Poverty and Health:

Dr Reuben Esena, PhD

25th FAMSA Summit – UG, Legon –Accra, Ghana

Monday 17th May 2010

University of Ghana, Business School

...an impossible combination and the solution thereof

1

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.

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]

3

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 services4

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

5

Overview

Key factors contributing to current health crisis

Health Systems Health financing Issues - Accessibility Health outcomes – U5MR, MMR Way forward

6

Key Factors Contributing to Current Health Crisis

7

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

8

Examples of environmental hazards cont..

Food poisoning - salmonellosis, botulism anthrax

Insects vectors - malaria, yellow fever, sleeping sickness, typhus

Animals - Dog bites and snake bites.

9

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.

10

Income deficiency problems

Negative effects of income deficiency leads to limited purchasing power to provide:-

-Adequate salaries

- Equipment

-Drugs

11

Income deficiency problems cont…

- Meetings- Travel- Consultants- Management- Professional bodies- Conferences- Workshop

12

Negative effects of income deficiency

Also leads to poor distribution of resources

DISTRICTLEVEL

$

CENTRAL LEVEL

REGIONALLEVEL

13

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.

14

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.

15

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 16

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

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

18

HEALTH SYSTEMS.

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

20

Views on Health

.

What is health ?

Why is health important?

Narrow organic definition Broad holistic definition

As a right As a consumption good As an investment good

21

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

22

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

The Iron Triangle or the Holy Grail?

All nations struggle tobalance access to healthcarewith quality and cost efficiency.

Is there one perfect solution for all nations?24

Conceptual Framework

WHO

Financing: 2. Financing

Creating Resources: 3. Human resources

management 4. Pharmaceuticals

management

Delivering Services: 5. Service provision 6. Information systems

Criteria: Equity Access Quality

Efficiency Sustainability

Health System Functions Health System Performance

Impact

Stewardship: 1. Stewardship/ governance

Health Impact

25

Health System Model used to assess HFA

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

Political, social and cultural values

Environment

Healthneeds

26

Four survival patterns and transitions between them

The health transition in the Third World

The health transition in

The West

The firsthealth transition

27

Health

Medical

Non-medical

Institutions

Knowledge

Commodities

Does one cog drive the others?

28

ACCESSIBILITY TO HEALTH CARE

.

29

Health financing paradigm in SSA

Current paradigmCurrent 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

30

Proposed paradigmProposed 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

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?

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

32Sources: Disease Control Priorities Project, 2007; and African Development Bank, 2002.

332.0

3.0

3.0

3.3

4.0

4.0

4.0

4.8

5.0

6.0

7.0

7.0

7.0

7.2

7.2

8.0

8.0

8.0

8.0

8.0

8.0

8.0

8.1

9.0

9.0

9.0

9.0

10.0

11.0

11.3

12.0

12.0

13.0

13.0

13.0

14.0

14.5

15.0

0.0 5.0 10.0 15.0 20.0

Ethiopia

Burundi

Chad

Egypt

DRC

Eq. Guinea

Nigeria

Sudan

Angola

Niger

CAR

Kenya

Burkina Faso

Djibouti

Cote d'Ivoire

Mauritius

Rwanda

Swaziland

Cape Verde

Mali

Mauritania

Togo

Tunisia

Madagascar

Malawi

Zambia

Senegal

South Africa

Mozambique

Libya

Uganda

Namibia

Tanzania

Gambia

Ghana

Sao Tome

Zimbabwe

Botswana

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.

Health financing levels are low – the $34 package of basic health services

0 10 20 30 40 50 60

BurundiDRC

EthiopiaSierra LeoneMadagascar

LiberiaNiger

Guinea-Eritrea

TanzaniaMozambique

CARMauritania

Rw andaTogo

GambiaUgandaMalaw i

ChadKenyaGuineaNigeria

MaliBenin

Burkina FasoAngolaGhana

Zimbabw eCongo

ZambiaCôte d'Ivoire

LesothoCameroon

The CMH targetPer capita health spending, 2004

Per capita govt. expenditure on health Out-of-pocket expenditure on health Private pooled expenditure on health

34

Source: WHO SISNote: 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.

The CMH Target

Few countries spend $34+

…What difference would the Abuja target make?

$-

$10

$20

$30

$40

$50

$60

$70

$80

Buru

ndi

DR

Congo

Eth

iopia

Eritr

ea

Lib

eria

Mala

wi

Sie

rra L

eone

Rw

anda

Madagascar

Nig

er

Uganda

Gam

bia

Mozam

biq

ue

Tanzania

CA

R

Togo

Mali

Guin

ea

Burk

ina F

aso

Ghana

Maurita

nia

Zam

bia

Kenya

Zim

babw

e

Nig

eria

Chad

Benin

Lesoth

o

Senegal

Cam

ero

on

Côte

d'Ivoire

Angola

Congo

<$250 $250-$499 $500-$999 $1,000+

country, sorted by GDP per capita

healt

h e

xp

en

dit

ure

(U

S$, 2004)

public spending private spending Abuja shortfall in public spending

CMH target $34

Source: World Bank, WDI 2007; author’s calculations.

