HOW MUCH IS HEALTH IN

AFRICA?:ENSURING EQUITY AND SUSTAINABILITY IN THE PROVISION

OF HEALTHCARE

1. RISKS2. INTERVENTIONS3. EQUITY, AFFORDABILITY AND

SUSTAINABILITY

AFRICAN STATISTICS A child dies every three seconds from AIDS and extreme poverty, often before their fifth birthday.

More than 1 billion people do not have access to clean water.

About 120,000 African children are participating in armed conflicts. Some are as young as 7 years

WORLD BANK

ARE THESE STATISTICS

REAL?

OUR TRUE STATE?1. Under estimation

Lack of real assessment capabilities. Unpatriotism (semi)Illiteracy Antagonism mentality

2. Exaggeration

Selfish interests!

3. ACTUAL STATE OF ISSUES

Proper records Honesty Efficient regulatory systems Generate appropriate interests

THEREFORE...... How much are our RISKS? How much do we loose to diseases? Economic Social Academic Political Psychological How easily can we afford healthcare?

2. ASSESSING OUR INTERVENTIONS

NIGERIA: Professor Dora Nkem Akunyuli.....

Nigeria: good people, great

nation!/?

WHAT HAVE WE DONE? Training and Re-training-Universities,

Research Institutions, Associations etc Several Projects and Initiatives....APIN,

Global Health Fund Infrastructure development: Hospitals,

Electricity, Global Mobile System(for communication)

Bridges/Partnership (Local/ International)

Organizations (Treaties, Declarations etc) NEPAD etc.

HOW MUCH IMPACT?

EQUITY, AFFORDABILITY AND SUSTAINABILITY

Equity Affordability Sustainability

RISKSINTERVENTIONS

THE PEOPLE

EQUITY

‘The absence of systematic differences in health, both between and within countries that are judged to be avoidable by reasonable action’

WHO’s Commission on Social Determinants of Health (CSDH), 2008

FACTORS AFFECTING EQUITY IN AFRICA1. What breeds differences amongst

countries/states/individuals? Non-preventable factors

Preventable factors

NON-PREVENTABLE FACTORS

Racial/Tribe selection Genetic make-up?

PREVENTABLE FACTORS Unequal distribution of basic amenities Skewed Industrialization Poor Education Corruption Lack of political will Misplaced priorities Poor economy Uninformed health personnel Lack of advocacy/negotiating skills by

health personnel

AFFORDABILITY

How many Africans can

afford qualitative healthcare?

AFFORDABILITY CONT’DContending issues Government Operators of healthcare Healthcare providers Public

SUSTAINABILITY HEALTHCARE?

PRIVILEDGE?

CHANCE?

LUCK?

RIGHT!

HEALTH FINANCING

Single most important factor

in delivering equal, affordable and sustainable

healthcare?

WHY FOCUS ON FINANCING? Advances in medical technology, higher

population and providers’ expectations, income growth, health system development are some determinants

Increased inequalities in health spending between and within countries

Health care financing is at the center of most health policy reforms

WHO 2007

WHY FINANCING?...CONT’D Financial resource generation

Economic efficiencyAllocative efficiency…producing the right things

Technical efficiency…producing things right

Social protection Equity

Horizontal equityVertical equity

COMPONENTS OF HEALTHCARE FINANCING• Collection

• Pooling

• Purchasing

WHO

Functions Objectives

Revenue Collection

Pooling

Purchasing

raise sufficient and sustainable revenues in an efficient and equitable manner to provide individuals with both a basic package of essential services and financial protection against unpredictable catastrophic financial losses caused by illness and injury

manage these revenues to equitably and efficiently pool health risks allowing for subsidies from healthy to unhealthy, rich to poor, and productive workers to dependents

assure the purchase of health services is strategic and both allocatively and technically efficient (for whom to buy, what services to buy, from who to buy, and how to pay)

THE HOW OF HEALTH FINANCING

24

NATIONAL HEALTH SERVICE (e.g. UK,Scandinavian Countries)

Provincial / Regional Government Single Payer System (e.g., Canada, Spain)

SOCIAL HEALTH INSURANCE – Ghana,

Nigeria etc

Voluntary Private Insurance Model (e.g. US)

•Direct payment (out-of-pocket) at point of service ( e.g., prevailing system in most low income countries)

MIXED SYSTEM

Micro Insurance

25

CATASTROPHIC HEALTH EXPENDITURE AND IMPOVERISHMENT 1995–2002; I.R. IRAN

Reduce expenditures on other basic needs

Push some households into poverty

May cause consumers to forgo health services and suffer illness

Catastrophic health expenditures

0

0.5

1

1.5

2

2.5

% o

f h

ou

seh

old

s

1995 1996 1997 1998 1999 2000 2001 2002

Catastrophic EXP Impoverishing

26

NHS SYSTEMSFINANCED THROUGH GENERAL REVENUES, COVERING WHOLE POPULATION, CARE PROVIDED THROUGH PUBLIC PROVIDERS OR CONTRACTING

