Health System Financing Implications of Chronic Health Conditions: Insights from Sri Lanka

Transcription

1 Health System Financing Implications of Chronic Health Conditions: Insights from Sri Lanka Prioritizing chronicity: An Agenda for Public Health Research on Chronic Disease for sub-saharan Africa and Asia March, 2010 Bandar Sunway, Malaysia Ravi P. Rannan-Eliya Institute for Health Policy

2 Sri Lanka background facts Lower-Middle Income developing country GDP per capita $2,000 75% rural population 17% under-fives stunted Advanced health transition Life expectancy ~72 years IMR ~12/1000 live births Ageing population Pop >60 years ~12% Increasing to ~30% by 2050 Low health spender 4.0% of GDP (total) $50 per capita (govt) Health financing mix 50% public from taxes 50% private mostly out-ofpocket Health services Evolved from MCH model Govt delivery dominated by hospitals Private sector mostly outpatient and pharmacies 1

3 Conventional wisdom System does well nothing to worry about Yes NCDs are increasing, but no need to worry yet, as these are diseases of rich countries and we have the MDGs to focus on! Let s not make the mistakes of the rich countries: we should focus on cost-effective primary prevention and health promotion And anyway, we can t afford do what rich countries do 2

4 The reality: Higher burden from NCDs than appreciated 3

5 Annual Deaths from NCDs have far outpaced those from MDG conditions and war 35,000 30,000 25,000 20,000 15,000 10,000 5,000 0 MDGs War IHD & Diabetes All child deaths Maternal TB Malaria HIV/AIDS IHD Diabetes 4

6 Mortality rates for NCDs in Sri Lanka already higher than OECD countries Data are age-standardized mortality rates for

7 The reality: Impressive health performance, but also odd gaps in health outcomes 6

8 Life expectancy not improving in older men since 1970s 7

9 Emerging gap with developed countries in older adult male mortality, Sri Lanka vs. USA USA Sri Lanka Life expectancy at age 65 (years) Males Females 8

10 Emerging gap in mortality is in NCDs especially CVD and diabetes All causes Cardiovascular disease Diabetes Injuries 9

11 The reality: Global and local evidence of health systems underperformance 10

12 20 Stagnation in male life expectancy not unusual, but persistence is USA Life expectancy at age 65 (years) Males Females

13 Decline in death and disability in rich countries since 1970s due to NCDs, led by heart disease Male 2,000 1,800 1,600 Infectious and parasitic diseases Other diseases Respiratory disease Injuries and poisoning Circulatory disease Cancer Female 2,000 1,800 1,600 Infectious and parasitic diseases Other diseases Respiratory disease Injury and Poisoning Circulatory disease Cancer 1,400 1,400 Deaths per 100,000 1,200 1, Deaths per 100,000 1,200 1, Changes in age standardized mortality rates by disease group, Australia Source: John Goss, AIHW

14 Medical treatment driving older adult health gains, more than prevention Evidence best for ischaemic heart disease (IHD) Epidemiological models indicate that medical therapies account for half of all reductions in heart disease deaths in rich countries, with rest due to control of risk factors, primarily smoking Econometric analyses suggesting a higher role for therapies in USA (65%) Recently, link shown between NCDs/ treatment and disability/frailty 13

15 But evidence of failure in Sri Lanka to exploit global advances 14

16 Systematic under-treatment of heart patients in public sector Range in other countries Range in other countries Sri Lanka Aspirin Beta-blockers ACEI Statins Survey of heart patients in 10 developing countries by WHO (Mendis et al., 2005) 15

17 Any availability during year of IHD medications by levels in public sector,

18 Unexpected finding Very high mortality from asthma health services quality indicator 17

19 Under-consumption of medicines most marked for NCD medicines Anti-bacterials Beta blockers DDD/1000 poulation/day DDD/1000 poulation/day Sri Lanka OECD Lowest - Netherlands OECD Median - Iceland OECD Highest- Greece - Sri Lanka OECD Lowest - Spain OECD Median - Iceland OECD Highest- Germany Anti-diabetics 80 Drugs for obstructive airways disease/asthma DDD/1000 poulation/day DDD/1000 poulation/day Sri Lanka OECD Lowest -Iceland OECD median - Sweden OECD Highest - Finland - 5 Sri Lanka 22 OECD Lowest - Slovak Republic OECD Median - Belgium OECD Highest- Australia Source: OECD countries for 2006 from OECD Health Data 2008, and Sri Lanka for 2008 computed from data provided by MOH and IMS-Health (Sri Lanka) 18

20 Summary so far... Good health systems performance in Sri Lanka, but failings in areas of adult male and NCD mortality Growing evidence of role of health services in reducing NCD mortality in rich countries Under-provision of treatments for NCDs: IHD, asthma and diabetes in Sri Lanka 19

