Global Health Disparities: the role of health financing, donor assistance, and human resources CGFNS Symposium Philadelphia, December 2007

Marko VujicicThe World Bank

Outline

Global health disparitiesHealth financing disparities Global action to address financing disparities - donor assistance for health (DAH)The role of human resources for health (with emphasis on nursing)

Global Health Disparities

All regions off track. On a regional level, SSA and SA

worst off track in achieving health MDGs

EAP MDG AttainmentEAP MDG Attainment

Achieved 1

On track 2

Off track 3

Seriously off track 4

No data 5

East Asia and Pacificby number of countries

-100%

-50%

0%

50%

100%

Poverty Malnutrition Completion Gender Childmortality

Births Water Sanitation

24 countries

P P

P P P

P

P

P

P - Philippines

Source: World Bank, DEC, 2006

Causes of Death Vary Greatly by Causes of Death Vary Greatly by Country Income LevelCountry Income Level

Life Expectancy at birth (1960-2005)

0

10

20

30

40

50

60

70

80

90

1960-1970 1970-1980 1980-1990 1990-2000 2000-2005

Life

Exp

ecta

ncy

at B

irth

SSA

Asia

Europe

LAC

North America

Oceania

Life Expectancy

Africa

MDG Attainment

www.gapminder.org

Health Financing Disparities

There is Tremendous Variability in There is Tremendous Variability in Health Outcomes But There is an Health Outcomes But There is an Overall TrendOverall Trend

050

100

150

200

250

Infa

nt

Mora

lity R

ate

(per

1,0

00 liv

e b

irth

s)

10 100 250 1000 2500 10000 25000Total health spending per capita

Source: World Development Indicators, WHO 2007Note: Health spending per capita in current US$; Log scale ACP countries in blue

INFANT MORTALITY RATE VS TOTAL HEALTH SPENDING PER CAPITA

Health Financing

Domestic Resource Mobilization Domestic Resource Mobilization is Much More Limited in MICs is Much More Limited in MICs and LICsand LICs

RegionsTotal Revenue as % of GDP

Tax Revenue as % of GDP

Social Security Taxes as % of

GDP

Early 2000s

Americas 20.0 16.3 2.3Sub-Saharan Africa 19.7 15.9 0.3Central Europe, Baltics, Russia & Other Former Soviet Republics 26.7 23.4 8.1Middle East & North Africa 26.2 17.1 0.8Asia & Pacific 16.6 13.2 0.5Small Islands (Pop. < 1 million) 32.0 24.5 2.8

Low-income countries 17.7 14.5 0.7Low middle-income countries 21.4 16.3 1.4Upper middle-income countries 26.9 21.9 4.3High income Countries 31.9 26.5 7.2

Spending on Health Compared withSpending by other Ministries

Figure 2.1.5.1: Comparison of public spending on Health, Education and Military as % of total public spending

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

Sud

an

Cam

eroo

n

Mor

occo

Com

oros

Nam

ibia

Ben

in

Ken

ya

Moz

ambi

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Rw

anda

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Cap

e V

erde

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o

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Mad

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Sw

azila

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ocra

tic R

epub

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go

Eth

iopi

a

Sen

egal

Erit

rea

Equ

ator

ial G

uine

a

Bur

undi

Alg

eria

Djib

outi

Sou

th A

fric

a

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pt, A

rab

Rep

.

Ang

ola

Cha

d

Mau

ritan

ia

Con

go, R

ep.

Sie

rra

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e

Bur

kina

Fas

o

Tun

isia

Uga

nda

Gab

on

Liby

a

Uni

ted

Rep

ublic

of T

anza

nia

Nig

er

Mau

ritiu

s

Mal

awi

Zam

bia

Gha

na

Gui

nea

Gam

bia,

The

Gui

nea-

Bis

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Mal

i

Cen

tral

Afr

ican

Rep

ublic

Bot

swan

a

Sey

chel

les

Sao

Tom

e an

d P

rinci

pe

Nig

eria

Libe

ria

Som

alia

% o

f to

tal p

ub

lic s

pen

din

g

Public spending on health as % of total public spending Public spending on education as % of total public spending

