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Global Health Disparities: the role of health financing, donor assistance, and human resources

Global Health Disparities: the role of health financing, donor assistance, and human resources. CGFNS Symposium Philadelphia, December 2007 Marko Vujicic The World Bank. Outline. Global health disparities Health financing disparities

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Global Health Disparities: the role of health financing, donor assistance, and human resources

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  1. Global Health Disparities: the role of health financing, donor assistance, and human resources CGFNS Symposium Philadelphia, December 2007 Marko Vujicic The World Bank

  2. Outline • Global health disparities • Health financing disparities • Global action to address financing disparities - donor assistance for health (DAH) • The role of human resources for health (with emphasis on nursing)

  3. Global Health Disparities

  4. All regions off track. On a regional level, SSA and SA worst off track in achieving health MDGs

  5. EAP MDG Attainment P P P P P P P P P - Philippines Source: World Bank, DEC, 2006

  6. Causes of Death Vary Greatly by Country Income Level

  7. Africa Life Expectancy

  8. MDG Attainment www.gapminder.org

  9. Health Financing Disparities

  10. There is Tremendous Variability in Health Outcomes But There is an Overall Trend

  11. Health Financing

  12. Domestic Resource Mobilization is Much More Limited in MICs and LICs

  13. Spending on Health Compared with Spending by other Ministries

  14. Progress Towards the Abuja Target Has been Slow & Sometimes Negative Percentage Point Change in Health Expenditure as percentage of National Budget 1998-2002

  15. But the Abuja Target is Not Enough To Reach the MDGs US$34

  16. Share of Public Spending toReach Targets

  17. Donor Assistance for Health

  18. Donor Funding: Are Commitments Being Delivered? ODA is Rising But is Far Short of What is Needed to Meet the MDG (0.54) and Monterrey Commitments (0.70) To meet 2010 commitments (ODA of US$130 billion per year), need an average increase of about 8% per year Source: OECD DAC database.

  19. A Large Part of the Increase in Aid is Not Directed to Financing the Incremental Costs of Meeting the MDGs Net ODA disbursements from DAC donors $106.5 billion in 2005 $79.6 billion in 2004 Debt relief Other special purpose grants Other components of ODA In 2005, ODA peaked at US$ 106.5 billion -- most of this increase was due to debt relief and exceptional mobilization (Tsunami, Kashmir earthquake)

  20. Donor Aid for Health has Increased Significantly Most of the recent increases: • Focus on Africa • Focus on specific diseases • Come from bilaterals and multilaterals (GAVI, Global Fund) Source: Michaud 2006

  21. Where Does All the Aid Go? On average, for every $1 disbursed by donors to our 14 case study countries, we estimate: • Not recorded in balance of payment $0.30 • Recorded in BOP but not in Govt spending $0.20 • Aid earmarked to specific projects $0.30 • Budget support $0.20 • 1990s structural adjustment provided a larger share of aid as general budget resources.

  22. ODA is the Main Source of External Finance for SSA, Twice as Large as FDI and Nearly Four Times the as Large as Remittances Total long-term flows of $41 billion in 2003 Total long-term flows of $340 billion in 2003 Source: World Bank. Global Monitoring Report. 2005.

  23. However, Donor Commitments for Health are Volatile and Unpredictable Try managing this…

  24. Nutrition HIV/AIDS Malaria Vertical Aid Distorts Priorities Case management Community Management Drug Use Skilled birth attendance New born care PMTCT Safe and Supportive Environment Health system Maternal health Source: WHO, Mbewe

  25. Basic Problems in Current ODA System • Lack of predictability of funding and large differences between donor commitments and disbursements at the country level • There is a growing concern about the ‘verticalization’ of aid and the need to focus holistically on health systems as opposed to specific diseases or interventions • Large numbers of new actors and donors and the plethora of ‘new’ aid instruments (e.g., SWaps, PRSPs, PRSCs, PRGFs, MTEFs, etc.) create problems of management • Lack of responsiveness and flexibility of aid to sudden problems and crises • Little accountability of donors for the absence of results and lack of M&E systems which are needed to ensure that the additional resources are being used as prioritized and achieving results • A significant portion of aid is off-budget and often doesn’t even enter into the balance of payments or the government’s budget • Countries need to create ‘fiscal space’ to absorb these large increases in external assistance, a potentially problematic situation given IMF fiscal ceiling

  26. What is Needed? • A “Needs Assessment” which identifies systemic constraints and implementation bottlenecks for the delivery of essential services and the required process to address them; • Capacity development plans linked to policy and institutional needs including assessing complementarities with other sectors, analyzing the role of non-state partners (NGOs, civil society, and the private sector), and integrating national health systems with global programs; • Improve theinterface between MOF and MOH as co-leaders working with other relevant ministries; • Ensure consistency between health sector development plans, SWAps, the overall budget including cross-sectoral trade-offs and the macroeconomic framework, in consultation with the IMF; • Apply the Paris Principles of aid effectiveness to the health sector in country-specific circumstances including harmonization and alignment behind government strategies and processes, managing for results, and mutual accountability; • Strengthen systems of management for results, including monitoring and evaluation, appropriate indicators, and mutual accountability; and, • Determine major financing gaps and potential additional funding resources, eventually adjusting the plans to available resources and capacity to deliver.

  27. What Will Donors Have to Do? • Harmonize procedures (procurement, financial mgt, monitoring & reporting) Provide increased and predictable long term financing • Finance recurrent costs • Assess effectiveness and appropriateness of new financing instruments • Offer consistent policy advice • Focus on achieving results • Submit to common assessment of their own performance

  28. What Does This Mean for Countries? • Develop credible strategies and plans to foster economic growth, deal with implementation bottlenecks, and reach MDGs as part of PRSPs, SWAPs, MTEFs, and public expenditure programs • Improve governance • Enhance absorptive capacity through decentralization, efficient targeting mechanisms, and institutional reforms • Develop financing, management, and regulatory mechanisms for equitable and effective pooling of insurable health risks as a necessary concomitant to MDG and CMH intervention choices. • Integrate vertical programs into a well functioning health system to maximize health-specific and cross-sectoral outcomes and reduce transactions costs • Monitor and evaluate results

  29. What Does This Mean for Countries?

  30. Global Disparities in Human Resources for Health – Nursing Focus

  31. Measuring the impact of out-migration We know that having enough staff is important for achieving outcomes (but is at best a necessary condition)

  32. Measuring the impact of out-migration On a regional level, SSA and SA also have lowest staffing levels

  33. Measuring the impact of out-migration Flows of migrant nurses into selected countries (Source: OECD, 2007)

  34. Measuring the impact of out-migration • Migration is a two way street. (Source: CIHI)

  35. Measuring the impact of out-migration (Source: NCSBN)

  36. Measuring the impact of out-migration • Developed countries relying more and more on migrant health workers to fill labor shortages • Source of migrant health workers has changed dramatically in recent years - developing countries are the main source • Debate on impact of out-migration • WHO resolution 57.19 • UK Code of conduct • Bilateral agreements

  37. UGANDA -Gap for attaining PEPFAR target KENYA -Gap for attaining PEPFAR target

  38. Measuring the impact of out-migration • Debate does not focus on fiscal side. i.e. are there enough funded positions to absorb the doctors and nurses who leave the country? • Short term • Vacancy data • Inaccurate – often measured relative to norms • Budget execution data • Difficult to collect • Two illustrative examples • Kenya • Malawi • Long term • How easily could additional funded positions be created through increased fiscal space for health? • Donor funding vs. domestic resources

  39. Kenya

  40. Kenya

  41. Kenya

  42. Malawi

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