Emerging issues in health care in developing countires

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
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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
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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
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DISTRIBUTION POPULATION & WEALTH (GNP)
(WB 2001)
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EPIDEMIOLOGICAL TRANSITION IN
DEVELOPING COUNTRIES
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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”.

DEATH BY COMMUNICABLE & NON-COMMUNICABLE
DISEASES (ESTIMATES FOR 2002)
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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

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
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Number of persons with diabetes:
trends in developed vs. developing countries
0
50
100
150
200
250
2000 2025
millions
Developed
Developing
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developing countries.
World Health is in Transition
Nutritional:
Diets are rapidly changing,
physical activity reduced.
Demographic: Population ageing.
Globalization: Increasing global influences.
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From Traditional to Modern.....
Transportation
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From Traditional to Modern.....
Marketing of Food
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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”
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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

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.
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Summary of Causes: Premature Death
Source : Shroeder, S. 2007
30% Biological
70% social/environmental
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…. “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).
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THE REPORT OF THE COMMISSION ON THE SOCIAL
DETERMINANTS OF HEALTH, 2008
“Social injustice is killing people
on a grand scale.”
- CSDH & WHO, 2008

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"(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

WORLD POVERTY
PEOPLE LIVING ON LESS THAN $1.25 A DAY
WORLD DEVELOPMENT INDICATORS 2008
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•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%

The vicious Cycle of Poverty and Ill-health, Das 2013
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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
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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

Successful Global Health Initiative
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Successful Global Health Initiative
1. HIV/AIDS
2. Polio
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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.
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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.
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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
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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
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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)
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
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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*
January 13, ‘03
India celebrated its
2nd anniversary
without a case of
polio.
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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.
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A sad story of Mental Health
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Mental disorders account for 5 of the top 10
in Global Burden of Disease (DALY’s)
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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

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%)
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GLOBAL CONTEXT:

 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).
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“There is No Health without Mental Health”

Some Bottlenecks of health-care delivery
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FIVE COMMON SHORTCOMINGS OF HEALTH-CARE DELIVERY (WHO 2008)
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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.

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).
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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.
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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

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.
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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).
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WAY FORWARD
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Towards a fairer and effective health care delivery

PRIMARY HEALTH CARE
SOCIAL DETERMINANTS OF HEALTH
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…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.

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
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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)
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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
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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.
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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.
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SOME EXAMPLES
 Barefoot Doctors, China
 Gramin Cooperative Health Movement,
Bangladesh
 Jan Swasthya Abhiyan, India
 Sonagachi Project, India
 CRHP, Comprehensive Rural Health Project
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1930S’ BAREFOOT DOCTORS
ARE FARMERS
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Some evidence towards
people centered health systems
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GRAMEEN BANK
& BRAC
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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.

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.
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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%)
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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
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BASIC PRINCIPLES CONTRIBUTING TO THE
CONCEPT OF CIVIL SOCIETY
 Social Capital
 Democratization
 Governance
 Human Rights
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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

Emerging issues in health care in developing countires

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