Global Health History Seminar 11 May 2011 -- one ... · BANGLADESH INDIA INDONESIA NEPAL SRI LANKA...
Transcript of Global Health History Seminar 11 May 2011 -- one ... · BANGLADESH INDIA INDONESIA NEPAL SRI LANKA...
Global Health History Seminar 11 May 2011
--
one perspective from WHO
Ritu Sadana, ScDDepartment of Health Systems Financing
World Health OrganizationGeneva
OverviewOverview
1) Policy perspective
2) Monitoring and analyses
3) Connecting to other determinants
C-PHC S
-PHC Reforms & Minimum Packages
MDGs Scaling-up Universal Coverage
1978
1993
2000
2001
2002
1982
WHO Constitution (1948) defined health as physical, social & mental; downplayed during 1950s era of disease campaigns.
Broad social and economic dimensions re-emerge under Health for All agenda (1970s), yet action falters in 1980s.
1990s: paradigm of health as "private" "market" approach dominants; some exceptions.
2000s: "pendulum swing" and new action involving multiple partners and stakeholders, including 2005 launch of PMNCH
1948
2008
2008 Commission social Determinants of Health, re emergence of PHC
2010
2010 Universal coverage based on sustainable financingReport cover
history …
2005
1987
Safe Motherhood
MDG Goal 5: Improve maternal health
Indicators to monitor progress
5.1 Maternal mortality ratio 5.2 Proportion of births attended by skilled health personnel
Goal and Targets
5.A: Reduce by three quarters, between 1990 and 2015, the maternal mortality ratio
5.3 Contraceptive prevalence rate 5.4 Adolescent birth rate 5.5 Antenatal care coverage (at least one visit and at least four visits) 5.6 Unmet need for family planning
5.B: Achieve, by 2015, universal access to reproductive health
Implications -What can the health sectordo?
Implications -What can government do? What can others do?
5.A: Reduce by three quarters, between 1990 and 2015, the maternal mortality ratio
5.B: Achieve, by 2015, universal access to reproductive health
Global, regional and national agenda Global, regional and national agenda
Challenge: health system constraints to achieve MDGsChallenge: health system constraints to achieve MDGs
Source: Travis et al., 2004, Lancet
Typical constraints Health system response
Financial inaccessibility, inability to pay, informal fees
Develop risk pooling strategies
Physical inaccessibility, distance to facility Reconsideration of long term plan for capital investment and location of facilities
Inappropriately skilled staff Review of basic medical and nursing training curricula to ensure appropriate skills
Poorly motivated staff Performance review systems, greater clarity of roles and expectations, review of salary structures and promotions
Weak planning and management Restructuring of MoH, recruitment and development of cadre of dedicated managers
Lack of intersectoral action and partnerships Building system of local government incorporating representatives from across sectors, promote accountability to people
Poor quality of care amongst private sector providers
Development of accreditation and regulation systems
OverviewOverview
2) Monitoring and analyses
Effectiveness Coverage:
effective services to all in need – universal coverage
Contact Coverage
Acceptability Coverage
Accessibility Coverage
Availability Coverage
Tanahashi 1978 Total or Target Population
A model of service access
Coverage curve
Yet usually measure availability or accessibility coverage
Yet usually measure availability or accessibility coverage
The proportion of the population in need of an intervention who have received an effective intervention -- effectiveness coverage
The key to measurement of effective coverage is to determine what constitutes an effective intervention.