Strengths

Pools risks for whole population

Relies on many different revenue sources

Single centralized governance system has the potential for administrative efficiency and cost control

Weaknesses

Unstable funding due to nuances of annual budget process

Often disproportionately benefits the rich

Potentially inefficient due to lack of incentives and effective public sector management

27

SOCIAL HEALTH INSURANCE

PUBLICLY MANDATED FOR SPECIFIC GROUPS, FINANCED THROUGH PAYROLL TAXES, SEMI-AUTONOMOUS ADMINISTRATION, CARE PROVIDED THROUGH OWN, PUBLIC, OR PRIVATE FACILITIES

Strengths

Additional health revenue source

As a ‘benefit’ tax, there may be more ‘willingness to pay’

Removes financing from annual general government appropriations process

Generally provides covered population with access to a broad package of services

Can effectively redistribute between high and low risk and high and low income groups in covered population

Often serves as the basis for the expansion to universal coverage

Weaknesses

Poor are often excluded unless subsidized by government

Potential negative impact on employment

Administrative cost can be high

Can lead to cost escalation unless effective contracting mechanisms are in place

Poor coverage for preventive services

Often needs to be subsidized from general revenues

COMMUNITY BASED HEALTH INSURANCENOT-FOR-PROFIT PREPAYMENT PLANS FOR HEALTH CARE, WITH COMMUNITY CONTROL AND VOLUNTARY MEMBERSHIP, CARE GENERALLY PROVIDED THROUGH NGO OR PRIVATE FACILITIES

Strengths Community-run and not-for-

profit

Promotes pre-payment

Mobilizing additional resources, providing access and financial protection in LICs

CBHI can be a helpful complement but is not a substitute for NHS or SHI systems

Weaknesses Difficult to scale up

Financial protection are limited due to the small size of most schemes

The financial sustainability of most schemes is questionable

Should be encouraged when alternatives are not viable

29

PRIVATE HEALTH INSURANCEFINANCED THROUGH PRIVATE VOLUNTARY CONTRIBUTIONS TO FOR- AND NON-PROFIT INSURANCE ORGANIZATIONS, CARE REIMBURSED IN PRIVATE AND PUBLIC FACILITIES

Strengths

As a prepayment and risk pooling mechanism is generally preferable to out of pocket expenditure

May increase financial protection and access to health services for those able to pay

When an “strategic purchasing” function is present it may also encourage better quality and cost-efficiency of health care providers

Weaknesses

Associated with high administrative costs and profit (up to 40%)

It is generally inequitable Applicability in LICs and

MICs requires well developed financial markets and strong regulatory capacity

Has the potential to divert resources and support from mandated health financing mechanisms

30

TRANSITION TOWARDS UNIVERSAL COVERAGE

Limited Governmentfundedprogrammes

Direct payment at the point of services

1. Limited socialhealth insurance forcivil servants2. Public Programmes for vulnerable groups

1. Direct payment atthe point of service

2. Limited privatehealth insurance

Majority of population Covered through:

Government revenue funded programme

and/or

Social health insurance

Private health insuranceProvides supplementarycoverage

Private spendingPublic spending

CONCLUSIONS

DEATH! WHERE IS THY STING?

President Shehu Musa Yar’Adua’s

death?

CASE SCENARIOS 1. A 16-year-old boy has a 1-day history of pain inthe right ear. He swims every morning. The rightear canal is red and swollen. He has pain whenthe auricle is pulled or the tragus is pushed.Which of the following is the most likelydiagnosis?(A) Acute otitis media(B) Bullous myringitis(C) Chronic otitis media(D) External otitis(E) Mastoiditis

2. A 29years old divorced lady, 32wks

G6P4+1 (2 alive) was rushed into the Emergency Room of a teaching hospital with a history of 24 hours acute sharp abdominal pains with 13 hours history of drainage of liqour. She’s had a previous history of similar occurrence around the same gestational age.

What are the differential diagnoses?Discuss the management of the most

likely diagnosis?

WHAT DO YOU DESIRE TO SPECIALIZE IN?

Surgeon Physician Community Physician?

WHAT IS HUMAN

SECURITY?

HUMAN SECURITY

A child that did not dieA disease that did not spread into an

epidemicA dissident that was not silencedA religious friction that did not

degenerate into a crisis

United Nations Development Programme (UNDP) 1994

WHICH IS THE BEST FOCUS?

The Public

Individual patient

ęşe gan!