Health Sector Reform,Epidemiological and Demographic Challenges

or

Why We Need More Public Health Capacity

in Central Asia

Armin Fidler

The World Bank

2

Has (Curative) Health Sector Reform Crowded Out Public Health in ECA?

Health Reforms over the past decade in FSU Countries emerged from political – economic change Modernized health sector (created building blocks) Started to reverse steep health outcome decline

Problems with fiscal sustainability, quality, equity New Challenges – Need modern Public Health

Public Health Systems: entrenched legacy of SES Preparedness for new health threats?

Surveillance: TB, AIDS, Avian Flu Disease Burden: Economic Impact of Chronic Diseases Priority Setting: Population ageing and demographic challenge

3

Health System Performance Embedded in Economic Performance

Sources: World Bank (2002), World Development Indicators 2002, World Bank: <www.worldbank.org/data/>; MONEE project database.

0

2,000

4,000

6,000

8,000

10,000

12,000

1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001

Central Europe

Baltic States

Western CIS

Bulgaria and Romania

Other South-Eastern Europe

Central Asia

Caucasus

4

Rich Spend More – But Better?

Source: HFA database/World Bank 2004

<= 12

<= 10

<= 8

<= 6

<= 4

<= 2

No data

EU-15: 8.9 (2004)EU-15: 8.9 (2004)Central, South East Europe & Baltics: 5.8 (2004)Central, South East Europe & Baltics: 5.8 (2004)

5

Health Spending Outgrows Total Public Expenditures in High Income Countries

-5

0

5

10

15

20

25

BE DK DE EL ES FR IE IT LU NL AT PT FI SE UK EU-15

average annual increase in public expenditure on health care, 1999-2002*

average annual increase in total government expenditure, 1999-2002*

6

And So Do Pharmaceutical Expenditures…

0

5

10

15

20

25

30

35 Poland

Bosnia-Herzegovina

Serbia-Montenegro

Macedonia

Croatia

Latvia

Slovenia

Romania

Albania

Bulgaria

Czech Republic

Hungary

Estonia

Slovak Republic

Lithuania

Total Pharmaceutical Expenditure % Total Health Care Expenditure, World Bank, 2004

7

How To Contain Pressures On Spending While Focusing on Results?

Address inherited oversupply of hospital infrastructure Progress slow in most countries Only Estonia seems to have tangible results to show

Optimize benefits package: Co-payments: focus on equity + access for vulnerable PHC/Family Medicine: Solve problems, gate-keeping

Health financing to focus on purchasing not paying Contractual relationships with providers are still rare

Manage pharmaceutical expenditures + medical technology: Price regulation versus quantity (Total cost = unit cost x quantity) HTA rarely used. Recurrent (operating costs) for HT!

Conundrum: Wages, Migration

8

Widening Health Gap EU - FSU

Note: Calculations based upon current "life tables" for the year 2004. "Europe" includes countries outside of the EU-15.Source: World Health Organization Life Tables, 2004,

A 20-year old Man's Odds of Dying Before Age 65: Europe, U.S., Russia, 2004

0

10

20

30

40

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Russia

Europe

USA

EU-15

9

AIDS in Russia – World Bank Model

Demographic Results (Optimistic)Demographic Results (Optimistic)

• GDP falls 4.15% (2010) and 10

Economic Results (Optimistic)Economic Results (Optimistic)

• Dramatic impact absent prevention/treatment- Mortality from 500/mo. (2005) to 21,000/mo. (2020)- Cumulative HIV+ from 1.2 mln (2005) to 5.4 mln (2020)

• Prevention high cost-benefit as long as ARV price > $300/person/year (Pess)

10

Shrinking Populations (000)

Russia -18, 103Ukraine -7, 272Romania -1, 774Bulgaria -1, 364Belarus -1, 063Hungary -991Czech -710Latvia -375Georgia -319Croatia -283Lithuania -198Estonia -165Moldova -161Slovenia -107Slovakia -3

Expanding Populations (000)

Turkey +19, 666Uzbekistan +9, 257Tajikistan +2, 594Turkmenistan +1, 937Azerbaijan +1, 562Kyrgyzstan +1, 507Albania +856BiH +424Kazakhstan +364Armenia +263

ECA 2000-2025: Little Change In Population Size Including Russia And Turkey: +5 Million People

11

Sources: The Demographic Yearbook of Russia: 1993 (State Committee of the Russian Federation on Statistics, Moscow, 1993), Table 2.5; The Demographic Yearbook of Russia: 2004 (State Committee of the Russian Federation on Statistics, Moscow, 2004), Table 2.6; Human Mortality Database, available online at www.mortality.org, accessed January 20, 2005.