21 Do these gaps matter? The financing burden 20

22 10,000 Expenditures by disease group and age, Sri Lanka ,000 8,000 7,000 6,000 5,000 4,000 3,000 2,000 1, Acute Respiratory Infections Benign Neoplasms Cardiovascular Disease Chronic Respiratory Disease Congenital Anomalies Diabetes Mellitus Diseases of the Digestive System Endocrine & Metabolic Disorders Genitourinary Diseases Ill-defined conditions & other Contacts Infectious & Parasitic Diseases Injuries Malignant Neoplasms Maternal Conditions Mental Disorders Musculoskeletal Disorders Neonatal Causes Nervous System & Sense Organ Disorders Nutritional Deficiencies Oral Health Other Anaemias and Blood/ Immune Disorde Skin Diseases Unspecified Abnormal Clinical & Laborato 21

23 Inadequate public financing means that burden of financing for most NCDs fall on households with increased risk of financial hardship Malignant neoplasms Other Ischemic Heart Disease Acute Myocardial Infarction Diabetes Mellitus Asthma % 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Public Private 22

24 Do these gaps matter? Equity 23

25 Ranking divisional secretariats by socioeconomic status (SES) using Census data Estimation of standardized mortality rates by divisional secretariats (all causes) 24

26 IHD mortality by quintiles: higher in rich than in poor Male Female All Poorest Richest 25

27 Diabetes mortality by quintiles Male Female All Poorest Richest 26

28 Hypertensive mortality by quintiles 60 Male Female All Poorest Richest 27

29 Asthma mortality by quintiles Male Female All Poorest Richest 28

30 Hypertension mortality for all ages by DSDs, Sri Lanka Asthma mortality for all ages by DSDs, Sri Lanka

31 Current CVD risks by SES decile higher in rich 40% 35% 30% Prevalence (%) 25% 20% 15% 10% 5% 0% Poorest Richest Smoking Obesity Low activity High TC:HDL Ratio Hypertension Diabetes 30

32 Future 10 year risk of CVD deaths by SES quintile higher in poor 45,000 40,000 35,000 30,000 25,000 20,000 15,000 10,000 5,000 0 Poorest Q2 Q3 Q4 Richest 31

33 What difference would public investment in treatment and secondary prevention of IHD make in Sri Lanka? 32

34 Deaths saved in 10 years under different intervention strategies secondary versus primary prevention High baseline risk with two interventions 37,660 Population strategy (9% cholesterol reduction) 25,106 High baseline risk with statins 24,309 High baseline risk with antihypertensives 16,009 Population strategy (2% cholesterol reduction) 5,073 Single risk factor strategy 1, ,000 20,000 30,000 40,000 33

35 Treatment more pro-poor than primary prevention High baseline risk with antihypertensives High baseline risk with two interventions Population strategy (9% cholesterol reduction) Poorest Q2 Q3 Q4 Richest 34

36 Can Sri Lanka afford treatment and secondary prevention of IHD? 35

37 Bulk purchasing by public sector makes provision of NCD medicines affordable Percentage of expenditures on selected medicines by source (%) Percentage of volumes of selected medicines financed by source (%) Statins 4 96 Statins Drugs for obstructive airway diseases 7 93 Drugs for obstructive airway diseases Diuretics Diuretics Calcium Channel Blockers Calcium Channel Blockers Beta-blockers 7 93 Beta-blockers Anti-hypertensives Anti-hypertensives Anti-diabetics Anti-diabetics ACE Inhibitors ACE Inhibitors Anti-bacterials for systemic use Anti-bacterials for systemic use % 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Public (%) Private (%) Ratio of public to private sector unit prices for selected medicines (%) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Public (%) Private (%) Cost of increasing MOH supplies to 80% of OECD median level (Rs mi Statins 20 Drugs for obstructive airway diseases 83 Drugs for obstructive airway diseases 3 Diuretics 22 Diuretics 91 Calcium Channel Blockers 8 Calcium Channel Blockers 135 Beta-blockers 8 Anti-hypertensives 53 Beta-blockers expenditures Required increase Anti-diabetics 13 Anti-hypertensives 105 ACE Inhibitors 16 Anti-bacterials for systemic use 82 Anti-diabetics Source: Sri Lanka for 2008 from MOH and IMS-Health (Sri Lanka), and OECD countries for 2006 from OECD Health Data

38 Key findings Excess burden in NCDs driving emerging gap in mortality and slowdown in life expectancy gains Excess burden dominated by CVD, but also high burdens from asthma Evidence of substantial gap in provision of costeffective treatment for NCDs due to lack of public financing Expansion of 2y prevention/treatment feasible with available resources and likely to have substantial pro-poor benefits But expansion depends on restructuring primary care 37

39 Implications for developing countries Expansion of secondary prevention and treatment of NCDs critical and appropriate Financing is increasingly affordable for many developing countries Expansion requires public financing Cost of failure to invest will be growing inequities, failures in risk protection, and lags in health gains Financing will also need primary care reform 38