Global Institutions in Health

Peter C. Smith

Imperial College Business School and Institute for Global Health

Global Institutions in Health

• Funding and Development– World Bank

– International Monetary Fund

– Global Fund

• Coordinating, informing & technical support– World Health

Organization

– European Commission

• Forum and Advocacy– Global Health Council

– World Economic Forum

– Organization for Economic Cooperation and Development

– Commonwealth Fund

Millennium Development Goals (2000)

• to eradicate extreme poverty and hunger;

• to achieve universal primary education;

• to promote gender equality and empower women;

• to reduce child mortality;

• to improve maternal health;

• to combat HIV/AIDS, malaria, and other diseases;

• to ensure environmental sustainability; and

• to develop a global partnership for development.

World Health Report 2000

• The health system:

“… all the activities whose primary purpose is to promote, restore or maintain health.”

WHO 2000 Efficiency Rankings

WHR 2000 Composite Indicator of Attainment

• Overall health outcomes (measured by disability-adjusted life expectancy)

• Inequality in health (measured by an index based on child mortality)

• Overall health system responsiveness, reflecting respect for persons and client orientation (as assessed by a panel of 1,791 key informants in 35 countries)

• Inequality in health system responsiveness (as assessed by the key informants)

• Fairness of financing (measured by an index based on the proportion of non-food expenditure spent on health care).

The WHO approach to setting weights

• Ask 1,006 internet respondents from 125 countries to score the five aspects of performance on a 100 point scale

• Consistency across respondents

• But do they understand what is required? – Relative value of an additional unit of

achievement, at all levels of performance, given the chosen scales of measurement.

Objections in principle

nations legitimately have different objectives and priorities; nations operate in different environmental, economic and

political circumstances; the composite is not helpful as it offers no policy guidance; the methodology is too complex to understand and explain; many countries do not have the capacity to interpret the

implications of the index; media coverage may be unhelpful or misleading.

Tallinn Charter, 2008

“We, the member states, commit ourselves to:

o Promote shared values of solidarity, equity and participation ...

o Invest in health systems, and foster investment across sectors that influence health ...

o Promote transparency and be accountable ...o Make health systems more responsive ...o Engage stakeholders ...o Foster cross-country learning and

cooperation ...o Ensure that health systems are prepared and

able to respond to crises ...”

AMI hospital costs (€)

395.97

1025.76

1861.02

2866.36

5013.64

5916.455599.30

7450.22

592.15

1181.53

5369.53

3720.88

1415.79

2541.84

4161.15

6225.55

7616.89

308.88

2868.16

1282.55

4384.72

483.05

8282.36

9374.21

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

10000

Hungary(n=2)

Poland(n=5)

Spain(n=5)

Germany(n=13)

England(n=3)

France(n=3)

Netherlands(n=6)

Italy(n=5)

in €

none PCI performed in hospitals mixed PCI performed in all hospitals

395.97

1025.76

1861.02

2866.36

5013.64

5916.455599.30

7450.22

592.15

1181.53

5369.53

3720.88

1415.79

2541.84

4161.15

6225.55

7616.89

308.88

2868.16

1282.55

4384.72

483.05

8282.36

9374.21

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

10000

Hungary(n=2)

Poland(n=5)

Spain(n=5)

Germany(n=13)

England(n=3)

France(n=3)

Netherlands(n=6)

Italy(n=5)

in €

none PCI performed in hospitals mixed PCI performed in all hospitals

Tiemann, O. (2008), Variations in Hospitalisation Costs for Acute Myocardial Infarction: A Comparison across Europe, Health Economics, 17S.

Appendectomy hospital costs (€)

0

500

1,000

1,500

2,000

2,500

3,000

3,500

Denmark England France Germany Netherlands Italy Spain Hungary Poland

in €

2,908

2,514

2,711

2,366

1,5141,466

2,037

2,193

1,702

2,027

2,920

1,547

1,922

2,150

1,552

1,898

2,195

1,461

1,632

694

517594 527

370469

673

200

466

Schreyögg, J. (2008), A micro-costing approach to estimating hospital costs for appendectomy in a cross-European context, Health Economics, 17S.

Hip replacement hospital costs (€)

€ 6,982

€ 6,364€ 6,101 € 5,932

€ 5,691 € 5,605

€ 3,599

€ 2,125

€ 1,294

€ 4,524

€ 5,466

€ 4,011 € 4,070

€ 3,190

€ 8,482

€ 7,622

€ 6,782

€ 7,853

€ 8,739

€ 5,380

€ 9,740

€ 8,332€ 8,646

€ 1,290€ 1,509

€ 5,683

€ 4,457€ 4,126

€ 1,298

€ 2,431

€ 6,925

€ 6,754€ 6,927

€ 0

€ 2,000

€ 4,000

€ 6,000

€ 8,000

€ 10,000

€ 12,000

Italy(N=5)

Germany(N=8)

France(N=5)

Denmark (N=2)

England(N=2)

Netherlands(N=7)

Spain(N=5)

Poland(N=6)

Hungary(N=2)

Results fromother studies

in €

UK 1996/1997:

US 1993-1996:

Canada 1988:

Sweden 2000:

Stargardt, T. (2008), Health Service Costs in Europe: Cost and Reimbursement of Primary Hip Replacement in Nine Countries, Health Economics, 17S.

