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Poverty and Health:

Poverty and Health:. ...an impossible combination and the solution thereof. Dr Reuben Esena, PhD 25 th FAMSA Summit – UG, Legon –Accra, Ghana Monday 17 th May 2010 University of Ghana, Business School. Introduction 1.

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Poverty and Health:

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  1. Poverty and Health: ...an impossible combination and the solution thereof Dr Reuben Esena, PhD 25th FAMSA Summit – UG, Legon –Accra, Ghana Monday 17th May 2010 University of Ghana, Business School

  2. Introduction 1 • 100 million people are driven into poverty each year due to catastrophic expenditure on health related needs (WHO 2009), • The problem is more pervasive in Africa where there are little risk-mitigating mechanisms against health-related negative shocks. • Resource gap is a problem – but health systems constraints are an important bottleneck impeding achievement of health sector goal.

  3. Introduction 2 • Crises in Human Resource for Health: • To reach MDGs, SSA needs 1 million additional skilled workers • Leadership effectiveness in SSA are often weak e.g. As seen from various public expenditure tracking surveys [PETS]

  4. 4.4 billion people live in developing countries • Of these..... • Three-fifths lack basic sanitation • Almost one-third have no access to clean water • A quarter do not have adequate housing • A fifth have no access to modern health services

  5. Health is a Right • “… health, which is a state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity, is a fundamental human right and … a most important world-wide social goal.” • Alma Ata Declaration-1973

  6. Overview • Key factors contributing to current health crisis • Health Systems • Health financing Issues - Accessibility • Health outcomes – U5MR, MMR • Way forward

  7. Key Factors Contributing to Current Health Crisis

  8. Examples of environmental hazards • Increasing harmful gases at home and at work – (Industrial/Vehicles) • Soil related helminthes, toxic and radioactive wastes. • Water related diseases-Childhood diarrhoea, Hepatitis,Typhoid, Schistosomiasis, Guinea worm

  9. Examples of environmental hazards cont.. • Food poisoning - salmonellosis, botulism anthrax • Insects vectors - malaria, yellow fever, sleeping sickness, typhus • Animals - Dog bites and snake bites.

  10. Rapid population growth • The national population growth rate -2.7% • Large overcrowded urban population • Overcrowded hospitals with large outpatient clinics • MCH clinics are unable to keep up with the numbers of young fertile women.

  11. Income deficiency problems • Negative effects of income deficiency leads to limited purchasing power to provide:- -Adequate salaries - Equipment -Drugs

  12. Income deficiency problems cont… • Meetings • Travel • Consultants • Management • Professional bodies • Conferences • Workshop

  13. Negative effects of income deficiency Also leads to poor distribution of resources $ CENTRAL LEVEL REGIONAL LEVEL DISTRICT LEVEL

  14. Immune and dietary deficiency problems • The HIV/AIDS Crisis • Challenge to inter-sectorial response. • Dietary deficiency compound the HIV/AIDS challenge. • A challenge to social and economic sectors.

  15. Symptoms and signs of sick health services. • Glaring inequities • Rural/urban & urban/peri-urban differentials • Social class disparities. • Inability of the poor to feed, purchase medicines and to pay for health services.

  16. Symptoms and signs of sick health services. cont… • Reduced morale of personnel • Migration of personnel • Lower standards of care • Decreased geographical coverage • Diminished choice of services • Poor maintenance of equipment • Inability to supervise Public Health activities • Brain drain

  17. The Brain Drain • G8 has 30 X doctors/population than SSA yet… • E.g. Exodus of physicians mainly from Ghana, Malawi and Namibia • Despite commitments of developed countries not to recruit, recruitment continues… Over 2,000 South African nurses registered in UK a year following policy not to poach, twice as many as before • Push factors: inadequate health systems

  18. The Brain Drain • The US with 130,000 foreign physicians • Saved an estimated $US 26 billion in training costs for nationals • Option: compensation to developing countries

  19. . Health systems

  20. What is Health? By far, the most accepted definition is that of the World Health Organization: “[Health is] the state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (WHO, 1948) and the “extent to which an individual or group is able to realize aspirations and satisfy needs, and to change or cope with the environment. Health is a resource for everyday life, not the objective of living; it is a positive concept, emphasizing social and personal resources as well as physical capabilities” (WHO, 1984). Health Indicators, Part I

  21. Views on Health • . Broad holistic definition Narrow organic definition What is health ? Why is health important? As a right As a consumption good As an investment good

  22. Health systems • Combination of resources, organization, financing, and management that culminates in the delivery of health services to the population Roemer MI. National health systems of the world, volume 1. New York, Oxford University Press, 1991 • All activities whose primary purpose is to promote, restore and maintain health World Health Report 2000

  23. Goals of a health care system • Universal and equal access to reasonable health care • control of health care costs at an affordable level • effective use of resources

  24. The Iron Triangle or the Holy Grail? All nations struggle to balance access to healthcare with quality and cost efficiency. Is there one perfect solution for all nations?

