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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!
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