Heavy dependence on donor funding raises concerns: sustainability, priorities

HIV/AIDS Disbursements* Relative to Size of Health Sector and GDP in 2005

Country % of public health spending

% of total government

spending

% of GDP

Ethiopia 43.8 3.3 1.1

Kenya 51.9 3.8 1.1

Mozambique 23.2 2.8 1.0

Rwanda 80.6 Not available 2.5

Tanzania 26.7 4.4 0.7

Uganda 150.2 12.7 3.1

Zambia 40.3 4.0 1.2

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.

Heavy dependence on donor funding raises sustainability and predictability concerns: Rwanda

10%18% 25% 32%

19%

40% 30%

42% 25%

28%

50% 52%33%

42%53%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1998 2000 2002 2003 2006

Public Private DonorSource: Rwanda NHA 1998-2006

Health Financing: sources of revenue

Direct out of pocket payments Premiums for NHIS Tax revenues Grants from development partners Financial credits

38

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

39

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

40

Policy Measures contd.

Ensure effectiveness of aid in the health sector

Ensure financial sustainability of the National Health Insurance fund

Etc

41

Limited Public

Funding (for vulnerable)

Out-of-pocket payments predominate

Majority of population

covered through publicly funded schemes (e.g.

general taxation, social insurance)

Private insurance for

secondarycoverage

Private Insurance pools cover other segments of the

population

Increasing public share of health

financing through targeted coverage

for vulnerable populations

Potential Model Towards Universal Coverage(WHO)

Public Spending

Private Spending

Financing Fairness

Capacity Building/ Institutional StrengtheningLOW HIGH

HEALTH INDICATORS

Access U5MR MMR GDP

Health Indicators

44

90% preventable

And undernutrition implicated in 50% of child deaths

9.5 million children under five die annually

Source: State of the World’s Children, UNICEF 2008

Causes of Under 5 Child Mortality,2000-2003

Bryce et al. WHO estimates of the causes of death in children. Lancet 200546

Causes of Under 5 Mortality by Region, 2000-2003

Bryce et al. WHO estimates of the causes of death in children. Lancet 2005

African RegionAfrican Region

4.396 million

21%

16%

18%

5%

6%

26%

5%

2%

47

Trends in Child Mortality Relative to MDG-4

Sub-Saharan Africa

South Asia

Latin America

East Asia

Under-FiveMortalityRate

244

188

171

62

206

129

92

42.6

122

5431

17.8

123

58

36

19.1

1970 1990 2004 2015

MDG-4Goals

Source: The State of the World’s Children, 2006

48

51

WHERE? The 10 African countries where newborns have the highest risk of dying

Rank (out of 46 countries)

Country Neonatal mortality rate

(per 1,000 live births)

46 Liberia 66

45 Côte d'Ivoire 65

44 Mali 57

43 Sierra Leone 56

42 Angola 54

41 Somalia 49

40 Guinea-Bissau 48

39 Central African Republic 48

38 Nigeria 48

37 Congo DR 47

Maternal Mortality in 2005

Source: WHO/UNICEF/UNFPA/The World Bank estimates, App. 15, pub 2007

Africa 276,000 = > 51%

Asia 242,000 = 45%

Latin America & the Caribbean

15,000 = 3%

Other 3,000 = < 1%

Total estimated deaths 536,000

The Lifetime Risk of Maternal Death

1:59South Asia

1:22Sub-

Saharan Africa

1:8,000Industrialized

contries

1:280LAC

Source: WHO/ UNICEF/UNFPA, The WorldBank. Maternal Mortality Estimates 2005,App 8, pub 2007

The chance of a woman dying as a result of pregnancy is 200 x greater in sub-Saharan Africa than it is in the United States

Causes of Maternal Mortalityin the Developing World

Indirect 14%

HIV3%

Other direct causes 5%

unclassified 6%

Sepsis 11% Anemia

8%

Hypertensive Disorder

10%

Hemorrhage 31%

Unsafe Abortion 5%

Obstructed Labor 7%

Other direct causes include embolism, ectopic pregnancy, anesthesia-related. Indirect causes include: malaria, heart disease.

Source:Adapted from " WHO Analysis of causes of maternal deaths: A systematic review.” The Lancet, vol 367, April 1, 2006.

Pareto Chart

Pareto's Principle; the “80-20 Rule”; the "Vital Few” versus the “Trivial Many” rule

A special form of a vertical bar chart and a tool for setting priorities

... The richest fifth of the world’s population have 74 times the income of the poorest fifth.

