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Poverty and Health:. ...an impossible combination and the solution thereof. Dr Reuben Esena, PhD 25 th FAMSA Summit – UG, Legon –Accra, Ghana Monday 17 th May 2010 University of Ghana, Business School. Introduction 1.

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poverty and health

Poverty and Health:

...an impossible combination and the solution thereof

Dr Reuben Esena, PhD

25th FAMSA Summit – UG, Legon –Accra, Ghana

Monday 17th May 2010

University of Ghana, Business School

introduction 1
Introduction 1
  • 100 million people are driven into poverty each year due to catastrophic expenditure on health related needs (WHO 2009),
  • The problem is more pervasive in Africa where there are little risk-mitigating mechanisms against health-related negative shocks.
  • Resource gap is a problem – but health systems constraints are an important bottleneck impeding achievement of health sector goal.
introduction 2
Introduction 2
  • Crises in Human Resource for Health:
    • To reach MDGs, SSA needs 1 million additional skilled workers
  • Leadership effectiveness in SSA are often weak e.g. As seen from various public expenditure tracking surveys [PETS]
4 4 billion people live in developing countries
4.4 billion people live in developing countries
  • Of these.....
  • Three-fifths lack basic sanitation
  • Almost one-third have no access to clean water
  • A quarter do not have adequate housing
  • A fifth have no access to modern health services
health is a right
Health is a Right
  • “… health, which is a state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity, is a fundamental human right and … a most important world-wide social goal.”
      • Alma Ata Declaration-1973
  • Key factors contributing to current health crisis
  • Health Systems
  • Health financing Issues - Accessibility
  • Health outcomes – U5MR, MMR
  • Way forward

Key Factors Contributing to

Current Health Crisis

examples of environmental hazards
Examples of environmental hazards
  • Increasing harmful gases at home and at work – (Industrial/Vehicles)
  • Soil related helminthes, toxic and radioactive wastes.
  • Water related diseases-Childhood diarrhoea, Hepatitis,Typhoid,

Schistosomiasis, Guinea worm

examples of environmental hazards cont
Examples of environmental hazards cont..
  • Food poisoning - salmonellosis, botulism anthrax
  • Insects vectors - malaria, yellow fever, sleeping sickness, typhus
  • Animals - Dog bites and snake bites.
rapid population growth
Rapid population growth
  • The national population growth rate -2.7%
  • Large overcrowded urban population
  • Overcrowded hospitals with large outpatient clinics
  • MCH clinics are unable to keep up with the numbers of young fertile women.
income deficiency problems
Income deficiency problems
  • Negative effects of income deficiency leads to limited purchasing power to provide:-

-Adequate salaries

- Equipment


income deficiency problems cont
Income deficiency problems cont…
  • Meetings
  • Travel
  • Consultants
  • Management
  • Professional bodies
  • Conferences
  • Workshop
negative effects of income deficiency
Negative effects of income deficiency

Also leads to poor distribution of resources








immune and dietary deficiency problems
Immune and dietary deficiency problems
  • The HIV/AIDS Crisis
  • Challenge to inter-sectorial response.
  • Dietary deficiency compound the HIV/AIDS challenge.
  • A challenge to social and economic sectors.
symptoms and signs of sick health services
Symptoms and signs of sick health services.
  • Glaring inequities
  • Rural/urban & urban/peri-urban differentials
  • Social class disparities.
  • Inability of the poor to feed, purchase medicines and to pay for health services.
symptoms and signs of sick health services cont
Symptoms and signs of sick health services. cont…
  • Reduced morale of personnel
  • Migration of personnel
  • Lower standards of care
  • Decreased geographical coverage
  • Diminished choice of services
  • Poor maintenance of equipment
  • Inability to supervise Public Health activities
  • Brain drain
the brain drain
The Brain Drain
  • G8 has 30 X doctors/population than SSA yet…
  • E.g. Exodus of physicians mainly from Ghana, Malawi and Namibia
  • Despite commitments of developed countries not to recruit, recruitment continues…

Over 2,000 South African nurses registered in UK a year following policy not to poach, twice as many as before

  • Push factors: inadequate health systems
the brain drain1
The Brain Drain
  • The US with 130,000 foreign physicians
    • Saved an estimated $US 26 billion in training costs for nationals
    • Option: compensation to developing countries
what is health
What is Health?

