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The Challenge of Health Systems in Global Health HIV Center Grand Rounds March 2009

The Challenge of Health Systems in Global Health HIV Center Grand Rounds March 2009. Today’s presentation. The New Challenge in Global Health Following the money – the countries’ own The Rockefeller Foundation’s Strategy. A brief history of Global Health. End of Euro- colonialism.

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The Challenge of Health Systems in Global Health HIV Center Grand Rounds March 2009

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  1. The Challenge of Health Systems in Global HealthHIV Center Grand RoundsMarch 2009

  2. Today’s presentation The New Challenge in Global Health Following the money – the countries’ own The Rockefeller Foundation’s Strategy

  3. A brief history of Global Health End of Euro- colonialism End of the Cold War The MarketMeltdown Tropical Medicine International Health Global Health A New World Health ? ? 2010's 1960's 1990's • Colonial arrangements • Pioneer age/missions • Western tech experts • Parasitic diseases and anti-viral vaccines • Eradication campaigns • New UN member states • East-West geopolitical divide • International solidarity • Health as social construction • Primary Health Care for all (Alma Ata to Selective PHC) • Globalization: trade, markets, ICT • AIDS and MDGs • WHO joined by WB, NGOs • New Philanthropy & Funds • Public-private partnerships • Health Systems neglect

  4. Increasing funding for health- ODA reaching 20 Bn a year 1990 2008 2000

  5. . . .but no enough improvement in MDGs 4, 5

  6. The new challenge in global health Nearly 10 million children die every year Most die from preventable causes because of weak health systems Source: “Where and why are 10 million children dying every year?” Black RE, Morris SS, Bryce J, Lancet 2003; 361: 2226-34)

  7. Problems resulting from neglected health systems • Access • Limited availability of basic health services • A global crisis in human resources for health • Uneven availability of medicines and supplies • Quality • Ignorance/misapplication of proven interventions • Fatal mistakes • Few provider incentive structures • Lack of quality standards • Affordability • High out-of-pocket expenditures • Impoverishing catastrophic expenses • Undeveloped health insurance HEALTHSYSTEMS

  8. Healthcare in low-income countries is primarily funded OOP (<$825) ($825 - $3,255) ($3,256 - $10,065) ($10,066+) Source: WHO National Health Accounts, updated 2002.

  9. Today’s presentation The New Challenge in Global Health Following the money – the countries’ own The Rockefeller Foundation’s Strategy

  10. Following the Money • Relation between spending and health offers important, sometimes counterintuitive insights • Health financing – key “control knob” available to policy makers • Health financing critical to improve: • Risk protection • Coverage of services - Health outcomes & Equity • Efficiency (and quality) of service delivery

  11. Health Freakonomics • There is some “right” level of health spending • Trying to reach it in poor countries, while reigning on costs in rich countries • Modern cost-effective interventions progressively wipe out disease • As people grows healthier, age-adjusted health spending eventually declines

  12. Good Health at Low Cost 300 2 1 Poorer countries' health is worse off, in general... ...but poor countries vary widely in health outcomes 250 Rwanda 200 R2 = 0.58 Childhood (<5) mortality (per 1,000) 150 3 And good health exists across a range of GDP 100 Kenya N=178 countries 50 0 100 1,000 10,000 100,000 GDP per capita ($US, PPP) It’s not just about the level of health spending, but how resources are used Source: WHO/IMF 2005

  13. What we don’t know is the ‘How?’ • How do countries make tax-financing, public delivery work in low income settings? • How do countries, with weak capacity, manage the public-private mix in financing effectively? • How do countries expand social insurance to rural/poor populations? • How do some countries achieve universal coverage and MDGs at low cost?

  14. Countries’ total health spending strongly tied to GDP Strong link between countries' wealth and total health spending “The First Law of Health Economics” • This relationship is largely unaffected by: • Relative share of public / private spending • External donor assistance (which may inadvertently crowd out spending elsewhere) R2 = 0.95 THE per capita ) [log] N = 178 GDP per capita [log] Source: Jacques van der Gaag; WHO/IMF 2005

  15. Public /Private Mix (2004 data) AIID Jacques van der Gaag 2008

  16. The Economic Transition of Health Mexico Argentina USA Lux. South Africa Norway Switzerland Russia China Bangladesh Nigeria Rwanda India Eritrea Burundi Thailand France THE per capita (nominal USD, 2005) Canada UK Japan R2 = 0.95 Qatar y = 0.0276x1.0887 Singapore S. Korea Saudi Arabia GDP per capita (nominal USD, 2005) Source: WHO, IMF, 2008

