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Today’s presentation
The New Challenge in Global Health
Following the money – the countries’ own
The Rockefeller Foundation’s Strategy
3
1960's 1990's
End of Euro-colonialism
End of theCold War
2010's
The MarketMeltdown
A brief history of Global Health
Tropical Medicine
International Health
Global Health ? A New World
Health ?
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
6
Nearly 10 million children die every year
Source: “Where and why are 10 million children dying every year?” Black RE, Morris SS, Bryce J, Lancet 2003; 361: 2226-34)
The new challenge in global health
Most die from preventable causes because of weak health systems
7
Problems resulting from neglected health systems
Quality• Ignorance/misapplication of proven
interventions• Fatal mistakes• Few provider incentive structures• Lack of quality standards
Access• Limited availability of basic health services• A global crisis in human resources for health• Uneven availability of medicines and supplies
HEALTHSYSTEMS
Affordability• High out-of-pocket expenditures• Impoverishing catastrophic
expenses• Undeveloped health insurance
8
Healthcare in low-income countries is primarily funded OOP
0% 20% 40% 60% 80% 100%
High Income
Upper MiddleIncome
Lower MiddleIncome
Low Income
Private: out of pocket Private: pooled Public
Source: WHO National Health Accounts, updated 2002.
(<$825)
($825 - $3,255)
($3,256 - $10,065)
($10,066+)
10
Today’s presentation
The New Challenge in Global Health
Following the money – the countries’ own
The Rockefeller Foundation’s Strategy
11
Following the Money
• Relation between spending and health offers important, sometimes counterintuitive insights
• Health financing – key “control knob” available to policy makers
• Health financing critical to improve: Risk protection Coverage of services - Health outcomes & Equity Efficiency (and quality) of service delivery
12
Health Freakonomics
• There is some “right” level of health spending
• Trying to reach it in poor countries, while reigning on costs in rich countries
• Modern cost-effective interventions progressively wipe out disease
• As people grows healthier, age-adjusted health spending eventually declines
14
Good Health at Low CostC
hild
hoo
d (<
5)
mor
talit
y (p
er 1
,000
)
R2 = 0.58
GDP per capita ($US, PPP)
Rwanda
Kenya
Poorer countries' health is worse off, in general...
...but poor countries vary widely in health
outcomes
And good health exists across a range of GDP
1 2
3
0
50
100
150
200
250
300
100 1,000 10,000 100,000
Source: WHO/IMF 2005
It’s not just about the level of health spending, but how resources are used
N=178 countries
15
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?
16
Countries’ total health spending strongly tied to GDP
Strong link between countries' wealth and total health spendingStrong link between countries'
wealth and total health spending
10
100
1000
10000
100 1000 10000 100000
TH
E p
er c
ap
ita
) [l
og
]
GDP per capita [log]
R2 = 0.95
“The First Law of Health Economics”
Source: Jacques van der Gaag; WHO/IMF 2005
This relationship is largely unaffected by:
• Relative share of public / private spending
• External donor assistance (which may inadvertently crowd out spending elsewhere)
N = 178
17
Public /Private Mix (2004 data)Public /Private Mix (2004 data)
AIIDAIID
Dependent Variable: Log Health Expenditures / capitaDependent Variable: Log Health Expenditures / capita
ConstantConstant -3.60-3.60 ******
(0.000)(0.000)
Log GDP / capitaLog GDP / capita 1.091.09 ******
(0.000)(0.000)
Public Expenditure SharePublic Expenditure Share 0.00020.0002
(0.01)(0.01)
R-SquaredR-Squared 0.960.96
NN 175175
Jacques van der Gaag 2008
19
R2 = 0.95
Source: WHO, IMF, 2008
Saudi Arabia
USA
Switzerland
South Africa
France
Japan
Qatar
Singapore
Indi
a
Thailand
Russia
China
Rw
anda
Eritr
ea
Bang
lade
sh
GDP per capita (nominal USD, 2005)
Argentina MexicoLux.