By far, the most accepted definition is that of the World Health Organization:

“[Health is] the state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (WHO, 1948) and the “extent to which an individual or group is able to realize aspirations and satisfy needs, and to change or cope with the environment. Health is a resource for everyday life, not the objective of living; it is a positive concept, emphasizing social and personal resources as well as physical capabilities” (WHO, 1984).

Health Indicators, Part I

views on health
Views on Health
  • .

Broad holistic definition

Narrow organic definition

What is health ?

Why is health important?

As a right

As a consumption good

As an investment good

health systems1
Health systems
  • Combination of resources, organization, financing, and management that culminates in the delivery of health services to the population

Roemer MI. National health systems of the world, volume 1. New York, Oxford University Press, 1991

  • All activities whose primary purpose is to promote, restore and maintain health

World Health Report 2000

goals of a health care system
Goals of a health care system
  • Universal and equal access to reasonable health care
  • control of health care costs at an affordable level
  • effective use of resources
the iron triangle or the holy grail
The Iron Triangle or the Holy Grail?

All nations struggle to

balance access to healthcare

with quality and cost efficiency.

Is there one perfect solution for all nations?

health system model used to assess hfa

Political, social and cultural values

  • Financing
  • Human resources
  • Public/private mix
  • Organization and management
  • Resource allocation
  • Selection of technology
  • Coverage by health services
  • Utilization of health services




Quality of life



Health System Model used to assess HFA
four survival patterns and transitions between them

The health

transition in

the Third


The firsthealth


The health

transition in

The West

Four survival patterns and transitions between them
does one cog drive the others
Does one cog drive the others?







health financing paradigm in ssa
Health financing paradigm in SSA

Proposed paradigm

  • Acute shortage of funds to meet targets, but also problem of how funds spent
  • Governments should lead effort to explore innovative financing mechanisms
  • Focus also on how money is spent, not just how much
  • Collaborate with donor partners to ensure external resources help build the health system

Current paradigm

  • Diagnosis: Principal problem facing the region is a shortage of funds
  • Solutions:
    • (1) Mobilize internal and external resources
    • (2) Focus on key diseases and conditions
    • (3) Set targets and monitor progress
health financing targets
Health financing: Targets

Abuja: Government spending on health should be at least 15% of total government spending

East Asia & Pacific: 10.1%

Latin America and the Caribbean: 12.5%

Commission on Macroeconomics & Health (CMH): Estimated $34 per capita for a basic package of health service

East Asia & Pacific: $62 (current US$)

Latin America and the Caribbean: $272 (current US$)

Are targets meaningful? Relevant?

africa region is off track to meet the mdgs
Africa region is off-track to meet the MDGs
  • What is needed to meet the MDGs?
    • One estimate: more than 12% of GDP (at regional level) would need to be spent on health to reach the targets by 2015
      • Current level: 4.7% of GDP goes to health
    • Additional $20-25 billion per year needed

Sources: Disease Control Priorities Project, 2007; and African Development Bank, 2002.


Percentage of national budgets allocated to health sector

Source: African Union. Progress Report on the Implementation of the Plans of Action of the Abuja Declarations for Malaria, HIV/AIDS and Tuberculosis; Revised Final Draft, 22 December 2005.

health financing levels are low the 34 package of basic health services
Health financing levels are low – the $34 package of basic health services

Few countries spend $34+

The CMH Target

Source: WHO SIS

Note: Countries spending >$90 total per capita on health were excluded to improve graph’s readability. These countries include Swaziland, Mauritius, Namibia, Gabon, South Africa, and Botswana.

what difference would the abuja target make
…What difference would the Abuja target make?

Source: World Bank, WDI 2007; author’s calculations.

heavy dependence on donor funding raises concerns sustainability priorities
Heavy dependence on donor funding raises concerns: sustainability, priorities

Notes: Disbursements include PEPFAR, GFATM, and World Bank MAP funding.

