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Global health 110617


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© Copyright Jean-Pierre Unger 2001

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Global health 110617

  1. 1. 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
  2. 2. Plan <ul><li>Global health definitions </li></ul><ul><li>Global Epidemiological and Demographical Challenges </li></ul><ul><li>No global health without LMIC health systems </li></ul><ul><li>Strategic priorities </li></ul><ul><li>A role for the EU </li></ul>
  3. 3. 1. Conflicting concerns on global health definition ? <ul><li>Political issues attached to global health definition </li></ul><ul><li>Industrialised countries stressed LMIC-born pandemics prevention </li></ul><ul><li>Malaria, AIDS, TB </li></ul><ul><li>SARS, avian-flu, H1N1, Ebola </li></ul><ul><li>Low and Middle Income Countries (LMIC, & IHP+) want strengthening health systems </li></ul><ul><li>Poor access to care = generalised torture (by toothache or renal colitis) </li></ul><ul><li>(2000, UNDP: > 50% LIC population ?) </li></ul><ul><li>Avoidable suffering linked to poor access  political instability </li></ul>
  4. 4. A common North South concern <ul><li>U nder utilisation of available resources </li></ul><ul><li>Internal brain drain </li></ul><ul><li>Bureaucratic proliferation </li></ul><ul><li> Transaction costs of current international aid +++ </li></ul>
  5. 5. Total annual resources needed for AIDS under disease specific organisation pattern 17th March, 2011 European Parliament Funding gap
  6. 6. 2. Contemporary epidemiological and demographical global challenges <ul><li>communicable diseases: 11 million deaths yearly. </li></ul><ul><li>chronic diseases: above 10 million deaths yearly </li></ul><ul><li>By 2020, mental depression will be LMIC leading morbidity cause </li></ul><ul><li>SARS, avian and swine flus, Ebola, …: </li></ul><ul><ul><li>News papers headlines </li></ul></ul><ul><ul><li>Very limited casualties so far in the last 50 years </li></ul></ul><ul><ul><li>potential risks </li></ul></ul>
  7. 7. Epidemiological challenges <ul><ul><li>But prevention of multiresistance </li></ul></ul><ul><ul><li>= largely absent of international programs </li></ul></ul>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
  8. 8. Demographic challenges <ul><li>Ageing: </li></ul><ul><ul><li>Big part of overall chronic diseases mortality </li></ul></ul><ul><ul><li>Health financing problems </li></ul></ul><ul><li>migrations </li></ul><ul><ul><li>Rural / urban </li></ul></ul><ul><ul><li>North South </li></ul></ul><ul><ul><li> political and health problems </li></ul></ul><ul><li>Nineties: 100 million females deficit in Asia. </li></ul><ul><li>Today, much more. </li></ul>
  9. 9. Failure to reach (the quite limited) MDGs <ul><li>% adults HIV + = stable since 2000: 33 million </li></ul><ul><li>± 40% of PLWHA needing treatment were receiving the medicines, far from the 100% aimed at in 2010 </li></ul><ul><li>TB prevalence in Africa: 1990-2007: +47% </li></ul><ul><li>Non-health MDGs: Health care expenditure = the main cause of falling into poverty </li></ul>
  10. 10. 3. Why this failure to control diseases? A negative feedback loop <ul><li>For success, disease control programmes need patients consulting for various symptoms = pool of users needed for detection </li></ul><ul><li>Unfortunately, international policies allocate patients to private sector and disease control to public </li></ul><ul><li>Furthermore, disease control programs limit access to care in those services where they are integrated (e.g. services with a social mission) </li></ul><ul><li>QED (with math model) </li></ul>
  11. 11. 3. Demands on health systems to tackle global challenges <ul><li>H1N1, H5N1, SARS demand </li></ul><ul><li>early and large access to care </li></ul><ul><li>MR-malaria, MR-TB or HAI demand </li></ul><ul><li>Adherence </li></ul><ul><li>Continuity of care </li></ul><ul><li>Access to hospital </li></ul><ul><li>Communication between first line and hospital </li></ul><ul><li>Implementation of standard treatments </li></ul><ul><li>Effective regulation </li></ul>
