Transcript Africa`s health challenge and institutional context Session 2

Africa’s health challenge
and institutional context
Health Dialogue
4 April 2011
Nairobi
Overview
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Africa’s health challenge
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Indicators and underlying factors: demand,
supply & efficiency
Institutional context and reform
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Health system functions
Financing in the African context
Hierarchy of reform
Other reform perspectives & approaches
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Progress but “lags”, and some
reversals – life expectancy/death
LE at birth:
 Joined world in rapid progress from circa 1950-1990: up from 39 to 50
 Significantly lags the world (2008): Africa 53, global 68 (America 76;
South-East Asia 65)
 Great diversity:
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among countries (73 in Mauritius versus 42 in Zimbabwe)
within countries (rural/urban; income groups, education of mother)
Steady progress in some, reversals in others (Lesotho 61 to 47 1990 to
2008)
 Key factors in increasing life expectancy/driving down mortality?
Mortality:
 Adult 45q15: 392@180
 Child mortality: 142@65
 Maternal mortality: Disproportionate in many but also good progress in
some
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Explaining the lag? A Ghana
case 2001
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Young man with treatable disease (“Burkitt’s lymphoma”):
 Access to public system but costly, medicine not in public
system
 Private medicine but (very) costly
For many even less “access” – regional disparities
Human resources and facilities
“Needless deaths of thousands of people from treatable
diseases”
Innovation and solutions: outreach/community health
workers
Many responses in Ghana since then – partly reviewed in
case study
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Demand for services and disease
burden
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Disability adjusted life years (DALYs)
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Classify DALYs according to diagnostic categories to which they are
related
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Group I – communicable diseases, maternal, perinatal, nutritional conditions
Group II – non-communicable diseases
Group III – injuries
1990 Sub-Saharan Africa/Latin America
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Sum of YLL (years of life lost due to death) and YLD (years of healthy life
lost as a result of disability)
Group 1: 65.9%/35.3%
Group 2: 18.4%/48.2%
Group 3: 15.4%/16.4% (Murray 1997)
Africa a double burden? Triple? Quadruple?
How does it help?
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Measuring progress; help determine disease control priorities; Evidence for
reallocation
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Demand for services & disease
burden –
Leading causes of burden of disease – WHO Africa region
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2
3
4
5
6
7
8
9
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HIV/AIDS
Lower respiratory infections
Diarrhoeal diseases
Malaria
Neonatal infections and other
Birth asphyxia and birth trauma
Prematurity and low birth weight
Tuberculosis
Road traffic accidents
Protein–energy malnutrition
DALYs
(Millions)
46.7
42.2
32.2
30.9
13.4
13.4
11.3
10.8
7.2
7.1
Source:Global burden of Disease 2004 (WHO)
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% of total
DALYs
12.4
11.2
8.6
8.2
3.6
3.6
3
2.9
1.9
1.9
Service provision & access:
average and distribution
Member State
Immunisation rates:
 Very high in some (close to
100%)
 Low in others – and have
been declining
 Inequalities: Nigeria 75%
for richest 20%; 17% for
poorest 20%
Attended births:
 Again wide range
 Rich&poor; rural&urban;
education of mother
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MDG 5
Births attended by
skilled health
personnel (%)
2000–2008
Mauritius
Algeria
Botswana
Djibouti
South Africa
99
95
94
93
91
Somalia
Eritrea
Niger
Chad
Ethiopia
33
28
18
14
6
WHO African Region
Global
47
66
Source: WHO 2010 database (view data
qualifications in source)
Supply factors: funding,
resources, efficiency
Spending on health ranges from
13.9% of GDP (Burundi) to
2.1% (Equatorial Guinea)
Average WHO Africa: 6.2% of
GDP compared to 13.6% in
Americas, 3.6% in SE Asia
Per capita health $ low: ave of
$76 ($41 in SE Asia and
$801 global average)
Gov health spend as % of
government spend from
Rwanda (19.5%) to as low as
Congo (5.1%) – 6 countries
8 Abuja target
around
Africa in Health
11% of the world's people
24% of the global disease burden
1% of global health expenditure
3% of the world's health workers
Source: IFC 2007
Number of physicians per 10,000 population
Supply factors: physicians per
10,000
11-25
2-10
1
less than 1
0
5
10
15
Num ber of countries
9
20
25
Demand, funding and resources not the
whole story - efficiency
Sub-Saharan Africa and SE Asia
compared?
 Diversity of outcomes for countries with
same wealth/inputs
 Evidence of waste
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Looking for reform options: elements of
health systems
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Looking for reform options: financing
systems
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Social insurance versus national health
systems vs mixed
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Collection – private payments (OOP),
insurance/contributory, general govt
revenue,
Pooling to spread risk
Purchasing/provider payment – fee for
service, capitation, case-mix adjusted
Africa: govt significant but private bigger:
little insurance & pooling of risks. Integrated
hierarchical systems typical – little active
purchasing
A hierarchy of reforms or policy options
Policy level
Systemic
Reform type
Objective
Restructuring/ Equity/
redesign
access
Reorientation/ Allocative
Programmatic
reprogramming efficiency
Issues
Public/private mix; financing
mechanisms
Evaluation of priorities & assessment
of cost-effectiveness
Organisational Reorganisation
Technical
Efficiency
Instrumental
Institutional Information, technology, HRD,
intelligence research
Reinforcement
Source: Adapted from Frenk (1994)
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Enhance productivity in institutions,
quality
Other reform perspectives/approaches
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Macro expenditure constraints versus micro efficiency
enhancement on demand & supply side (OECD)
Incentives: Reimbursement mechanisms & reward
systems
Moving from a historic centralised system:
decentralisation; private sector involvement;
integration (@vertical programmes); (donor)
coordination (comprehensiveness of budgets)
PFM reform: linking policy & budgets, certainty &
credibility (MTEFs), output & performance orientation
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