Structuring national health systems to deliver better services Peter Annear pannear@unimelb.edu.au Asia and the Pacific Policy Society Conference 2014 Confronting the Pacific s health challenges Crawford School of Public Policy, ANU Canberra, 17-18 September 2014
Health systems Defined as all organizations, people and actions whose primary intent is to promote, restore or maintain health (WHO 2007, Everybody s Business) Universal health coverage Defined as ensuring that all people can use the health services they need, of sufficient quality, while ensuring that the use of these services does not expose the user to financial hardship (WHO 2010, World Health Report: Universal Coverage)
Indonesia Pakistan Nigeria Bangladesh Philippines Ethiopia Vietnam Thailand Congo, Dem. Rep. Myanmar South Africa Tanzania Kenya Sudan Uganda Malaysia Nepal Ghana Mozambique Madagascar Sri Lanka Cameroon Angola Cote d'ivoire Niger Burkina Faso Malawi Cambodia Mali Zambia Zimbabwe Senegal Chad Guinea Rwanda South Sudan Somalia Benin Burundi Papua New Guinea Lao PDR Togo Sierra Leone Eritrea Singapore Central African Republic Congo, Rep. Liberia Mauritania Mongolia Namibia Lesotho Botswana Gambia, The Guinea-Bissau Gabon Mauritius Swaziland Timor-Leste Fiji Bhutan Equatorial Guinea Comoros Cabo Verde Brunei Darussalam Maldives French Polynesia New Caledonia Vanuatu Sao Tome and Principe Guam Tonga Micronesia, Fed. Sts. Kiribati Seychelles Northern Mariana Islands Marshall Islands Palau Tuvalu 20,000,000.0 Population (Total) 2010 18,000,000.0 16,000,000.0 14,000,000.0 12,000,000.0 10,000,000.0 8,000,000.0 6,000,000.0 4,000,000.0 2,000,000.0 0.0
Singapore Guam Brunei Darussalam Maldives New Caledonia French Polynesia Vietnam Malaysia Cabo Verde Thailand Sri Lanka Seychelles Mauritius Tonga Vanuatu Cambodia Indonesia Bangladesh Fiji Micronesia, Fed. Sts. Philippines Kiribati Nepal Bhutan Lao PDR Mongolia Pakistan Timor-Leste Sao Tome and Principe Myanmar Madagascar Senegal Namibia Gabon Rwanda Papua New Guinea Sudan Ethiopia Eritrea Mauritania Ghana Comoros Kenya Liberia Tanzania Benin Gambia, The Uganda Congo, Rep. Niger Togo Guinea Burkina Faso Zambia South Africa Somalia Mali Cameroon Zimbabwe Guinea-Bissau Malawi South Sudan Burundi Equatorial Guinea Nigeria Angola Chad Cote d'ivoire Mozambique Congo, Dem. Rep. Swaziland Central African Republic Lesotho Botswana Sierra Leone 90.0 Life expectancy at birth, total (years) 2010 80.0 70.0 60.0 50.0 40.0 30.0 20.0 10.0 0.0
Mongolia Singapore Maldives Palau Brunei Darussalam Vietnam Malaysia Tuvalu Pakistan Sri Lanka Tonga Myanmar Marshall Islands Fiji Nigeria Thailand Kiribati Namibia Botswana Bangladesh Cabo Verde Indonesia Sudan Lao PDR Cambodia Micronesia, Fed. Sts. Madagascar Cote d'ivoire Mauritania Uganda Vanuatu Guinea Ghana Congo, Rep. Mali Zambia Benin Senegal Rwanda Papua New Guinea Togo Burkina Faso Guinea-Bissau Gambia, The Somalia Mozambique Bhutan Ethiopia Sierra Leone Malawi Niger Liberia Tanzania 3.0 Physicians (per 1,000 people) 2010 2.5 2.0 1.5 1.0 0.5 0.0
Marshall Islands Sierra Leone Micronesia, Fed. Sts. Tuvalu Liberia Kiribati Rwanda Lesotho Palau Uganda Burundi South Africa Malawi Swaziland Namibia Togo Burkina Faso Tanzania Guinea-Bissau Sao Tome and Principe Congo, Dem. Rep. Vietnam Niger Cote d'ivoire Mali Sudan Mongolia Guinea Zambia Mauritania Nepal Cambodia Maldives Mozambique Botswana Timor-Leste Nigeria Mauritius Ghana Cameroon Senegal Tonga Gambia, The Vanuatu Ethiopia Madagascar Kenya Benin Equatorial Guinea Cabo Verde Philippines Fiji Singapore Papua New Guinea Bhutan Chad Malaysia Central African Republic Thailand Bangladesh Seychelles Gabon Comoros Sri Lanka Angola Eritrea Pakistan Indonesia Brunei Darussalam Lao PDR Congo, Rep. South Sudan Myanmar 18.0 Health expenditure, total (% of GDP) 2010 16.0 14.0 12.0 10.0 8.0 6.0 4.0 2.0 0.0
