Health Infrastructure

Julia Walsh MD, MPH

April 2009

Health System Structure

National Health Accounts 2004-Regional Averages

Region Health exp/cap

Health%GDP

%

Public

%Gov

exp

%External

Resources%Private

Out-of-Pocket

AFR $108 6 44 9 9 49

N/SAm 2,720 13 48 17 0.1 32

SE

Asia

99 4 27 5 2 90

Eur 1,564 9 74 14 0.1 70

E Med 224 5 49 8 1 88

WPac 480 6 57 13 0.3 86

Global 777 9 56 14 0.3 52

Health Expenditures, 2001 By Country Income Level

Source: Disease Control Priorities in Developing Countries, second edition, Table 1.2.

Country Group

Health Expenditure

Per Capita

(2001 US$)

Health Expenditure

(Percent of GDP)

Public Sector Expenditures

(Percent of Total Health Expenditures)

Low Income 23 4.4 26.3

Middle Income 118 6.0 51.1

High Income 2,841 10.8 62.1

Countries in the European Union

1,856 9.3 73.5

World 500 9.8 59.2

Conclusion

• Poorest countries few resources

• Private Out of Pocket expenditures large proportion of health expenditures in poorest countries

• Dependence on external assistance

Unvaccinated children

Large Purchasers of Vaccines and other Pharmaceuticals

• PAHO Vaccine Revolving Fund

• Unicef – Vaccines & many other essential drugs

• UNFPA – Family planning methods

• USAID – largest purchaser of condoms

• Clinton HIV Initiative – Negotiates prices for HIV diagnostics and treatment

Source: Prata N, Montagu D, Jeffrerys E. Private sector, human resources, and health franchising in Africa. Bulletin WHO 2005;83:274-9.

Time Trends in the Use of Private Sector Health Services in Egypt

0

10

20

30

40

50

60

70

80

90

1984

(ECPS)

1988

(DHS)

1991

(EM

CH)

1992

(DHS)

1995

(DHS)

2000

(DHS)

% p

riv

ate

Contraception

ANC**

Delivery *

Diarrhoea care

ARI care

Conclusion

• Low coverage for sick children

• Private sector providers important

• No time trend

Facility Type

Pop

ulation

Served

Area C

overed(sq

. km

)

Beds

Personnel Communication TransportationKey

Medication Stockouts

Family Planning Methods

Inp

atient

Lab

or Delivery

Chamba Govt. Health Center

22570 84 0 01 MA21 HSA

Personal cell phone2 way radio

DHO Ambulance, when availableBicycle ambulance

Malaria drugs for Antibiotics (abx) STI

MinipillDepo ProveraCondoms

LambuliraGovt. Health Center

38332 98 0 02 MAs18 HSA

2 way radio only

DHO Ambulance, when availableBicycle ambulance

TB drugsMalaria DrugsNevirapine

MinipillDepo ProveraCondoms

MakwapalaGovt. Health Center

32576 98 0 02 MAs18 HSA

2 way radio only

DHO Ambulance, when availableBicycle ambulance

TB drugsSTI abx

MinipillDepo ProveraCondoms

LikangalaGovt. Community Hospital

31080 115 12 31 MA2 NM22 HSA

Personal cell phone2 way radio

DHO Ambulance, when available

TB drugsNevirapinesyrupSTI abx

Depo Proveracondoms

Matawale(Acting District Hospital)

Govt. Community Hospital

47668 86 18 8

4 CO1 MA1 CHN11 NM20 HSA

2 way radio onlyOne hospital-based ambulance

None

All methods available Depo Provera in short supply

MatiyaCHAM (RC)Community Hospital

46004 131 23 41 MA1 NM16 HSA

Personal cell phone2 way radio

DHO Ambulance, when available

NoneCondoms only

Mayaka CHAM (RC)Community Hospital

39767 123 12 61 MA3 NM24 HSA

Personal cell phone2 way radio

DHO Ambulance, when available

Malaria drugsSTI abx

DepoProveraCondoms

PirimitiCHAM (RC)Community Hospital

26995 71 33 31 RN7 NM21 HSA

Hospital cell phone2 way radio

DHO Ambulance, when availableParish automobile, when available

Malaria and STI drugs in short supply

DepoProveraCondoms

Baseline Data Findings: Health Centers

Funding for Vaccine Delivery

• Global Alliance for Vaccines Initiative (GAVI – Unicef, WHO, Gates, World Bank, Pharma, other donors,)– Poorest countries - <$1000/capita pppGDP– Supported by Country donations & Philanthropy– IFFIm & Advanced Market Commitment (AMC)

• WHO – technical guidelines and expertise• Unicef

– Purchase large quantities for GAVI, World Bank & governments– Support country programs

• World Bank • PAHO – purchase through revolving fund, technical

expertise • National governments

International Finance Facility for Immunization (IFFIm) of

Global Alliance for Vaccines Initiative (GAVI)

• Problem – 2.3M annual deaths from vaccine preventable

diseases in poor countries

• Solution – Accelerate availability and predictability of

funds for immunization– Funds used by GAVI in 72 poorest countries

for vaccine purchase & delivery & for strengthening health systems

GAVI – IFFIm Operations

IFFIm Operations

• Launched 2006 by UK Initiative under Gordon Brown

• UK, France, Italy, Spain, Norway, South Africa, Sweden, [Brazil in negotiation] pledged $5.3B over 20 years

• Issues triple A rated bonds [Fitch, Moody, S&P] on capital markets converting long term contracts to immediately available cash

• World Bank manage Treasury functions• Bond Investors repaid from donor pledges

Current Coverage and Minimum Coverage Goals

Condition and Interventions Coverage Current 2007

Maternal Mortality/Perinatal Conditions Refocused antenatal care 65 80Skilled birth attendance 45 80

Childhood MortalityImmunization Services-polio, diptheria, 75 90

pertussis, tetanus, Hep B, Hemophilus BImmunization Services-measles 68 80Treatment of childhood illnesses

--Acute respiratory infection 59 70--Diarrhea 52 70

MalariaInsecticide treated nets and residual indoor spraying 2 50Treatment for clinical episodes of malaria 31 60

Source: Science March, 2002; www.cmhealth.org/wg5.htm

Current Coverage and Minimum Coverage Goals (con’t)

Condition and Interventions Coverage Current 2007

TuberculosisShort course treatment of smear 44 60positive and smear negative patients

Tobacco-Attributable DiseasesTax greater than 80% of retail price, 20 80Complete advertising and promotion bans, Consumer information, cessation programs

HIV/AIDS and STIsInterventions to decrease sexual transmission 10-20 70Other preventive interventions <1-10 40Palliative Care 6-20 40Highly active antiretroviral therapy <5 45

Source: Science March, 2002; www.cmhealth.org/wg5.htm

Annual Incremental Costs in Billions by Disease Type (2002 US$)

2007 high-cost estimate (%) 2007Low High

Maternity-related condition 2.80 4.48 16%

Child immunization (including measles)

0.78 1.13 4%

Treatment of childhood illnesses 3.26 4.13 14%

Malaria Prevention 1.64 2.38 8%

Malaria Treatment 0.37 0.57 2%

Tuberculosis Treatment 0.47 0.62 2%

HIV Prevention 6.18 6.76 24%

HIV/AIDS care 2.78 2.85 10%

High-active antiretroviral therapy 4.28 5.78 20%

All Interventions 22.57 28.70 100%