  17. US THE China’s THE Take off Source: Bradford J. DeLong, 1998

  18. Sub Saharan Africa growing faster than the World’s average Income Elasticity Greater than 1 Source: IMF, World Outlook Database, 2007

  19. Projected U.S. Health Spending % GDP 50% GDP by 2080 Aging (dark blue) Just a small driver Source: US Congressional Budget Office, Nov 2007

  20. Factors that influence health status •  Health Behaviors 50 percent •  Genetics 20 percent •  Environment 20 percent •  Access to Care 10 percent  Eighty percent of health status, including the prevention of premature deaths, is preventable, 70 % by public health, and 10 % by medical treatment. Source: McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA.1993; 270:2207-2212; CDC and the University of California, Institute for the Future, 2000; and Prevention Report,“A Time for Partnership, Report of State Consultations on the Role of Public Health,” U.S. Public Health Service, December 1994/January 1995. 

  21. “Baumol’s Cost Disease” Baumol's cost disease: Labor intensive services, such as health care, face productivity lag - cannot substitute capital for labor as efficiently as the general economy, so the cost of producing them goes up faster than general inflation • The phenomenon arises outside the health market • Traditional cost control does not decrease total spending • Attempts to do so distort the system and miss opportunities

  22. A new challenge for L&MICs this macro-micro collision course might create a wave of catastrophic expenditures and pull back many into poverty On the macro level (countries), richer countries spend more in health than poorer ones But on the micro level (individuals), the income elasticity of demand goes in the opposite direction. Unless there is social protection or insurance

  23. Even though health spending has increased dramatically, the percentage of the population that is uninsured continues to rise 1990 2006 U.S. Total Health Expenditure as a percentage of GDP1 Total U.S. GDP: $5,803 billion Total U.S. GDP: $13,195 billion U.S. THE: $714 billion U.S. THE: $2,105 billion U.S. Percentage of Population Uninsured2 Total U.S. population: 296.8 million Total U.S. population: 248.9 million Uninsured Americans: 46.9 million Uninsured Americans: 34.6 million 1National Health Expenditure Accounts, U.S. Deparment of Health and Human Services, http://www.cms.hhs.gov/NationalHealthExpendData/downloads/tables.pdf. 2U.S. Census Bureau. "Income, Poverty, and Health Insurance Coverage in the United States: 2007." August 2008.

  24. Seguro Popular, México Year 2006 1994 2001

  25. POLICY IMPLICATIONS • Don’t fight the transition –cost controls fail to cap total spending. • Plan ahead – invest the growth in equity and quality. • Get more health “bang for the buck” - improve health system performance. Invest more in action-oriented research and professional capacity for HS stewardship.

  26. Global health has neglected health systems Even with broad definition1, <15% of total global health contribution target of health systems... ...And some of the neediest countries receive very little health systems aid Sample countries:Share of total contributions per aid category 2006 Global Bilateral and Multilateral Public Health Contributions ($B) Total contribution (%) Largely targeting doctors, nurses, traditional public health % of total contribution Other (basic health, reproductive health, medical research and services) 49% 19% 15% 11% 5% Vertical disease control 1. See appendix for categories of aid included in definition Note: Data only includes bilateral and some multilateral agencies, and does not include private non-profit organizations Source: Online query of two sectors in the OECD Creditor Reporting System (CRS) Database: (1) Health (2) Population Policies & Reproductive Health, 2006 Health systems

  27. “More research is needed” Source: Research!America, GFHR 2007

  28. Today’s presentation The New Challenge in Global Health Following the money – the countries’ own The Rockefeller Foundation’s Strategy

  29. Opportunity for health systems performance and equity The Economic Transition of Health + the epidemiological transition in health + the ICT revolution = unprecedented transformation of health systems and the need and possibility of universal health coverage (access to quality services affordable to all through pre-paid risk-pooled financing)

  30. WHO Health Systems Framework THS targets strategiesfor health systems transformation

  31. Strategies Activities Fostering HS Research and Agenda setting Evidence-based advocacy Enhancing HS Capacity in developing countries Professional support for National HS Stewardship Harnessing the role of the private sector in health Knowledge, capacity and Country demostrations Leveraging interoperable eHealth systems in global health Country-level capability & new PPPs THS activities Vision:Universal Health Coverage Guiding Principle: Improve health systems performance, not just purchase products or services

