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Trends and Challenges in World Health

• Simon Blair
• 15 May 2001

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Presentation Outline

• 2001 its place in time (successful evolution)
• Existing and emerging issues (the challenges)
• Trends in hospital reform
• Transferable lessons from global reform

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Health Reform and the World Bank

• Why ? The Banks vision to reduce poverty and
  improve living standards through sustainable
  growth and investment in people
• Health 9 GDP , and rising

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Total Health Expenditure as Percent GNP
18
16
14
12
1977
10
HE as GNP
1987
8
1997
6
4
2
0
100
1000
10000
100000
LN GNP per capita
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Health Reform and the World Bank

• Why ? The Banks vision
• Health 9 GDP
• Rapid portfolio growth 1970 2001. 300 health
  reform projects
• 88 countries projects totaling US 18.6b
• Focal shift PHC/public health health
  systems and hospitals

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1900-2000 Sustained Progress

• Diptheria (1901), malaria (1902), diabetes
  (1922), electrocardiogram (1924), penicillin
  (1928), HBGs (1930), tuberculosis (1952), DNA
  (1953), poliomyelitis (1954), heart
  cathetarization (1956), CAT (1979) .

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A Century of Unparalleled Improvement
6.0
80
1997
75
5.5
70
5.0
Life Expectancy
65
4.5
60
Fertility Rates
Life Expectancy in Years
4.0
55
50
3.5
45
3.0
40
Total Fertility Rates
2.5
35
2.0
30
1950
60
70
80
90
2000
10
20
30
2050
40
Years
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1900-2000 Sustained Progress

• Nobel Prizes
• Life Expectancy up, fertility rates down
• children who die before 5 50 of 1960
• 3m children p.a. saved by immunization
• 1m p.a. saved via improved diarrhea control
• Child malnutrition rates 20 lower than 1970
• People now live 25 years longer than in 1900

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2001 Critical Existing and Emerging Issues

• WHOs Double Burden of Disease
• the emerging epidemic of non- communicable
  diseases
• the unfinished health agenda
• Reducing the burden of inequity
• the balance sheet is indelibly stained

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Challenge 1 The Onslaught of Non-communicable
Diseases

• From 35 (1998) 57 (2020) of international
  disease burden
• Infectious diseases 49 to 22
• CVD will largest single cause of DALYs
• Lung cancer rates will rocket up due to tobacco
  usage
• Injuries will infectious diseases worldwide as
  source of ill health by 2020

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Challenge 2 The Unfinished Health Agenda

• Infectious diseases in developing countries
• The 5 major childhood conditions still 21 of
  all deaths in low/middle income countries
• Pneumonia, diarrhea, measles, malaria and
  malnutrition 70 childhood deaths globally
• In adult conditions HIV/Aids and TB 2/3 major
  causes of disease burden in developing countries
• 30 world still without safe water and sanitation

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A world of incomplete epidemiological
transition, in which epidemiologically polarized
sub-populations have been left behind

• World Health Report 1999

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Challenge 3 Reducing the Burden of Inequity

• The inexorable link poverty and ill health. (25
  of the worlds population 1.4 billion people
  continue to live on incomes of lt 1 per day. Half
  live on incomes lt 2 per day.)

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Only 11 Percent of Global Spending for 90 Percent
of the Worlds Population
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Exaggerated by Income / Spending Correlation
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Health Achievement and Health Resources, 1997
75
70
65
60
55
DALE
50
45
40
35
30
25
1
10
100
1000
10000
Ln Health expenditure per capita
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Challenge 3 Reducing the Burden of Inequity

• The inexorable link poverty and ill health
• 93 of global disease burden is in low/middle
  income countries
• 2m children die p.a. from vaccine preventable
  diseases
• lt 10 of global funding for health research is
  devoted to 90 of the health problems

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Challenge 3 Reducing Inequity (continued)

• Per capita health expenditures vary almost 1000
  fold from US4 per capita p.a. to 3800. (Ratio
  using PPP adjusted 250x)
• TB is 4 times more prevalent in poor subgroups of
  populations
• 70 of the worlds 36m HIV cases are in Sub
  Saharan Africa

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Systemic and Environmental Challenges

• Affordability and securing adequate levels
• Stabilizing the policy pendulum
• Redefining the role of the State
• Market imperfections in the private sector
• Poor performance
• Lack of sophisticated purchasing and/or
  purchasing accountability
• Absences of single health systems

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Trends in Hospital Reform (1)

• Caveat impossibility of homogeneity
• Decentralization increased hospital autonomy
  increasing focus upon governance and stewardship
  issues
• Hospital consolidation / rationalization use of
  networks service substitution
• Focus upon continuums of care and criticality
  of system-wide integration
• Managerial efficiency seen as cost-effective

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Trends in Hospital Reform (2)

• The evolution allocation to purchasing
• Increased private sector participation
• Performance quality accorded higher priority
• Information systems becoming mandatory
• Increasing community participation
• Introduction / expansion of user-charges

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From the Database of 300/88Lessons

• The criticality of political will
• Address both the supply side and the demand sides
  of the equation
• Incrementalism more successful than big-bang
• Authoritative and consistent policy-driven
  decision making is necessary considering
  financing, regulation and organizational reform
  together

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Lessons (continued)

• The non-negotiable relevance of local
  circumstances
• Market-influenced incentive measures can be
  advantageous
• Process and outcome foci are critical
• Develop institutional capacity in advance
• Cost-containment alone does not result in long
  term success

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• Trends and Challenges