Health Challenges and their Determinants in the EMR/MENA

Transcription

1 Health Challenges and their Determinants in the EMR/MENA Sameen Siddiqi, Regional Adviser, Health Policy and Planning, WHO EMRO The Middle East and North Africa Health Policy Forum Conference on Better Policies for Better Health September 8-10, 2007 Cairo, Egypt

2 Outline of the presentation EM and MENA Regions Health challenges Priority public health conditions Health system challenges Health determinants WHO EMRO s response 2

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4 Burden of Disease in MENA

5 National burden of disease Egypt 1999/ DALYs Noncommunicable diseases Communicable, maternal, perinatal, nutritional conditions Injuries Males Females Disease groups Source: National Information Center for Health & Population, Ministry of Health & Population 5

6 National burden of disease Egypt 1999/ DALYs Injuries IHD Lower resp inf Hypertensive disease Asthma Cerebrovasc disease Diarrheal disease Cirrhosis liver Nephrosis Diabetes mellitus Rheumatologic disorder Male Female Specific disease categories 6 Source: National Information Center for Health & Population, Ministry of Health & Population

7 National burden of disease study- Islamic Republic of Iran DALY per 10,000 population YLL YLD Homozgan East Azerbaijan Khorasan Bushehr Yazd Charmahal & Bakhtiari 7

8 Burden of disease by the top 20 BOD groups in Iran

9 UAE Yemen Infant and Maternal Mortality in EMR Infant Mortality Rate Maternal Mortality Ratio 9 Egypt Iran Iraq Jordan Kuwait Lebanon Libya Morocco Oman Pakistan Palestine Qatar Saudi Arabia Somalia Sudan Syria Tunisia UAE Yemen Afghanistan Bahrain Djibouti Egypt Iran Iraq Jordan Kuwait Lebanon Libya Morocco Oman Pakistan Palestine Qatar Saudi Arabia Somalia Sudan Syria Tunisia Afghanistan Bahrain Djibouti per 1,000 live births per 100,000 live births

10 Inequities in health outcomes in countries of EMR/MENA Low est Highest Low est Highest Low est Highest Low est Highest U5 mortality /1,000 LB Stunting in U5 children (%) Births attended by SBA (%) Income quintiles Measles cov. <1 children(%) Egypt (2005) Morocco (2004) Yemen (1997) Source: Demographic and Health Surveys 10

11 Prevalence of selected risk factors in EMR sub regions Risk Factor Proportion consuming alcohol Mean systolic pressure (mm Hg) Mean cholesterol (mmol/l) Mean hemoglobin level (g/dl) Overweight (BMI kg/m 2 ) Proportion with no physical inactivity Underweight (% < 2SD weight for age) Unplanned pregnancies (% not using modern contraceptives) Unsafe health care injections (exposing to Hep B) EMR-B 10% % 8% 63% 0% EMR-D 5% % 25% 82% 12% Urban air pollution (Conc of particles < 10µg/m 3 ) Vitamin A deficiency (% with night blindness) 1% 16% Source: WHR 2002 EMR D: Afghanistan, Djibouti, Egypt, Iraq, Morocco, Pakistan, Sudan, Somalia, Yemen 11

12 Prevalence of smoking among adults 2000/02 Jordan Egypt Tunisia Kuwait Oman Males 51% 32% 46% 30% 9% Females 8% 7% 4% 2% 0% Lebanon 52.6% Demographic, Social and Health Indicators for Countries of the Eastern Mediterranean

13 Health workforce challenges Distribution of physicians and nurses Afghanistan Bahrain Djibouti Egypt Iran Iraq Jordan Kuwait Lebanon Libya Morocco Oman Pakistan Palestine Qatar Saudi Arabia Sudan Syria Tunisia UAE Yemen Physicians Nurses and midwives per 10,000 population

14 Health workforce challenges Imbalanced and mal-distributed Internal and external brain drain Issues related to quality of training Lack of accreditation system Lack of motivation and absenteeism Perverse incentives and moonlighting Continuing professional development not institutionalized 14

