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Health in Africa

Health in Africa. Anja Smith Stellenbosch University 13 September 2013. What issues/topics come to mind when you think of “health in Africa”?. Which of these are most important and why?. Objectives: Exposure to economic frameworks to think through implications of diseases in Africa

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Health in Africa

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  1. Health in Africa Anja Smith Stellenbosch University 13 September 2013

  2. What issues/topics cometo mind when you think of “health in Africa”? Which of these are most important and why? Objectives: Exposure to economic frameworks to think through implications of diseases in Africa Understand key concepts used to prioritise health decision-making and track health outcomes To understand why more health expenditure does not always lead to better health outcomes

  3. What makes health different from other development topics (e.g. employment, education, housing, etc.)?

  4. Health an outcome of many inputs: health services, nutrition, sanitation, housing, education, etc. • Health has both a stock and flow component • Loss of health imposes two sets of cost: • healthcare costs • loss of income when ill

  5. What makes health different? (2) Arrow’s (1963) perspective: Uncertainty and medical care • Demand for health services not constant but “irregular and unpredictable” • Severe market entry restrictions: high educational costs, licensing for medical doctors • Information asymmetries: • Information asymmetry between doctor and patient: “product uncertainty”, agency problem • Insurance information asymmetries: 1) Moral hazard: riskier behaviour due to fact of being insured 2) Adverse selection: selection of poor(er) risks into insurance pool

  6. Why does health matter?Health and economic growth • Macroeconomic evidence: • impact is small, evidence is ambiguous, many identification and measurement problems

  7. Why does health matter?Health and economic growth • Microeconomic evidence: • “clear[er] causal relationship from health to earning potential and income” (Jack & Lewis, 2011) • “Some dimensions of health status and some health inputs do affect labour supply and worker productivity. In several cases, the effect tends to be largest for the poorest.” (Strauss and Thomas, 1998 : 798) WHY?

  8. Why does health matter?Health and economic growth (2) • Taller men earn higher wages (Strauss & Thomas, 1998) • Household surveys show that poor health reduces number of hours worked but evidence of impact on productivity and wages less clear: “…the health indicators used in those studies tend to reflect shorter-term health problems but wages tend to adjust relatively slowly.” (Jack & Lewis, 2011)

  9. Health cycle

  10. Health expenditure prioritisation: how should we decide which ill person to help when we have limited resources?

  11. Disability-adjusted life-years: -Number of years lost due to death, disability or illness-Because it emphasises “years lost” if disease strikes it places greater emphasis on the value of young life

  12. What summary measures can we use to track health outcomes?

  13. Health outcomes Key concepts: • Life expectancy at birth • Under-five mortality rate: probability per 1,000 that a newborn baby will die before age five • Maternal mortality rate/ratio: number of maternal deaths during a given period per 100,000 live births

  14. Themes • Public vs. private sector • Expenditure • Financing • Efficiency • Supply: facilities, staff, medication, etc. • Demand: information, need, responsiveness

  15. Health and developmentCase study: Economic and social burden of malaria

  16. Health and developmentCase study: Economic and social burden of malaria • How does malaria prevalence influence development? • Are all these channels valid? Which are likely to have the biggest impact? • Immediate vs. long-term impacts?

  17. Health outcomes in Africa Life expectancy at birth in years by WHO regionby gender, 2009

  18. Health outcomes in Africa Maternal mortality ratio per 100,000 live births by WHO region

  19. Burden of disease Distribution of burden of diseases as % of total DALYs by broader causes by WHO region, 2004

  20. Burden of disease (2) Leading (10) causes of burden of diseases as % of total disability-adjusted life years (DALYs), African region, 2004

  21. Broad causes of death (males)Western Cape 2010 Source: Western Cape Mortality Profile 2010

  22. Causes of death (females)Western Cape 2010 Source: Western Cape Mortality Profile 2010

  23. Burden of disease (3): malaria Classification of countries by stage of malaria elimination (December 2012), WHO Malaria Report 2012