Public spending on military as % of total public spending

-1.5

-1

-0.5

0

0.5

1

1.5

2

2.5

3

3.5

Lib

eria

So

ma

ria

Nig

eria

Sie

rra L

eo

ne

Sw

azila

nd

Su

da

n

Eth

iop

ia

Tog

o

Ma

law

i

So

uth

Afric

a

Rw

an

da

Nam

ibia

Zam

bia

Be

nin

Zim

ba

bw

e

Djib

ou

ti

Ke

nya

Tan

za

nia

Cen

tral A

frica

Re

pu

blic

Uga

nd

a

Ma

li

Lesoth

o

Bu

rkin

a F

aso

An

go

la

Se

ne

ga

l

Ma

urita

nia

Cam

ero

on

Ga

mb

ia

Mo

za

mb

ique

Dem

. Rep

. Co

ng

o

Pe

ce

nta

ge

Percentage Point Change in Health Expenditure as percentage of National Budget 1998-2002

Progress Towards the Abuja TargetHas been Slow & Sometimes Negative

Fig. 3.1.2: Expenditure on Health Compared to CMH Target Would Meeting the Abuja Targets Make Much Difference?

excludes all countries with total spend > $100 per capita

0

10

20

30

40

50

60

70

80

90

100

Bur

undi

Com

oros

Djib

outi

Erit

rea

Eth

iopi

a

Ken

ya

Mad

agas

car

Mal

awi

Moz

ambi

que

Rw

anda

Uga

nda

Tan

zani

a

Ben

in

Bur

kina

Cap

e V

erde

Côt

e d'

Ivoi

re

Gam

bia

Gha

na

Gui

nea

Gui

nea-

Libe

ria

Mal

i

Mau

ritan

ia

Nig

er

Nig

eria

Sen

egal

Sie

rra

Leon

e

Tog

o

Ang

ola

Cam

eroo

n

CA

R

Cha

d

Con

go

DR

Con

go

S T

ome

Leso

tho

Sw

azila

nd

Egy

pt

Mor

occo

Sud

an

E Africa W Africa Central Africa SAfrica

N Africa

Private Spending

Abuja Shortall in Public Spending

Current Public Spend

CMH Target

Macromedia Contribute 3.lnk

But the Abuja Target is Not EnoughTo Reach the MDGs

US$34

Share of Public Spending toReach Targets

Figure 3.1.3 Share of Public Spending Required to achieve per capita public health expenditure of $34

Source: WHO 2002 excludes DRC, Niger and Ethiopia where share would need to exceed 100%

-20

0

20

40

60

80

100

Burun

di

Djibou

ti

Kenya

Mala

wi

Moz

ambiq

ue

Seych

elles

Tanza

nia

Zimba

bwe

Burkin

a Fas

o

Côte

d'Ivo

ire

Ghana

Guinea

-Biss

au Mali

Niger

ia

Sierra

Leo

ne

Angola

Centra

l Afri

can

Repub

lic

Congo

Gabon

Botsw

ana

Namib

ia

Swazila

nd

Egypt

Mor

occo

Tunisi

a

% o

f b

ud

get

Donor Assistance for Health

Donor Funding: Are Commitments Being Delivered? Donor Funding: Are Commitments Being Delivered? ODA is Rising But is Far Short of What is Needed to Meet ODA is Rising But is Far Short of What is Needed to Meet the MDG (0.54) and Monterrey Commitments (0.70)the MDG (0.54) and Monterrey Commitments (0.70)

To meet 2010 commitments (ODA of US$130 billion per year), need an average increase of about 8% per yearTo meet 2010 commitments (ODA of US$130 billion per year), need an average increase of about 8% per yearSource: OECD DAC database.

