ANNE MILLS
HEALTH ECONOMICS AND FINANCING
PROGRAMME
LONDON SCHOOL OF HYGIENE AND
TROPICAL MEDICINE
THE HEALTH CHALLENGE
n
n
Unparalleled improvement in health:
life expectancy in low income countries
increased by 22 years 1960-95
Total burden of preventable disease
remains very high; is concentrated in
poorest countries and poorest
populations
ARGUMENT OF CMH WG5:
A FEW CONDITIONS MATTER MOST
n
Avoidable mortality in LMICs accounts for:
n
n
n
n
n
n
87% of chance of death in under 5s
60% in males 5-29
82% in females 5-29
51% in females 30-69
communicable diseases contribute around 90% of this
mortality
A few conditions account for most of excess
mortality:
n
n
diarrhoea, perinatal conditions, vaccine preventable
diseases, lower respiratory tract infections, malaria (for
<5s)
HIV/AIDS, injury, CVD, maternal conditions, TB (for 529s)
CONDITIONS AND INTERVENTIONS
n
n
n
n
n
n
n
Maternal and perinatal mortality (skilled
attendants at birth; ante and post natal
care)
Vaccine-preventable diseases
Treatment of childhood illness including
provision of micro-nutrients
Malaria (prevention and treatment)
TB
HIV/AIDS (prevention and treatment)
Smoking (regulation and taxes)
THE HEALTH SYSTEM CHALLENGE
n
n
n
n
Interventions within the health sector exist;
are of proven effectiveness, but not
implemented on a sufficiently wide scale
Coverage levels well below desirable levels,
especially in poorest groups
Limited evidence of major gains from
public/health sector reforms of last decade
Persistence of vertical/horizontal dichotomy:
little evidence to support claims that:
n
n
disease specific programmes strengthen weak
health systems, or
strengthening health systems produces effective
disease control
CURRENT COVERAGE LEVELS (%)
(COUNTRIES GNP<$1200) (source: WG5)
Antenatal care
Skilled birth attendance
65
45
Immunization services- polio, diphtheria,
pertussis, tetanus
Immunization services – Measles
Treatment of childhood illnesses – ARI
75
Treatment of childhood illnesses – Diarrhoea
52
Insecticide treated nets; residual indoor spraying
Treatment for clinical episodes of malaria
Short course TB treatment; smear + & -ve patients
2
31
44
HIV/AIDS interventions outside the health sector
Other HIV/AIDS preventive interventions
Palliative care for AIDS
Highly-active antiretroviral therapy
68
59
10-20
0 - 10
6-10
<1
THE HEALTH SYSTEM CHALLENGE
n
n
n
n
Interventions within the health sector exist;
are of proven effectiveness, but not
implemented on a sufficiently wide scale
Coverage levels well below desirable levels,
especially in poorest groups
Limited evidence of major gains from
public/health sector reforms of last decade
Persistence of vertical/horizontal dichotomy:
little evidence to support claims that:
n
n
disease specific programmes strengthen weak
health systems, or
strengthening health systems produces effective
disease control
n
Requirements:
n
n
n
n
scaling up availability of interventions
scaling up health system to which poor
have access
Funding needs to be primarily public,
but provision may be mixed (public,
NGO, shops etc)
Great majority of interventions don’t
require sophisticated services but
‘close-to-client’ health system
KEY ELEMENTS OF A WELL
FUNCTIONING HEALTH SYSTEM
n
n
n
Accessible local infrastructure which
is adequately equipped and staffed
by well trained and motivated health
workers
Strengthened management of the
health system at all levels
Categorical programmes to provide
technical and financial support for
certain disease control efforts (eg
malaria)
ILLUSTRATIVE SERVICE DELIVERY
REQUIREMENTS FOR TB AND MALARIA
Level of care
TB
Malaria
Hospital
DOTS; complic. Tx of complicated malaria
TB cases
Health centre/
health post
DOTS
Tx uncomplicated malaria
Intermittent treatment of
pregnant women for
malaria
Outreach
services
Epidemic planning and
response
Indoor residual spraying
Outside health
sector/no direct
service delivery
Social marketing of ITNs
CONSTRAINTS TO SCALING UP
Community
Inadequate demand for effective
and household interventions; barriers to use of effective
interventions
Health
services
delivery
Shortage and maldistribution of qualified
staff; low pay; poor motivation; inadequate
availability of drugs and medical supplies
Health sector
policy &
strategic
management
Weak drug policies and supply systems;
