Emerging issues in health care in developing countires

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Emerging issues in Health care in developing countries, Shaping a fairer and effective health care delivery, Social determinants of health as urgent imperative, good health at low cost, vicious cycle …

Emerging issues in Health care in developing countries, Shaping a fairer and effective health care delivery, Social determinants of health as urgent imperative, good health at low cost, vicious cycle of poverty and ill-health, Das 2013.

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  • 1. EMERGING ISSUES IN HEALTH CARE IN DEVELOPING COUNTRIES: SHAPING A FAIRER AND EFFECTIVE HEALTH CARE DELIVERY Dr. Shankar Das Introductory Lecture 17th June 2013, TISS, Mumbai shankardass07@gmail.com SDas/2013
  • 2. Objectives: (Trends, Experiences, Priorities, and Lessons)  Changing Health scenario: epidemiological transition  Health Indicators and contextual realities  Social determinants: an urgent imperative  Some bottlenecks of health care delivery  Lessons learned global/local  Way forward SDas/2013
  • 3. EVELOPING COUNTRIES  Developing countries are characterized by relatively high population growth rates, low gross national product (GNP) per capita, low standards of living, including poor standards of health ,education housing and sanitation.  DCs contain about 75% of world’s population but have only 12% of world’s GNP (WB,2001) South-East Asia region European region Western Pacific region African region Region of the Americas Eastern Mediterranean region WHO regions SDas/2013
  • 4. DISTRIBUTION POPULATION & WEALTH (GNP) (WB 2001) SDas/2013
  • 5. EPIDEMIOLOGICAL TRANSITION IN DEVELOPING COUNTRIES SDas/2013 As life expectancy increases…….. Major causes of death & disability shift from communicable to non-communicable ones. In the developing world: Dual Disease Burden Firstly unfinished agenda of dealing with infectious diseases e.g. TB and malaria Secondly, emerging epidemic of HIV/AIDS and rise of non-communicable diseases in developing countries. According to WHO (2000), there has been an increase in the consumption of alcohol and tobacco and an adoption of unhealthy lifestyles synonymous with a “Western life style” resulting in increased incidence of obesity, diabetes, cardiovascular diseases etc. Meanwhile, the burden of infectious disease remains. Combined impact of communicable and non-communicable diseases, has been described as a “double whammy”.
  • 6. DEATH BY COMMUNICABLE & NON-COMMUNICABLE DISEASES (ESTIMATES FOR 2002) SDas/2013 Injuries (9.1%) Noncommunicable conditions (58.6%) of which 50% are due to CVD Communicable diseases, maternal and perinatal conditions and nutritional deficiencies (32.3%) Total deaths: 57,027,000 Source:WHO, WHR, 2003
  • 7. 0 1000 2000 3000 4000 5000 6000 7000 8000 Unsafe health care injections Vitamin A deficiency Zinc deficiency Urban air pollution Iron deficiency Indoor smoke fromsolid fuels Unsafe water, sanitation, and hygiene Alcohol Physical inactivity High Body Mass Index Fruit and vegetable intake Unsafe sex Underweight Cholesterol Tobacco Blood pressure High Mortality Developing Countries Low Mortality Developing Countries Developed Countries World Deaths in 2000 attributable to selected leading risk factors Number of deaths (000s) Source: WHR 2002 SDas/2013
  • 8. Number of persons with diabetes: trends in developed vs. developing countries 0 50 100 150 200 250 2000 2025 millions Developed Developing SDas/2013