  25. Conceptual Framework WHO

  26. Political, social and cultural values • INPUTS • Financing • Human resources • Public/private mix • PROCESS • Organization and management • Resource allocation • Selection of technology • OUTPUTS • Coverage by health services • Utilization of health services OUTCOMES Morbidity Mortality Quality of life Healthneeds Environment Health System Model used to assess HFA

  27. The health transition in the Third World The firsthealth transition The health transition in The West Four survival patterns and transitions between them

  28. Does one cog drive the others? Non-medical Medical Commodities Institutions Health Knowledge

  29. . ACCESSIBILITY TO HEALTH CARE

  30. Health financing paradigm in SSA Proposed paradigm • Acute shortage of funds to meet targets, but also problem of how funds spent • Governments should lead effort to explore innovative financing mechanisms • Focus also on how money is spent, not just how much • Collaborate with donor partners to ensure external resources help build the health system Current paradigm • Diagnosis: Principal problem facing the region is a shortage of funds • Solutions: • (1) Mobilize internal and external resources • (2) Focus on key diseases and conditions • (3) Set targets and monitor progress

  31. Health financing: Targets Abuja: Government spending on health should be at least 15% of total government spending East Asia & Pacific: 10.1% Latin America and the Caribbean: 12.5% Commission on Macroeconomics & Health (CMH): Estimated $34 per capita for a basic package of health service East Asia & Pacific: $62 (current US$) Latin America and the Caribbean: $272 (current US$) Are targets meaningful? Relevant?

  32. Africa region is off-track to meet the MDGs • What is needed to meet the MDGs? • One estimate: more than 12% of GDP (at regional level) would need to be spent on health to reach the targets by 2015 • Current level: 4.7% of GDP goes to health • Additional $20-25 billion per year needed Sources: Disease Control Priorities Project, 2007; and African Development Bank, 2002.

  33. Percentage of national budgets allocated to health sector Source: African Union. Progress Report on the Implementation of the Plans of Action of the Abuja Declarations for Malaria, HIV/AIDS and Tuberculosis; Revised Final Draft, 22 December 2005.

  34. Health financing levels are low – the $34 package of basic health services Few countries spend $34+ The CMH Target Source: WHO SIS Note: Countries spending >$90 total per capita on health were excluded to improve graph’s readability. These countries include Swaziland, Mauritius, Namibia, Gabon, South Africa, and Botswana.

  35. …What difference would the Abuja target make? Source: World Bank, WDI 2007; author’s calculations.

  36. Heavy dependence on donor funding raises concerns: sustainability, priorities Notes: Disbursements include PEPFAR, GFATM, and World Bank MAP funding. Source: Heller, Peter. “Pity the Finance Minister”: Issues in Managing a Substantial Scaling up of Aid Flows. IMF Working Paper WP/05/180. September 2005.

  37. Heavy dependence on donor funding raises sustainability and predictability concerns: Rwanda 100% 90% 33% 80% 42% 50% 52% 53% 70% 60% 50% 42% 25% 40% 30% 28% 30% 40% 20% 32% 25% 10% 19% 18% 10% 0% 1998 2000 2002 2003 2006 Public Private Donor Source: Rwanda NHA 1998-2006

  38. Health Financing: sources of revenue • Direct out of pocket payments • Premiums for NHIS • Tax revenues • Grants from development partners • Financial credits

  39. Policy Objective • To mobilize resources and ensure equitable and sustainable financing of the health sector • Resource mobilization (GOG, NHI, grants, loans & out-of-pocket payment) • Equitable & efficient allocation of health resources • Efficient utilization of health resources

  40. Policy Measures • Mobilization from all sources of funds, both domestic and international • Pursue equity in health financing • Risk pooling • Target resources to services for the poor, vulnerable groups & public health interventions • Reduce catastrophic cost of care

  41. Policy Measures contd. • Ensure effectiveness of aid in the health sector • Ensure financial sustainability of the National Health Insurance fund • Etc

  42. Financing Fairness Capacity Building/ Institutional Strengthening Majority of population covered through publicly funded schemes (e.g. general taxation, social insurance) Increasing public share of health financing through targeted coverage for vulnerable populations Limited Public Funding (for vulnerable) Private insurance for secondary coverage Private Insurance pools cover other segments of the population Out-of-pocket payments predominate Potential Model Towards Universal Coverage(WHO) Public Spending HIGH LOW Private Spending

  43. HEALTH INDICATORS Access U5MR MMR GDP

  44. Health Indicators

  45. 9.5 million children under five die annually 90% preventable And undernutrition implicated in 50% of child deaths Source: State of the World’s Children, UNICEF 2008

  46. Causes of Under 5 Child Mortality,2000-2003 Bryce et al. WHO estimates of the causes of death in children. Lancet 2005

  47. African Region 4.396 million 21% 16% 18% 5% 6% 26% 2% 5% Causes of Under 5 Mortality by Region, 2000-2003 Bryce et al. WHO estimates of the causes of death in children. Lancet 2005

  48. Trends in Child Mortality Relative to MDG-4 Sub-Saharan Africa South Asia 244 Latin America 206 East Asia 188 Under- Five Mortality Rate 171 123 129 122 92 58 62 MDG-4 Goals 36 42.6 54 19.1 31 17.8 1970 1990 2004 2015 Source: The State of the World’s Children, 2006

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