Source: Heller, Peter. “Pity the Finance Minister”: Issues in Managing a Substantial Scaling up of Aid Flows. IMF Working Paper WP/05/180. September 2005.

heavy dependence on donor funding raises sustainability and predictability concerns rwanda
Heavy dependence on donor funding raises sustainability and predictability concerns: Rwanda



































Source: Rwanda NHA 1998-2006

health financing sources of revenue
Health Financing: sources of revenue
  • Direct out of pocket payments
  • Premiums for NHIS
  • Tax revenues
  • Grants from development partners
  • Financial credits
policy objective
Policy Objective
  • To mobilize resources and ensure equitable and sustainable financing of the health sector
    • Resource mobilization (GOG, NHI, grants, loans & out-of-pocket payment)
    • Equitable & efficient allocation of health resources
    • Efficient utilization of health resources
policy measures
Policy Measures
  • Mobilization from all sources of funds, both domestic and international
  • Pursue equity in health financing
    • Risk pooling
    • Target resources to services for the poor, vulnerable groups & public health interventions
    • Reduce catastrophic cost of care
policy measures contd
Policy Measures contd.
  • Ensure effectiveness of aid in the health sector
  • Ensure financial sustainability of the National Health Insurance fund
  • Etc

Financing Fairness

Capacity Building/ Institutional Strengthening

Majority of population covered through publicly funded schemes (e.g. general taxation, social insurance)

Increasing public share of health financing through targeted coverage for vulnerable populations

Limited Public Funding (for vulnerable)

Private insurance for secondary


Private Insurance pools cover other segments of the population

Out-of-pocket payments predominate

Potential Model Towards Universal Coverage(WHO)

Public Spending



Private Spending

health indicators






9.5 million children under five die annually

90% preventable

And undernutrition implicated in 50% of child deaths

Source: State of the World’s Children, UNICEF 2008

causes of under 5 child mortality 2000 2003
Causes of Under 5 Child Mortality,2000-2003

Bryce et al. WHO estimates of the causes of death in children. Lancet 2005

causes of under 5 mortality by region 2000 2003

African Region

4.396 million









Causes of Under 5 Mortality by Region, 2000-2003

Bryce et al. WHO estimates of the causes of death in children. Lancet 2005

trends in child mortality relative to mdg 4
Trends in Child Mortality Relative to MDG-4

Sub-Saharan Africa

South Asia


Latin America


East Asia





















1970 1990 2004 2015

Source: The State of the World’s Children, 2006

maternal mortality in 2005
Maternal Mortality in 2005

Source: WHO/UNICEF/UNFPA/The World Bank estimates, App. 15, pub 2007


The Lifetime Risk of Maternal Death


Industrialized contries


South Asia


Sub-Saharan Africa



The chance of a woman dying as a result of pregnancy is 200 x greater in sub-Saharan

Africa than it is in the United States

Source: WHO/ UNICEF/UNFPA, The WorldBank. Maternal Mortality Estimates 2005,App 8, pub 2007


Other direct causes include embolism, ectopic pregnancy, anesthesia-related. Indirect causes include: malaria, heart disease.

Source:Adapted from " WHO Analysis of causes of maternal deaths: A systematic review.” The Lancet, vol 367, April 1, 2006.

pareto chart
Pareto Chart
  • Pareto's Principle; the “80-20 Rule”; the "Vital Few” versus the “Trivial Many” rule
  • A special form of a vertical bar chart and a tool for setting priorities

... The richest fifth of the world’s population have 74 times the income of the poorest fifth.

..The top three billionaires have assets greater than the combined GNP of all least developed countries and their 600 million people.

percentage of people living below the poverty line
Percentage of People living below the poverty line
  • Europe and Central Asia 3.5%
  • Latin America and Caribbean 23.5%
  • Sub-Saharan Africa 38.5%
  • Middle East and North Africa 4.1%
  • South Asia 43.1%
why do the poor have higher morbidity and mortality rates
Why do the poor have higher morbidity and mortality rates?
  • The poor
    • have less access to, and availability of, health services including mental health services.