  • 9. developing countries. World Health is in Transition Nutritional: Diets are rapidly changing, physical activity reduced. Demographic: Population ageing. Globalization: Increasing global influences. SDas/2013
  • 10. From Traditional to Modern..... Transportation SDas/2013
  • 11. From Traditional to Modern..... Marketing of Food SDas/2013
  • 12. 00 SDas/2013
  • 13. PM’S LETTER TO CHIEF MINISTERS OF EVERY STATE “A number of reports and surveys, including the NFHS-3 …seem to indicate a noticeable decline in the qualitative aspects of the [ICDS] programme. There is strong evidence that the programme has not led to any substantial improvement in the nutritional status of children under six. Our prevalent rate of under-nutrition in this age group remains one of the highest in the world” SDas/2013
  • 14. SDas/2013
  • 15. Countries WHO 194 WHO 2000 Ranking Responsiveness, Fairness, Distribution,Health Status Total % GDP Ex 2008 Life expectancy at birth IMR/1000 live births MMR /1 lakh live births Low Income 1990 2011 1990 2011 1990 2010 Afghanistan 173 7.4 42 48 129 36 1300 460 Bangladesh 88 3.3 54 68 97 26 800 240 Sierra Leone ---- 13.3 40 47 158 49 1300 890 Angola 181 3.3 42 38 144 43 1200 450 LowerMiddle Income 1990 2011 1990 2011 1990 2010 Bhutan 124 5.5 55 67 96 25 1000 180 India 112 4.2 57 65 81 32 600 200 Indonesia 92 2.3 65 68 54 15 600 220 Pakistan 122 2.6 59 65 95 36 490 260 Sri Lanka 76 4.1 68 75 24 08 85 35 Upper MiddleIncome 1990 2011 1990 2011 1990 2010 Brazil 125 8.4 67 73 49 10 120 56 Malaysia 49 4.3 71 74 15 03 53 29 High Income 1990 2011 1990 2011 1990 2010 Australia 32 8.5 77 82 08 03 10 07 Japan 10 8.3 79 83 05 01 12 05 UK 18 8.7 76 80 08 03 10 12 USA 37 15.2 75 78 09 04 12 21 SDas/2013Trends in Ranking, GDP Expenditure, Life Expectancy & Mortality in Selected Countries Compiled from WHO (Global Health Observatory 2012) and World Development Indicator 2011
  • 16. The wealthier the country, the healthier the population, right? Not necessarily. USA has highest health expenditure 15.2% of GDP in the world but health indicators are lower, Life expectancy at 78 with 37th rank on world health ranking. Even if a country becomes wealthier, the population's health may not improve unless the income is used and distributed wisely to promote equality in the various "social determinants of health" – education, employment, basic amenities and gender equality. Some countries and regions with low per-capita wealth, such as China, Costa Rica Cuba and the Indian state of Kerala have improved health regardless (good health at low cost) of a lack of money. Due to tackling social determinants and promoting equity in health, e.g. historic commitment to health as a social goal, social welfare orientation, participatory orientation, equity orientation, inter- sectoral policies for health, linkages between social & economic development. SDas/2013
  • 17. Summary of Causes: Premature Death Source : Shroeder, S. 2007 30% Biological 70% social/environmental SDas/2013
  • 18. …. “Within countries there are dramatic differences in health that are closely linked with degrees of social disadvantage. Differences of this magnitude, within and between countries, simply should never happen. These inequities in health, are avoidable health inequalities, arise because of the circumstances in which people grow, live, work, and age, and the systems put in place to deal with illness. The conditions in which people live and die are, in turn, shaped by political, social, and economic forces” (CSDH 2008). SDas/2013