A Large Part of the Increase in Aid is Not Directed to A Large Part of the Increase in Aid is Not Directed to Financing the Incremental Costs of Meeting the MDGsFinancing the Incremental Costs of Meeting the MDGs

4.2

23

45.2 45.2

30.2 38.3

Net ODA disbursements from DAC donors

Other components of ODA

Other special purpose grants

Debt relief$79.6 billion in 2004

$106.5 billion in 2005

In 2005, ODA peaked at US$ 106.5 billion -- most of this increase was due to debt relief and exceptionalIn 2005, ODA peaked at US$ 106.5 billion -- most of this increase was due to debt relief and exceptional mobilization (Tsunami, Kashmir earthquake)mobilization (Tsunami, Kashmir earthquake)

Donor Aid for Health has Donor Aid for Health has Increased SignificantlyIncreased Significantly

Source: Michaud 2006

Most of the recent increases:

•Focus on Africa

•Focus on specific diseases

•Come from bilaterals and multilaterals (GAVI, Global Fund)

Where Does All the Aid Where Does All the Aid Go?Go?

On average, for every $1 disbursed by donors to our 14 case study countries, we estimate:

•Not recorded in balance of payment $0.30•Recorded in BOP but not in Govt spending $0.20•Aid earmarked to specific projects $0.30•Budget support $0.20

•1990s structural adjustment provided a larger share of aid as general budget resources.

ODA is the Main Source of External Finance for SSA, Twice as Large as ODA is the Main Source of External Finance for SSA, Twice as Large as FDI and Nearly Four Times the as Large as RemittancesFDI and Nearly Four Times the as Large as Remittances

Total long-term flows of $41 billion

in 2003

Total long-term flows of $340 billion in 2003

Source: World Bank. Global Monitoring Report. 2005.

However, Donor Commitments for However, Donor Commitments for Health are Volatile and UnpredictableHealth are Volatile and Unpredictable

Try managing this…

Vertical Aid Distorts PrioritiesVertical Aid Distorts Priorities

Drug Use

Malaria

Nutrition HIV/AIDS

Health system

PMTCT

Maternal health

New born care

Safe and Supportive

Environment

Skilled birth attendance

Case management

Community

Management

Source: WHO, Mbewe

Basic Problems in Current ODA SystemBasic Problems in Current ODA SystemLack of predictability of funding and large differences between donor commitments and disbursements at the country levelThere is a growing concern about the ‘verticalization’ of aid and the need to focus holistically on health systems as opposed to specific diseases or interventionsLarge numbers of new actors and donors and the plethora of ‘new’ aid instruments (e.g., SWaps, PRSPs, PRSCs, PRGFs, MTEFs, etc.) create problems of management Lack of responsiveness and flexibility of aid to sudden problems and crisesLittle accountability of donors for the absence of results and lack of M&E systems which are needed to ensure that the additional resources are being used as prioritized and achieving resultsA significant portion of aid is off-budget and often doesn’t even enter into the balance of payments or the government’s budgetCountries need to create ‘fiscal space’ to absorb these large increases in external assistance, a potentially problematic situation given IMF fiscal ceiling

What is Needed?What is Needed?A “Needs Assessment” which identifies systemic constraints and implementation bottlenecks for the delivery of essential services and the required process to address them; Capacity development plans linked to policy and institutional needs including assessing complementarities with other sectors, analyzing the role of non-state partners (NGOs, civil society, and the private sector), and integrating national health systems with global programs;Improve the interface between MOF and MOH as co-leaders working with other relevant ministries;Ensure consistency between health sector development plans, SWAps, the overall budget including cross-sectoral trade-offs and the macroeconomic framework, in consultation with the IMF;Apply the Paris Principles of aid effectiveness to the health sector in country-specific circumstances including harmonization and alignment behind government strategies and processes, managing for results, and mutual accountability;Strengthen systems of management for results, including monitoring and evaluation, appropriate indicators, and mutual accountability; and, Determine major financing gaps and potential additional funding resources, eventually adjusting the plans to available resources and capacity to deliver.

What Will Donors Have to Do?What Will Donors Have to Do?

Harmonize procedures (procurement, financial mgt, monitoring & reporting) Provide increased and predictable long term financingFinance recurrent costsAssess effectiveness and appropriateness of new financing instrumentsOffer consistent policy adviceFocus on achieving resultsSubmit to common assessment of their own performance

What Does This Mean for What Does This Mean for Countries?Countries?