Norway
UKCanada
Bur
undi
S. Korea
Nig
eria
TH
E p
er c
apit
a (n
om
ina
l U
SD
, 20
05)
y = 0.0276x1.0887
The Economic Transition of Health
20Source: Bradford J. DeLong, 1998
28 75
255
717
1,359
1,878
0
200
400
600
800
1000
1200
1400
1600
1800
2000
1960 1970 1980 1990 2000 2004
Bil
lio
ns (
US
D)
US THE
China’s THETake off
21
Sub Saharan Africa growing faster than the World’s average
Source: IMF, World Outlook Database, 2007
Income Elasticity
Greater than 1
Country %
Nigeria 465
Thailand 311
Bangladesh 298
Kenya 263
Tanzania 198
India 193
Vietnam 173
Ghana 150
Cambodia 142
Uganda 84
Rwanda 79
South Africa 36
Projected THE growth (2005-2013)
24
Projected U.S. Health Spending
Source: US Congressional Budget Office, Nov 2007
% GDP
50% GDP by 2080 Aging (dark blue)
Just a small driver
25
Factors that influence health status
Health Behaviors 50 percent
Genetics 20 percent
Environment 20 percent
Access to Care 10 percent
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.
Eighty percent of health status, including the prevention of premature deaths, is preventable, 70 % by public health, and 10 % by medical treatment.
26
“Baumol’s Cost Disease”
1. The phenomenon arises outside the health market
2. Traditional cost control does not decrease total spending
3. Attempts to do so distort the system and miss opportunities
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
27
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
28
86.1%
13.9%
Uninsured
Insured 84.2%
15.8%
87.7%
12.3%
Health
Other
Total U.S. GDP:$5,803 billion
16.0%
84.0%
Total U.S. GDP:$13,195 billion
1990 2006
U.S. Total Health Expenditure as a percentage of GDP1
U.S. Percentage of Population Uninsured2
Total U.S. population:296.8 million
Total U.S. population:248.9 million
Even though health spending has increased dramatically, the percentage of the population that is uninsured continues to rise
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.
U.S. THE:$714 billion
U.S. THE:$2,105 billion
Uninsured Americans:34.6 million
Uninsured Americans:46.9 million
32
POLICY IMPLICATIONS
1. Don’t fight the transition – cost controls fail to cap total spending.
2. Plan ahead – invest the growth in equity and quality.
3. Get more health “bang for the buck” - improve health system performance.
Invest more in action-oriented research and
professional capacity for HS stewardship.
33
6.8
2.6
2.1
1.50.8 13.6
0
5
10
15
Ver
tical
dise
ase
cont
rol
Bas
iche
alth
Hea
lthsy
stem
s
Rep
rodu
ctiv
ehe
alth
Med
ical
rese
arch
and
serv
ices
Tot
al
Global health has neglected health systems
...And some of the neediest countries receive very little health systems aid
...And some of the neediest countries receive very little health systems aid
Even with broad definition1, <15% of total global health contribution target of health systems...
Even with broad definition1, <15% of total global health contribution target of health systems...
1. See appendix for categories of aid included in definitionNote: Data only includes bilateral and some multilateral agencies, and does not include private non-profit organizationsSource: Online query of two sectors in the OECD Creditor Reporting System (CRS) Database: (1) Health (2) Population Policies & Reproductive Health, 2006
17 15 10 10 6
72
26
78 8476 79 84
17
57
8 614
81
21
815 15
0
25
50
75
100
Gha
na
Vie
tnam
Nig
eria
Uga
nda
Cam
bodi
a
Ken
ya
Rw
anda
Indi
a
Total contribution (%)
Health systemsVertical disease control
Other (basic health, reproductive health, medical research and services)
($B)
2006 Global Bilateral and Multilateral Public Health Contributions
Sample countries:Share of total contributions per aid category
Largely targeting doctors, nurses, traditional public
health
% of total contribution
49% 19% 15% 11% 5%
34
“More research is needed”
37
28
0.3
0
5
10
15
20
25
30
35
40
Dollars (billions)
2006
Pharma NIH AHRQ
Source: Research!America, GFHR 2007
35
Today’s presentation
The New Challenge in Global Health
Following the money – the countries’ own
The Rockefeller Foundation’s Strategy
37
Opportunity for health systems performance and equity
The Economic Transition of Health+
the epidemiological transition in health+
the ICT revolution=
unprecedented transformation of health systemsand the need and possibility of
universal health coverage (access to quality services affordable to all
through pre-paid risk-pooled financing)
40
Guiding Principle: Improve health systems performance, not just purchase products or services
Vision: Universal Health Coverage
THS activities
Evidence-basedadvocacy
Professional support for National HS Stewardship
Knowledge, capacity andCountry demostrations
ActivitiesActivities Strategies Strategies
Country-levelcapability & new PPPs
Enhancing HS Capacity in developing countries
Harnessing the role of the private sector in health
Leveraging interoperable eHealth systems in global health
Fostering HS Research and Agenda setting
42
What will THS look like in the developing world?