  • 19. SDas/2013 THE REPORT OF THE COMMISSION ON THE SOCIAL DETERMINANTS OF HEALTH, 2008 “Social injustice is killing people on a grand scale.” - CSDH & WHO, 2008
  • 20. SDas/2013 "(The) toxic combination of bad policies, economics, and politics is, in large measure, responsible for the fact that a majority of people in the world do not enjoy the good health that is biologically possible." - Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health, WHO, 2008
  • 21. WORLD POVERTY PEOPLE LIVING ON LESS THAN $1.25 A DAY WORLD DEVELOPMENT INDICATORS 2008 SDas/2013 •Central problem of the developing countries is Poverty. • ½ the world's population lives on less than $2 a day (World Bank 2001). •Poverty stems not just from a lack of resources, but from lack of entitlement: famines happen, not because there is not enough food, but because poor people are not allowed to eat the food that is there (Amartya Sen). •Economic development is essential to welfare. 48% 37% 2.5% 15%
  • 22. SDas/2013
  • 23. The vicious Cycle of Poverty and Ill-health, Das 2013 SDas/2013
  • 24. SOCIAL DETERMINANTS OF HEALTH  Income and social Status  Social Support networks  Education and literacy, i.e. health literacy  Employment/Working conditions  Social Environments  Physical Environments  Life Skills  Personal health Practices and coping skills  Healthy child development  Biology and genetic endowment  Health Services  Gender  Culture SDas/2013
  • 25. SDas/2013 THE WIDENING TREND IN MORTALITY BY EDUCATION IN RUSSIA, 1989-2001 0.4 0.45 0.5 0.55 0.6 0.65 0.7 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 Calendar year 45p20 elementary university 45 p20 = probability of living to 65 yrs when aged 20 yrs Source: Murphy et al, AJPH, 2006
  • 26. Successful Global Health Initiative SDas/2013
  • 27. Successful Global Health Initiative 1. HIV/AIDS 2. Polio SDas/2013
  • 28. AIDS HAS NOW BECOME A CHRONIC MANAGEABLE DISEASE AND IS NO LONGER A DEATH SENTENCE! Globally, 34.0 million people were living with HIV at the end of 2011. The incidence fell by more than 25% in Cambodia, India, Nepal and Thailand between 2001 and 2009. A recent report by UNAIDS shows that 25 countries, since 2001, have reduced new infections by more than 50% and in the past two years there has been a 60% increase in the number of people accessing life-saving treatment. SDas/2013
  • 29. 2012 SDas/2013
  • 30. SDas/2013
  • 31. SDas/2013
  • 32. SDas/2013
  • 33. POLIO : PARALYSIS AND DEATH  Global Polio Eradication Initiative in 1988  “POLIO ANYWHERE IS A THREAT TO CHILDREN EVERYWHERE”.  Incidence of polio has reduced by 99%  In 1988 from 3,50,000 cases reported from 125 endemic countries  In 2011, 620 cases reported from 16 countries mostly from – India, Nigeria, Pakistan & Afghanistan. SDas/2013
  • 34. Cameroun WORLD - WILD POLIO VIRUS CASES - 2011 650 CASES IN 16 COUNTRIES Pakistan Countries Wild cases 2011 Pakistan 198 Nigeria 62 India 1 Afghanistan 80 DRCongo 93 Chad 132 Cote d'lvoire 36 CAR 4 China 21 Mali 7 Angola 5 Kenya 1 Guinea 3 Congo 1 Niger 5 Gabon 1 Total 650 Chad Afghanistan India Angola DRC Congo Gabon Nigeria Niger Mali Cote d’lvoire Guinea Kenya China CAR WHO India NPSP 2012 SDas/2013
  • 35. Cameroun WORLD - WILD POLIO VIRUS CASES - 2012 202 CASES IN 4 COUNTRIES Pakistan Countries Wild cases 2012 Pakistan 56 Afghanistan 31 Chad 5 Nigeria 110 Total 202 Afghanistan Chad Nigeria * data as on 28 November 2012 WHO India NPSP 2012 SDas/2013