The measurement of effective coverage, as an intermediate goal, is expected to link health system performance measurement more directly to managerial practices and decision-making process at local, regional and national levels
Income per capita and life-expectancy: most countriesIncome per capita and lifelife--expectancyexpectancy: most countries
Source: Wilkinson & Pickett, The Spirit Level (2009)
Patterns of access to health services by household wealth
Patterns of access to health services by household wealth
Household wealth
Acc
ess
to h
ealth
ser
vice
s
1
2
3
1: Mass Deprivation2: Queuing3: Marginal Exclusion
World Health Report, 2005
WHO Advisory Committee on
Health Monitoring and Statistics
December 2006
Life expectancy
Adult mortality
Child mortality*
HIV prevalence
DTP3 coverage
Institutional delivery or skilled birth attendant*
Child stunting*
Tobacco use
Total health expenditure per capita
Doctors' density
Nurses/midwives' density
Healthy Life Expectancy
"Recommend that a small set of priority indicators which should be disaggregated by equity measures within countries when appropriate"
Skilled birth attendance, 20 countries, African Region (AFRO, 2010)
Skilled birth attendance, 20 countries, African Region (AFRO, 2010)
Benin
Burkina Faso
Cameroon
Cote d'Ivoire
EthiopiaGhana
Guinea
Kenya
Madagascar
Malawi
Mali
Mozambique
NamibiaNiger
Rwanda
Senegal
Tanzania
Uganda
ZambiaZimbabwe
-20
-15
-10
-5
0
5
10
15
20
-20 -15 -10 -5 0 5 10 15 20
Change in average (%)
Chan
ge in
diff
eren
ce b
etw
een
the
low
est a
nd th
e hi
ghes
t wea
lth q
uint
iles
(%)
Decrease in averageIncrease in inequity
Increase in averageIncrease in inequity
Increase in averageDecrease in inequity
Decrease in averageDecrease in inequity
Changes in Kenya, DHS data 1998 and 2003Changes in Kenya, DHS data 1998 and 2003Relative gap
Widening/status quo
Narrowing
B. - DPT3 coverage
A. Best outcome- Use of modern contraception for women with expressed need- Stunting in Children
Improving
Population Average
D. Worst outcome- Delivery by skilled attendants- Prevalence of underweight among women
C.- Infant mortality rate- Under-five mortality rate- Prevalence of overweight among women
Worsening/ status quo
Modern contraceptive use, 20 countries, African Region (AFRO, 2010)
Modern contraceptive use, 20 countries, African Region (AFRO, 2010)
Zimbabwe
Zambia
Uganda
Tanzania
Senegal
Rwanda
Niger
Namibia
Mozambique
Mali
Malawi
Madagascar
Kenya
Guinea
Ghana
Ethiopia
Cote d'Ivoire
Cameroon
Burkina Faso
Benin
-25
-20
-15
-10
-5
0
5
10
15
20
-20 -15 -10 -5 0 5 10 15 20 25
Change in average (%)
Cha
nge
in d
iffer
ence
bet
wee
n th
e lo
wes
t and
the
high
est w
ealth
qui
ntile
s (%
)
Decrease in averageIncrease in inequity
Increase in averageIncrease in inequity
Increase in averageDecrease in inequity
Decrease in averageDecrease in inequity
Anti-malarial drugs during pregnancy, selected African Countries
Anti-malarial drugs during pregnancy, selected African Countries
0
20
40
60
80
100
Burk
ina
Faso
Chad
Zim
babw
e
Zam
bia
Cam
eroo
n
Gha
na Mal
i
Nig
eria
Rwan
da
Uga
nda
Cong
o
Ethi
opia
Gui
nea
Beni
n
Keny
a
Sene
gal
Mad
agas
car
Tanz
ania
Mal
awi
perc
enta
ge
Least Poor Poorest Average
Counselling of HIV during antenatal care, selected African Countries
Counselling of HIV during antenatal care, selected African Countries
0
20
40
60
80
100
Sene
gal
Gui
nea
Nig
eria
Tanz
ania
Keny
a
Cam
eroo
n
Gha
na
Moz
ambi
que
perc
enta
ge
Least Poor Poorest Average
Prevalence of maternal underweight, four South East Asian countries (year indicated) Prevalence of maternal underweight, four
South East Asian countries (year indicated)
33
17 2115 15 10
65
46
27
50
37
26
0
20
40
60
80
BGD-97 BGD-04 NPL-96 NPL-01 IND-98 LKA-00Perc
enta
ge [w
omen
und
erw
eigh
t] Richest Poorest Average
Inequalities in skilled birth attendance between richest and poorest 20% Source: DHS, national surveys (year indicated)
0
20
40
60
80
100
1997 2000 2004 1998 1997 2003 1996 2001 1993 2000 2006
Skill
ed b
irth
atte
ndan
ce (%
)
Richest 20% Poorest 20% Average
INDIABANGLADESH INDONESIA NEPAL SRI LANKA THAILAND
