From Global Health to Publicly Oriented

Local Health…Systems

J.-P. Unger, senior lecturerInstitute of Tropical Medicine, Antwerp, Belgium First European Seminar on Global HealthOrganised by the European CommissionBrussels, June the 27th, 2011

Plan

1. Global health definitions

2. Global Epidemiological and Demographical Challenges

3. No global health without LMIC health systems

4. Strategic priorities

5. A role for the EU

1. Conflicting concerns on global health definition ?

Political issues attached to global health definition

Industrialised countries stressed LMIC-born pandemics prevention

•Malaria, AIDS, TB

•SARS, avian-flu, H1N1, Ebola

Low and Middle Income Countries (LMIC, & IHP+) want strengthening health systems

•Poor access to care = generalised torture (by toothache or renal colitis)

(2000, UNDP: > 50% LIC population ?)

•Avoidable suffering linked to poor access political instability

A common North South concern

Under utilisation of available resources•Internal brain drain

•Bureaucratic proliferation

• Transaction costs of current international aid +++

17th March, 2011 European Parliament

Total annual resources needed for AIDS under disease specific organisation pattern

Funding gap

2. Contemporary epidemiological and demographical global challenges

• communicable diseases: 11 million deaths yearly.

• chronic diseases: above 10 million deaths yearly• By 2020, mental depression will be LMIC leading morbidity

cause

• SARS, avian and swine flus, Ebola, …:– News papers headlines

– Very limited casualties so far in the last 50 years

– potential risks

Epidemiological challenges

But prevention of multiresistance

= largely absent of international programs

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 yearHospital acquired infections (USA only) 1700000 99000 5,82 2002

Demographic challenges

• Ageing: – Big part of overall chronic diseases mortality– Health financing problems

• migrations – Rural / urban

– North South

– political and health problems

• Nineties: 100 million females deficit in Asia.

Today, much more.

Failure to reach (the quite limited) MDGs

• % adults HIV + = stable since 2000: 33 million• ± 40% of PLWHA needing treatment were receiving

the medicines, far from the 100% aimed at in 2010• TB prevalence in Africa: 1990-2007: +47%• Non-health MDGs: Health care expenditure = the

main cause of falling into poverty

3. Why this failure to control diseases? A negative feedback loop

2. For success, disease control programmes need patients consulting for various symptoms = pool of users needed for detection

3. Unfortunately, international policies allocate patients to private sector and disease control to public

4. Furthermore, disease control programs limit access to care in those services where they are integrated (e.g. services with a social mission)

5. QED (with math model)

3. Demands on health systems to tackle global challenges

H1N1, H5N1, SARS demand •early and large access to care

MR-malaria, MR-TB or HAI demand•Adherence•Continuity of care•Access to hospital•Communication between first line and hospital•Implementation of standard treatments•Effective regulation

Consequence

• Strengthening LMIC health systems should be (re)conceived while introducing a new MDG:

Universal access to multifunction, quality health care

• Multifunction care = family medicine care + general hospital care

Indicators to assess health system strengthening and communicate on governance

•access to professional first line health care (expressed in number of sickness episodes per year per inhabitant) and

•hospital admission rates

•Indicators of care quality (e.g. disease specific case fatality rates)

Such care should meet simple quality criteria

Care should be

•continuous (to avoid resistance to antiretroviral and TB statics)

•integrated (to enable the patient moving to the appropriate program and reduce bureaucratic costs)

•bio-psychosocial (to be effective /acceptable)

•effective e.g. tuberculosis case fatality rate

•efficient

4. Strategies to strengthen health systems in LMIC

Health insurances failed to secure access to care

•Colombia 1997-2003: – insurance coverage rate from 54% up to 62% but

– outpatient consultation rate 23.8% down to 9.5%

•Peru 2007 – 2008: – 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

– those who didn’t consult increased from 50.5 to 56%

•Ghana 2007 -2009: – insurance coverage increasing from 0% to 60% but

– user fees increased from 9 to 11% of total health expenditure

Insurance universal coverage, a fashionable strategy….unlikely to work

• All these examples point to the existence of significant non-financial barriers to access to individual health care

• and to limited effectiveness of health insurance in LMIC

What to do?

Let’s not target public health financing on the poor if we want national solidarity and equity

Let’s export the principles of the European health financing system

Financing: supply side financing doesn’t permit to only finance MOH services !!

Taxes

(or Bismarkian) National health fund

MoH

MoH servicesNot for profit private org.

Commercial sector

Individuals Social sector

Demand-side financing

Promote a health sector with a social mission

MoH private

Disease control X

Health care X

Promote a health sector with a social mission

Mission

Status

Social Commercial

MOH Care + Disease control

Care

private Care + Disease control

Care

What to do?1. Integrate and strengthen the publicly oriented,

socially motivated health care delivery sector2. Integrate the administration of disease control

programs into general health care management3. Strengthen bio-psychosocial care in first line4. Strengthen general hospitals5. Coordinate first line services + Hospital in a local

health system6. Facilitate field experiments and bottom up flows

of information towards national health policies

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Addressing fragmentation

Local health

systems

H

Interinstitutional management of local

health systems

Interinstitutional, professional management and decentralised budgets

European Parliament

Methods in health policy research, health care

management and planning

5. Which role for the EU?

• promoting peace and stability while

• Responding to peoples’ demand for individual health care

• Preventing and early detecting pandemics

• Thus strengthen health systems while making health care acceptable

• Implications for care quality, systems functions, development strategies and management

5. Which role for the EU?

• Europe has the world largest experience in securing access to good health care

• Let’s use it in technical assistance to support

• Integrated local health systems with a social mission

• And let’s negotiate EU support against decent public financing of health care delivery in socially motivated health services

17th March, 2011 European Parliament

THANK YOU

DANK U

DANKE SCHÖN

ευχαριστώGRAZIE

DZIĘKUJĘ

OBRIGADO

GRACIAS

MERCI