  • 36. Last wild poliovirus cases by type, India WPV2 24/10/1999 Aligarh (UP) WPV1 13/01/2011 Howrah (WB) WPV3 22/10/2010 Pakur (JH) * data as on 30 November 2012 Cases in 2011: 1 (last case 13 January 2011) Cases in 2010: 42 Cases in 2009: 741 Cases in 1991: 6,028 Cases in 1985: 150,000 Pulse Polio Programme Number of Oral Polio Vaccine (OPV) doses administered in 2011: 900 million SDas/2013
  • 37. Location of wild poliovirus and VDPV cases by type, India 2010 2011 State P2 P3 Total Chhattisgarh 1 0 1 Madhya Pradesh 1 0 1 Orissa 0 1 1 Punjab 1 0 1 Rajasthan 1 0 1 Uttar Pradesh 2 0 2 Total 6 1 7 VDPVs State P1 P3 Total West Bengal 1 0 1 Total 1 0 1 WPVs State P1 P2 Total Uttar Pradesh 0 3 3 Karnataka 0 1 1 Tamil Nadu 0 1 1 Total 0 5 5 VDPVs State P1 P3 Total West Bengal 6 2 8 Maharashtra 5 0 5 Bihar 3 6 9 Jharkhand 3 5 8 Jammu & Kashmir 1 0 1 Uttar Pradesh 0 10 10 Haryana 0 1 1 Total 18 24 42 WPVs State P2 West Bengal 1 Total 1 VDPV 2012* * data as on 30 November 2012 January 13, ‘03 India celebrated its 2nd anniversary without a case of polio. SDas/2013
  • 38. The team of public health workers braves harsh weather to reach out to flooded villages in remote embankment areas of Kosi River 2007-2008. They walked barefooted for miles in waist deep water with the vaccine carriers on their back. SDas/2013
  • 39. A sad story of Mental Health SDas/2013
  • 40. Mental disorders account for 5 of the top 10 in Global Burden of Disease (DALY’s) SDas/2013 GLOBAL CONTEXT: HIV/AIDS Uni-polar Depressive Disorders Road Traffic Accidents Tuberculosis Alcohol Use Disorders Self-Inflicted Injuries Iron-deficiency Amaemia Schizophrenia Bipolar Affective Disorder Violence
  • 41. SDas/2013
  • 42. By 2020 depression will be the second most costly (DALYs) disease worldwide 8,50,000 suicides every year are attributed to depression world-wide. (App. 15%) SDas/2013 GLOBAL CONTEXT:
  • 43. SDas/2013
  • 44. SDas/2013
  • 45.  It is very strange only 40% of the countries in the world don’t have mental health policy and over 30% have no special programs related to MBD (WHO2002)  Health plans frequently don’t cover MBD at the same time as other illness.”(WHO Report,2001). SDas/2013 “There is No Health without Mental Health”
  • 46. Some Bottlenecks of health-care delivery SDas/2013
  • 47. FIVE COMMON SHORTCOMINGS OF HEALTH-CARE DELIVERY (WHO 2008) SDas/2013 Inverse care: People with more resources/less health need consume the most care and vice versa. Public spending on health services most often benefit rich more than poor in HLIC . Impoverishing care: People lack social protection and payment for care is largely OOP, often means catastrophic expenses. Over 100 million people annually fall into poverty because they have to pay for health care. Fragmented care: Excessive specialization and narrow focus of many disease control programmes Discourage a holistic approach to health care. Health services for poor are often highly fragmented and severely under-resourced. Developmental aid often adds to the fragmentation. Unsafe care: Poor safety and hygiene standards leads to high rates of hospital-acquired infections. Medication errors and other avoidable adverse effects that are an underestimated cause of death and ill-health. Misdirected care: Resource allocation around curative services at great cost, neglecting the potential of primary prevention and health promotion to prevent up to 70% of the disease burden.