15 Total health expenditure per capita in countries of the Eastern Mediterranean Region 2001 (international dollars) Somalia Afghanistan Sudan Yemen Pakistan Djibouti Iraq Egypt Morocco Libyan Arab Jamahiriya Oman Jordan Islamic Republic of Iran Syrian Arab Republic Tunisia Saudi Arabia Kuwait Bahrain Lebanon Qatar United Arab Emirates Direct payment Other sources

16 Catastrophic health expenditure and impoverishment ; Iran Catastrophic health expenditures Reduce expenditures on other basic needs Push some households into poverty Cause consumers to forgo health services and suffer illness Catastrophic Impoverishing % of households Source: Razavi et al (2005) 16

17 Health care financing - Issues Over 50% of EMR population lives in seriously under funded health systems Share of out-of-pocket is over 45% in most EMR countries (in some up to 75%) 2% households exposed to catastrophic health expenditure annually and half are impoverished Expatriates in the region do not have proper health insurance coverage Pooling schemes are fragmented Purchasing function is passive and in most schemes payment method is fee-for-service Major technical and allocative inefficiencies in almost all health systems in EMR 17

18 Health system governance Principles and Thematic Areas Governance of the Health System: Principles Strategic vision Participation and consensus Rule of law Transparency Responsiveness Equity and inclusiveness Effectiveness and efficiency Accountability Information/intelligence Ethics Thematic Areas Evidence based and ethical national health policies Strategic planning, priority setting and budgetary frameworks Health legislation, regulation standard setting and enforcement Institutional strengthening of MOH Intersectoral action for health Donor coordination mechanisms Monitoring aid effectiveness Global health governance 18

19 Health system governance matrix Sudan Governance principle Central level Principal findings MOH Policy level MOH Implementation level Strategic vision Public spending on health ranked among the lowest in the region (0.9% of GDP). National health policy with PHC as the main strategy. No mechanisms to review or revise health policies exist. Health financing and health promotion have either no clear mechanism or inefficient means of implementation. Participation and consensus orientation Consultation with the partners, including private sector and civil society, is minimal. Consultative mechanism to discuss health plans, programs and budgets, proposed regulations etc. is inadequate. Local legislative assembly approves policy matters. Technical and sectoral representation is not guaranteed in assemblies Rule of law No separate consumer protection law exists. Laws are not updated for long periods of time No distinct penal code for health care delivery related issues; cases are dealt under the general laws of country Absence of consumer rights organizations and lack of awareness among citizens about their rights Transparency State policy favours access to information but is mostly dependent upon personal relationships No mechanisms to monitor the transparency of decisions about resource allocations within health Policies regarding staff recruitment not always adhered. Higher levels control promotions, localities have no control Responsivene ss Development of pro-poor policies and a focus on vulnerable groups are considered as priorities Public spending biased towards spending on secondary and tertiary centres in urban areas. Ad hoc needs assessments are performed by MOH User satisfaction surveys not commonly undertaken. Equity and inclusiveness Various social protection schemes address financial barriers for the poor, not properly assessed. The constitution, the 25 years strategy for health and the PRSP recognize the issue of equity Limited access for poor - user fees, urban-rural disparities and staff in rural areas lack incentives. Effectiveness and efficiency Civil service is demotivated, salaries in public service are considered low, with no staff incentive Situation better regarding qualified public health personnel posted at FMOH. Attrition of mid-level qualified staff Quality of public health training is questionable. Most staff supplements income through private practice Accountabilit y Media has limited role in highlighting health issues and protecting the interests of public. Oversight committee in parliament plays an important role. No system for monitoring of assets and life styles of civil servants exists. Political interference in day-to-day management in the form of influencing decisions regarding appointment, transfer and promotion. Performance audit of staff is done as a routine Intelligence and information Prevalent culture supports incremental planning and the absence of evidence based decision making. Poor quality of data, delayed reporting, and poor analysis are main problems. Information is not used for decisions Community based and private sector data are not collected. The births and deaths registration system is weak. Ethics Ethics in research is not a well developed area. No mechanism to monitor ethics in health care. A national research ethics committee recently established in FMOH A booklet containing some guidelines on ethics 19in medical practice is published but not largely circulated or practiced.