Develop credible strategies and plans to foster economic growth, deal with implementation bottlenecks, and reach MDGs as part of PRSPs, SWAPs, MTEFs, and public expenditure programsImprove governanceEnhance absorptive capacity through decentralization, efficient targeting mechanisms, and institutional reforms Develop financing, management, and regulatory mechanisms for equitable and effective pooling of insurable health risks as a necessary concomitant to MDG and CMH intervention choices.Integrate vertical programs into a well functioning health system to maximize health-specific and cross-sectoral outcomes and reduce transactions costsMonitor and evaluate results

What Does This Mean for What Does This Mean for Countries?Countries?International Health Partnership

Washington

Geneva

Brazzaville (HHA)

Asia?

Inter-agency country

'Health Sector' Teams

Inter-agency country

'Health Sector' Teams

e.g.• National Plans & Strategies • Compacts & donor incentives• Results Based Financing• Service Delivery• Aid effectiveness: health as tracer• Country monitoring and evaluation

'Scaling up'Inter-agency Core TeamScaling Up

Reference GroupWHO, WB, UNICEF, UNFPA, UNAIDs,

Global Fund, GAVI, Gates

Inter-agency working groups

Inter-agency working groups

Political Advocacy Ministers, H8 Heads of Agencies, etc

Regular Partner Forums

Regular Partner Forums

e.g.Development partners (donors)NGOsPartnerships

working groupsworking groups Partner ForumsPartner Forums

Global Disparities in Human Resources for Health – Nursing Focus

Measuring the impact of out-migration

We know that having enough staff is important for achieving outcomes (but is at best a necessary condition)

Measuring the impact of out-migration

On a regional level, SSA and SA also have lowest staffing levels

Measuring the impact of out-migration

Flows of migrant nurses into selected countries (Source: OECD, 2007)

Measuring the impact of out-migration

Migration is a two way street.

First Time Nursing Registrations in Canada by Foreign Trained Nurses, Top 5 Source Countries

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200

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2000 2001 2002 2003 2004 2005

Philippines

UK

France

USA

Haiti

First Time Nursing Registrations in Canada by Foreign Trained Nurses, Next 5 Countries

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2000 2001 2002 2003 2004 2005

India

RussianFederationChina

Lebanon

Romania

First Time Nursing Registrations in Canada by Foreign Trained Nurses, SSA Countries

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5

10

15

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25

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35

40

2000 2001 2002 2003 2004 2005

South Africa

Nigeria

Ghana

Zambia

Zimbabw e

(Source: CIHI)

Measuring the impact of out-migrationNCLEX Exam Passers in US, Selected Countries

4617

1549

897

0

500

1000

1500

2000

2500

3000

3500

4000

4500

5000

Philippines India Canada

2000

2005

NCLEX Exam Passers in US, Selected Countries

215

176

12597 89

6846 45 43 35 34 25 24 23 17 17 12 12

0

50

100

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200

250

Chi

na UK

Nig

eria

Ken

ya

Jam

aica

Japa

n

Sou

th A

fric

a

Rom

ania

Aus

tral

ia

Pol

and

Gha

na

Nep

al

New

Zea

land

Pak

ista

n

Sin

gapo

re

Trin

idad

&T

obag

o

Guy

ana

Zim

babw

e

2000 2005

(Source: NCSBN)

Measuring the impact of out-migration1. Developed countries relying more

and more on migrant health workers to fill labor shortages

2. Source of migrant health workers has changed dramatically in recent years - developing countries are the main source

Debate on impact of out-migration WHO resolution 57.19 UK Code of conduct Bilateral agreements

0 100 200 300 400flows to UK Canada US combined

SSA

SAS

LAC

EAP

Ghana

Kenya

Zimbabwe

Ethiopia

Malawi

Senegal

Sierra Leone

Liberia

Gambia

Cameroon

Uganda

Pakistan

Nepal

Haiti

Peru

Chile

Nicaragua

Belize

Indonesia

Fiji

Outmigration of nurses from US, UK, Canada combined

KENYA -Gap for attaining PEPFAR target

UGANDA -Gap for attaining PEPFAR target

0.02

0.01

0.02

0.01

0.01

0.01

0.02

0.04

0.01

0.00

0.00

0.01

0.01

0.01

0.29

0.00

0.00

0.00

0.04

0.08

0.00

0.01

0 .1 .2 .3Outflow of Nurses as share of Domestic Stock of Nurses

SSA

SAS

LAC

EAP

Ghana

Kenya

Zimbabwe

Ethiopia

Malawi

Senegal

Sierra Leone

Liberia

Gambia

Cameroon

Uganda

India

Pakistan

Nepal

Haiti

Peru

Chile

Nicaragua

Belize

Philippines

Indonesia

Fiji

Nurse out migrations as share of domestic stock

Measuring the impact of out-migration1. Debate does not focus on fiscal side. i.e.

