“Trends and Challenges in World Health”

1. “Trends and Challenges in World Health” Simon Blair 15 May 2001

2. Presentation Outline • 2001 – its place in time (successful evolution) • Existing and emerging issues (the challenges) • Trends in hospital reform • Transferable lessons from global reform

3. Health Reform and the World Bank • Why ? The Bank’s vision – “to reduce poverty and improve living standards through sustainable growth and investment in people” • Health = 9% GDP , and rising

4. Total Health Expenditure as Percent GNP 18% 16% 14% 12% 1977 10% HE as % GNP 1987 8% 1997 6% 4% 2% 0% 100 1000 10000 100000 LN GNP per capita

5. Health Reform and the World Bank • Why ? The Bank’s vision • Health = 9% GDP • Rapid portfolio growth 1970 – 2001. 300 health reform projects • 88 countries; projects totaling US $18.6b • Focal shift: PHC/public health health systems and hospitals

6. 1900-2000: Sustained Progress • Diptheria (1901), malaria (1902), diabetes (1922), electrocardiogram (1924), penicillin (1928), HBGs (1930), tuberculosis (1952), DNA (1953), poliomyelitis (1954), heart cathetarization (1956), CAT (1979) ….

7. A Century of Unparalleled Improvement 6.0 80 1997 75 5.5 70 5.0 Life Expectancy 65 4.5 60 Fertility Rates Life Expectancy in Years 4.0 55 50 3.5 45 3.0 40 Total Fertility Rates 2.5 35 2.0 30 1950 60 70 80 90 2000 10 20 30 2050 40 Years

8. 1900-2000: Sustained Progress • Nobel Prizes • Life Expectancy up, fertility rates down • % children who die before 5 = 50% of 1960 • 3m children p.a. saved by immunization • 1m p.a. saved via improved diarrhea control • Child malnutrition rates 20% lower than 1970 • People now live 25 years longer than in 1900

9. 2001 : Critical Existing and Emerging Issues • WHO’s “Double Burden of Disease” the emerging epidemic of non- communicable diseases the unfinished health agenda • Reducing the burden of inequity “the balance sheet is indelibly stained”

10. Challenge 1: The Onslaught of Non-communicable Diseases • From 35% (1998) – 57% (2020) of international disease burden • Infectious diseases : 49% to 22% • CVD will = largest single cause of DALYs • Lung cancer rates will rocket up due to tobacco usage • Injuries will = infectious diseases worldwide as source of ill health by 2020

11. Challenge 2: “The Unfinished Health Agenda” • Infectious diseases in developing countries • The 5 major childhood conditions still = 21% of all deaths in low/middle income countries • Pneumonia, diarrhea, measles, malaria and malnutrition = 70% childhood deaths globally • In adult conditions HIV/Aids and TB 2/3 major causes of disease burden in developing countries • 30% world still without safe water and sanitation

12. “A world of incomplete epidemiological transition, in which epidemiologically polarized sub-populations have been left behind” World Health Report 1999

13. Challenge 3: Reducing the Burden of Inequity • The inexorable link: poverty and ill health. (25% of the world’s population [1.4 billion people] continue to live on incomes of < $1 per day. Half live on incomes < $2 per day.)

14. Only 11 Percent of Global Spending for 90 Percent of the World’s Population

15. Per Capita Exp (US$) Average* Min Max (US$) 4.0 USA SAS 16 5 18 3.5 EAP 21 1,000 8 130 3.0 Singapore 237 2.5 5 42 AFR Per capita Total Health Expenditure 100 2.0 54 6 MNA 118 1.5 ECA 120 34 336 10 1.0 India LAC 234 877 8 0.5 Rwanda 3642 High Income 425 2329 0.0 100,000 10,000 100 1,000 2.0 2.5 3.0 3.5 4.0 4.5 5.0 * weighted average Per capita GDP Exaggerated by Income / Spending Correlation

16. Health Achievement and Health Resources, 1997 75 70 65 60 55 DALE 50 45 40 35 30 25 1 10 100 1000 10000 Ln Health expenditure per capita

17. Challenge 3: Reducing the Burden of Inequity • The inexorable link : poverty and ill health • 93% of global disease burden is in low/middle income countries • 2m children die p.a. from vaccine preventable diseases • < 10% of global funding for health research is devoted to 90% of the health problems

18. Challenge 3: Reducing Inequity (continued) • Per capita health expenditures vary almost 1000 fold : from US$4 per capita p.a. to $3800. (Ratio using PPP adjusted $ = 250x) • TB is 4 times more prevalent in poor subgroups of populations • 70% of the world’s 36m HIV cases are in Sub Saharan Africa

19. Systemic and Environmental Challenges • Affordability and securing adequate $ levels • Stabilizing the policy pendulum • Redefining the role of the State • Market imperfections in the private sector • Poor performance • Lack of sophisticated purchasing and/or purchasing accountability • Absences of ‘single’ health systems

20. Trends in Hospital Reform (1) • Caveat : impossibility of homogeneity • Decentralization; increased hospital autonomy; increasing focus upon governance and stewardship issues • Hospital consolidation / rationalization; use of ‘networks’; service substitution • Focus upon ‘continuums of care’ and criticality of system-wide integration • Managerial efficiency seen as cost-effective

21. Trends in Hospital Reform (2) • The evolution : allocation to purchasing • Increased private sector participation • Performance quality accorded higher priority • Information systems becoming mandatory • Increasing community participation • Introduction / expansion of user-charges

22. From the Database of 300/88:“Lessons” • The criticality of political will • Address both the supply side and the demand sides of the equation • Incrementalism more successful than ‘big-bang’ • Authoritative and consistent policy-driven decision making is necessary – considering financing, regulation and organizational reform together

23. “Lessons” (continued) • The non-negotiable relevance of local circumstances • Market-influenced incentive measures can be advantageous • Process and outcome foci are critical • Develop institutional capacity in advance • Cost-containment alone does not result in long term success

24. “Trends and Challenges”