Global Health History Seminar 11 May 2011

--

one perspective from WHO

Ritu Sadana, ScDDepartment of Health Systems Financing

World Health OrganizationGeneva

sadanar@who.int

OverviewOverview

1) Policy perspective

2) Monitoring and analyses

3) Connecting to other determinants

C-PHC S

-PHC Reforms & Minimum Packages

MDGs Scaling-up Universal Coverage

1978

1993

2000

2001

2002

1982

WHO Constitution (1948) defined health as physical, social & mental; downplayed during 1950s era of disease campaigns.

Broad social and economic dimensions re-emerge under Health for All agenda (1970s), yet action falters in 1980s.

1990s: paradigm of health as "private" "market" approach dominants; some exceptions.

2000s: "pendulum swing" and new action involving multiple partners and stakeholders, including 2005 launch of PMNCH

1948

2008

2008 Commission social Determinants of Health, re emergence of PHC

2010

2010 Universal coverage based on sustainable financingReport cover

history …

2005

1987

Safe Motherhood

MDG Goal 5: Improve maternal health

Indicators to monitor progress

5.1 Maternal mortality ratio 5.2 Proportion of births attended by skilled health personnel

Goal and Targets

5.A: Reduce by three quarters, between 1990 and 2015, the maternal mortality ratio

5.3 Contraceptive prevalence rate 5.4 Adolescent birth rate 5.5 Antenatal care coverage (at least one visit and at least four visits) 5.6 Unmet need for family planning

5.B: Achieve, by 2015, universal access to reproductive health

Implications -What can the health sectordo?

Implications -What can government do? What can others do?

5.A: Reduce by three quarters, between 1990 and 2015, the maternal mortality ratio

5.B: Achieve, by 2015, universal access to reproductive health

Global, regional and national agenda Global, regional and national agenda

Challenge: health system constraints to achieve MDGsChallenge: health system constraints to achieve MDGs

Source: Travis et al., 2004, Lancet

Typical constraints Health system response

Financial inaccessibility, inability to pay, informal fees

Develop risk pooling strategies

Physical inaccessibility, distance to facility Reconsideration of long term plan for capital investment and location of facilities

Inappropriately skilled staff Review of basic medical and nursing training curricula to ensure appropriate skills

Poorly motivated staff Performance review systems, greater clarity of roles and expectations, review of salary structures and promotions

Weak planning and management Restructuring of MoH, recruitment and development of cadre of dedicated managers

Lack of intersectoral action and partnerships Building system of local government incorporating representatives from across sectors, promote accountability to people

Poor quality of care amongst private sector providers

Development of accreditation and regulation systems

OverviewOverview

2) Monitoring and analyses

Effectiveness Coverage:

effective services to all in need – universal coverage

Contact Coverage

Acceptability Coverage

Accessibility Coverage

Availability Coverage

Tanahashi 1978 Total or Target Population

A model of service access

Coverage curve

Yet usually measure availability or accessibility coverage

Yet usually measure availability or accessibility coverage

The proportion of the population in need of an intervention who have received an effective intervention -- effectiveness coverage

The key to measurement of effective coverage is to determine what constitutes an effective intervention.

The measurement of effective coverage, as an intermediate goal, is expected to link health system performance measurement more directly to managerial practices and decision-making process at local, regional and national levels

Income per capita and life-expectancy: most countriesIncome per capita and lifelife--expectancyexpectancy: most countries

Source: Wilkinson & Pickett, The Spirit Level (2009)

Patterns of access to health services by household wealth

Patterns of access to health services by household wealth

Household wealth

Acc

ess

to h

ealth

ser

vice

s

1

2

3

1: Mass Deprivation2: Queuing3: Marginal Exclusion

World Health Report, 2005

WHO Advisory Committee on

Health Monitoring and Statistics

December 2006

Life expectancy

Adult mortality

Child mortality*

HIV prevalence

DTP3 coverage

Institutional delivery or skilled birth attendant*

Child stunting*

Tobacco use

Total health expenditure per capita

Doctors' density

Nurses/midwives' density

Healthy Life Expectancy

"Recommend that a small set of priority indicators which should be disaggregated by equity measures within countries when appropriate"

Skilled birth attendance, 20 countries, African Region (AFRO, 2010)

