Chronic disease management in healthcare systems in low and middle income countries

Transcription

1 Chronic disease management in healthcare systems in low and middle income countries Dr. Sania Nishtar; SI, FRCP, Ph.D Institute of Medicine of the National Academies Committee on preventing the global epidemic of cardiovascular disease: meeting the challenges in developing countries Public information-gathering session: April 13, 2009

2 Context Issues Possible solutions

3 Management of NCDs involves actions on a spectrum Conducive policy framework, legislative and regulatory support, existence of public health infrastructure; professional capacity and stewardship Rehabilitation Secondary Prevention Primary Prevention Primordial Prevention/Health Promotion Population Approach High-risk Approach Evidence Nishtar S. National Action Plan for the Prevention and Control of Non-communicable diseases in Pakistan. Heartfile, Ministry of Health and World Health Organization; 2004.

4 Health systems domains Governance Inputs Policies and plans Financing Human resource Infrastructure Medicines and products Technologies Output Service capacity and quality Services availability and coverage Service utilization Health outcomes Health information systems Nishtar S. Choked Pipes Health Systems Reform in Pakistan. Heartfile, 2009: in press

5 Health systems domains Governance Inputs Policies and plans Financing Human resource Infrastructure Output Service capacity and quality Services availability and coverage Health outcomes Social determinants of health Intersectoral factors Health seeking behaviour Medicines and products Technologies Health information systems Service utilization Overall performance of governance Nishtar S. Choked Pipes Health Systems Reform in Pakistan. Heartfile, 2009: in press

6 Health systems domains Governance Inputs Policies and plans Financing Human resource Infrastructure Medicines and products Technologies Health information systems Output Service capacity and quality Services availability and coverage Service utilization Health outcomes Social determinants of health Intersectoral factors Health seeking behaviour Overall performance of governance Nishtar S. Choked Pipes Health Systems Reform in Pakistan. Heartfile, 2009: in press

7 Context Issues Possible solutions

8 Diversity in health systems designs.. Welfare systems funded through revenues or payroll taxes Social Health Insurance models Systems where privately pooled individual contributions finance private service delivery Mixed Health System where publicly financed healthcare exists alongside a market system

9 Indicators for assessing the performance of a health system Fairness in financing Prioritizing public sources over private sources of financing health Protection against catastrophic expenditure Responsiveness Equity in health outcomes

10 Private health spending, mostly out-of of-pocket, dominates Private health as % of total health spending Out-of-pocket as % of private health spending Afghanistan India Cambodia Vietnam Nigeria Indonesia Sudan China Senegal Tanzania Brazil Algeria Angola Colombia 0% 20% 40% 60% 80% 100% 0% 20% 40% 60% 80% 100% National Health Accounts. World Health Organization.

11 Health systems domains Fairness in financing Predominance of public sources of finances over private sources of financing health Protection against catastrophic expenditure Responsiveness Equity in health outcomes

12 Composition of Shocks Relative Prevalence of different categories of shocks (% of all shocks faced by households Natural c alamitie s, 7 % Agric ultural s hoc ks, 4 % He alth s hoc ks, 5 4 % Ec onimic s hoc ks, 2 8 % Law and orde r, 3 % Family matte rs, 4 % Natural calamities Law and order Agricultural shocks Family matters ters Econimic shocks Health shocks

13 Health systems domains Fairness in financing Predominance of public sources of finances over private sources of financing health Protection against catastrophic expenditure Responsiveness Equity in health outcomes

14 Percentage of children receiving care fever or cough in public and private health facilities I Sub-Saharan Africa I I Asia I Public Sector Informal Private Sector Formal Private Sector Source: Supon Limwattananon 2008.

15 Percentage of deliveries in public and private health facilities I Sub-Saharan Africa I I Asia I Public Sector Informal Private Sector Formal Private Sector Source: Supon Limwattananon 2008.