20 Health system challenges Service provision Continuous pressure on delivery systems with increasing complexity and expectations from population groups Poor regulation, accreditation and quality standards Disharmony between primary, secondary and tertiary levels Disconnect among responsibility, performance and accountability in delivery of healthcare Inadequate targeting of those in most need for healthcare Limited assessment of implications of: Contracting out health services Liberalization of trade in health services Decentralization of health services Disrupted health services in countries in conflicts 20

21 Public and private distribution of hospital beds (per 10,000 population) Egypt Jordan Lebanon Sudan Syria Public Private Source: Country studies on private health sector in EMR countries, WHO EMRO,

22 Human workforce in public and private sectors in Lebanon Health workforce Number Public Private Total Physicians Dentists Pharmacists Nurses Health technicians Physiotherapists

23 Health facilities in private sector- Egypt Types of facilities Number % Single physician clinics 30, Polyclinics 7, Dental clinics 6, Medical laboratories 4, Dental laboratories Private hospitals 1, Renal dialysis centers X-ray centers Physiotherapy centers Opticians Investment hospitals* Gymnasiums 671 1, Source: Non-Governmental Institutions and Licensing Gen. Dept., MOHP,

24 Health system challenges Medical technologies Tools to set norms and standards on assessment, selection and use 16 Unimpeded transfer of technology between countries 14 Availability 12 of essential technologies at different levels HT programs 10 integrated within national health systems CT 8 Improved access to safe blood, blood products and MRI injections 6 4 Accessible, safe diagnostic imaging and lab services 2 Strengthened capacity at PHC to provide essential 0 surgical care Canada France Lebanon United Tunisia UAE Yemen (2003) (2003) (2001) Kingdom (2003) (2003) (2005) Improved access and use (2004) of safe and appropriate medical devices per million population 24

25 Medical tourism: Jordanian Perspective Directorate of medical tourism established in partnership with private sector MOH has office at airport to facilitate entry 120,000 patients sought medical services in Jordan in 2002 (private hospitals share 55%) In 2001 estimated revenues from medical tourism in Jordan US$ 620 million Patients visit from Yemen, Bahrain, Sudan, Syria, Libya, Palestine and Saudi Arabia 25

26 Medical tourism: Yemeni perspective No visa or foreign exchange restrictions for patients 2003 estimate for all patients 40,000 Jordan is the most frequently visited country US$ million Travel and Health Expenditure by Yemeni Patients on Foreign Treatment Other countries include Saudi Arabia, Egypt, Syria Year Source: Expenditures extracted from balance of payments estimates of Central Bank of Yemen

27 Social determinants of health in the Eastern Mediterranean Women s empowerment/enablement status of women and their role in the health of families; Gender dynamics e.g. female genital mutilation as gender and health issue; Child labor and street children related to poverty and marginalization; Lifestyle and behavioral issues diet, physical activity, hygiene behavior; Migrant workers movements within and between countries can result in marked health inequities; Inequitable health systems result in barrier in access to essential health care; Conflicts and emergencies and the creation of health inequities; 27

28 Health determinants in conflict countries Social determinants specific to the conflict setting The loss of human rights Breaches of medical neutrality Stress, distress and disease New dimensions of social determinants Vulnerable groups: children and women Loss of livelihood and community support Provision of, and access to, health services 28

29 WHO EMRO s response Capacity development in policy analysis tools, health systems Strengthen/establish health policy units in health ministries In-depth review and policy dialogue with governments AFG, IRA, SUD, PAK, YEM Health policy and systems research trade & health, governance, contracting, private sector, SDH Establishment of network of regional health system experts virtual Forum Establish EMR health system observatory 29

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31 atory/main/forms/main.aspx Thank you 31