Inequalities in skilled birth attendance, six South East Asian countries (year indicated)
Inequalities in skilled birth attendance, six South East Asian countries (year indicated)
% Population In Lowest Wealth Quintile Across Different States of India (2005- 2006)
Trend of Institutional Delivery (1992-2006)Trend of Institutional Delivery (1992-2006)
63.4
79.3
87.3
37.5
51.1
64.7
43.9
52.6
64.6
35.6
46.3
52.7
25.5
33.6
38.7
0
10
20
30
40
50
60
70
80
90
100
Perc
enta
ge
Tamil Nadu Karnataka Maharashtra Gujarat All India
DHS-1 (1992-93) DHS-2 (1998-99) DHS-3 (2005-06)
Institutional Delivery by Wealth Quintile (2005 – 2006)Institutional Delivery by Wealth Quintile (2005 – 2006)
68.2
84.386.2
94.698
87.8
29.2
47.2
58.6
83.2
96.5
64.7
21
40.2
54.1
75.6
94.2
64.6
15.6
31.2
40.8
61.1
85.9
52.7
12.7
23.5
39.2
57.9
83.7
38.7
0
10
20
30
40
50
60
70
80
90
100
Perc
enta
ge
Tamil Nadu Karnataka Maharashtra Gujarat All India
Q1 Q2 Q3 Q4Q5Q3 Q4Q5Q1 Q2 Q3 Q4Q5 Q1 Q2 Q3 Q4Q5 Q1 Q2 Q3 Q4Q5 Q1 Q2 Q3 Q4Q5
Wealth quintile
Q1- Poorest
Q2- Poor
Q3- Middle
Q4- Rich
Q5-Richest
Average
Q4Q5Q5Q5
Universal coverageUniversal coverage
Universal coverage, as defined by WHO Member States, requires all people to have access to needed health services - prevention, promotion, treatment and rehabilitation - without the risk of financial hardship associated with accessing services.
World Health Report 2010 raises basic questions:
-- Who is covered?
-- Which services are covered?
-- What proportion of the costs are covered?
Source: World Health Assembly resolution 58.33 "Sustainable health financing, universal coverage, and social health insurance" May 2005; and World Health Report 2010 Health Systems Financing the Path to Universal Coverage.
Cervical Cancer Screening, 25-64 years Cervical Cancer Screening, 25-64 years
Cervical Cancer Screening, by global wealth deciles, 57 countries, WHS 2002
Cervical Cancer Screening, by global wealth deciles, 57 countries, WHS 2002
Source: Gakidou, Nordhagen, Obermeyer (2008)
Universal Coverage without financial hardshipUniversal Coverage without financial hardship
Financial barriers should not prevent people receiving needed services – payments at the point of service should be as low as possible
Contributions to the health system should be in relation to their capacity to pay
A substantial part of funds for health should be pooled to allow risk pooling – e.g. the sick should not bear the full costs of their illness
Services should be received according to need
Number of People Suffering Financial Catastrophe and Impoverishment Due to Health Spending
Number of People Suffering Financial Catastrophe and Impoverishment Due to Health Spending
- 30 60 90
WPR
AMR
SEA
EUR
AFR
EMR
Number of people (million)
impoverishment
catastrophic
WHO Region
David Evans, Department of Health Systems Financing, WHO
OverviewOverview
3) Connecting to other determinants
Causes of the Causes of Health inequities Causes of the Causes of Health inequities
Where do health differences among social groups originate, if we trace them back to their deepest roots?
What pathways lead from root causes to the stark differences in health status observed at the population level?
Where and how should we intervene to reduce health inequities?
Class
Prestige
Power
Commission on Social Determinants of Health, 2008
Determinants of skilled birth attendanceDeterminants of skilled birth attendance
0%
20%
40%
60%
80%
100%
BANGLADESH(2004)
INDIA (1999) INDONESIA(2003)
NEPAL (2001)
Health systems factors
Intermediary determinants
Socioeconomic position
Socioeconomic political context
8 2
8
5 7
4 9
6 9
3
4 0
3 1
0
10
20
30
40
50
60
70
80
90
A t l e a s t o n e A N C A l l r e c o m m e n d e d A N C A s s i s t e d b y h e a l t h
p r o f e s s i o n a l
D e l i v e r y i n h e a l t h f a c i l i t y
N e v e r E x p e r i e n c e d s p o u s a l v i o l e n c e E v e r e x p e r i e n c e d s p o u s a l v i o l e n c e ( P h y s i c a l / S e x u a l / E mo t i o n a l
Source: NFHS-3
Spousal Violence and Utilization of Maternal Healthcare, India
Thank you!Thank you!