaag; WHO/IMF 2005 The Economic Transition of Health This relationship is largely unaffected by: Relative share of public / private spending External donor assistance (which may inadvertenly crowd out spending elsewhere) Country% Nigeria 465 Thailand 311 Bangladesh 298 Kenya 263 Tanzania 198 India 193 Vietnam 173 Ghana 150 Cambodia 142 Uganda 84 Rwanda 79 South Africa 36 Projected THE growth ( ) Income elasticity > 1.0 N = 174 Together with the changing burden of disease (from acute to chronic), this economic transition will transform health systems worldwide

19 19 R 2 = 0.95 Source: WHO, IMF, 2008 Saudi Arabia USA Switzerland South Africa France Japan Qatar Singapore India Thailand Russia China Rwanda Eritrea Bangladesh GDP per capita (nominal USD, 2005) Argentina Mexico Lux. Norway UK Canada Burundi S. Korea Nigeria THE per capita (nominal USD, 2005) y = x The Economic Transition of Health

20 20 Source: Bradford J. DeLong, 1998 US THE China’s THE Take off

21 21 Sub Saharan Africa growing faster than the World’s average Source: IMF, World Outlook Database, 2007 Income Elasticity Greater than 1 Country% Nigeria 465 Thailand 311 Bangladesh 298 Kenya 263 Tanzania 198 India 193 Vietnam 173 Ghana 150 Cambodia 142 Uganda 84 Rwanda 79 South Africa 36 Projected THE growth ( )

22 22 WHO Member State GDP pc, US$ THE pc, US$ THE, % G D P ODA as % THE Public % THE OOP, % of Private HE THE pc, US$ Bangladesh Cambodia Chile7, China1, Cuba… … France35,0433, Ghana Haiti India Kenya Mexico7, Mozambique Qatar53,3332, Rwanda Thailand2, Uganda USA41,9706, …

23 23 BRIC Economies surpass G3 countries by 2050 China India Japan US Germany Goldman Sachs THE PATH TO 2050 Country 2050 projected GDP (2005 US$, millions) 2 THE/Cap projected THE (2005 US$, millions) 3 Brazil$8,028,000$2,187$555,807 Canada$2,983,000$5,182$221,558 China$48,571,000$2,405$3,388,867 France$4,870,000$5,309$362,424 Germany$5,440,000$5,478$405,882 India$27,235,000$1,073$1,779,261 Italy$3,128,000$4,181$228,297 Japan$8,040,000$5,886$603,388 Mexico$7,838,000$4,338$573,780 Nigeria$3,708,000$821$237,018 S Korea$3,684,000$6,593$279,043 Russia$6,162,000$4,170$449,640 UK$5,067,000$5,504$378,194 USA$37,666,000$7,136$2,871,452

24 24 Projected U.S. Health Spending Source: US Congressional Budget Office, Nov 2007 % GDP 50% GDP by 2080 Aging (dark blue) Just a small driver

25 25 Factors that influence health status  Health Behaviors50 percent  Genetics20 percent  Environment20 percent  Access to Care10 percent Source: McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA.1993; 270: ; CDC and the University of California, Institute for the Future, 2000; and Prevention Report, “A Time for Partnership, Report of State Consultations on the Role of Public Health,” U.S. Public Health Service, December 1994/January Eighty percent of health status, including the prevention of premature deaths, is preventable, 70 % by public health, and 10 % by medical treatment.

26 26 “Baumol’s Cost Disease” 1.The phenomenon arises outside the health market 2.Traditional cost control does not decrease total spending 3.Attempts to do so distort the system and miss opportunities Baumol's cost disease: Labor intensive services, such as health care, face productivity lag - cannot substitute capital for labor as efficiently as the general economy, so the cost of producing them goes up faster than general inflation

27 27 A new challenge for L&MICs this macro-micro collision course might create a wave of catastrophic expenditures and pull back many into poverty On the macro level (countries), richer countries spend more in health than poorer ones But on the micro level (individuals), the income elasticity of demand goes in the opposite direction. Unless there is social protection or insurance

28 28 Total U.S. GDP: $5,803 billion Total U.S. GDP: $13,195 billion U.S. Total Health Expenditure as a percentage of GDP 1 U.S. Percentage of Population Uninsured 2 Total U.S. population: million Total U.S. population: million Even though health spending has increased dramatically, the percentage of the population that is uninsured continues to rise 1 National Health Expenditure Accounts, U.S. Deparment of Health and Human Services, 2 U.S. Census Bureau. "Income, Poverty, and Health Insurance Coverage in the United States: 2007." August U.S. THE: $714 billion U.S. THE: $2,105 billion Uninsured Americans: 34.6 million Uninsured Americans: 46.9 million

