Global Issues in Health Care

1. Global Issues in Health Care Jean Yan Chief Scientist Nursing and Midwifery World Health Organization Geneva

2. Healthy People, Healthy World A Reality

3. The Vision … the attainment by all peoples of the highest possible level of health WHO Constitution … a state of complete physical, mental and social well- being and not merely the absence of disease

4. Millennium Development Goals (1990 – 2015) Goal 4 reduce child mortality Target: reduce by 2/3rds (under-five mortality rate) Goal 5 improve Maternal Health Target: reduce by ¾, the maternal mortality ratio Goal 6 combat HIV/AIDS, malaria and other diseases Target: halt by 2015 and begin to reverse spread of HIV/AIDS, malaria and other major diseases Primary Health Care – the key to attaining acceptable level of health for all people

5. The Essence of Primary Health Care "health is not a commodity that is given, it must be generated from within". "health action should not be imposed from outside, foreign to the people, it must be a response of the communities to problems they perceive, supported by an adequate infrastructure" (Mahler, 1998)

6. The Global Health Situation • Inequities in access to care and health outcomes • Impoverishing costs • Erosion of trust in health care

7. Inequities • Access to health care 1.3 Billion individuals globally with no access to health care 58 million of women ( out of 136M) who will give birth in a year, will receive no medical assistance during childbirth and postpartum period – endangering lives of mothers and babies • Health outcomes Life expectancy : 40 years difference between the riches and poorest countries , Norway – 12 years within country Child health (under 5 mortality rate) : vast difference exist within countries and individual cities - e.g . Nairobi) - below 15/1000 in high income group, - 254/1000 in slums in the same city In many cases – people who are well-off are generally healthier , have best access to the best care while the poor are left to take care of themselves

8. Infant mortality rate (deaths per 1,000 live births) (PAHO, 2005)

9. Growing inequalities in global health: the widening gap in infant mortality experience IMR: babies dying before age 1 per thousand born live SSA World (UNICEF, 2003)

10. Under 5 mortality (per 1000 live births) by wealth group (Houweling et al, 2007)

11. Mortality over 25 years according to level in the occupational hierarchy: Whitehall (Marmot & Shipley, BMJ, 1996)

12. Life expectancy of Indigenous Peoples (Bramley et al, 2005)

13. Access to health services according to ethnicity (IDB, 2004)

14. The widening trend in mortality by education in Russia,1989-2001 (probability of living to 65 yrs when aged 20 yrs) (Murphy et al, 2005)

15. Infant mortality in Brazil by race and mother's education, 1990 (Pinto da Cunha, 1997)

16. Social exclusion in health and environment • 152 million people without access to safe drinking water and basic sanitation 120 million people without access to health services due for economic reasons • 107 million people without access to health services for geographic reasons

17. The social determinants of health

18. Impoverishing Costs • Annual government health expenditures $20 per person in low income $6,000 per person in high income countries • Out of pocket health expenditures 40% in low income countries ( 5.6 billion) 20% in high income countries Result: 100M people below the poverty line each year ( due to rising HC costs , system for financial protection in disarray)

19. Erosion of trust in health care:health as a commodity and care driven by profitability HC often delivered according to a disease model , high technology, specialist care and the power ofprevention ignored • unnecessary tests and procedures, frequent and longer hospitalization • higher overall costs, exclusion of people who can't pay • fragmented health care focused on national disease and projects with little attention to coherence, decrease investment in infrastructures , services and staff • People reduced to program targets • Health workforce deployment: ½ of physicians and ¾ of nurses and midwives working in hospitals • Specialist perform tasks that are better managed by general practitioners, family doctors and nurses – leading to inefficiency, limited access to comprehensive health care. Health care failing to respond to expectations of the public – patient-centered, fair, affordable and efficient

20. Guarantees social protection in health for all citizens Contributes to the elimination of inequities in access to health services Guarantees quality health services Assures excluded social groups equal opportunity to receive integral health care Satisfies the population’s health needs, demands & expectations Eliminates the inability to pay as a barrier to access to health care Towards a health system that … PAHO/WHO XLIII Directing Council, Washington DC 2002

21. Link PHC with Millennium Development Goals Outcomes MDGs PHC renewal • Provides a framework for achieving MDGs by: • Strengthening the entire health system • Providing a focus on equity • Integrating different approaches to service delivery • Addressing social determinants of health • Equity : Access • Quality: efficient, effective • Solidarity : Community • participation • Strategy: • Alliances • Networks MDG targets

22. The renewed PHC : 4 reform areas(WHR 2008) Service Delivery Universal Coverage Public Policy Leadership Health care responsive to the expectations of the public – patient-centered, fair, affordable and efficient