Male Life Expectancy at Birth,Switzerland vs Russia, 1970-2003

55.00

60.00

65.00

70.00

75.00

80.0019

7019

7119

7219

7319

7419

7519

7619

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7819

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8219

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8419

8519

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8819

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9119

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9819

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Russia

Switzerland

12

Spill-Over Into Other Sectors:

Impact on productivity, savings and growth: Downward pressures on production and incomes from shrinking labor

forces combined with high labor taxes Changes in public and private savings rates have public expenditure and

investment impact. High morbidity and premature mortality has real impact on GDP (Russia

model)

Social Protection – Social Risk Mitigation: Pension systems, health financing + insurance (including for long-term

care), and individual savings must be in place, or elderly may fall into deprivation.

Strengthen the mechanisms to provide social services to the elderly, especially home-based institutions (evidence of cost-effective assisted living compared to institutionalization).

13

Resources and Aging: Who is Prepared?

Source: United Nations Secretariat, World Population Prospects: The 2004 Revision and World Urbanization Prospects: Maddison, Angus. The World Economy: Historical Statistics. (Development Centre Studies, OECD)

GDP per Capita vs. Percentage of Population Aged 65+: Eastern Europe, 2000

0

5000

10000

15000

20000

25000

30000

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Percentage of Population Aged 65+

GD

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Belarus

Estonia

Latvia

Lithuania

Moldova

Russia

Ukraine

United States

Western Europe

Bulgaria

Czech Republic

Hungary

Poland

Romania

Slovak Republic

14

Does Anyone Still Talk About Public Health?

Health financing arrangements and curative health systems changed over the past decade

New incentives, more market, “medicalization” of health Many Western countries no good role models!

Public health practice and training is lagging behind Few evidence-based, internationally accredited local training

opportunities Low professional status of PH, few well trained professionals Powerful SES, but highly resistant to change and modernization

But the capacity of a health system to deal with future challenges largely depends on functioning public health system

Emerging infectious diseases (HIV, TB); Burden of chronic diseases, injuries, life-style determinants, aging

15

Evaluation of ECA Surveillance Systems WB/CDC 2004

Completeness, timeliness, quality poor Surveillance and vital statistics overly complex and

lacking integration Duplicate/parallel reporting with different results

Generalizability, representativity, validity poor Infectious diseases: long history but few resources

Morbidity reporting: excess data, large staff; aggregate

summaries, de-linked variables

Risk factor surveillance – still in its infancy, limited

population coverage

Most FSU countries still use Semashko model!

16

Surveillance + Intelligence Functions

Determining priorities and guiding evidence-based health programs

Developing health policies and assessing health system needs

Documenting health care and planning long-term strategies

Monitoring effectiveness of prevention and increasing public awareness

Proposing/supporting legislation Informing resource allocation decisions and preparing

proposals for funding

17

EU Example: Reducing Mortality Largely Depends On Public Health Policy

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All Causes Circulatory System Cerebro-vascular

18

Free Movement of Infectious Agents?(and what would happen in case of an Avian Flu Pandemic?)

Wider European Neighbourhood

Russian Federation

Ukraine

United Kingdom

Tuberculosis incidence per 100,000

0

10

20

30

40

50

60

70

80

90

100

1980 1990 2000

Belarus

19

Changes In Population Structures:Implications for Service Need + Resource Allocation

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-15

-10

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20

A Call For Action: Political, economic, epidemiological and demographic

transition poses far reaching implications for the 21st century for health and social systems.

FSU may see fast increasing health and social expenditures which (unchecked) may cause strains on fiscal performance, and equity concerns.

While NMS may catch up with EU average health outcomes over next decade, many FSU countries are falling further behind in most health indicators.

Health Reforms seem often biased: Either, towards health financing and systems modernization - Or, investment in infrastructure and equipment or other inputs But: both are often crowding out urgently needed investments in

public health and evidence-based medicine!