Building Sustainable Health Systems Janet Hatcher Roberts

Objectives To understand the concepts of inequity To understand the key elements of a health system

Of all the forms of inequality, injustice in health is the most shocking and the most inhumane (Attributed to Dr. Martin Luther King) in: Paul Farmer, Pathologies of Power

Measuring Health and Wealth: Should The Map Be Different?

World Land Area: Geographic Perspective

Distribution of the World’s Population

The Distribution of the World’s Population "Out of every 100 persons added to the population in the coming decade, 97 will live in developing countries." Hania Zlotnik, India Pakistan China Japan Indonesia Bangladesh Thailand Philippines Russian Federation Australia Nigeria Brazil Ethiopia Iran Turkey Germany France Spain Egypt Kenya USA Canada Ukraine South Africa

Distribution of the World’s Wealth USA India Indonesia Bangladesh Philippines China Japan Russian Federation Australia Germany France Spain Switzerland Fr Guyana UK Italy

Distribution of Poverty in the World USA Canada Nigeria Ethiopia Egypt Kenya India Indonesia Bangladesh Philippines China Japan Russian Federation Australia Pakistan Thailand South Africa

If wealth is not distributed fairly or equitably, will health be distributed fairly or equitably?

What Determines Wealth Determines Health Poverty Employment Education Safe clean water Social exclusion –Urban / Rural –Gender –Race, ethnicity –Other minority status Poor housing Poor, dysfunctional health systems

Equity in health implies addressing differences in health status that are unnecessary, avoidable and unfair.

How can health outcomes be measured and recorded?

Leading Causes of Mortality and Burden of Disease world, 2004 % 1.Ischaemic heart disease Cerebrovascular disease Lower respiratory infections COPD Diarrhoeal diseases HIV/AIDS Tuberculosis Trachea, bronchus, lung cancers Road traffic accidents Prematurity, low birth weight 2.0 % 1.Lower respiratory infections Diarrhoeal diseases Depression4.3 4.Ischaemic heart disease HIV/AIDS3.8 6.Cerebrovascular disease Prematurity, low birth weight Birth asphyxia, birth trauma Road traffic accidents Neonatal infections and other 2.7 MortalityDALYs

Per cent distribution of age at death by region, 2004

Proportional Distribution of Infectious Disease Mortality World Health Report

Disease Burden in Developing Countries A large proportion of the worldwide disease burden occurs in LMIC countries LMICHICRatio LMIC/HIC Group 1 Communicable Diseases :1 Group 2 Non Communicable Diseases :1 Injuries :1 SOURCE: Global Forum for Health Research. The 10/90 Report on Health Research pg. 91

I Distribution of Disease Burden, Health Care Workers and Health Care Expenditure Americas vs. Sub-Saharan Africa,

Inequity of Health Outcome Distribution

Mortality among males, 15 – 60 years of age: The world health report

Distribution of deaths in the world by sex, 2004

Leading causes of disease burden for women aged 15–44 years, high-income countries, and low- and middle-income countries, 2004

Comparison of the proportional distribution of deaths and YLL by region, 2004

Comparison of the proportional distribution of deaths and YLL by leading cause of death, 2004

Distribution of child deaths for selected causes by selected WHO region, 2004

Burden of disease by broad cause group and region, 2004

Proportional Distribution of people living with HIV, years (2003) NigeriaEthiopia Kenya India South Africa Tanzania Botswana Zimbabwe Russian Federation N=29.2 million

Proportional Distribution of Malaria Deaths, Sudan Uganda India Malawi Tanzania Mozambique Zimbabwe Demo Rep Congo Ghana Angola

Proportion of Cholera Cases, Sudan Somalia Pakistan Zambia Tanzania Mozambique Demo Rep Congo Ghana Angola

What lies ahead?

Global projections for selected causes, 2004 to 2030 Updated from Mathers and Loncar, PLoS Medicine, 2006 Cancers Stroke Perinatal Road traffic accidents HIV/AIDS TB Malaria Acute respiratory infections Ischaemic HD

If the burden of disease and death is not fairly distributed… is the risk? What are the opportunities for intervention?

Cost effectiveness by itself is relevant for achieving the best overall health, but not necessarily for the second health goal, that of reducing inequities. Populations with worse than average health may respond less well to an intervention, or it may cost more to reach or to treat certain population. If we have a concern for inequities we should be willing to sacrifice some overall health gains for criteria that are not all based on cost effectiveness (World Health Organization 2000)

SOURCE: WHO World Health Report 2002.