23. Progress can be achieved in short time periods In 9 years In 15 years In 7 years LIFE EXPECTANCY ACCESS TO POTABLE WATER POVERTY PRIMARY SCHOOL ENROLMENT 89% 56 yrs 15m 33% 7m 48 yrs 18% 46% Sri Lanka 1946 - 1953 South Africa 1994 - 2001 China 1990 - 1999 Botswana 1970 - 1985

24. Renewed PHC Progress is not a given: child deaths in 1975 and 2006

25. PHC’s Impact on Population Health PHC was a significant contributor to improved population health in OECD countries 10000 PYLL Low PC Countries 5000 High PC Countries PYLL=Potential Years of Life Lost (Measure of premature mortality) 0 1970 1980 1990 2000 Lost Premature Mortality and PHC Performance In 18 OECD Countries, 1970-1998 Macinko et al., 2003

26. PHC’s Impact on Population Health PHC reforms in Costa Rica significantly reduced mortality in adults and children –– With reform ++ Without reform For every 5 additional years after PHC reform, child mortality was reduced by 13% Trends in Under-5 Mortality in Districts With and Without PHC Reform Costa Rica, 1985-2001 … and adult mortality was reduced by 4% Rosero-Bixby, 2004

27. Health Systems with Strong PHC Are More Efficient Stronger PHC UK DK NTH FIN SP CAN AUS SWE JAP GER US BEL FR Weaker PHC Starfield & Shi, 2002

28. The HRH Challenge • Unequal distribution -the parts of the world experiencing the greatest burden of disease have the lowest numbers of health care providers • The highest density of health workers is in urban settings leaving rural areas underserved • Lack of national policy and plan on human resources for health in most countries • Inadequate capacity to train more • Member states not able to provide basic services because of the HRH crisis

29. Worker Density by Region

30. The Health Workforce Nurses and midwives : The main providers of health care , urban and rural (improved access and coverage) Source: Australia's Health Workforce. Productivity Commission Position Paper. Canberra, 2005.

31. Contributions of Nursing and Midwifery to Primary Health Care ( improved health outcomes) Trained N& M can deliver approximately 80% of the health care and up to 90% of the pediatric care currently provided by primary care physicians at equal or better quality and lower costs Under utilization of nurse practitioners in the US – cost the country as much as $ 8.7 B annually(Tournquist ' 97) Health Prevention and promotion– better use of existing preventive measures reduces the global health burden of disease by 70% (WHR 08) Skilled attendant at birth saves mothers and babies Nurses – a valuable resource for global health

32. The renewed PHC : 4 reform areas(WHR 2008) Service Delivery Universal Coverage Public Policy Leadership

33. Now More than Ever : Nursing and Midwifery Contributing to PHC Universal Coverage: rural and remote areas - Korea : utilization of nurses as community health practitioners (CHP) – a total of 1850 , each responsible for 1500 – 2000 population. High satisfaction level from clients, improved health status and decreased risk behaviors ( smoking and drinking alcohol) - Belize : Community – based psychiatric/mental health program by trained nurse practitioners ( 10 months). Mental health hospital – closed ( only six beds in acute hospital), .National program staffed by nurse practitioners, only two psychiatrist needed at national level.. - Bahrain – Adequate number of nurses and midwives trained to work in the 4 tiered health system. Results: 22 health centers opened through out the kingdom providing 12-24 hours of care. 2.8 million visits to health centers, increased diabetic visits, children screening and immunizations Service delivery - Yemen . Use of community midwives , increase in clinic attendance - Botswana : nurses providing family health . Sustained intervention for care of stroke patients resulting in families assuming responsibility for own health - Brazil : nurse – led care during deliveries … no maternal deaths from pregnancy or childbirth - Australia : Renal replacement therapy provided by nurse practitioners, no medical officers needed - Denmark : Care of the elderly provided by nurses . Health assessment, activities of daily living higher, average bed days lower, running costs for care- lower and life expectancy increased by 30% Source: Compendium of PHC studies : 38 teams from 29 countries across 6 regions