  • 48. GLOBAL CRISIS IN HUMAN RESOURCES FOR HEALTH (1. ROCKEFELLER’S JOINT LEARNING INITIATIVE, 2004, 2. THE WORLD HEALTH REPORT, 2006)  Chronic shortage –well trained health workers  Chronic under investment in human resources  Reasons being - Growing migration (LIC-HIC, Public-Private sector), Illness/death, Training/education, underemployment/unemployment.  Devastation caused by loss of health workers because of HIV/AIDS (Sub-Saharan African countries). SDas/2013
  • 49. We have ample evidence that worker numbers and quality are positively associated with immunization coverage, better PHC delivery, child & maternal survival. So, workforce is central to advancing health. SDas/2013
  • 50. SDas/2013 Asia Latin America North America Africa Oceania Europe Poverty, imperfect private labour markets, lack of public funds, bureaucratic red tape and political interference produce shortages and underutilized talent (WHO 2006). 57withcriticalshortage,2.4million
  • 51. IMPACT OF USER FEE  When fees were introduced or increased, the use of health-care services decreased significantly (Palmer & Lagarde 2011)  When user fees were introduced or increased, people’s use of preventive and curative health-care services decreased.  Infant mortality and maternal mortality increased. SDas/2013
  • 52. SDas/2013
  • 53. Corruption and Health Sector Corruption Mars India’s Health Care System Christopher Potter (ex-programme manager, health and family welfare programme, European Commission) Washington, DC January 30, 2013 World Bank Group President Jim Yong Kim Speech on Anti-Corruption at the Center for Strategic and International Studies Uttar Pradesh, India NRHM Scam is an alleged corruption scandal in which top politicians and bureaucrats are alleged to have siphoned off a massive sum estimated at 10,000 crore (US$1.82 billion). At least five people are said to have been murdered in an attempt to cover-up large-scale irregularities, (TOI Oct.2012). SDas/2013
  • 54. WAY FORWARD SDas/2013 Towards a fairer and effective health care delivery
  • 55. PRIMARY HEALTH CARE SOCIAL DETERMINANTS OF HEALTH SDas/2013 …declaration of Alma-Ata on Primary health Care in 1978, the value still lie at the core of WHO’ commitment. PHC tested and remained true even while the global health context remarkably changed over last three decades…. (Dr. Margaret Chan 2008) A new global agenda for health equity. Final report of the Commission concludes - Inequities are killing people on a "grand scale“. Dr. Chan - "This ends the debate decisively. SHDs are important determinants to achieve health of all. Lifestyles, social environment that determine access to health services and health of poor people.
  • 56. SDas/2013
  • 57. MILLENNIUM DEVELOPMENT GOALS (2000-2015)  Eight Millennium DevelopmentGoals (MDGs) Goal 1: : Eradicate Extreme Hunger and Poverty Goal 2: : Achieve Universal Primary Education Goal 3: Promote Gender Equity & empower women Goal 4: Reduce Child Health Goal 5: Improve Maternal Health Goal 6: Combat HIV/AIDS, Malaria others diseases Goal 7: Ensure Environmental Sustainability Goal 8: Develop a Global Partnership for Development SDas/2013
  • 58. PHC Themes and Values Factors improved health Status : China, Costa Rica, Sri Lanka, Kerala - Good Health at low cost Policy Factors Suggested Indicators •Equity •Social justice •Community Participation •Prevention/Health Promotion •Inter-sectoral Collaboration •Appropriate Use of Resources •Sustainability •Nation-wide coverage 1. Historic commitment to health as a social goal 2. Social welfare orientation 3. 3. Participatory orientation 4. 5. Inter-sectoral policies for health: linkages between social and economic development 6. PHC based on the following principles : (Legislation, Government expenditure, Establishment of hospitals and health centers, missionary influences) (Preventive health measures, Food subsidies, Educational Programs, Land reform ) (Universal Franchise, Extent of decentralization, NGO and community involvement, Health/education/nutritional status of women and minorities, Urban/rural coverage) (Sustained improvement in health statistics, Incentives and mechanisms to ensure linkages, training programmes) SDas/2013
  • 59. SDas/2013 WHO 2008
  • 60. SDas/2013