Life expectancy at birth

Males Females

Total expenditure on health as % GDP

Source OECD HEALTH DATA 2008, June 08

0

2

4

6

8

10

12

14

16

18

1960 1970 1980 1990 2000

Australia

Canada

France

Germany

Italy

Japan

Netherlands

Norway

Spain

Sweden

Switzerland

UK

USA

Trends in out-of-pocket: % total health expenditure

Source: OECD Health Data 2009

OECD Health care quality indicators project

1. Breast cancer five-year survival rate

2. Mammography screening rate3. Cervical cancer five-year survival

rate4. Cervical cancer screening rate5. Colorectal cancer five-year

survival rate6. Incidence of vaccine preventable

diseases (Pertussis, measles, and hepatitis B)

7. Coverage for basic vaccination programme, age 2, (Pertussis, measles, and hepatitis B)

8. Asthma mortality rate, ages 5-39

9. In-hospital mortality rate within 30 days of hospital admission for acute myocardial infarction

10. In-hospital mortality rate within 30 days of hospital admission for stroke

11. Waiting times for surgery after hip fracture, over age 65

12. Influenza vaccination, over age 65

13. Smoking rate14. Retinal exams in diabetics 15. Asthma admission rate

Sandra Garcia Armesto, Maria Luisa Gil Lapetra, Lihan Wei, Edward Kelley and the Members of the HCQI Expert Group (2007)“Health care quality indicators project 2006: data collection update report”,Paris: OECD.

Health at a Glance OECD Indicators

https://www.oecd.org/health /hcqi

OECD RankingsCountry Unexplained life years

added

Australia 2.5

Canada -0.7

France 0.4

Germany -1.0

Hungary -3.1

Iceland 2.6

Netherlands -0.3

Norway -1.5

Sweden 0.5

Switzerland -0.4

UK 0.0

USA -4.0

• After adjusting for determinants of life expectancy– Health care spending

– Education

– GDP

– Pollution

– Alcohol

– Tobacco

– DietJoumard, I., C. Andre, C. Nicq and O. Chatal (2008) Health status determinants: lifestyle, environment, health care resources and efficiency. Economics Department WorkingPaper 627. Paris: OECD.

Access to Doctor When Sickor Need Medical Attention

42

10

2230

55

20

49

5 4

41

12

30

20

53

0

25

50

75

Same-day appointment Wait of 6 days or more

Percent

AUS CAN GER NETH NZ UK US AUS CAN GER NETH NZ UK US

Source: 2007 Commonwealth Fund International Health Policy Survey.Data collection: Harris Interactive, Inc.

C. Schoen, R. Osborn, M. Doty, M. Bishop, J. Peugh, N. Murukutla, “Toward Higher-Performance Health Systems: Adults’ Health Care Experiences in Seven Countries, 2007,” Health Affairs Web Exclusive (Oct. 31, 2007).

Doctor-Patient CommunicationPercent reported doctor: AUS CAN GER NETH NZ UK US

Always knows important information about your medical history

69 67 78 71 69 63 62

Always explains things so you can understand

79 75 71 71 80 71 70

Always spends enough time with you

73 59 70 71 69 59 56

Always tells you about your treatment options and involves you in decisions about your treatment

66 62 62 60 67 54 61

Source: 2007 Commonwealth Fund International Health Policy Survey.Data collection: Harris Interactive, Inc.

C. Schoen, R. Osborn, M. Doty, M. Bishop, J. Peugh, N. Murukutla, “Toward Higher-Performance Health Systems: Adults’ Health Care Experiences in Seven Countries, 2007,” Health Affairs Web Exclusive (Oct. 31, 2007).

Commonwealth Fund, May 2007

MIRROR, MIRROR ON THE WALL:AN INTERNATIONAL UPDATE ON THE COMPARATIVE PERFORMANCE OF AMERICAN HEALTH CAREKaren Davis, Cathy Schoen, Stephen C. Schoenbaum, Michelle M. Doty,Alyssa L. Holmgren, Jennifer L. Kriss, and Katherine K. Shea

Some concluding comments

• Objectives of international agencies

• Culture and history

• Opportunities and constraints– Obama health reforms (CMWF)

– Swine flu (WHO)

• Governance and bureaucracy