Access to Water: Privatization of a public good

Access to Water

Health Systems Strengthening and the Early Assessment of Interventions Historical perspective: Primary health care interventions: the technologies that were felt would make a difference Health For All By the Year 2000 Primary health/primary health care (selected pkg) Maternal child health Adequate supply of safe water and sanitation Immunization, prevention of endemic diseases Promotion of food supply and nutrition Education around prevailing health problems and methods of prevention and control

A Systems Solution The way that a health system is designed, financed and operated has the potential to act as a powerful determinant of health.

What is a Health System? A health system comprises all health actions whose primary intent is to improve health

Health System Health Information Systems Data for Decision-making Research for Development (Evidence-Based planning and policy-making) Evidence-Based Decision-Making (Clinical and Community-based) Health Human Resources Health Financing and Resource Allocation Service delivery - treatments and programs Community interventions and health promotion Stewardship and Leadership Transparent and Accountable Public/Private Sector Strong and vibrant Civil Society Social Deter- minants of Health Frame work “ Health in all policies ” Vision: Equity and Accountability

Sustainable Health Systems What is a Sustainable Health System? –Cost effective –Maintains and improves health –Appropriate interventions –Needs based –Integrates inter sectoral intervention policy approaches Sustainable Health System

Addressing the determinants of health such as literacy, income and employment which are likely inequitably distributed in any country and more so where poverty is higher has been an important strategy How transferable is the determinants of health model at a global level? Is it more or less relevant in the global context? What role does literacy, poverty, employment play in terms of health status? Vision: Equity, Population Health

Policies which support health? We need to acknowledge the interrelationships at the policy level (Ministries of Education, Youth, Environment, Transportation). Nurses need to be prepared to work in policy environments outside of the health care system and the health system A good and safe road: a better predictor of maternal mortality? Health In All Policies: Inter Sectoral Policy Development

World Health Expenditure Data (% of GDP) SOURCE: WHO (2002) Patterns of Global Health Expenditures: Results for 191 Countries EIP/HFS/FAR Discussion Paper No. 51

Extending Prepayment Protecting families from catastrophic expenditures Including the poor Choices of health interventions for resource allocation Health Systems Financing

Balancing personal and public health services Improving quality in service provision Competition among health care providers Health Systems Financing Provision

Issues of human resource development including policy support, appropriate training and allocation which includes community based outreach are critical components for training. In an LMIC context: Professionals should ideally be a mix of health and social professionals A well trained cadre of community based workers who can carry out initial assessments, administer simple medications and other interventions in outreach as well as clinic based situations is essential Human Resource Development

Supply/ demand of human resources Investment decisions concerning technology and its acquisition and use Investment in knowledge This year, this week at the WHA, a resolution on health worker migration will be considered Human Resource Development Resource Generation

Why a strong health system is important “Throwing more money at the diseases and not at the systems is not going to be productive.”(Bernard ) “Having a weak health system not only makes it hard to scale up the response; it also means that the health system starts to get weaker, through burn-out of staff and through other” systematic breakdowns resulting from excessive stresses upon the system.”

World distribution of health workers (2006)

Why is this an important element of a health system and what is the role of nursing research? What can be or should be done with research results to strengthen primary care? What about community based research? How will such research give insights into equity and health? Who has heard about the Global Health Research Initiative? Research For Development

If it is important that primary and secondary care policies and planning are reinforced through a culture of social justice, equity and evidence Capacity to utilize reliable, valid data for decision making for resource allocation to improved primary care service delivery needs to be enhanced Capacity development at the municipal level for effective planning and resource allocation targeted at priority areas is needed for these shifts in resources to occur Capacity Building for Planning Evidence Based Resource Allocation

The Impact of Decentralization on Planning National Local Community Continuum of Health Response Problem Identification Data Analysis Intervention, Prevention Strategies Local Needs coordination Programs & Services Capacity is not being developed and sustained at the right level Money remains at the national level Data Collection Policy Devt

Evidenced based planning and resource allocation within a health systems context relies and requires an integrated health information system (institutionally based and population based. A more integrated population based information system which gathers information inside and outside the institutions that deliver care is required Nurses are often in an ideal situation to be aware of the situation, have the relationships with communities and households and know what information is reliable and useful. These data can inform decision makers and agents of change such as civil society about the entire population, eg., those who are not accessing essential health and social services, those who are accessing prevention programs and what is their relative impact and most importantly where do key inequities exist Integrated health information systems: data for decision making

Core to any health system. Unless access to treatment services and programs is present, the health of a population will not be improved. Services and programs need to fairly or equitably distributed to ensure that access is fair, ie affordable, available and appropriate.. Strengthen the policy uptake overall and in particular strengthen primary care services and programs access to treatment, services and programs Equitable access to treatment, services and programs