34. Now More than Ever : Nursing and Midwifery Contributing to PHC Leadership -Haiti –nurse –led care in ambulatory and clinic care , resulted in gains in controlling malnutrition, malaria and TB - China– nurse –led innovation in community health ( rehab and palliative care) : Nurse coordinated the care provided by multi-disciplinary teams – physiotherapists, nutritionists, optometrist, psychologist, music therapist , Results : improved aged persons ability to manage own well –being, decrease in hospitalization - Canada – nurse-managed care for medically deprived communities. Nurses coordinate and supervise the work of volunteers, community partners, town councils, business organizations , referrals to physicians. . 16 sites, 24 nurse managers, 18,500 clients( 1 nurse per 800 clients, average of 8-25 clients per day) Public Policy - Oman : government commitment to increase access to basic health care brings long-term improvements, five year national health plan. Includes use of 1400 nurses, resulting in 85% increase in clinic visits, 1 PHC per 10,000 population, high immunizations coverage, fall in infant mortality rate ( from 170/1000 in 1970 to 16/1000 in 2006) - Thailand: one PHC per every village, Nurses of the Community Program 33 educational institutions, 300 administrative organizations , 60 community hospitals. Provide essential services : maternal and children, elderly, disease surveillance and control, involve in local policy development to improve quality life. All graduates are working in their own or nearby community . Source: Compendium of PHC studies : 38 teams from 29 countries across 6 regions

35. Health Professionals : a Valuable Resource for Global Health Nursing and midwifery , a solution to today's increasingly complex needs in health care delivery and PHC provision Nation of Healthy People Healthy World (MDGs) • Nursing and Midwifery Practitioners: 16 million nurses and midwives, 60% of health care providers • Better trained member of the team, coordinate and manage health services, support and supervise other team members, well trusted by the community, delivers services with scarce resources. • Shown rapid transformation of nursing practice and the re-orientation of professional training to support PHC. ( made possible by their versatility , numbers and capacity )

36. Global Response • Strengthening nursing and midwifery (WHA 59.27-2006)_ acknowledges the crucial contribution of nursing and midwifery to efforts for improved health outcomes. • Rapid Scaling Up of health workforce production (WHA 59.23-2006)- aims to achieve a rapid increase in the number of qualified health workers in countries experiencing shortages

37. Islamabad Declaration 4-6 March, 2007 • Founded on belief that efficient, effective nursing and midwifery services are critical to achieving the MDGs, health systems strengthening, and the general health of all nations. • Three themes: scaling up nursing and midwifery capacity skill mix of existing and new cadres of workers positive workplace environments.

38. Scaling –up N&M Capacity InitiativesPolicy to Action WHA Resolution Strengthening N&M Geneva Global Work Plan & Launch Geneva Islamabad Declaration Pakistan Action Plan Zambia

39. Global Work plan for Scaling-up Nursing and Midwifery Capacity to contribute to the MDGs Better Health Outcomes Strengthened Health Service (PHC) Adequate and appropriate #s of Satisfied, motivated N%M workforce Global Program of Work

40. Global Work plan for Scaling-up Nursing and Midwifery Capacity to contribute to the MDGs Global Program of Work Commitment & Support ( political & Constituencies) Resources Outputs Adequate # of tutors to Scale-up production of N&M workforce PHC accessible in Areas of greatest Health needs Productivity and retention Of N&M workforce Increased Leadership and management skills strengthened in support of N&M PHC services • Core Elements • Education and Training • Health Service Provision • Workplace environment • Talent management • Partnership

41. Success Measures • Adequate number of competent N&M – increased production and Increased capacity of educational institutions – tutors, IPE • Enhanced access to competent nurses and midwives who provide care, supervision and support in all settings. • Leaders effective in integrated N&M in the national health program • A positive workplace environment – C149 , healthy workforce • Coordinated, integrated, collaborative, sustainable approach to planning, policy and health care delivery • Expansion of partnerships and networks

42. Participating GPW countries Serbia Qatar Bhutan Somalia Nicaragua India Zambia Argentina

43. Action Now ! • Investment in nursing and midwifery • Active engagement in policy and decision-making at all levels • Updated and scale-up training : PHC focused • Innovative practice models • Leadership – shared, collective, multi-disciplinary and multi-sectoral • Alliances and Networks

44. VOLUNTEER OPPORTUNITIES AT WHO • SCHOLAR PROGRAM - PhD - mid-career to senior level nursing leaders - three months • INTERNSHIP PROGRAM - Masters level - work experience - 8 weeks ( on –site or off –site)

45. World of Global Health : Nursing and Midwifery Services Great highest possible level of health Leadership Innovation Action (partnerships and team work ) Good Policymakers' continued investment and support for N&M are vital in making PHC a reality

46. A Message • Good it is To receive peace from the World • Better it is To give peace to the world • Best, by far the best , it is To become the peace of the World Sri Chinmoy

47. A Final Message for PHC • Good it is To receive ( health ) from the World - HFA • Better it is To give (health) to the world • Best, by far the best , it is To become the healthy people for the Healthy World Sri Chinmoy

48. Our world, Our health… A Reality

49. All TOGETHER We Can MAKE THINGS HAPPEN FOR IMPROVED GLOBAL HEALTH !

50. Thank You