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Africa’s health challenge and institutional context

This article provides a comprehensive overview of Africa's health challenge and the institutional context in which it operates. It covers topics such as indicators and underlying factors, healthcare system functions, financing, and reform perspectives. The article also discusses the progress made in improving life expectancy and reducing mortality rates, as well as the disparities and barriers to accessing healthcare services in the region. Additionally, it explores the need for innovation and solutions, such as community health workers, to address the health challenges in Africa.

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Africa’s health challenge and institutional context

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  1. Africa’s health challenge and institutional context Health Dialogue 4 April 2011 Nairobi

  2. Overview • Africa’s health challenge • Indicators and underlying factors: demand, supply & efficiency • Institutional context and reform • Health system functions • Financing in the African context • Hierarchy of reform • Other reform perspectives & approaches

  3. Progress but “lags”, and some reversals – life expectancy/death LE at birth: • Joined world in rapid progress from circa 1950-1990: up from 39 to 50 • Significantly lags the world (2008): Africa 53, global 68 (America 76; South-East Asia 65) • Great diversity: • among countries (73 in Mauritius versus 42 in Zimbabwe) • within countries (rural/urban; income groups, education of mother) • Steady progress in some, reversals in others (Lesotho 61 to 47 1990 to 2008) • Key factors in increasing life expectancy/driving down mortality? Mortality: • Adult 45q15: 392@180 • Child mortality: 142@65 • Maternal mortality: Disproportionate in many but also good progress in some

  4. Explaining the lag? A Ghana case 2001 • Young man with treatable disease (“Burkitt’s lymphoma”): • Access to public system but costly, medicine not in public system • Private medicine but (very) costly • For many even less “access” – regional disparities • Human resources and facilities • “Needless deaths of thousands of people from treatable diseases” • Innovation and solutions: outreach/community health workers • Many responses in Ghana since then – partly reviewed in case study

  5. Demand for services and disease burden Disability adjusted life years (DALYs) Sum of YLL (years of life lost due to death) and YLD (years of healthy life lost as a result of disability) Classify DALYs according to diagnostic categories to which they are related Group I – communicable diseases, maternal, perinatal, nutritional conditions Group II – non-communicable diseases Group III – injuries 1990 Sub-Saharan Africa/Latin America Group 1: 65.9%/35.3% Group 2: 18.4%/48.2% Group 3: 15.4%/16.4% (Murray 1997) Africa a double burden? Triple? Quadruple? How does it help? Measuring progress; help determine disease control priorities; Evidence for reallocation

  6. Demand for services & disease burden –Leading causes of burden of disease– WHO Africa region

  7. Service provision & access: average and distribution Immunisation rates: Very high in some (close to 100%) Low in others – and have been declining Inequalities: Nigeria 75% for richest 20%; 17% for poorest 20% Attended births: Again wide range Rich&poor; rural&urban; education of mother

  8. Supply factors: funding, resources, efficiency Spending on health ranges from 13.9% of GDP (Burundi) to 2.1% (Equatorial Guinea) Average WHO Africa: 6.2% of GDP compared to 13.6% in Americas, 3.6% in SE Asia Per capita health $ low: ave of $76 ($41 in SE Asia and $801 global average) Gov health spend as % of government spend from Rwanda (19.5%) to as low as Congo (5.1%) – 6 countries around Abuja target

  9. Supply factors: physicians per 10,000

  10. Demand, funding and resources not the whole story - efficiency • Sub-Saharan Africa and SE Asia compared? • Diversity of outcomes for countries with same wealth/inputs • Evidence of waste

  11. Looking for reform options: elements of health systems

  12. Looking for reform options: financing systems • Social insurance versus national health systems vs mixed • Collection – private payments (OOP), insurance/contributory, general govt revenue, • Pooling to spread risk • Purchasing/provider payment – fee for service, capitation, case-mix adjusted • Africa: govt significant but private bigger: little insurance & pooling of risks. Integrated hierarchical systems typical – little active purchasing

  13. A hierarchy of reforms or policy options

  14. Other reform perspectives/approaches • Macro expenditure constraints versus micro efficiency enhancement on demand & supply side (OECD) • Incentives: Reimbursement mechanisms & reward systems • Moving from a historic centralised system: decentralisation; private sector involvement; integration (@vertical programmes); (donor) coordination (comprehensiveness of budgets) • PFM reform: linking policy & budgets, certainty & credibility (MTEFs), output & performance orientation

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