  • 61. CORE ACTIVITIES OF PRIMARY HEALTH CARE 1. Education concerning prevailing health problems and the methods of preventing and controlling them 2. Promotion of food supply and proper nutrition 3. An adequate supply of safe water and basic sanitation 4. Maternal and child health care, including family planning 5. Immunization against the major infectious diseases 6. Prevention and control of locally endemic diseases 7. Appropriate treatment of common diseases and injuries 8. Basic laboratory services and provision of essential drugs. 9. Training of health guides, health workers and health assistants. 10. Referral services 11. Mental health 12. Physical handicaps 13. Health and social care of the elderly SDas/2013
  • 62. BASIC REQUIREMENTS OF SOUND PHC (THE 8 A’S AND THE 3 C’S) Appropriateness *Actual service needs *Priorities *Proper selection *Trained/qualified personnel Availability *Medical care can be obtained whenever people need it. Adequacy *services proportionate to requirement. * Sufficient volume of care to meet need and demand of a community Accessibility *Reachable *convenient services *Geographic, economic, cultural accessibility Acceptability *Satisfactory & culturally sensitive *communication and care is trustworthy Affordability *Cost should be within the means and resources of the individual Assessability *Medical care can be readily evaluated. Accountability *Feasibility of regular review of financial records by certified public accountants. Completeness *All aspects of a medical problem, including prevention, early detection, diagnosis, treatment, follow up measures, & rehabilitation. Comprehensiven ess *care is provided for all types of health problems. Continuity *management of care over time be coordinated among providers. SDas/2013
  • 63. SDas/2013 Campbell 2010
  • 64. CIVIL SOCIETY  “civil society” the NGOs, Unions, academia, human right organizations and/or institutions composed of lay people sharing common goals and using their common frameworks to advocate for changes to meet their needs. SDas/2013
  • 65. SOME EXAMPLES  Barefoot Doctors, China  Gramin Cooperative Health Movement, Bangladesh  Jan Swasthya Abhiyan, India  Sonagachi Project, India  CRHP, Comprehensive Rural Health Project SDas/2013
  • 66. 1930S’ BAREFOOT DOCTORS ARE FARMERS SDas/2013
  • 67. Some evidence towards people centered health systems SDas/2013
  • 68. GRAMEEN BANK & BRAC SDas/2013 Nobel Laureate Prof. Muhammad Yunus, founder, Grameen Bank, Bangladesh. “The work of Grameen Bank is extremely well and if implemented in the state, would help to finance women and self—help groups. Bangladesh tries to reach to the lowest strata of women and gives them credit. --------------------------------------------------------------------------------------------------------------------- BRAC, in Bangladesh, largest NGO in the world, established by Sir Fazle Hasan Abed in 1972 after the independence of Bangladesh. Present in all 64 districts of Bangladesh as well as in Afghanistan, Pakistan, Sri Lanka, Uganda, Tanzania, South Sudan, Sierra Leone, Liberia, Haiti and The Philippines as of 2012.
  • 69. THE JAN SWASTHYA ABHIYAN The JSA is the Indian circle of the People's Health Movement, a worldwide network of people’s organisations, civil society organisations, NGOs, social activists, health professionals, academics and researchers working to establish health and equitable development as top priorities through comprehensive primary health care and action on the social determinants of health. SDas/2013
  • 70. SDas/2013
  • 71. SONAGACHI PROJECT  The Sonagachi project (1992) is a CSWs' cooperative that operates in Kolkata & empowers CSWs to insist on condom use and to stand up against abuse.  While some are crediting DMSC with keeping a relatively low rate of HIV infection among prostitutes in Sonagachi -- 5.17% of the 13,000 CSWs. (average HIV rate for female CSWs in India is estimated to be 5.1%) SDas/2013
  • 72. CHWS INDIA: THE JAMKHED EXPERIENCE  CRHP, Comprehensive Rural Health Project (Estd. 1970) Founder Drs. Rajnikant & Mabelle Arole bring health care to poorest of poor.  Started hospital but to break caste barriers, helped build wells  1974 farmers did needs survey and ask Aroles to train women as CHWs  Expanded training to focus on ante natal care and income generation  By 1990 had become international training centre  Recipient of Mother Teresa Award (2005), Padma Bhushan (1990) and Ramon Magsaysay (1979), died at the age of 77.  http://www.crhpjamkhed.org/cgi-sys/suspendedpage.cgi This Account has been suspended SDas/2013
  • 73. BASIC PRINCIPLES CONTRIBUTING TO THE CONCEPT OF CIVIL SOCIETY  Social Capital  Democratization  Governance  Human Rights SDas/2013
  • 74. CONCLUSION  Literatures presents great hopes and challenges.  Whether these are met depends on leadership and commitment.  Now is the time for dialogue not diatribe.  Role models are critical. SDas/2013