29 29 Seguro Popular, México Year 1994

30 start of health system intervention ~55% decline from 1997–2003 MDG target for Tanzania Childhood (<5) mortality (per 1,000) Year DSS data for Rufiji district, Tanzania DHS estimates for rural coastal zone, Tanzania Official MDG target trajectory for Tanzania Improving country HS capabilities works Tanzania Essential Health Interventions Project (TEHIP) Pilot project researching and testing innovations in planning, priority setting, and resource allocation at district level Improving country HS capabilities TEHIP resulted from focus on efficiency of HS, IDRC-facilitated capacity development for improved data analysis, and better stewardship by MoH and district managers

31 31 POLICY IMPLICATIONS 1.Don’t fight the transition – cost controls fail to cap total spending. 2.Plan ahead – invest the growth in equity and quality. 3.Get more health “bang for the buck” - improve health system performance 4.Stay the course with the poorest countries – equity is paramount 5.Deal with transnational issues – they will only grow. 6.Recognize the importance of developments outside the health sector. 7.Invest more in action-oriented research and evaluation.

32 32 POLICY IMPLICATIONS 1.Don’t fight the transition – cost controls fail to cap total spending. 2.Plan ahead – invest the growth in equity and quality. 3.Get more health “bang for the buck” - improve health system performance. Invest more in action-oriented research and professional capacity for HS stewardship.

33 33 Global health has neglected health systems...And some of the neediest countries receive very little health systems aid Even with broad definition 1, <15% of total global health contribution target of health systems See appendix for categories of aid included in definition Note: Data only includes bilateral and some multilateral agencies, and does not include private non-profit organizations Source: Online query of two sectors in the OECD Creditor Reporting System (CRS) Database: (1) Health (2) Population Policies & Reproductive Health, 2006 Total contribution (%) Health systems Vertical disease control Other (basic health, reproductive health, medical research and services) ($B) 2006 Global Bilateral and Multilateral Public Health Contributions Sample countries: Share of total contributions per aid category Largely targeting doctors, nurses, traditional public health % of total contribution 49%19%15%11%5%

34 34 “More research is needed” Source: Research!America, GFHR 2007

35 35 Today’s presentation The New Challenge in Global Health Following the money – the countries’ own The Rockefeller Foundation’s Strategy

36 36

37 37 Opportunity for health systems performance and equity The Economic Transition of Health + the epidemiological transition in health + the ICT revolution = unprecedented transformation of health systems and the need and possibility of universal health coverage (access to quality services affordable to all through pre-paid risk-pooled financing)

38 38 TRANSFORMING HEALTH SYSTEMS RF overarching vision is to harness smart globalization and holistic systems to achieve universal health coverage in the 21st century. The core hypothesis: As globalization advances, new technologies, changing burdens of disease, and increasing health care costs are transforming HS around the world, and there is a window of opportunity to promote strategies that steer this inevitable transformation toward better and more equitable HS performance.

39 39 WHO Health Systems Framework THS targets strategies for health systems transformation

40 40 Guiding Principle: Improve health systems performance, not just purchase products or services Vision: Universal Health Coverage THS activities Evidence-based advocacy Professional support for National HS Stewardship Knowledge, capacity and Country demostrations Activities Strategies Country-level capability & new PPPs Enhancing HS Capacity in developing countries Harnessing the role of the private sector in health Leveraging interoperable eHealth systems in global health Fostering HS Research and Agenda setting

41 41 Intermediate outcomes (3-5 years) Intermediate outcomes (3-5 years) Activities (1-3 years) Strategies Evidence-based Advocacy and consensus building Ministerial academy, HS Network, Country HS data Fostering collaborative Networks and platforms Enhancing HS Capacity in developing countries Harnessing the role of the private sector in health Promoting the design and implementation of interoperable eHealth systems Country-level innovation & replication Health systems a global priority Professional stewardship of health systems in LDCs Integrated eHealth systems in 5 countries Improved private sector engagement in health systems Access Affordability Quality Long-term goals (5+ years) Long-term goals (5+ years) THS Theory of Change Harnessing the transformation of health systems for better performance Fostering HS Research and Agenda setting