(See http://www.cdc.gov/omh/AMH/factsheets/mental.htm)

    • are less likely to receive needed health services,
    • receive a poorer quality of health care,
    • are underrepresentedin health research and among health care professionals,
    • have lower levels of education, and
    • are more likely to live in poverty
task of improving health
Task of Improving Health

Obstacles to progress

  • Poverty
  • Uneven distribution of health services.
  • Lack of appropriate technology.
  • Inadequate supply and distribution of pharmaceuticals.
  • Bad management .
  • Inappropriate government programmes.
some important choices
Some important choices
  • In attempting to produce healthy people, we are faced with 3 variables:
    • Technology
    • Resources
    • Management
an effective public health system



Programs & Services


An Effective Public Health System
why management
Why Management?
  • Two-thirds of child deaths could be prevented by interventions that are available today and feasible for implementation in low-income countries at high levels of population coverage.
  • The main challenge today is to transfer what we already know into action.”
  • Jones et al, “How many child deaths can we prevent this year?” The Lancet, July 5, 2003.

Lessons from WHO's leadership and management needs assessments(WHO Department of Health Systems Governance and Service Delivery)

regional co operation integration
Regional Co-operation & Integration
  • Partners to assist institutions
  • Utilize national expertise: students & staff of higher Institutions
  • Collaboration:
    • African Region
    • Universities
    • WAHO
    • Research Institutes (e.g. Noguchi)
    • MOH/Finance/Universities/
  • Strategic Partners
    • UG - Ghana School Public Health
    • AFENET
    • Corporate Africa
  • Capacity Development
    • Advocates
    • Trainers of Trainers (TOT)
  • Technical Assistance
    • CDC
  • Sustainability
review government policies
Review Government Policies
  • Review Health Policies:
    • equitable access, safety, and cost.
    • define Govt role in Health
    • community oriented
    • provide direction to health reform
    • guide the many actors in public health.
target appropriate public health services
Target appropriate Public Health services
  • Priority public health services (AIDS,TB, malaria, hepatitis B)
  • Neglected Tropical Diseases
  • Full operating cost to implement the package
    • including salary of public health staff
develop national medicine policy
Develop national medicine policy
  • with a reform on how essential drugs should be produced, registered and made available to service providers
  • Policy and regulation on rational use of drugs must be effectively implemented
promote sustainable development
Promote sustainable development

by ensuring that “external assistance” projects and programmes are absorbed early into national system

research development
Research & development
  • Promoting evidence–based research system
    • Appropriate indicators
  • Training: graduates on Quality Research
  • Monitoring & Evaluation systems
    • Projects
    • Programmes
    • Processes
health financing paradigm in ssa1
Health financing paradigm in SSA

Proposed paradigm

  • Acute shortage of funds to meet targets, but also problem of how funds spent
  • Governments should lead effort to explore innovative financing mechanisms
  • Focus also on how money is spent, not just how much
  • Collaborate with donor partners to ensure external resources help build the health system

Current paradigm

  • Diagnosis: Principal problem facing the region is a shortage of funds
  • Solutions:
    • (1) Mobilize internal and external resources
    • (2) Focus on key diseases and conditions
    • (3) Set targets and monitor progress
process improvement
Process Improvement

A systematic, data-based method for improving the quality of work processes

TQM (continuous improvement)

It uses team decision-making to improve processes that affect the quality of products and services for a customer.

involve all stakeholders
Involve all Stakeholders
  • A stakeholder is one person, or group of persons, having an interest or concern in a particular process resulting from some direct or indirect involvement.









Funding Agents

widening access to health services
Widening Access to Health Services
  • Increasing physical access to care
    • Scaling up the establishment of Community-based Health Planning & Services (CHPS)
  • Community mobilization combined with community-based deployment of the nurse is the most effective intervention
21 st century health care
21st Century Health Care

Improving quality by promoting a culture of safety through Value-Driven Health Care

Information-rich, patient-focused enterprises

Information and evidence transform interactions from reactive to proactive (benefits and harms)

Evidence is continually refined as a by-product of care delivery

21st Century Health Care

Actionable information available – to clinicians AND patients – “just in time”

  • 4.4 billion people living in developing countries, 20% have no access to modern health facilities
  • High U5MR & MMR in SSA
  • Requires effective Health Systems to resolve these problems
  • Need for a new paradigm for health financing in SSA
  • Govt. Policies to target community health needs

“Never doubt that a small group of committed citizens can change the world; indeed it is the only thing that ever has!”

-Margaret Mead

  • World Bank (2008). Dollar a Day Revisited
  • WHO (2005). Expenditures on Health Related Needs
  • WHO (2008). Leadership and Management needs Assessment
  • CDC (2008). SMDP - MIPH
  • Lancet (2005). Neonatal Survival