Global health 110617
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Global health 110617



© Copyright Jean-Pierre Unger 2001

© Copyright Jean-Pierre Unger 2001



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  • You give a lot of weight to HIV-AIDS in your presentation!
  • Polarizing??
  • 1. Create or strengthen or create around existing MoH services

Global health 110617 Global health 110617 Presentation Transcript

  • From Global Health to Publicly Oriented Local Health… Systems J.-P. Unger, senior lecturer Institute of Tropical Medicine, Antwerp, Belgium   First European Seminar on Global Health Organised by the European Commission Brussels, June the 27 th , 2011
  • Plan
    • Global health definitions
    • Global Epidemiological and Demographical Challenges
    • No global health without LMIC health systems
    • Strategic priorities
    • A role for the EU
  • 1. Conflicting concerns on global health definition ?
    • Political issues attached to global health definition
    • Industrialised countries stressed LMIC-born pandemics prevention
    • Malaria, AIDS, TB
    • SARS, avian-flu, H1N1, Ebola
    • Low and Middle Income Countries (LMIC, & IHP+) want strengthening health systems
    • Poor access to care = generalised torture (by toothache or renal colitis)
    • (2000, UNDP: > 50% LIC population ?)
    • Avoidable suffering linked to poor access  political instability
  • A common North South concern
    • U nder utilisation of available resources
    • Internal brain drain
    • Bureaucratic proliferation
    •  Transaction costs of current international aid +++
  • Total annual resources needed for AIDS under disease specific organisation pattern 17th March, 2011 European Parliament Funding gap
  • 2. Contemporary epidemiological and demographical global challenges
    • communicable diseases: 11 million deaths yearly.
    • chronic diseases: above 10 million deaths yearly
    • By 2020, mental depression will be LMIC leading morbidity cause
    • SARS, avian and swine flus, Ebola, …:
      • News papers headlines
      • Very limited casualties so far in the last 50 years
      • potential risks
  • Epidemiological challenges
      • But prevention of multiresistance
      • = largely absent of international programs
    cases deaths CFR date SARS 8422 916 10,88 02.11-0307 H1N1 57000000 ± 15000 0,03  10.02 H5N1 561 328 58,47 03-11.06 Ebola 1280 940 73,44 97-07 MR-TB 440000 150000 34,09 each year Hospital acquired infections (USA only) 1700000 99000 5,82 2002
  • Demographic challenges
    • Ageing:
      • Big part of overall chronic diseases mortality
      • Health financing problems
    • migrations
      • Rural / urban
      • North South
      •  political and health problems
    • Nineties: 100 million females deficit in Asia.
    • Today, much more.
  • Failure to reach (the quite limited) MDGs
    • % adults HIV + = stable since 2000: 33 million
    • ± 40% of PLWHA needing treatment were receiving the medicines, far from the 100% aimed at in 2010
    • TB prevalence in Africa: 1990-2007: +47%
    • Non-health MDGs: Health care expenditure = the main cause of falling into poverty
  • 3. Why this failure to control diseases? A negative feedback loop
    • For success, disease control programmes need patients consulting for various symptoms = pool of users needed for detection
    • Unfortunately, international policies allocate patients to private sector and disease control to public
    • Furthermore, disease control programs limit access to care in those services where they are integrated (e.g. services with a social mission)
    • QED (with math model)
  • 3. Demands on health systems to tackle global challenges
    • H1N1, H5N1, SARS demand
    • early and large access to care
    • MR-malaria, MR-TB or HAI demand
    • Adherence
    • Continuity of care
    • Access to hospital
    • Communication between first line and hospital
    • Implementation of standard treatments
    • Effective regulation
  • Consequence
    • Strengthening LMIC health systems should be (re)conceived while introducing a new MDG:
    • Universal access to multifunction, quality health care
    • Multifunction care = family medicine care + general hospital care
  • Indicators to assess health system strengthening and communicate on governance
    • access to professional first line health care (expressed in number of sickness episodes per year per inhabitant ) and
    • hospital admission rates
    • Indicators of care quality (e.g. disease specific case fatality rates)
  • Such care should meet simple quality criteria
    • Care should be
    • continuous (to avoid resistance to antiretroviral and TB statics)
    • integrated (to enable the patient moving to the appropriate program and reduce bureaucratic costs)
    • bio-psychosocial (to be effective /acceptable)
    • effective e.g. tuberculosis case fatality rate
    • efficient
  • 4. Strategies to strengthen health systems in LMIC
    • Health insurances failed to secure access to care
    • Colombia 1997-2003:
      • insurance coverage rate from 54% up to 62% but
      • outpatient consultation rate 23.8% down to 9.5%
    • Peru 2007 – 2008:
      • social Insurance coverage from 42,7 up to 63,5% in extremely poor population and from 26.6 to 44.7 in the other but
      • those who didn ’ t consult increased from 50.5 to 56%
    • Ghana 2007 -2009:
      • insurance coverage increasing from 0% to 60% but
      • user fees increased from 9 to 11% of total health expenditure
  • Insurance universal coverage, a fashionable strategy….unlikely to work
    • All these examples point to the existence of significant non-financial barriers to access to individual health care
    • and to limited effectiveness of health insurance in LMIC
  • What to do?
    • Let ’ s not target public health financing on the poor if we want national solidarity and equity
    • Let ’ s export the principles of the European health financing system
  • Financing: supply side financing doesn ’ t permit to only finance MOH services !! Taxes (or Bismarkian) National health fund MoH MoH services Not for profit private org. Commercial sector Individuals Social sector Demand-side financing
  • Promote a health sector with a social mission MoH private Disease control X Health care X
  • Promote a health sector with a social mission Mission Status Social Commercial MOH Care + Disease control Care private Care + Disease control Care
  • What to do?
    • Integrate and strengthen the publicly oriented , socially motivated health care delivery sector
    • Integrate the administration of disease control programs into general health care management
    • Strengthen bio-psychosocial care in first line
    • Strengthen general hospitals
    • Coordinate first line services + Hospital in a local health system
    • Facilitate field experiments and bottom up flows of information towards national health policies
  • 17th March, 2011 Addressing fragmentation Local health systems H Interinstitutional management of local health systems Interinstitutional, professional management and decentralised budgets
  • European Parliament Methods in health policy research, health care management and planning
  • 5. Which role for the EU?
    • promoting peace and stability while
    • Responding to peoples ’ demand for individual health care
    • Preventing and early detecting pandemics
    • Thus strengthen health systems while making health care acceptable
    • Implications for care quality, systems functions, development strategies and management
  • 5. Which role for the EU?
    • Europe has the world largest experience in securing access to good health care
    • Let ’ s use it in technical assistance to support
    • Integrated local health systems with a social mission
    • And let ’ s negotiate EU support against decent public financing of health care delivery in socially motivated health services