42 42 What will THS look like in the developing world? Improving country HS capabilities Harnessing the private sector Leveraging eHealth Focus: sub-Saharan Africa and South / SE Asia Continue to refine country list to reflect: Country governance and political commitment to universal coverage GDP trends and OOP expenditure as a proportion of THE Evolving partner and donor landscape Rockefeller capacity and other initiatives Log GDP/Capita (PPP, $) U5MR (per 1000) Log GDP per capita versus Child (<5) mortality rate Median U5MR = 29 Median Log GDP/Capita = 3.78

43 43 What will success look like? Health Systems and Universal Coverage highlighted in the global health agenda Professional stewardship of health systems is occurring in low-and middle income countries Integrated national eHealth systems are in place in select countries Health systems are construed as actively engaging both the public and private sectors There is better and equitable access, affordability, and quality of health services for poor people

44 44 Health systems agenda gaining momentum Sept 07May 08Jul 08Oct 08Nov 08 WHO’s HSS Strategy after Mexico 2004 Atlanta meeting of UNSG & The Elders: HS a top priority WHO High Level consultation on HS G8 summit (Japan): HS WG & HLTF Jul 09 Bellagio series Bellagio sessions on Health Systems 2009 G8 summit (Italy) US IOM Report on Global Health UN ECOSOC takes up health World Health Assembly May 09

45 45 Thanks

46 46 THS landscape Bilateral European: UK - DFID, Dutch, Germany, AFD NORAD, SIDA, DANIDA, Irish Aid USA: USAID, PEPFAR Asia: Japan, AusAID G8 (Japan, Italy, Canada) Others: Technical Partners Other World Bank (IFC/WBI) UNICEF IDA EC GAVI & GFATM NIH Fogarty Center Others: Private Gates Foundation CARSO UN Foundation Aga Khan Foundation Doris Duke Foundation Wellcome Trust Corporations (IT, insurance) Others: Donors HMN ISfTeH IMIA OpenMRS mHealth alliance NEPAD Carso Ministries of Health and Telecomms Universities: Columbia U., Duke U., George Washington U., Mekerere U., U. of California at SF AHPSR Public Health Foundation of India World Federation of Public Health Associations MoH R4D/Brookings UK IDS U. of Toronto U. of Zambia LSTHM HLSP Thai IHPP IHP, Sri Lanka CGD Global eHealth Systems Health Systems Capabilities Private Sector in Health R4D/Brookings WHO Columbia University Harvard University Sri Lanka IHP Duke University UK IDS International AIDS Society Research & Agenda Setting

47 % EMR system implemented in multiple rural health clinics predominantly focused on HIV/AIDS care Patient waiting time reduced by 38% Admin personnel-patient time reduced by 50% Preparation time for MoH monthly reports down from 2 weeks to 1 hour Decreased cost per patient: –MMRS HIV/AIDS patient = $250/yr –PEPFAR HIV/AIDS patient = $1500/yr Improved quality of care: –Ability to prioritize relationship-based care –Detect patterns in data Leveraging eHealth is working Source: Informatics in Primary Care (2005), WHO, interviews Kenya's Monsoriot Medical Record System (MMRS) Leveraging eHealth % 2005 Mobile phone subscribers, Kenya, per 100 inhabitants Infrastructure growth enables additional eHealth implementations Infrastructure growth enables additional eHealth implementations Bellagio participants confirmed similar infrastructure growth around the world Internet users per 100 people Updated: fixed animation

48 48 Assessment/ Research CAN Policy CAN Capacity CAN Resource CAN World eHealth Collaborative Action Network: we can! Technical CAN Public health systems Nat’l reporting systems Admin systems Supply chain mgmt Technical CAN Technical Collaborative Action Network Technical CAN ADT Lab sys Radiol. sys Pharma sys Tele- med Patient-level systems System-level Collaborative Action Network EMR Open Vista Epic Care- ware Siga Saude Open- EHR Component-Level Collaborative Action Network EMR OpenMRS Makerere Univ. Google MRC Regenstrief UCC / Tanzania Partners in Health Millenium Villages Indiv. Developer Project-level Collaborative Action Network Network of Networks: World eHealth CAN

49 49 Why Focus on the Private Sector? The private sector in most developing countries is… Large: A large percentage of health expenditure and provision is already private Growing: Much of the expected growth in overall health expenditures is likely to initially be in the private sector. Neglected: Ministries of health, along with international agencies and donors, tend to focus on the public sector. Madhya Pradesh, India Source: De Costa, 2007

50 50 Pharmacies Social Marketing NGOs Private clinicians Private Hospitals Village health workersInformal providers Many faces of the Private sector

51 51


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