are there enough funded positions to absorb the doctors and nurses who leave the country?

Short term Vacancy data

Inaccurate – often measured relative to norms Budget execution data

Difficult to collect Two illustrative examples

Kenya Malawi

Long term How easily could additional funded positions be

created through increased fiscal space for health? Donor funding vs. domestic resources

Economic Categories 2001/2002 2001/2002 2002/2003 2002/2003 2003/2004 2003/2004 2004/05 2004/05 2005/06 2005/06

Actual as % of

Printed

Actual as % of

Approved

Actual as % of

Printed

Actual as % of

Approved

Actual as % of

Printed

Actual as % of

Approved

Actual as % of Printed

Actual as % of

Approved

Actual as % of Printed

Actual as % of

Approved

Total Recurrent (Gross) 121 100 106 100 96 97 109 99 98 96.30 Salaries and Other Personnel 121 97 102 100 98 100 122 101 102 100.24 Transfers, Subsidies and Grants 135 98 108 100 100 100 98 98 100 99.69 Drugs and Medical Consumables 87 99 93 92 80 80 94 94 83 90.17 Other Operations & Maintenance 121 120 108 98 102 95 99 99 90 74.09 Purchase of Plant & Equipment 85 80 99 98 73 74 95 95 86 94.52 Kenyatta National Hospital 142 100 126 105 100 100 100 100 100 100.00 Moi Referral Hospital 267 100 121 100 109 100 100 100 100 100.00

Kenya

New Recruits into MOH Health Workforce

0%10%20%30%40%50%60%70%80%90%

100%

Female Male

Other

Employed Private

Employed NGO

Employed FBO

Employed MOH

Unemployed

Total Applicants 6566Total Qualified Applicants (Shortlisted) 4466Total Selected Applicants (Deployed MOH) 677

KENYA

3.8

3.9

4.0

4.1

4.2

4.3

4.4

4.5

4.6

4.7

2000 2001 2002 2003 2004

0.0

2.0

4.0

6.0

8.0

10.0

12.0

THE/GDP

GHE/G

Kenya

Graph 3 Graph 4 Public Sector Wage Bill as Share of GDP

8.1% 8.5%9.2% 9.2%

8.7%7.9% 7.5% 7.2%

0%

2%

4%

6%

8%

10%

12%

2000 2001 2002 2003 2004 2005 2006* 2007*

Public Sector Wage Bills as Share of Government Expenditure

34%38% 38% 39% 38%

36% 35% 34%

0%

5%

10%

15%

20%25%

30%

35%

40%

45%

50%

2000 2001 2002 2003 2004 2005 2006* 2007*

Source: IMF Kenya Article IV 2003 – Make 2 graphs- WDI up until 2004 (or most recent) then second graoh with BOP table 3 figures (2004-2009)

Kenya

MOH Staff Recruited and Lossed

0

500

1000

1500

2000

2500

3000

3500

2001 2002 2003 2004 2005 2006

Year

To

tal

Nu

mb

er o

f S

taff

Staff Recruited

Staff Lossed

Health Wage Bill as Share of Public Sector Wage Bill

7.7%8.5% 8.9% 8.6%

9.4%

10.7% 10.9%

0%

2%

4%

6%

8%

10%

12%

2000 2001 2002 2003 2004 2005 2006* 2007*

Malawi

145 152137

150

198270 200

0

50

100

150

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250

300

350

400

450

1994 1995 1996 1997 1998 1999 2000

Retirement Resignation Dismissal & redundancy Death

MALAWI

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

2000 2001 2002 2003 2004

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

THE/GDP

GHE/G