weak management systems; competing
donor programmes
Public policies Rigidities of government bureaucracy;
across sectors limited communications and transport
infrastructure
Environmental Poor governance; political instability;
characteristics unfavourable physical environment
RELAXING CONSTRAINTS: EXAMPLES OF
PRIORITY ACTIONS
LEVEL OF
CONSTRAINT
Community and
household
Health services
delivery
POSSIBLE PRIORITY ACTIONS
Use local groups/NGOs to
encourage community
mobilisation
Use social marketing and retail
sector to make effective drugs
available
Improve quantity and
performance of health workers
Use outreach services & NGOs
where public sector difficult to
extend
RELAXING CONSTRAINTS: EXAMPLES OF
PRIORITY ACTIONS
LEVEL OF
CONSTRAINT
Health sector
policy and
strategic
management
POSSIBLE PRIORITY
ACTIONS
Strengthen management
capacity
Strengthen drug supply and
distribution system
Public policies
across sectors
Give greater employment
responsibilities to health
sector
FACILITATING FACTORS
Community and
household
Community involvement and
accountability
Health services
delivery
Staff motivation; team work; frequent
communication; supervision and
feedback
Health sector policy
and strategic
management
Liaison units; effective technical and
managerial support; participative,
bottom up approaches involving
community, managers, health workers
Public policies
cutting across
sectors
Decentralisation at regional and local
levels; intersectoral collaboration
Environmental
characteristics
Political and macroeconomic stability;
commitment, leadership and ownership
of all partners (government, staff,
community)
THE IMPORTANCE OF HUMAN
RESOURCES
n
n
n
n
Context of scaling up health services
Assuming funds forthcoming: greatly
increased demand for health workers
in some developing countries
Increased demand from some high
income countries
Importance of increasing quantity,
quality, and motivation
HUMAN RESOURCE AVAILABILITY AND
REQUIREMENTS
2015 ESTIMATES BY SKILL LEVEL: TANZANIA
50,000
40,000
30,000
2015 Tanzania A
2015 Tanzania R
20,000
10,000
0
Unskilled
Nurse /
Midwife
Clinical
Technical
Admin. /
Manag.
2015 Tanzania A
11,350
16,080
7,030
1,920
140
2015 Tanzania R
14,790
44,560
26,850
10,440
2,330
HUMAN RESOURCE AVAILABILITY AND
REQUIREMENTS
2015 ESTIMATES BY SKILL LEVEL:CHAD
10,000
8,000
6,000
2015 Chad A
2015 Chad R
4,000
2,000
0
Unskilled
Nurse /
Midwife
Clinical
Technical
Admin. /
Manag.
2015 Chad A
1,210
1,920
220
170
30
2015 Chad R
4,250
7,690
4,540
1,960
360
2015 ESTIMATES BY DISEASE AREA:
TANZANIA
25,000
20,000
FT
E
15,000
10,000
5,000
0
IMCI/EPI
MPC
HIV/AIDS
Malaria
Tuberculosis
Availability
NM
17,020
15,460
10,280
1,800.0
10
16,080
C
1,920
2,210
20,310
2,270.0
140
7,030
T
690
700
2,960
460.0
100
1,920
2015 ESTIMATES BY DISEASE AREA: CHAD
4,500
4,000
3,500
FTE
3,000
2,500
2,000
1,500
1,000
500
0
IMCI/EPI
MPC
HIV/AIDS
Malaria
Tuberculosis
Availability
NM
3,890
2,140
1,480
170
10
1,920
C
1,350
350
2,100
690
50
220
T
200
210
510
40
20
170
RURAL GPs IN SOUTH AFRICA
(Mills et al 2003)
STAFF EXPERIENCES
Province 1
Province 2
n=15 (all
doctors)
n=10 (8 drs;
2 nurses)
I like my work
67%
70%
Quality of service provided
80%
80%
I would rather be working elsewhere
27%
0%
I trust my superiors
27%
30%
My supervisors understand my needs
33%
20%
If I work hard this is recognised
67%
20%
I worry about losing my job
67%
50%
Patients appreciate our work
40%
100%
Community members tend to abuse facility
100%
50%
KEY MOTIVATORS AND FACTORS CAUSING JOB DISSATISFACTION
HEALTH WORKERS IN TWO INDIAN STATES (Brown 2002)
Job Factor
Factors
important in an
ideal job (Rank
order)
Factors causing job
dissatisfaction
*(Rank order)
State 1
State 2
State 1
State 2
3
9
8
4
1
9
2
2
Challenging work
Training opportunities
5
Opportunities to advance
3
Good working relationships with
colleagues
1
1
Time for family
7
8
7
1
10
8
3
5
5
Good income
Good employment benefits
4
Good working location
9
6
3
7
Good physical working conditions
10
2
6
4
Tools to use skills on the job
2
5
4
6
* Difference between ideal and actual scores
IMPROVING HUMAN RESOURCES
n
Identify training needs:
n
n
n
types of worker
quantities required
Make health service employment
more attractive to improve
recruitment, retention, distribution
and performance
n
n
financial incentives
non financial incentives