Skilled birth attendance, 20 countries, African Region (AFRO, 2010)

Benin

Burkina Faso

Cameroon

Cote d'Ivoire

EthiopiaGhana

Guinea

Kenya

Madagascar

Malawi

Mali

Mozambique

NamibiaNiger

Rwanda

Senegal

Tanzania

Uganda

ZambiaZimbabwe

-20

-15

-10

-5

0

5

10

15

20

-20 -15 -10 -5 0 5 10 15 20

Change in average (%)

Chan

ge in

diff

eren

ce b

etw

een

the

low

est a

nd th

e hi

ghes

t wea

lth q

uint

iles

(%)

Decrease in averageIncrease in inequity

Increase in averageIncrease in inequity

Increase in averageDecrease in inequity

Decrease in averageDecrease in inequity

Changes in Kenya, DHS data 1998 and 2003Changes in Kenya, DHS data 1998 and 2003Relative gap

Widening/status quo

Narrowing

B. - DPT3 coverage

A. Best outcome- Use of modern contraception for women with expressed need- Stunting in Children

Improving

Population Average

D. Worst outcome- Delivery by skilled attendants- Prevalence of underweight among women

C.- Infant mortality rate- Under-five mortality rate- Prevalence of overweight among women

Worsening/ status quo

Modern contraceptive use, 20 countries, African Region (AFRO, 2010)

Modern contraceptive use, 20 countries, African Region (AFRO, 2010)

Zimbabwe

Zambia

Uganda

Tanzania

Senegal

Rwanda

Niger

Namibia

Mozambique

Mali

Malawi

Madagascar

Kenya

Guinea

Ghana

Ethiopia

Cote d'Ivoire

Cameroon

Burkina Faso

Benin

-25

-20

-15

-10

-5

0

5

10

15

20

-20 -15 -10 -5 0 5 10 15 20 25

Change in average (%)

Cha

nge

in d

iffer

ence

bet

wee

n th

e lo

wes

t and

the

high

est w

ealth

qui

ntile

s (%

)

Decrease in averageIncrease in inequity

Increase in averageIncrease in inequity

Increase in averageDecrease in inequity

Decrease in averageDecrease in inequity

Anti-malarial drugs during pregnancy, selected African Countries

Anti-malarial drugs during pregnancy, selected African Countries

0

20

40

60

80

100

Burk

ina

Faso

Chad

Zim

babw

e

Zam

bia

Cam

eroo

n

Gha

na Mal

i

Nig

eria

Rwan

da

Uga

nda

Cong

o

Ethi

opia

Gui

nea

Beni

n

Keny

a

Sene

gal

Mad

agas

car

Tanz

ania

Mal

awi

perc

enta

ge

Least Poor Poorest Average

Counselling of HIV during antenatal care, selected African Countries

Counselling of HIV during antenatal care, selected African Countries

0

20

40

60

80

100

Sene

gal

Gui

nea

Nig

eria

Tanz

ania

Keny

a

Cam

eroo

n

Gha

na

Moz

ambi

que

perc

enta

ge

Least Poor Poorest Average

Prevalence of maternal underweight, four South East Asian countries (year indicated) Prevalence of maternal underweight, four

South East Asian countries (year indicated)

33

17 2115 15 10

65

46

27

50

37

26

0

20

40

60

80

BGD-97 BGD-04 NPL-96 NPL-01 IND-98 LKA-00Perc

enta

ge [w

omen

und

erw

eigh

t] Richest Poorest Average

Inequalities in skilled birth attendance between richest and poorest 20% Source: DHS, national surveys (year indicated)

0

20

40

60

80

100

1997 2000 2004 1998 1997 2003 1996 2001 1993 2000 2006

Skill

ed b

irth

atte

ndan

ce (%

)

Richest 20% Poorest 20% Average

INDIABANGLADESH INDONESIA NEPAL SRI LANKA THAILAND

Inequalities in skilled birth attendance, six South East Asian countries (year indicated)

Inequalities in skilled birth attendance, six South East Asian countries (year indicated)

% Population In Lowest Wealth Quintile Across Different States of India (2005- 2006)

Trend of Institutional Delivery (1992-2006)Trend of Institutional Delivery (1992-2006)

