1. Health Infrastructure Julia Walsh MD, MPH April 2009

2. Health System Structure

3. National Health Accounts 2004 -Regional Averages RegionHealth exp/cap Health %GDP % Public %Gov exp %External Resources %Private Out-of-Pocket AFR$1086449949 N/SAm2,7201348170.132 SE Asia 994275290 Eur1,564974140.170 E Med2245498188 WPac480657130.386 Global777956140.352

4. 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 Income234.426.3 Middle Income1186.051.1 High Income2,84110.862.1 Countries in the European Union 1,8569.373.5 World5009.859.2

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

8. Unvaccinated children

9. 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

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

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

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

15. FacilityType PopulationServed Area Covered(sq. km) Beds PersonnelCommunicationTransportation Key Medication Stockouts Family Planning Methods InpatientLaborDelivery Chamba Govt. Health Center 225708400 1 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 383329800 2 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 325769800 2 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 31080115123 1 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 4766886188 4 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 46004131234 1 MA 1 NM 16 HSA Personal cell phone 2 way radio DHO Ambulance, when available None Condoms only Mayaka CHAM (RC) Community Hospital 39767123126 1 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 2699571333 1 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

16. 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

18. 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

19. GAVI – IFFIm Operations

20. 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

21. Current Coverage and Minimum Coverage Goals Condition and Interventions Coverage Current 2007 Maternal Mortality/Perinatal Conditions Refocused antenatal care 65 80 Skilled birth attendance 45 80 Childhood Mortality Immunization Services-polio, diptheria, 75 90 pertussis, tetanus, Hep B, Hemophilus B Immunization Services-measles 68 80 Treatment of childhood illnesses --Acute respiratory infection 59 70 --Diarrhea 52 70 Malaria Insecticide treated nets and residual indoor spraying 2 50 Treatment for clinical episodes of malaria 31 60 Source: Science March, 2002; www.cmhealth.org/wg5.htm

22. Current Coverage and Minimum Coverage Goals (con’t) Condition and Interventions Coverage Current 2007 Tuberculosis Short course treatment of smear 44 60 positive and smear negative patients Tobacco-Attributable Diseases Tax greater than 80% of retail price, 20 80 Complete advertising and promotion bans, Consumer information, cessation programs HIV/AIDS and STIs Interventions to decrease sexual transmission 10-20 70 Other preventive interventions <1-10 40 Palliative Care 6-20 40 Highly active antiretroviral therapy <5 45 Source: Science March, 2002; www.cmhealth.org/wg5.htm

23. Annual Incremental Costs in Billions by Disease Type (2002 US$) 2007 high-cost estimate (%) 2007 LowHigh Maternity-related condition2.804.4816% Child immunization (including measles) 0.781.134% Treatment of childhood illnesses3.264.1314% Malaria Prevention1.642.388% Malaria Treatment0.370.572% Tuberculosis Treatment0.470.622% HIV Prevention6.186.7624% HIV/AIDS care2.782.8510% High-active antiretroviral therapy 4.285.7820% All Interventions22.5728.70100%