Tuvalu Marshall Islands Micronesia, Fed. Sts. Kiribati Lesotho Palau Malawi Rwanda Swaziland Burundi Namibia Timor-Leste Vanuatu Burkina Faso South Africa Tonga Mongolia Mauritania Zambia Maldives Botswana Bhutan Togo Seychelles Mozambique Cabo Verde Vietnam Congo, Dem. Rep. Ghana Papua New Guinea Fiji Equatorial Guinea Thailand Tanzania Mali Gambia, The Mauritius Senegal Ethiopia Sao Tome and Brunei Darussalam Nepal Liberia Sierra Leone Niger Malaysia Guinea-Bissau Madagascar Benin Angola Uganda Sudan Guinea Central African Cote d'ivoire Kenya Gabon Cameroon Philippines Sri Lanka Nigeria Eritrea Comoros Singapore Congo, Rep. Bangladesh Cambodia Lao PDR Indonesia Chad Pakistan South Sudan Myanmar 16.0 Health expenditure, public (% of GDP) 2010 14.0 12.0 10.0 8.0 6.0 4.0 2.0 0.0
Tuvalu Brunei Darussalam Micronesia, Fed. Sts. Seychelles Vanuatu Bhutan Marshall Islands Kiribati Tonga Cabo Verde Timor-Leste Palau Papua New Guinea Thailand Lesotho Malawi Fiji Swaziland Equatorial Guinea Mauritania Maldives Botswana Burundi Mongolia Zambia Angola Congo, Rep. Ghana Gambia, The Mozambique Malaysia Namibia Rwanda Burkina Faso Ethiopia Senegal Benin Central African Republic Mauritius Madagascar Gabon South Africa Vietnam Lao PDR Togo Congo, Dem. Rep. Sri Lanka Eritrea Nepal Comoros Mali Kenya Tanzania Indonesia Philippines Bangladesh Sao Tome and Principe Niger Singapore Guinea South Sudan Guinea-Bissau Pakistan Sudan Cameroon Cote d'ivoire Nigeria Chad Uganda Cambodia Liberia Myanmar Sierra Leone 120.0 Health expenditure, public (% of total health expenditure) 2010 100.0 80.0 60.0 40.0 20.0 0.0
Rwanda Marshall Islands Micronesia, Fed. Sts. Malawi Palau Zambia Vanuatu Burkina Faso Swaziland Togo Congo, Dem. Rep. Madagascar Thailand Tonga Namibia Ethiopia Burundi Lesotho Tuvalu Ghana Mauritania South Africa Mali Sierra Leone Nepal Gambia, The Liberia Guinea-Bissau Niger Mauritius Uganda Fiji Mongolia Sudan Benin Central African Republic Mozambique Tanzania Seychelles Vietnam Kiribati Papua New Guinea Senegal Philippines Maldives Singapore Bangladesh Botswana Cameroon Bhutan Cote d'ivoire Cabo Verde Gabon Equatorial Guinea Indonesia Sri Lanka Guinea Malaysia Congo, Rep. Angola Brunei Darussalam Comoros Cambodia Kenya Sao Tome and Principe Nigeria Lao PDR Timor-Leste Pakistan South Sudan Eritrea Chad Myanmar 25.0 Health expenditure, public (% of government expenditure) 2010 20.0 15.0 10.0 5.0 0.0
Comoros Eritrea Tuvalu Mali Brunei Darussalam Micronesia, Fed. Sts. Chad Bangladesh South Sudan Nigeria Sudan Bhutan Cameroon Mauritania Singapore Congo, Rep. Cabo Verde Mongolia Guinea Equatorial Guinea Mauritius Niger Sierra Leone Benin Myanmar Central African Republic Pakistan Sao Tome and Principe Madagascar Gabon Togo Vietnam Nepal Philippines Sri Lanka Ethiopia Cambodia Lao PDR Malaysia Senegal Cote d'ivoire Kenya Indonesia Marshall Islands Burkina Faso Maldives Angola Burundi Lesotho Tonga Zambia Ghana Fiji Uganda Congo, Dem. Rep. Guinea-Bissau Vanuatu Papua New Guinea Thailand Malawi Tanzania Rwanda Gambia, The Palau Swaziland Seychelles Liberia Namibia Timor-Leste South Africa Mozambique Botswana Kiribati 120.0 Out-of-pocket health expenditure (% of total expenditure on health) 2010 100.0 80.0 60.0 40.0 20.0 0.0
