1. Health Sector Reform, Epidemiological and Demographic Challenges or Why We Need More Public Health Capacity in Central Asia Armin Fidler The World Bank

2. 2 Has (Curative) Health Sector Reform Crowded Out Public Health in ECA? Health Reforms over the past decade in FSU Countries emerged from political – economic change Modernized health sector (created building blocks) Started to reverse steep health outcome decline Problems with fiscal sustainability, quality, equity New Challenges – Need modern Public Health Public Health Systems: entrenched legacy of SES Preparedness for new health threats? Surveillance: TB, AIDS, Avian Flu Disease Burden: Economic Impact of Chronic Diseases Priority Setting: Population ageing and demographic challenge

3. 3 Health System Performance Embedded in Economic Performance Sources: World Bank (2002), World Development Indicators 2002, World Bank: ; MONEE project database.

4. 4 Rich Spend More – But Better? Source: HFA database/World Bank 2004 EU-15: 8.9 (2004) Central, South East Europe & Baltics: 5.8 (2004)

5. 5 Health Spending Outgrows Total Public Expenditures in High Income Countries

6. 6 And So Do Pharmaceutical Expenditures … Total Pharmaceutical Expenditure % Total Health Care Expenditure, World Bank, 2004

7. 7 How To Contain Pressures On Spending While Focusing on Results? Address inherited oversupply of hospital infrastructure Progress slow in most countries Only Estonia seems to have tangible results to show Optimize benefits package: Co-payments: focus on equity + access for vulnerable PHC/Family Medicine: Solve problems, gate-keeping Health financing to focus on purchasing not paying Contractual relationships with providers are still rare Manage pharmaceutical expenditures + medical technology: Price regulation versus quantity (Total cost = unit cost x quantity) HTA rarely used. Recurrent (operating costs) for HT! Conundrum: Wages, Migration

8. 8 Widening Health Gap EU - FSU Note: Calculations based upon current "life tables" for the year 2004. "Europe" includes countries outside of the EU-15. Source: World Health Organization Life Tables, 2004,

9. 9 AIDS in Russia – World Bank Model Demographic Results (Optimistic) GDP falls 4.15% (2010) and 10 Economic Results (Optimistic) Dramatic impact absent prevention/treatment - Mortality from 500/mo. (2005) to 21,000/mo. (2020) - Cumulative HIV+ from 1.2 mln (2005) to 5.4 mln (2020) Prevention high cost-benefit as long as ARV price > $300/person/year (Pess)

10. 10 Shrinking Populations (000) Russia-18, 103 Ukraine-7, 272 Romania-1, 774 Bulgaria-1, 364 Belarus-1, 063 Hungary-991 Czech-710 Latvia-375 Georgia-319 Croatia-283 Lithuania-198 Estonia-165 Moldova-161 Slovenia-107 Slovakia-3 Expanding Populations (000) Turkey +19, 666 Uzbekistan +9, 257 Tajikistan +2, 594 Turkmenistan +1, 937 Azerbaijan+1, 562 Kyrgyzstan +1, 507 Albania +856 BiH+424 Kazakhstan +364 Armenia +263 ECA 2000-2025: Little Change In Population Size Including Russia And Turkey: +5 Million People

11. 11 Sources: The Demographic Yearbook of Russia: 1993 (State Committee of the Russian Federation on Statistics, Moscow, 1993), Table 2.5; The Demographic Yearbook of Russia: 2004 (State Committee of the Russian Federation on Statistics, Moscow, 2004), Table 2.6; Human Mortality Database, available online at www.mortality.org, accessed January 20, 2005.www.mortality.org

12. 12 Spill-Over Into Other Sectors: Impact on productivity, savings and growth: Downward pressures on production and incomes from shrinking labor forces combined with high labor taxes Changes in public and private savings rates have public expenditure and investment impact. High morbidity and premature mortality has real impact on GDP (Russia model) Social Protection – Social Risk Mitigation: Pension systems, health financing + insurance (including for long-term care), and individual savings must be in place, or elderly may fall into deprivation. Strengthen the mechanisms to provide social services to the elderly, especially home-based institutions (evidence of cost- effective assisted living compared to institutionalization).

13. 13 Resources and Aging: Who is Prepared? Source: United Nations Secretariat, World Population Prospects: The 2004 Revision and World Urbanization Prospects: Maddison, Angus. The World Economy: Historical Statistics. (Development Centre Studies, OECD)

14. 14 Does Anyone Still Talk About Public Health? Health financing arrangements and curative health systems changed over the past decade New incentives, more market, “ medicalization ” of health Many Western countries no good role models! Public health practice and training is lagging behind Few evidence-based, internationally accredited local training opportunities Low professional status of PH, few well trained professionals Powerful SES, but highly resistant to change and modernization But the capacity of a health system to deal with future challenges largely depends on functioning public health system Emerging infectious diseases (HIV, TB); Burden of chronic diseases, injuries, life-style determinants, aging

15. 15 Evaluation of ECA Surveillance Systems WB/CDC 2004 Completeness, timeliness, quality poor Surveillance and vital statistics overly complex and lacking integration Duplicate/parallel reporting with different results Generalizability, representativity, validity poor Infectious diseases: long history but few resources Morbidity reporting: excess data, large staff; aggregate summaries, de-linked variables Risk factor surveillance – still in its infancy, limited population coverage Most FSU countries still use Semashko model!

16. 16 Surveillance + Intelligence Functions Determining priorities and guiding evidence-based health programs Developing health policies and assessing health system needs Documenting health care and planning long-term strategies Monitoring effectiveness of prevention and increasing public awareness Proposing/supporting legislation Informing resource allocation decisions and preparing proposals for funding

17. 17 EU Example: Reducing Mortality Largely Depends On Public Health Policy

18. 18 Free Movement of Infectious Agents? (and what would happen in case of an Avian Flu Pandemic?) Wider European Neighbourhood Russian Federation Ukraine United Kingdom Tuberculosis incidence per 100,000 0 10 20 30 40 50 60 70 80 90 100 198019902000 Belarus

19. 19 Changes In Population Structures: Implications for Service Need + Resource Allocation AGED AGING YOUNG

20. 20 A Call For Action: Political, economic, epidemiological and demographic transition poses far reaching implications for the 21 st century for health and social systems. FSU may see fast increasing health and social expenditures which (unchecked) may cause strains on fiscal performance, and equity concerns. While NMS may catch up with EU average health outcomes over next decade, many FSU countries are falling further behind in most health indicators. Health Reforms seem often biased: Either, towards health financing and systems modernization - Or, investment in infrastructure and equipment or other inputs But: both are often crowding out urgently needed investments in public health and evidence-based medicine!