Health Infrastructure Julia Walsh MD, MPH April 2009

Health System Structure

National Health Accounts Regional Averages RegionHealth exp/cap Health %GDP % Public %Gov exp %External Resources %Private Out-of-Pocket AFR$ N/SAm2, SE Asia Eur1, E Med WPac Global

Health Expenditures, 2001 By Country Income Level Source: Disease Control Priorities in Developing Countries, second edition, Table 1.2. Country Group Health Expenditure Per Capita (2001 US$) Health Expenditure (Percent of GDP) Public Sector Expenditures (Percent of Total Health Expenditures) Low Income Middle Income High Income2, Countries in the European Union 1, World

Conclusion Poorest countries few resources Private Out of Pocket expenditures large proportion of health expenditures in poorest countries Dependence on external assistance

Unvaccinated children

Large Purchasers of Vaccines and other Pharmaceuticals PAHO Vaccine Revolving Fund Unicef – Vaccines & many other essential drugs UNFPA – Family planning methods USAID – largest purchaser of condoms Clinton HIV Initiative – Negotiates prices for HIV diagnostics and treatment

Source: Prata N, Montagu D, Jeffrerys E. Private sector, human resources, and health franchising in Africa. Bulletin WHO 2005;83:274-9.

Time Trends in the Use of Private Sector Health Services in Egypt

Conclusion Low coverage for sick children Private sector providers important No time trend

FacilityType PopulationServed Area Covered(sq. km) Beds PersonnelCommunicationTransportation Key Medication Stockouts Family Planning Methods InpatientLaborDelivery Chamba Govt. Health Center MA 21 HSA Personal cell phone 2 way radio DHO Ambulance, when available Bicycle ambulance Malaria drugs for Antibiotics (abx) STI Minipill Depo Provera Condoms Lambulira Govt. Health Center MAs 18 HSA 2 way radio only DHO Ambulance, when available Bicycle ambulance TB drugs Malaria Drugs Nevirapine Minipill Depo Provera Condoms Makwapala Govt. Health Center MAs 18 HSA 2 way radio only DHO Ambulance, when available Bicycle ambulance TB drugs STI abx Minipill Depo Provera Condoms Likangala Govt. Community Hospital MA 2 NM 22 HSA Personal cell phone 2 way radio DHO Ambulance, when available TB drugs Nevirapine syrup STI abx Depo Provera condoms Matawale (Acting District Hospital) Govt. Community Hospital CO 1 MA 1 CHN 11 NM 20 HSA 2 way radio only One hospital- based ambulance None All methods available Depo Provera in short supply Matiya CHAM (RC) Community Hospital MA 1 NM 16 HSA Personal cell phone 2 way radio DHO Ambulance, when available None Condoms only Mayaka CHAM (RC) Community Hospital MA 3 NM 24 HSA Personal cell phone 2 way radio DHO Ambulance, when available Malaria drugs STI abx Depo Provera Condoms Pirimiti CHAM (RC) Community Hospital RN 7 NM 21 HSA Hospital cell phone 2 way radio DHO Ambulance, when available Parish automobile, when available Malaria and STI drugs in short supply Depo Provera Condoms Baseline Data Findings: Health Centers

Funding for Vaccine Delivery Global Alliance for Vaccines Initiative (GAVI – Unicef, WHO, Gates, World Bank, Pharma, other donors,) –Poorest countries - <$1000/capita pppGDP –Supported by Country donations & Philanthropy –IFFIm & Advanced Market Commitment (AMC) WHO – technical guidelines and expertise Unicef –Purchase large quantities for GAVI, World Bank & governments –Support country programs World Bank PAHO – purchase through revolving fund, technical expertise National governments

International Finance Facility for Immunization (IFFIm) of Global Alliance for Vaccines Initiative (GAVI) Problem –2.3M annual deaths from vaccine preventable diseases in poor countries Solution –Accelerate availability and predictability of funds for immunization –Funds used by GAVI in 72 poorest countries for vaccine purchase & delivery & for strengthening health systems

GAVI – IFFIm Operations

IFFIm Operations Launched 2006 by UK Initiative under Gordon Brown UK, France, Italy, Spain, Norway, South Africa, Sweden, [Brazil in negotiation] pledged $5.3B over 20 years Issues triple A rated bonds [ Fitch, Moody, S&P] on capital markets converting long term contracts to immediately available cash World Bank manage Treasury functions Bond Investors repaid from donor pledges

Current Coverage and Minimum Coverage Goals Condition and Interventions Coverage Current 2007 Maternal Mortality/Perinatal Conditions Refocused antenatal care Skilled birth attendance Childhood Mortality Immunization Services-polio, diptheria, pertussis, tetanus, Hep B, Hemophilus B Immunization Services-measles Treatment of childhood illnesses --Acute respiratory infection Diarrhea Malaria Insecticide treated nets and residual indoor spraying 2 50 Treatment for clinical episodes of malaria Source: Science March, 2002;

Current Coverage and Minimum Coverage Goals (con’t) Condition and Interventions Coverage Current 2007 Tuberculosis Short course treatment of smear positive and smear negative patients Tobacco-Attributable Diseases Tax greater than 80% of retail price, Complete advertising and promotion bans, Consumer information, cessation programs HIV/AIDS and STIs Interventions to decrease sexual transmission Other preventive interventions < Palliative Care Highly active antiretroviral therapy <5 45 Source: Science March, 2002;

Annual Incremental Costs in Billions by Disease Type (2002 US$) 2007 high-cost estimate (%) 2007 LowHigh Maternity-related condition % Child immunization (including measles) % Treatment of childhood illnesses % Malaria Prevention % Malaria Treatment % Tuberculosis Treatment % HIV Prevention % HIV/AIDS care % High-active antiretroviral therapy % All Interventions %