16 A disproportionate share of public health services accrue to the rich Public sector health services accruing to poorest and richest 20% of population in Africa Primary care Outpatient Inpatient Total Poorest quintile Richest quintile Preker, A.S., Langenbrunner, J.C. et al, 2005 Source: Preker, A.S., Langenbrunner, J.C. et al

17 Health systems domains Fairness in financing Predominance of public sources of finances over private sources of financing health Protection against catastrophic expenditure Responsiveness Equity in health outcomes

18 The triad of determinants of mayhem in a mixed health system Lack of transparency Nepotism, cronyism, preferential treatment Misappropriation of talent Clouding of business environment collusion in public procurements State capture and selective benefits Unethical marketing practices Inadequate public funding for health Unregulated burgeoning role of the private sector Absenteeism, shaving off hours ghost workers in public facilities Inability to maintain and deliberate undermining of public equipment Flourishing diagnostics in the private sector Dual job holding and care provided in the private sector Paucity and poor quality of supplies Public Sector Low Low quality of of public services Private Sector High cost of care Defeat the equity objective in health Sania Nishtar. Choked pipes Health Reform in Pakistan. In press: 2008

19 Impediments to management of NCDs because of limitations of health systems Screening and delivery of basic services Crumbling public infrastructure Inability to leverage the outreach of private providers Delivery of services outside of the basic category Gaps in purchaser-provider arrangements Limited attempts at broadening the base of financing arrangements and social protection arrangements Issues at the regulatory level Availability of medicines Medicines missing on the National Essential Drug List Collusion in procurements Pilferages from the supply chain Spurious drugs, quality issues

20 Impediments to management of NCDs because of limitations of health systems continued Workforce Quantitative, qualitative deployment issues CME programs not institutionalized Gaps in training and capacity building Health information systems Gaps in mortality and morbidity surveillance; limited registries; duplication of surveys; absence of apex agencies; absence of data policy and ethical oversight; gaps at the level of gaps in evidence-based decision making.

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23 Context Issues Possible solutions

24 Reform of health governance and reform outside the health Sector Macro-economic reform Tax reform Fiscal responsibility and debt limitation Growth Job creation and income supplementation Increase in fiscal space Increased resources for the health sector Improved Utilization Plugging pilferages Civil service and public management reform Anticorruption reform Improved social determinants of health Improved health status Improved performance of the health system Health Systems Reform Sania Nishtar. Choked pipes Health Reform in Pakistan. In press: 2008

25 Health systems reform and mainstreaming NCDs Changes in financing Increasing public sources of financing over private Improving utilization and plugging leakages Formal and informal sectors Reform of Primary Health Care Revitalizing public infrastructure Broadening the first point of contact Expanding the set of services including NCDs Strategic use of behaviour change communication Services outside of Primary Health Care Strategic purchasing PPS in infrastructure development

26 Health systems reform and mainstreaming NCDs Workforce Bridging key numerical gaps with prudent retention regulation, ensuring workforce for NCD management Institutionalizing CME and capacity building and revising curricula with the introduction of NCDs into modules Health Information systems Consolidating survey capacity and integrating surveillance of NCDs and improving cause of death systems Governance Institutional reform and civil service changes Strategic use of technology

27 Health reform FINANCING REFORM Public financing through revenues (Universal) Contribution of employers and employees into social security (Formally employed) Social protection to fund cash transfers for waivers in hospitals (Non-formally employed) SERVICES Essential Health Services Services outside the essential category DELIVERY CHANNELS Public sector First Level Care Facilities Non-state actors Public Hospitals Private Hospitals SERVICE DELIVERY REFORM Restructuring management and decentralization of controls Broadening essential service through private providers Evidence based approach to maximizing effectiveness Market harnessing means of regulation and quality assurance Sania Nishtar. Choked pipes Health Reform in Pakistan. In press: 2008

28 A new partnership for NCDs with a systems focus