Improving country HS capabilities
Harnessing the private sector
Leveraging eHealth
Focus: sub-Saharan Africa and South / SE Asia
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
0
50
100
150
200
250
300
2.75 3.25 3.75 4.25 4.75
Sierra Leone
MalaysiaSri Lanka
Pakistan
NigeriaRwanda
Tanzania
Andhra Pradesh
Uganda Cambodia
KenyaGhana
Bangladesh
India
Vietnam Thailand
South Africa
USA
Log GDP/Capita (PPP, $)
U5MR (per 1000)
Log GDP per capita versus Child (<5) mortality rate
Median U5MR = 29
Median Log GDP/Capita = 3.78
43
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
44
Health systems agenda gaining momentum
Sept 07 May 08 Jul 08 Oct 08 Nov 08
WHO’s HSS Strategy after Mexico 2004
Atlanta meeting of UNSG &
The Elders: HS a top priority
WHO High Level
consultation on HS
G8 summit (Japan): HS WG & HLTF
Jul 09
Bellagio seriesBellagio
sessions on Health
Systems
2009
G8 summit (Italy)
US IOM Report on
Global Health
UN ECOSOC takes up health
WorldHealth
Assembly
May 09
46
THS landscapeBilateralBilateral
• European: UK - DFID, Dutch, Germany, AFD NORAD, SIDA, DANIDA, Irish Aid
• USA: USAID, PEPFAR• Asia: Japan, AusAID• G8 (Japan, Italy, Canada)• Others:
Technical Partners
OtherOther
• World Bank (IFC/WBI)• UNICEF• IDA• EC• GAVI & GFATM• NIH Fogarty Center• Others:
PrivatePrivate
• Gates Foundation• CARSO• UN Foundation• Aga Khan Foundation• Doris Duke Foundation• Wellcome Trust• Corporations (IT, insurance)• Others:
Donors
• HMN• ISfTeH• IMIA• OpenMRS• mHealth alliance• NEPAD• Carso• Ministries of Health
and Telecomms
• 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• UK IDS• U. of Toronto• U. of Zambia• LSTHM• HLSP• Thai IHPP• IHP, Sri Lanka• CGD
Global eHealth Systems
Global eHealth Systems
Health Systems Capabilities
Health Systems Capabilities
Private Sector in Health
Private Sector in Health
• R4D/Brookings• WHO• Columbia University• Harvard University• Sri Lanka IHP• Duke University• UK IDS• International AIDS
Society
Research & Agenda Setting
Research & Agenda Setting
47
+700%
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
Leveraging eHealth is working
Source: Informatics in Primary Care (2005), WHO, interviews
Kenya's Monsoriot Medical Record System (MMRS)
Kenya's Monsoriot Medical Record System (MMRS)
Leveraging eHealth
18.5
13.5
7.85.03.8
0
10
20
30
2002 2003 2004 2006
+387%
2005
Mobile phone subscribers, Kenya, per 100 inhabitants
Infrastructure growth enablesadditional eHealth implementations
Infrastructure growth enablesadditional eHealth implementations
Bellagio participants confirmed similarinfrastructure growth around the world
4.76
3.73
2.58
1.781.24
0
2
4
6
Internet users per 100 people
2005 200620032002 2004
Updated: fixed animationUpdated: fixed animation
48
Assessment/ Research
CAN
Policy CAN
Capacity CAN
Resource CAN
World eHealth Collaborative Action Network: we can!
Technical CAN
Public health
systems
Nat’l reporting systems
Admin systems
Supply chain mgmt
Technical CAN
Technical Collaborative Action
Network
Technical CAN
ADT
Lab sys
Radiol. sys
Pharma sys
Tele-med
Patient-level systems
System-level Collaborative Action
Network
EMR
Open Vista
Epic
Care-ware
Siga Saude
Open-EHR
Component-Level Collaborative Action
Network
EMR
OpenMRS
Makerere Univ.
MRC
Regenstrief
UCC / Tanzania
Partners in Health
Millenium Villages
Indiv. Developer
Project-level Collaborative Action
Network
Network of Networks: World eHealth CAN
49
Why Focus on the Private Sector?
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.
Madhya Pradesh, IndiaSource: De Costa, 2007