  24. Burden of disease (4): HIV Adult (15-49 years) HIV prevalence in 2011 by WHO region, WHO 2013

  25. Burden of disease (5): TB Estimated TB incidence rates, 2011, WHO

  26. TB prevalence in South Africa relative to international context Cases per 100,000 Source: Western Cape DoH HIV &TB M&E presentation as derived from WHO Global Tuberculosis report 2012

  27. Why focus on TB? • Costs of tuberculosis: • Mortality • Reduced productivity due to morbidity • (Global) public intervention (and coordination) required as at least three externalities associated with TB (Jack, 2000): • Highly contagious disease that spreads through social contact, individuals unable to fully absorb the cost of the disease • Diagnosis externality: Early in disease individuals may be unaware of need for TB diagnosis and treatment as symptoms are similar to those of other diseases • Drug-resistance externalities: Incomplete treatment leads to exposure of community to the disease as well as exposure to more severe strains of the disease over time • Tuberculosis viewed as “disease of the poor”: control and cure of the disease can make contribution to poverty reduction (Jack, 2000)

  28. Human resources for health Nursing and midwifery personnel-to-population ratio, 2005-2010 Source: Health Situation Analysis in the African region, Atlas of Health Statistics 2012, WHO

  29. Translating expenditure into outcomes Life expectancy vs. total per capita healthcare expenditure for 175 countries (WHO, 2011) US$

  30. Translating expenditure into outcomes (2) Maternal mortality vs. total per capita healthcare expenditure, 161 countries - WHO, 2010 (maternal mortality) & 2011 (healthcare expenditure)

  31. Links in the chain in translating expenditure into outcomes in developing countries Filmer, Hammer & Pritchett, 2000 Incentives Expenditure Outcomes Choices • Case for primary care is often made by assuming that “the public sector could deliver whatever the government (or some international forum) decided ought to be delivered” • BUT • “Often, health service failures result from a systemic mismatch between the traditional civil service incentive structure and the tasks required in the health sector”. • Impact of primary healthcare often estimated as if translating healthcare expenditure into outcomes is simple technical process. • “But individuals are guided by their own knowledge and resources in judging the quality of their health care (and that of their children).” • “’…service delivery and overall effectiveness both depend on the demand for specific services, the price of services and the existing (and potential) supply in the private sector”. (emphasis added)

  32. Links in the chain in translating expenditure into outcomes in developing countries (2) Filmer, Hammer & Pritchett, 2000 Incentives Expenditure Outcomes Choices • Composition of expenditure, e.g. primary vs. secondary vs. tertiary care, HIV vs. TB, HIV vs. malaria, preventative vs. curative care • Output of the public sector: efficiency in translating inputs into outputs • Net impact of public sector supply on overall consumption: do people use more of the service simply because government is spending more? e.g. crowding-out of private services • Health production function: the impact of health inputs is mitigated by biological and medical facts, i.e. the effectiveness/appropriateness of certain treatments

  33. Additional resources Arrow, K. 1963. Uncertainty and the Welfare Economics of Medical Care. American Economic Review. 53(5): 941-973. Economist Intelligence Unit, 2011. Future of healthcare in Africa. Filmer, D., Hammer, J.S. & Pritchett, L.H., 2000. Weak links in the chain: a diagnosis of health policy in poor countries. World Bank Research Observer. 15(2): 199-224. August. Lagomarsino, G., Garabran, A. Adyas, A., Muga, R. & Otoo, N. 2012. Moving towards universal health coverage: health insurance reforms in nine developing countries in Africa and Asia. Lancet. 380(9845): 933–943. Strauss, J. & Thomas, D. 1998. Health, nutrition, and economic development. Journal of Economic Literature. 36(2), 766-817. William, J. & Lewis, M. 2010. Health investments and economic growth: macroeconomic evidence with microeconomic foundations. In Spence, M. and Lewis, M. Health and Growth, World Bank, Commission on Growth and Development. World Health Organization website: www.who.org World Health Organization. 2012. Atlas of African Health Statistics.

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