1. Africa’s health challenge and institutional context
Health Dialogue
4 April 2011
Nairobi

2. Overview Africa’s health challenge Institutional context and reform
Indicators and underlying factors: demand, supply & efficiency
Institutional context and reform
Health system functions
Financing in the African context
Hierarchy of reform
Other reform perspectives & approaches
* Based on an Evaluation of mid-2010

3. Progress but “lags”, and some reversals – life expectancy/death
LE at birth:
Joined world in rapid progress from circa : up from 39 to 50
Significantly lags the world (2008): Africa 53, global 68 (America 76; South-East Asia 65)
Great diversity:
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 to 2008)
Key factors in increasing life expectancy/driving down mortality?
Mortality:
Adult 45q15:
Child mortality:
Maternal mortality: Disproportionate in many but also good progress in some
* Based on an Evaluation of mid-2010

4. Explaining the lag? A Ghana case 2001
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
* Based on an Evaluation of mid-2010

5. Demand for services and disease burden
Disability adjusted life years (DALYs)
Sum of YLL (years of life lost due to death) and YLD (years of healthy life lost as a result of disability)
Classify DALYs according to diagnostic categories to which they are related
Group I – communicable diseases, maternal, perinatal, nutritional conditions
Group II – non-communicable diseases
Group III – injuries
1990 Sub-Saharan Africa/Latin America
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?
Measuring progress; help determine disease control priorities; Evidence for reallocation
* Based on an Evaluation of mid-2010 5

6. Demand for services & disease burden – Leading causes of burden of disease – WHO Africa region
* Based on an Evaluation of mid-2010 6

7. Service provision & access: average and distribution
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
* Based on an Evaluation of mid-2010 7

8. 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 around Abuja target
* Based on an Evaluation of mid-2010 8

9. Supply factors: physicians per 10,000
* Based on an Evaluation of mid-2010 9

10. 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
* Based on an Evaluation of mid-2010 10

11. Looking for reform options: elements of health systems
* Based on an Evaluation of mid-2010 11

12. Looking for reform options: financing systems
Social insurance versus national health systems vs mixed
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
* Based on an Evaluation of mid-2010 12

13. A hierarchy of reforms or policy options
* Based on an Evaluation of mid-2010 13

14. Other reform perspectives/approaches
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 programmes); (donor) coordination (comprehensiveness of budgets)
PFM reform: linking policy & budgets, certainty & credibility (MTEFs), output & performance orientation
* Based on an Evaluation of mid-2010 14