Basing intervention and promotion programs in the community enhances the opportunities for better access and availability and the cost effectiveness of such approaches suggests they should be promoted “Resourcing” of such programs allows for a more equitable distribution and likely a resulting positive health impact Are we providing the right training to delivery effective community interventions and health promotion programs? In Canada? Globally? Community Interventions and Health Promotion Programs

It is essential that decision makers, whether at the policy level or the program or clinical level have the information, knowledge, and analysis that will inform their decisions. Do we have an environment supportive of evidence, knowledge translation and uptake which will change nursing practice? Evidence based decision making needs to be supported by practitioners (doctors and nurses) whether for policies, or best practices based on evidence for clinical interventions such as medications, or surgery, or best practices for community interventions and programming are integral to primary care. How can we train those practitioners (doctors and nurses) already in decision making positions or create an environment in which evidence and KT are accepted and institutionalized? Are we prepared to do this at a global level with international partners? Evidence based Decision Making (Clinical and Community based)

Should we deal with the average or mean or the margins ie those who would be at the margin in terms of effectiveness evidence? This is at the heart heart of the equity issue. How can we determine whether an intervention works at the margins if we do not collect such evidence? Need to determine the best approaches to approaching, addressing and integrating health needs into primary care approaches Evidence based Decision Making (Clinical and Community based)

The active participation of civil society in the design, implementation and monitoring/assessment of programmes is an essential element of a successful public health/primary care strategy. Civil society keeps government’s feet to the fire on issues of social justice, raises awareness, demands transparency and accountability which relies on evidence and can positively influence the direction in which a government invests and allocates its resources to improve health and well being Strong and vibrant civil society

A responsive, transparent and accountable public sector which will support, embrace and sustain the policies, activities and programs is key to a sustainable health system. Mutual trust, and progress will only be achieved if these elements are strong and visible within the public sector and there is transparent partnership with the private sector. Transparent and Accountable Public/Private Sector

Principles of social justice and equity should be embedded in a health system What is required is civil society to be vigilent, especially in LMIC. These principles for a well functioning public sector which carries its stewardship functions are ones which are reinforced by a vibrant civil society which is respected and listened to as change occurs Transparent and Accountable Public/Private Sector

Article 25 Universal Declaration of Human Rights: “Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.”

Useful Websites and Other References Davey S. (2002) The 10/90 Report on Health Research 2001 – Global Forum for Health Research: Helping Correct the 10/90 Gap. Geneva, Switzerland. Islam A. (2003). The Millennium Development Goals: Basis for Enhanced Partnership and Cooperation. PowerPoint presentation to the APA/ICPD Meeting, Ottawa, 26 August MacKay Dr. J. and Eriksen Dr. M. (2002) The Tobacco Atlas. The World Health Organization. Brighton, UK: Myriad Editions Ltd. Murray C.J.L. and Lopez A.D. (eds.) (1996). The Global Burden of Disease. Cambridge, MA: Harvard University Press. Murray C.J.L. and Lopez A.D. (1997) “Mortality by cause for eight regions of the world: Global Burden of Disease Study.” The Lancet. 349: 1269 – Nacro K. (2003). Millennium Development Goals in UNFPA’s Work toward Poverty Reduction. PowerPoint presentation to the APA/ICPD Meeting, 26 August Poullier P. (2002) Patterns of Global Health Expenditures: Results for 191 Countries. WHO EIP/HFS/FAR Discussion Paper No. 51. Retrieved 4 September 2003 from Tejada de Rivero D.A. (2003) “Alma-Ata Revisted.” Perspectives in Health: The Magazine of the Pan American Health Organization (PAHO). 8(2): 3 – 7. The Global Fund. (2003) The Global Fund to Fight AIDS, Tuberculosis and Malaria; Brochure.

References (cont.) UNAIDS United Nations Population Fund (UNFPA). Population, Reproductive Health and the Millennium Development Goals: How the ICPD Programme of Action Promotes Poverty Alleviation and Human Rights. Brochure. UNFPA. Population, Reproductive Health, Poverty and the MDGs. Brochure. UNFPA (2003). The Impact of HIV/AIDS: A Population and Development Perspective. Population and Development Series No. 9. New York, NY. World Bank. Poverty Reduction Strategy Paper (PRSPs) World Health Organization (WHO). (1996) The Global Burden of Disease. Retrieved 28 August 2003 from WHO (2000). HIV, TB and Malaria – Three Major Infectious Diseases Threats: Background for the G8 discussions No. 1. Retrieved 29 August 2003 from WHO (2002a). Tuberculosis: Fact Sheet No Retrieved 28 August 2003 from WHO (2002b). World Health Report Retrieved 28 August 2003 from WHO (2005) Chronic Disease. Retrieved January from