63.4

79.3

87.3

37.5

51.1

64.7

43.9

52.6

64.6

35.6

46.3

52.7

25.5

33.6

38.7

0

10

20

30

40

50

60

70

80

90

100

Perc

enta

ge

Tamil Nadu Karnataka Maharashtra Gujarat All India

DHS-1 (1992-93) DHS-2 (1998-99) DHS-3 (2005-06)

Institutional Delivery by Wealth Quintile (2005 – 2006)Institutional Delivery by Wealth Quintile (2005 – 2006)

68.2

84.386.2

94.698

87.8

29.2

47.2

58.6

83.2

96.5

64.7

21

40.2

54.1

75.6

94.2

64.6

15.6

31.2

40.8

61.1

85.9

52.7

12.7

23.5

39.2

57.9

83.7

38.7

0

10

20

30

40

50

60

70

80

90

100

Perc

enta

ge

Tamil Nadu Karnataka Maharashtra Gujarat All India

Q1 Q2 Q3 Q4Q5Q3 Q4Q5Q1 Q2 Q3 Q4Q5 Q1 Q2 Q3 Q4Q5 Q1 Q2 Q3 Q4Q5 Q1 Q2 Q3 Q4Q5

Wealth quintile

Q1- Poorest

Q2- Poor

Q3- Middle

Q4- Rich

Q5-Richest

Average

Q4Q5Q5Q5

Universal coverageUniversal coverage

Universal coverage, as defined by WHO Member States, requires all people to have access to needed health services - prevention, promotion, treatment and rehabilitation - without the risk of financial hardship associated with accessing services.

World Health Report 2010 raises basic questions:

-- Who is covered?

-- Which services are covered?

-- What proportion of the costs are covered?

Source: World Health Assembly resolution 58.33 "Sustainable health financing, universal coverage, and social health insurance" May 2005; and World Health Report 2010 Health Systems Financing the Path to Universal Coverage.

Cervical Cancer Screening, 25-64 years Cervical Cancer Screening, 25-64 years

Cervical Cancer Screening, by global wealth deciles, 57 countries, WHS 2002

Cervical Cancer Screening, by global wealth deciles, 57 countries, WHS 2002

Source: Gakidou, Nordhagen, Obermeyer (2008)

Universal Coverage without financial hardshipUniversal Coverage without financial hardship

Financial barriers should not prevent people receiving needed services – payments at the point of service should be as low as possible

Contributions to the health system should be in relation to their capacity to pay

A substantial part of funds for health should be pooled to allow risk pooling – e.g. the sick should not bear the full costs of their illness

Services should be received according to need

Number of People Suffering Financial Catastrophe and Impoverishment Due to Health Spending

Number of People Suffering Financial Catastrophe and Impoverishment Due to Health Spending

- 30 60 90

WPR

AMR

SEA

EUR

AFR

EMR

Number of people (million)

impoverishment

catastrophic

WHO Region

David Evans, Department of Health Systems Financing, WHO

OverviewOverview

3) Connecting to other determinants

Causes of the Causes of Health inequities Causes of the Causes of Health inequities

Where do health differences among social groups originate, if we trace them back to their deepest roots?

What pathways lead from root causes to the stark differences in health status observed at the population level?

Where and how should we intervene to reduce health inequities?

Class

Prestige

Power

Commission on Social Determinants of Health, 2008

Determinants of skilled birth attendanceDeterminants of skilled birth attendance

0%

20%

40%

60%

80%

100%

BANGLADESH(2004)

INDIA (1999) INDONESIA(2003)

NEPAL (2001)

Health systems factors

Intermediary determinants

Socioeconomic position

Socioeconomic political context

8 2

8

5 7

4 9

6 9

3

4 0

3 1

0

10

20

30

40

50

60

70

80

90

A t l e a s t o n e A N C A l l r e c o m m e n d e d A N C A s s i s t e d b y h e a l t h

p r o f e s s i o n a l

D e l i v e r y i n h e a l t h f a c i l i t y

N e v e r E x p e r i e n c e d s p o u s a l v i o l e n c e E v e r e x p e r i e n c e d s p o u s a l v i o l e n c e ( P h y s i c a l / S e x u a l / E mo t i o n a l

Source: NFHS-3

Spousal Violence and Utilization of Maternal Healthcare, India

Thank you!Thank you!