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The Challenge of Health Systems in Global Health

HIV Center Grand Rounds

March 2009

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Today’s presentation

The New Challenge in Global Health

Following the money – the countries’ own

The Rockefeller Foundation’s Strategy

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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

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Increasing funding for health- ODA reaching 20 Bn a year

2000 20081990

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. . .but no enough improvement in MDGs 4, 5

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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

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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

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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+)

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Today’s presentation

The New Challenge in Global Health

Following the money – the countries’ own

The Rockefeller Foundation’s Strategy

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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

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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

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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

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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?

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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

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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

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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

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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)

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Projected U.S. Health Spending

Source: US Congressional Budget Office, Nov 2007

% GDP

50% GDP by 2080 Aging (dark blue)

Just a small driver

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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.

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“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

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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

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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

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Seguro Popular, México

2001 20062006Year 1994

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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.

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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%

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“More research is needed”

37

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0.3

0

5

10

15

20

25

30

35

40

Dollars (billions)

2006

Pharma NIH AHRQ

Source: Research!America, GFHR 2007

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Today’s presentation

The New Challenge in Global Health

Following the money – the countries’ own

The Rockefeller Foundation’s Strategy

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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)

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WHO Health Systems Framework

THS targets strategiesfor health systems transformation

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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

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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

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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

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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

45www.wordle.com

Thanks

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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

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+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

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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.

Google

MRC

Regenstrief

UCC / Tanzania

Partners in Health

Millenium Villages

Indiv. Developer

Project-level Collaborative Action

Network

Network of Networks: World eHealth CAN

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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

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•

Pharmacies

Social Marketing NGOs

Private clinicians Private Hospitals

Village health workers Informal providers

Many faces of the Private sector