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 11-12 March, 2010 Bandar Sunway, Malaysia Ravi P. Rannan-Eliya Institute for Health Policy
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
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
The reality: Higher burden from NCDs than appreciated 3
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 1971-2009 IHD Diabetes 4
Mortality rates for NCDs in Sri Lanka already higher than OECD countries Data are age-standardized mortality rates for 2000-2002 5
The reality: Impressive health performance, but also odd gaps in health outcomes 6
Life expectancy not improving in older men since 1970s 7
Emerging gap with developed countries in older adult male mortality, Sri Lanka vs. USA 19 17 USA Sri Lanka Life expectancy at age 65 (years) 15 13 11 9 7 1921 1946 1952 1963 1971 1981 2001 1921 1946 1952 1963 1971 1981 2001 Males Females 8
Emerging gap in mortality is in NCDs especially CVD and diabetes All causes Cardiovascular disease Diabetes Injuries 9
The reality: Global and local evidence of health systems underperformance 10
20 Stagnation in male life expectancy not unusual, but persistence is USA 1945-2000 19 19.07 18 Life expectancy at age 65 (years) 17 16 15 15.75 17.35 15.34 14 13 13.22 13.48 Males Females 12 1945 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 11
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 1,000 800 600 Deaths per 100,000 1,200 1,000 800 600 400 400 200 200 0 0 1922 1934 1946 1958 1970 1982 1994 1922 1934 1946 1958 1970 1982 1994 Changes in age standardized mortality rates by disease group, Australia 1922-2000 Source: John Goss, AIHW 2006 12
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
But evidence of failure in Sri Lanka to exploit global advances 14
Systematic under-treatment of heart patients in public sector 100 96 80 60 66 72 70 Range in other countries Range in other countries Sri Lanka 40 34 38 20 23 9 11 9 4 0 Aspirin Beta-blockers ACEI Statins Survey of heart patients in 10 developing countries by WHO (Mendis et al., 2005) 15
Any availability during year of IHD medications by levels in public sector, 2006 16
Unexpected finding Very high mortality from asthma health services quality indicator 17
Under-consumption of medicines most marked for NCD medicines Anti-bacterials 35 32 Beta blockers 90 30 80 70 77 25 DDD/1000 poulation/day 20 15 10 17 11 20 DDD/1000 poulation/day 60 50 40 30 20 20 47 5 10 7 - 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 250 70 70 200 201 60 DDD/1000 poulation/day 50 40 30 23 26 46 DDD/1000 poulation/day 150 100 109 20 50 10 - 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
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
Do these gaps matter? The financing burden 20
10,000 Expenditures by disease group and age, Sri Lanka 2005 9,000 8,000 7,000 6,000 5,000 4,000 3,000 2,000 1,000-0 1-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89 90-94 95+ 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
Inadequate public financing means that burden of financing for most NCDs fall on households with increased risk of financial hardship Malignant neoplasms 91.9 8.1 Other Ischemic Heart Disease 26.3 73.7 Acute Myocardial Infarction 56.9 43.1 Diabetes Mellitus 18.8 81.2 Asthma 13.4 86.6 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Public Private 22
Do these gaps matter? Equity 23
Ranking divisional secretariats by socioeconomic status (SES) using Census data Estimation of standardized mortality rates by divisional secretariats (all causes) 24
IHD mortality by quintiles: higher in rich than in poor 140 120 Male Female All 100 80 60 40 20 0 Poorest 2 3 4 Richest 25
Diabetes mortality by quintiles 35 30 Male Female All 25 20 15 10 5 0 Poorest 2 3 4 Richest 26
Hypertensive mortality by quintiles 60 Male Female All 50 40 30 20 10 0 Poorest 2 3 4 Richest 27
Asthma mortality by quintiles 50 45 Male Female All 40 35 30 25 20 15 10 5 0 Poorest 2 3 4 Richest 28
Hypertension mortality for all ages by DSDs, Sri Lanka 1999-2003 Asthma mortality for all ages by DSDs, Sri Lanka 1999-2003 29
Current CVD risks by SES decile higher in rich 40% 35% 30% Prevalence (%) 25% 20% 15% 10% 5% 0% Poorest 2 3 4 5 6 7 8 9 Richest Smoking Obesity Low activity High TC:HDL Ratio Hypertension Diabetes 30
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
What difference would public investment in treatment and secondary prevention of IHD make in Sri Lanka? 32
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 1,747 0 10,000 20,000 30,000 40,000 33
Treatment more pro-poor than primary prevention 35 30 High baseline risk with antihypertensives High baseline risk with two interventions Population strategy (9% cholesterol reduction) 25 20 15 10 5 0 Poorest Q2 Q3 Q4 Richest 34
Can Sri Lanka afford treatment and secondary prevention of IHD? 35
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 18 82 Drugs for obstructive airway diseases 7 93 Drugs for obstructive airway diseases 71 29 Diuretics 22 78 Diuretics 57 43 Calcium Channel Blockers 10 90 Calcium Channel Blockers 57 43 Beta-blockers 7 93 Beta-blockers 47 53 Anti-hypertensives 61 39 Anti-hypertensives 74 26 Anti-diabetics 11 89 Anti-diabetics 49 51 ACE Inhibitors 25 75 ACE Inhibitors 68 32 Anti-bacterials for systemic use 48 52 Anti-bacterials for systemic use 53 47 0% 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 86 2008 expenditures Required increase Anti-diabetics 13 Anti-hypertensives 105 ACE Inhibitors 16 Anti-bacterials for systemic use 82 Anti-diabetics 173-10 20 30 40 50 60 70 80 90-50 100 150 200 250 300 Source: Sri Lanka for 2008 from MOH and IMS-Health (Sri Lanka), and OECD countries for 2006 from OECD Health Data 2008. 36
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
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