Sierra Leone Myanmar Chad Nigeria Cameroon Sudan South Sudan Guinea Singapore Cambodia Bangladesh Pakistan Niger Mali Comoros Cote d'ivoire Sao Tome and Principe Eritrea Philippines Uganda Nepal Indonesia Kenya Togo Mauritius Central African Republic Vietnam Sri Lanka Gabon Benin Madagascar Lao PDR Guinea-Bissau Congo, Rep. Ethiopia Senegal Mongolia Congo, Dem. Rep. Malaysia Mauritania Burkina Faso Tanzania Equatorial Guinea Angola Ghana Zambia Burundi Maldives Liberia Cabo Verde Rwanda Gambia, The Fiji Lesotho Bhutan Thailand Swaziland Malawi Papua New Guinea Marshall Islands Tonga Palau Micronesia, Fed. Sts. Namibia Brunei Darussalam South Africa Vanuatu Mozambique Botswana Seychelles Timor-Leste Tuvalu Kiribati 90.0 Out-of-pocket health expenditure (% of private expenditure on health) 2010 80.0 70.0 60.0 50.0 40.0 30.0 20.0 10.0 0.0
(Negin, 2010. The Evolution of Primary Heath Care in Fiji: Past, Present and Future. Nossal HSHF Knowledge Hub)
Papua New Guinea 85% of PNG population is rural and remote The health system is decentralised, tiered and mixed publicprivate OOP payments are relatively high PHC services have deteriorated since decentralisation What role could the new process of decentralisation or the introduction of contracting of services play in strengthening government/church collaboration and service delivery? Ascroft, Sweeney, Samei, Morgan. 2011, Strengthening church and government partnerships for primary health care delivery in Papua New Guinea: Lessons from the international experience. Working Paper, Nossal Institute HPHF Knowledge Hub.
Aid Effectiveness Principles Principle 1: Country ownership Principle 2: Multi-year commitments aligned to nationally identified priorities High level of national ownership Multi-year commitments made by multiple donors based on national health sector plan Low level of country ownership Many agencies support a Partnership Agreement based on the national plan Principle 4: Development partners and countries pursue a harmonized approach A coordinated approach but processes have overshadowed delivery Coordination of aid delivery acknowledged as priority, beginning in 2009. Principle 5: Strengthened institutional mechanisms and capacity Principle 6: Provision of technical assistance that supports national ownership Principle 7: Joint assessment of the implementation. National procurement systems not currently used / low capacity Capacity is strong Agreed M&E framework but lack of baseline data AusAID is working through local systems and World Bank is engaged in building capacity of national financial management. Technical assistance is too focused on doing rather than building M&E framework was being developed in 2009 (Negin, 2010. Sector-Wide Approaches for health: lessons from and the. Nossal HSHF Knowledge Hub)
Structuring health systems for better service Solutions are context-specific Government and donor roles (Paris Declaration) HSS, NCDs and vertical programs (integrated service delivery) Supply-side interventions Provision of services (quality of care) Level of resources (5% of GDP) Mixed public-private service delivery Decentralisation/contracting Demand-side interventions OOP payments < 30% of health spending Access to services (overcoming barriers/geography/poverty) Financial protection and UHC (inappropriateness of SHI)
HSS structures in the Pacific The partnership between governments and donors and the role of governance Vertical vs horizontal approaches the allocation of resources Decentralisation with budget support coverage of the population Primary health care delivery and the challenge of tertiary care Universal Health Coverage and effective government leadership
Peter Annear Associate Professor NossaI Institute for Global Health Melbourne School of Population and Global Health The University of Melbourne http://ni.unimelb.edu.au pannear@unimelb.edu.au +61 3 9035 4065 +61 410 561 189 Copyright The University of Melbourne 2008