Transcript Trends and Challenges in World Health”

“Trends and Challenges in World
Health”
Simon Blair
15 May 2001
Presentation Outline
• 2001 – its place in time (successful
evolution)
• Existing and emerging issues (the
challenges)
• Trends in hospital reform
• Transferable lessons from global reform
Health Reform and the World
Bank
• Why ? The Bank’s vision – “to reduce
poverty and improve living standards
through sustainable growth and investment
in people”
• Health = 9% GDP , and rising
Total Health Expenditure as Percent GNP
18%
16%
HE as % GNP
14%
12%
1977
1987
1997
10%
8%
6%
4%
2%
0%
100
1000
10000
LN GNP per capita
100000
Health Reform and the World
Bank
• Why ? The Bank’s vision
• Health = 9% GDP
• Rapid portfolio growth 1970 – 2001. 300
health reform projects
• 88 countries; projects totaling US $18.6b
• Focal shift: PHC/public health health
systems and hospitals
1900-2000: Sustained Progress
• Diptheria (1901), malaria (1902), diabetes
(1922), electrocardiogram (1924), penicillin
(1928), HBGs (1930), tuberculosis (1952),
DNA (1953), poliomyelitis (1954), heart
cathetarization (1956), CAT (1979) ….
A Century of Unparalleled Improvement
6.0
1997
75
5.5
70
Life Expectancy
65
5.0
4.5
60
55
4.0
50
3.5
45
3.0
40
Total Fertility Rates
35
30
1950 60
70
80
90 2000 10
Years
20
30
40
2.5
2.0
2050
Fertility Rates
Life Expectancy in Years
80
1900-2000: Sustained Progress
•
•
•
•
•
•
•
Nobel Prizes
Life Expectancy up, fertility rates down
% children who die before 5 = 50% of 1960
3m children p.a. saved by immunization
1m p.a. saved via improved diarrhea control
Child malnutrition rates 20% lower than 1970
People now live 25 years longer than in 1900
2001 : Critical Existing and
Emerging Issues
• WHO’s “Double Burden of Disease”
the emerging epidemic of noncommunicable diseases
the unfinished health agenda
• Reducing the burden of inequity
“the balance sheet is indelibly stained”
Challenge 1: The Onslaught of
Non-communicable Diseases
• From 35% (1998) – 57% (2020) of
international disease burden
• Infectious diseases : 49% to 22%
• CVD will = largest single cause of DALYs
• Lung cancer rates will rocket up due to
tobacco usage
• Injuries will = infectious diseases
worldwide as source of ill health by 2020
Challenge 2: “The Unfinished
Health Agenda”
• Infectious diseases in developing countries
• The 5 major childhood conditions still = 21% of
all deaths in low/middle income countries
• Pneumonia, diarrhea, measles, malaria and
malnutrition = 70% childhood deaths globally
• In adult conditions HIV/Aids and TB 2/3 major
causes of disease burden in developing countries
• 30% world still without safe water and sanitation
“A world of incomplete
epidemiological transition, in
which epidemiologically
polarized sub-populations have
been left behind”
World Health Report 1999
Challenge 3: Reducing the
Burden of Inequity
• The inexorable link: poverty and ill health.
(25% of the world’s population [1.4 billion
people] continue to live on incomes of < $1
per day. Half live on incomes < $2 per day.)
Only 11 Percent of Global Spending for
90 Percent of the World’s Population
Global Health Expenditure 1997 = US$2.6 Trillion
Africa 0.4%
Middle East and N Africa 1.5%
Europe 2.4%
Americas 3.2
Asia 3.5%
Developed Countries 88.9%
Per capita Total Health Expenditure
Exaggerated by Income / Spending
Correlation
Per Capita Exp (US$)
Average* Min Max
(US$)
4.0
USA
3.5
SAS
16
5
18
1,0003.0
EAP
21
8
130
AFR
42
5
237
MNA
54
6
118
ECA
120
34
336
234
8
877
Singapore
2.5
1002.0
1.5
101.0
India
LAC
0.5
Rwanda
High Income 2329
0.0
1002.0
2.5
3.0
1,000
3.5
10,000
4.0
4.5
425 3642
100,000
5.0
* weighted average
Per capita GDP
DALE
Health Achievement and Health Resources, 1997
75
70
65
60
55
50
45
40
35
30
25
1
10
100
1000
Ln Health expenditure per capita
10000
Challenge 3: Reducing the
Burden of Inequity
• The inexorable link : poverty and ill health
• 93% of global disease burden is in
low/middle income countries
• 2m children die p.a. from vaccine
preventable diseases
• < 10% of global funding for health research
is devoted to 90% of the health problems
Challenge 3: Reducing Inequity
(continued)
• Per capita health expenditures vary almost
1000 fold : from US$4 per capita p.a. to
$3800. (Ratio using PPP adjusted $ = 250x)
• TB is 4 times more prevalent in poor
subgroups of populations
• 70% of the world’s 36m HIV cases are in
Sub Saharan Africa
Systemic and Environmental
Challenges
•
•
•
•
•
•
Affordability and securing adequate $ levels
Stabilizing the policy pendulum
Redefining the role of the State
Market imperfections in the private sector
Poor performance
Lack of sophisticated purchasing and/or
purchasing accountability
• Absences of ‘single’ health systems
Trends in Hospital Reform (1)
• Caveat : impossibility of homogeneity
• Decentralization; increased hospital autonomy;
increasing focus upon governance and stewardship
issues
• Hospital consolidation / rationalization; use of
‘networks’; service substitution
• Focus upon ‘continuums of care’ and criticality of
system-wide integration
• Managerial efficiency seen as cost-effective
Trends in Hospital Reform (2)
• The evolution : allocation to purchasing
• Increased private sector participation
• Performance quality accorded higher
priority
• Information systems becoming mandatory
• Increasing community participation
• Introduction / expansion of user-charges
From the Database of 300/88:
“Lessons”
• The criticality of political will
• Address both the supply side and the demand sides
of the equation
• Incrementalism more successful than ‘big-bang’
• Authoritative and consistent policy-driven
decision making is necessary – considering
financing, regulation and organizational reform
together
“Lessons” (continued)
• The non-negotiable relevance of local
circumstances
• Market-influenced incentive measures can
be advantageous
• Process and outcome foci are critical
• Develop institutional capacity in advance
• Cost-containment alone does not result in
long term success
“Trends and Challenges”