  32. What will THS look like in the developing world? Log GDP per capita versus Child (<5) mortality rate U5MR (per 1000) Median Log GDP/Capita = 3.78 Median U5MR = 29 Log GDP/Capita (PPP, $) Focus: sub-Saharan Africa and South / SE Asia Improving country HS capabilities Harnessing the private sector Leveraging eHealth • Continue to refine country list to reflect: • Country governance and political commitment to universal coverage • GDP trends and OOP expenditure as a proportion of THE • Evolving partner and donor landscape • Rockefeller capacity and other initiatives

  33. What will success look like? • Health Systems and Universal Coverage highlighted in the global health agenda • Professional stewardship of health systems is occurring in low-and middle income countries • Integrated national eHealth systems are in place in select countries • Health systems are construed as actively engaging both the public and private sectors There is better and equitable access, affordability, and quality of health services for poor people

  34. Health systems agenda gaining momentum Bellagio series World Health Assembly US IOM Report onGlobal Health Bellagio sessions on Health Systems Sept 07 May 08 Jul 08 Oct 08 Nov 08 May 09 Jul 09 2009 G8 summit (Italy) UN ECOSOC takes up health G8 summit (Japan): HS WG & HLTF WHO High Level consultation on HS WHO’s HSS Strategy after Mexico 2004 Atlanta meeting of UNSG &The Elders: HS a top priority

  35. Thanks www.wordle.com

  36. THS landscape Bilateral Private Other Donors • European: UK - DFID, Dutch, Germany, AFD NORAD, SIDA, DANIDA, Irish Aid • USA: USAID, PEPFAR • Asia: Japan, AusAID • G8 (Japan, Italy, Canada) • Others: • Gates Foundation • CARSO • UN Foundation • Aga Khan Foundation • Doris Duke Foundation • Wellcome Trust • Corporations (IT, insurance) • Others: • World Bank (IFC/WBI) • UNICEF • IDA • EC • GAVI & GFATM • NIH Fogarty Center • Others: Global eHealth Systems Health Systems Capabilities Research & Agenda Setting Private Sector in Health Technical Partners • Universities: Columbia U., Duke U., George Washington U., Mekerere U., U. of California at SF • AHPSR • Public Health Foundation of India • World Federation of Public Health Associations • MoH • R4D/Brookings • WHO • Columbia University • Harvard University • Sri Lanka IHP • Duke University • UK IDS • International AIDS Society • R4D/Brookings • UK IDS • U. of Toronto • U. of Zambia • LSTHM • HLSP • Thai IHPP • IHP, Sri Lanka • CGD • HMN • ISfTeH • IMIA • OpenMRS • mHealth alliance • NEPAD • Carso • Ministries of Health and Telecomms

  37. Leveraging eHealth is working Updated: fixed animation Bellagio participants confirmed similarinfrastructure growth around the world Leveraging eHealth Infrastructure growth enables additional eHealth implementations Kenya's Monsoriot Medical Record System (MMRS) • EMR system implemented in multiple rural health clinics predominantly focused on HIV/AIDS care • Patient waiting time reduced by 38% • Admin personnel-patient time reduced by 50% • Preparation time for MoH monthly reports down from 2 weeks to 1 hour • Decreased cost per patient: • MMRS HIV/AIDS patient = $250/yr • PEPFAR HIV/AIDS patient = $1500/yr • Improved quality of care: • Ability to prioritize relationship-based care • Detect patterns in data Internet users per 100 people +700% 2002 2003 2004 2005 2006 Mobile phone subscribers, Kenya, per 100 inhabitants +387% 2002 2003 2004 2005 2006 Source: Informatics in Primary Care (2005), WHO, interviews

  38. Technical CAN Technical CAN Technical CAN Patient-level systems Resource CAN Pharma sys EMR Supply chain mgmt EMR Siga Saude Policy CAN Nat’l reporting systems OpenMRS Regenstrief Lab sys Epic Google Millenium Villages Care-ware Radiol. sys MRC Indiv. Developer Admin systems Capacity CAN Partners in Health Makerere Univ. Open Vista ADT UCC / Tanzania Public health systems Open-EHR Project-level Collaborative Action Network Assessment/ Research CAN Tele-med Component-Level Collaborative Action Network System-level Collaborative Action Network Technical Collaborative Action Network World eHealth Collaborative Action Network: we can! Network of Networks: World eHealth CAN

  39. The private sector in most developing countries is… Large: A large percentage of health expenditure and provision is already private Growing: Much of the expected growth in overall health expenditures is likely to initially be in the private sector. Neglected: Ministries of health, along with international agencies and donors, tend to focus on the public sector. Why Focus on the Private Sector? Madhya Pradesh, IndiaSource: De Costa, 2007

  40. Many faces of the Private sector Private clinicians Private Hospitals Pharmacies Village health workers Informal providers Social Marketing NGOs

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