  12. 12. Consequence <ul><li>Strengthening LMIC health systems should be (re)conceived while introducing a new MDG: </li></ul><ul><li>Universal access to multifunction, quality health care </li></ul><ul><li>Multifunction care = family medicine care + general hospital care </li></ul>
  13. 13. Indicators to assess health system strengthening and communicate on governance <ul><li>access to professional first line health care (expressed in number of sickness episodes per year per inhabitant ) and </li></ul><ul><li>hospital admission rates </li></ul><ul><li>Indicators of care quality (e.g. disease specific case fatality rates) </li></ul>
  14. 14. Such care should meet simple quality criteria <ul><li>Care should be </li></ul><ul><li>continuous (to avoid resistance to antiretroviral and TB statics) </li></ul><ul><li>integrated (to enable the patient moving to the appropriate program and reduce bureaucratic costs) </li></ul><ul><li>bio-psychosocial (to be effective /acceptable) </li></ul><ul><li>effective e.g. tuberculosis case fatality rate </li></ul><ul><li>efficient </li></ul>
  15. 15. 4. Strategies to strengthen health systems in LMIC <ul><li>Health insurances failed to secure access to care </li></ul><ul><li>Colombia 1997-2003: </li></ul><ul><ul><li>insurance coverage rate from 54% up to 62% but </li></ul></ul><ul><ul><li>outpatient consultation rate 23.8% down to 9.5% </li></ul></ul><ul><li>Peru 2007 – 2008: </li></ul><ul><ul><li>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 </li></ul></ul><ul><ul><li>those who didn ’ t consult increased from 50.5 to 56% </li></ul></ul><ul><li>Ghana 2007 -2009: </li></ul><ul><ul><li>insurance coverage increasing from 0% to 60% but </li></ul></ul><ul><ul><li>user fees increased from 9 to 11% of total health expenditure </li></ul></ul>
  16. 16. Insurance universal coverage, a fashionable strategy….unlikely to work <ul><li>All these examples point to the existence of significant non-financial barriers to access to individual health care </li></ul><ul><li>and to limited effectiveness of health insurance in LMIC </li></ul>
  17. 17. What to do? <ul><li>Let ’ s not target public health financing on the poor if we want national solidarity and equity </li></ul><ul><li>Let ’ s export the principles of the European health financing system </li></ul>
  18. 18. 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
  19. 19. Promote a health sector with a social mission MoH private Disease control X Health care X
  20. 20. Promote a health sector with a social mission Mission Status Social Commercial MOH Care + Disease control Care private Care + Disease control Care
  21. 21. What to do? <ul><li>Integrate and strengthen the publicly oriented , socially motivated health care delivery sector </li></ul><ul><li>Integrate the administration of disease control programs into general health care management </li></ul><ul><li>Strengthen bio-psychosocial care in first line </li></ul><ul><li>Strengthen general hospitals </li></ul><ul><li>Coordinate first line services + Hospital in a local health system </li></ul><ul><li>Facilitate field experiments and bottom up flows of information towards national health policies </li></ul>
  22. 22. 17th March, 2011 Addressing fragmentation Local health systems H Interinstitutional management of local health systems Interinstitutional, professional management and decentralised budgets
  23. 23. European Parliament Methods in health policy research, health care management and planning
  24. 24. 5. Which role for the EU? <ul><li>promoting peace and stability while </li></ul><ul><li>Responding to peoples ’ demand for individual health care </li></ul><ul><li>Preventing and early detecting pandemics </li></ul><ul><li>Thus strengthen health systems while making health care acceptable </li></ul><ul><li>Implications for care quality, systems functions, development strategies and management </li></ul>
  25. 25. 5. Which role for the EU? <ul><li>Europe has the world largest experience in securing access to good health care </li></ul><ul><li>Let ’ s use it in technical assistance to support </li></ul><ul><li>Integrated local health systems with a social mission </li></ul><ul><li>And let ’ s negotiate EU support against decent public financing of health care delivery in socially motivated health services </li></ul>
  26. 26. 17th March, 2011 European Parliament THANK YOU DANK U DANKE SCHÖN ευχαριστώ GRAZIE DZIĘKUJĘ OBRIGADO GRACIAS MERCI