..The top three billionaires have assets greater than the combined

GNP of all least developed countries and their 600 million

people. 56

Percentage of People living below the poverty line

Europe and Central Asia 3.5% Latin America and Caribbean 23.5% Sub-Saharan Africa 38.5% Middle East and North Africa 4.1% South Asia 43.1%

57

Why do the poor have higher morbidity and mortality rates?

The poor have less access to, and availability of, health

services including mental health services. (See http://www.cdc.gov/omh/AMH/factsheets/mental.htm)

are less likely to receive needed health services, receive a poorer quality of health care, are underrepresented in health research and

among health care professionals, have lower levels of education, and are more likely to live in poverty

58

Task of Improving Health

Obstacles to progress Poverty Uneven distribution of health services. Lack of appropriate technology. Inadequate supply and distribution of

pharmaceuticals. Bad management . Inappropriate government programmes.

59

The Way Forward

60

Some important choices

In attempting to produce healthy people, we are faced with 3 variables: Technology Resources Management

61

An Effective Public Health System

Laboratory Programs & Services

Epidemiology

Management 62

Why Management?

Two-thirds of child deaths could be prevented by interventions that are available today and feasible for implementation in low-income countries at high levels of population coverage.

The main challenge today is to transfer what we already know into action.”

Jones et al, “How many child deaths can we prevent this year?” The Lancet, July 5, 2003.

63

Lessons from WHO's leadership and management needs assessments

(WHO Department of Health Systems Governance and Service Delivery)

64

Regional Co-operation & Integration

Partners to assist institutions Utilize national expertise: students &

staff of higher Institutions Collaboration:

African Region Universities WAHO Research Institutes (e.g. Noguchi) MOH/Finance/Universities/ 65

Strategy

Strategic Partners UG - Ghana School Public Health AFENET Corporate Africa

Capacity Development Advocates Trainers of Trainers (TOT)

Technical Assistance CDC

Sustainability66

Review Government Policies

Review Health Policies: equitable access, safety, and cost. define Govt role in Health community oriented provide direction to health reform guide the many actors in public health.

67

Target appropriate Public Health services

Priority public health services (AIDS,TB, malaria, hepatitis B)

Neglected Tropical Diseases Full operating cost to implement the

package including salary of public health staff

68

Develop national medicine policy

with a reform on how essential drugs should be produced, registered and made available to service providers

Policy and regulation on rational use of drugs must be effectively implemented

69

Promote sustainable development

by ensuring that “external assistance” projects and programmes are absorbed early into national system

70

Research & development

Promoting evidence–based research system Appropriate indicators

Training: graduates on Quality Research

Monitoring & Evaluation systems Projects Programmes Processes 71

Health financing paradigm in SSA

Current paradigmCurrent 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

72

Proposed paradigmProposed 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

Process Improvement

A systematic, data-based method for improving the quality of work processes

TQM (continuous improvement) It uses team decision-making to

improve processes that affect the quality of products and services for a customer.

Involve all Stakeholders

A stakeholder is one person, or group of persons, having an interest or concern in a particular process resulting from some direct or indirect involvement.

MOHMOHNGOsNGOsRegulatorsRegulators

Funding AgentsFunding Agents

WiderWiderCommunityCommunity

EmployeesEmployees

SuppliersSuppliers

CustomersCustomers

Widening Access to Health Services

Increasing physical access to care Scaling up the establishment of

Community-based Health Planning & Services (CHPS)

Community mobilization combined with community-based deployment of the nurse is the most effective intervention

75

21st Century Health CareImproving quality by promoting a culture of safety Improving quality by promoting a culture of safety

through Value-Driven Health Carethrough Value-Driven Health Care

21st Century Health Care

Information-rich, patient-Information-rich, patient-focused enterprisesfocused enterprises

Information and Information and evidence transform evidence transform

interactions from interactions from reactive to reactive to

proactive (benefits proactive (benefits and harms)and harms)

Evidence is Evidence is continually refined continually refined as a by-product of as a by-product of

care deliverycare delivery

Actionable information available – to Actionable information available – to clinicians AND patients – “just in time”clinicians AND patients – “just in time” 76

Summary

4.4 billion people living in developing countries, 20% have no access to modern health facilities

High U5MR & MMR in SSA Requires effective Health Systems to

resolve these problems Need for a new paradigm for health

financing in SSA Govt. Policies to target community health

needs 77

“Never doubt that a small group of committed citizens can change the world; indeed it is the only thing that ever has!”

-Margaret Mead

78

References

World Bank (2008). Dollar a Day Revisited WHO (2005). Expenditures on Health

Related Needs WHO (2008). Leadership and

Management needs Assessment CDC (2008). SMDP - MIPH Lancet (2005). Neonatal Survival

79

Merci !Thank you