Beyond Child Survival: The SDGs Khama Rogo MD PhD Head, Health in Africa Initiative The World Bank Group
The size of Africa.
African Renaissance 2000 2011
It is not Just a Matter of More Money * Percent deviation from rate predicted by GDP per capita Source: Spending and GDP from World Development Indicators database. Under-5 mortality from Unicef 2002 Source: Soucat, A. The Promise of RBF to Reach the Health MDGs and the Evidence Gap: How Impact Evaluation Can Inform Policy Dialogue.
The Changing Health Landscape in Africa Six building blocks for health systems Demography Health Insurance /RBF Pharma Service delivery Health financing REFORMS Disease patterns Service delivery Health workforce Working with Private Sector Human rights Professional ism/regula tion Health promotion Health information systems Access to essential medicines Financing Leadership/ governance
Africa s Demographic Dividend The Demographic Dividend in Africa Source: The Economist, December 17, 2011 6
Disease patterns are shifting Communicable diseases traditionally account for as much as 70% of the burden of disease in Africa Shift towards non-communicable diseases (NCDs) such as coronary heart disease and diabetes, mental illnesses due to lifestyle changes Increasing levels of NCDs linked to increasing levels of risk factors: alcohol, smoking, reduced physical activities, nutritional transition The dual impact of CDs and NCDs leading to significant burden on Africa s health systems: Insufficient resources and human capital to address this shift 7
WHAT NEXT? 8
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Traditional Input Financing: A Shift in Focus INPUTS (human resources, drugs, equipment, etc.) PROCESS (training, protocols and guidelines, financial management, procurement, etc.) Line item budgeting, input supply, monitoring of inputs and processes, reporting of results OUTPUTS (health service utilization, promotion activities) Monitoring and paying for outputs, increased leeway for local decision-making, verification of results OUTCOMES (maternal and child mortality, nutritional outcomes, life expectancy) Monitoring of outcomes, evidence based decision making to achieve results
What role pediatricians? 11
The current state of affairs Low demand leads to low (certainty about) health care revenues for healthcare providers financing Low healthcare revenues mean too much risk to invest in health care, keeping quality low SUPPLY: LOW Quality health care DEMAND: LOW Medical care usage Low willingness to pay and low capacity to pay lead to low demand LOW delivery LOW Low quality results in low trust in the system and low willingness to prepay for healthcare services 12
Big Bang Reforms in Anglophone Africa Anglophone countries in both West and East Africa experienced economic adversities that led to deterioration of their publicly funded national health services. Some countries have reacted with reforms leading to an aggressive scale up of government mandated health insurance. Ghana, for example, achieved 65 per cent coverage in less than five years. Notable feature of reforms is mix of public and private arrangements in both financing and service delivery. Old divisions between private/public, formal/informal and purchasers/providers are being re-visited. 40 Voluntary health insurance 30 25 20 Mandatory health insurance (incl. social security exp. on health) 15 10 Zimbabwe South Africa Uganda Tanzania Kenya Nigeria 0 Namibia 5 Ghana % of population covered 35 Source: Preker et al (forthcoming) 13
Gradual Incremental Reforms in Francophone Africa Despite the push for expansion of community based insurance and mandatory health insurance, coverage remains sparse and the contribution of health insurance to financing is still very weak. Universal coverage is unlikely to be attained if current trends persist, Francophone African countries might benefit from learning about the more innovative approaches being tested in Anglophone countries. Public Health Expenditure as % of National Budget (2006) % Point Change in Public Health Expenditure as % of National Budget 2000-2006 Source: Preker and Dukha (forthcoming) 14
Long-term solutions, flexible short-term actions Some key questions that need to be answered are: 1. Are SDGs politically feasible in Africa? Scaling up SDGs is often viewed as a technical matter but in reality is a political process 2. Who should pay for SDGs? What is the capacity of the government, private sector, notions of PPP How can we make training affordable? Subsidies, low interest loans, scholarships are needed 3. What are the priority Professional skills needs for SDGs? Skills, Levels, Task shifts, Preservice/inservice, CPD 4. How do we maintain momentum and quality in health sector? Roles of trainers and regulators Professional Associations and Colleges Benchmarking No single blueprint, rather variety of paths determined by history, current education/health financing systems and regional innovations 15
Fundamental Rethinking Are we honest brokers in SDG dialogues? Is there a true win-win in SDGs? Govt/Donors; Govt/Workers; Workers/Consumers? Is there a role for private investment? Commercial terms; Upstream reforms; Concessional financing 16
Training and task shifting What is the right combination? 17
Suggested Approach What is Needed Positive Investment Climate Can investment happen? Attractive Investment Opportunities Willing Investors Pub + Private Capacity to Close Transactions What type of investments? Who will invest? Making transactions happen Focus To ensure health investment To identify and develop can happen in a positive and investment opportunities that match assets with well regulated way market potential Services & Skills Policy reform Create mechanisms for dialogue across institutions and actors Regulatory reform and simplification Reduce barriers to competition Making it easier to operate and grow businesses Review incentives regimes Sector analyses and diagnostics Competitive assessments Assess growth prospects Identify product/market opportunities Establish quality standards Design and mobilize commercial and investment strategies 18 To identify and mobilize public and private investors well matched to targeted opportunities To assist and facilitate the process of making transactions happen Investor pipelines Investment promotion Investor outreach Qualification of investors Target and match investors with opportunities Opportunity awareness and image building Project packaging Deal origination Transaction support Negotiation assistance Capital raising support
Overwhelmed? NEVER!
ASANTENI SANA 20