Overview

Lowering the Barriers:Lowering the Barriers:Innovative Solutions to Innovative Solutions to

Increase Access to Health Increase Access to Health Services for Women and Services for Women and

ChildrenChildren

Sjoerd PostmaSenior Health Specialist

OverviewOverview

1. Socio-Economic Context2. MDGs (4/5/6) Overview in Asia/Pacific3. Identifying the Barriers to Achieving

MDGs at Local Levels4. Overcoming the Barriers:

Local Solutions5. Public Health Sector Management:

Lessons (to be) Learned

1. Socio-Economic Context

Billions

Less Developed Regions

More Developed Regions

Source: United Nations, World Population Prospects: The 2004 Revision (medium scenario), 2005.

Growth in More, Less Growth in More, Less Developed CountriesDeveloped Countries

Population by major areaPopulation by major area

6

Billions

3.9

5.3

0.9

2.0

0.60.80.7 0.5

Population percentage by major areaPopulation percentage by major area

7

Percentage

Life Expectancy at Birth, in Years

Source: United Nations, World Population Prospects: The 2004 Revision (medium scenario), 2005.

Trends in Life Expectancy, by Trends in Life Expectancy, by RegionRegion

Urban PopulationPercent

Source: United Nations, World Urbanization Prospects: The 2003 Revision (medium scenario), 2004.

Trends in Urbanization, by Trends in Urbanization, by RegionRegion

Projected Economic GNP Growth by Region:

Economic and Health Economic and Health Sector Challenges in Sector Challenges in

Asia/PacificAsia/Pacific• General improvements but growing inequities• Economic growth, meaning higher fiscal revenues, not

automatically translated into greater financing for health

• Graduation to middle income leads to loss of donor funding which is not immediately replaced

• Current health sector performance leaves much to be desired with regard to equity, efficiency and levels of public financing

• Current health challenges remain: MDGs, NTDs, TB/HIV/AUDS/Malaria/Dengue, Stunting

• Rapid demographic, epidemiological and environmental changes have health and fiscal implications: e.g., NCDs, ageing, lifestyle, food safety, (re)-emerging diseases, food security and safety

2. MDGs (4/5/6) overview in Asia/Pacific

MDGs overview for selected MDGs overview for selected DMCsDMCs

MDG1 MDG4 MDG5 MDG6 MDG7

with ADB Health Support UW child IMR <5 Mort SBA ANC HIV prev TB incid TB Prev Safe H20 Basic San

Indonesia

Lao PDR

Mongolia

Papua New Guinea

Pakistan

Philippines

Vietnam

Significant Others

China

India

Bangladesh

Sri-lanka

Central Asian Republics (Tajikistan has worst indicators, off track and reversing)

Pacific Islands (TB prevalence going up; San poor)

Achieved: On Track: Off Track: Reversing:

MDG progress by ADB regionMDG progress by ADB region

South Asia is off-track on 6 goals: gender equality, universal primary completion, child mortality, maternal mortality, communicable diseases and sanitation. It is on-track on water supply.

Central Asia is off track on four goals – child mortality, maternal mortality, communicable diseases, and sanitation

East Asia and Pacific are off track on child mortality, maternal mortality and communicable diseases.

Despite progress, massive deprivations continue

Without basic sanitation

Infected with TB

Living below $1.25/day

Births without skilled attendance

Without safe drinking water

Child deaths

Out of primary school

Maternal deaths

Living with HIV

Underweight children

Number (millions)

Latest 2015 Projected

1,863 1,783

83 69

9 8

871 701

22 19

466 367

3 3

15 11

0.14 0.10

7 …

Source: UNESCAP, ADB and UNDP. Accelerating Equitable Achievement of the MDGs: Closing Gaps in Health and Nutrition Outcomes, Asia-Pacific Regional MDG Report . February 2012.

15

In many cases, disparities are widening

16

Ealier Year

Gini coefficient

Later Year

Gini coefficient

1 GDP per capita (2000$) 1990 0.739 2010 0.7532 $1.25 per day poverty 1997 0.426 2004 0.4523 Underweight children 1995 0.296 2005 0.4544 Under-5 mortality 1990 0.378 2009 0.3875 Maternal mortality 1990 0.579 2008 0.5936 TB incidence 1990 0.405 2008 0.447

Gini indices of inter-country distribution of income and selected MDG indicators

Indicator

Sources : Staff calculation based on the United Nations MDG database.

From: Shila Chatterjee SDG meeting 6 May 2012

Sources : Ministry of Health and Population, New Era, and Macro International Inc,. 2007. Nepal Demographic and Health Survey 2006.

Country aggregates hide sub-national regional variations

17From: Shiladitya Chatterjee, SDG meeting 6 May 2012

Sources : Ministry of Health and Family Welfare, 2009. Nutrition in India: National Family Health Survey (NFHS-3) India 2005-06.

Country aggregates hide attainments by rich and poor

Children under 5 underweight , India 2005-06 (by wealth quintiles)

From: Shiladitya Chatterjee ,SDG meeting 6 May 2012

19

Health Spending Spending on health and education (% of GDP)

Share of total health expenditures to GDP, 2009

20

Sources : World Health Organization (2011). National Health Accounts . Geneva.

From: Shiladitya Chatterjee ,SDG meeting 6 May 2012

21

Health Personnel

0 5 10 15 20 25 30

BhutanIndonesia

NepalCambodia

ThailandLao PDR

BangladeshMyanmarViet NamSri Lanka

IndiaMalaysiaPakistan

IranPhilippines

ChinaTurkey

SingaporeRepublic of Korea

JapanMongolia

0 25 50 75 100

BangladeshNepal

Lao PDRPakistan

CambodiaIndia

BhutanMyanmar

PhilippinesIndonesia

TurkeyViet Nam

IranChina

Sri LankaThailand

MongoliaMalaysia

SingaporeJapan

Republic of Korea

H

Births attended by Skilled Health Personnel (%) Physicians per 10,000 population

Distribution of child deaths for selected causes by selected WHO region, 2004

3. Identifying the Barriers to Achieving MDGs at

Local Levels

The 4 ‘A’ Dimensions of Barriers

• (Geographic) Accessibility: service location (S), HH location (D), transport costs (D)

• Availability: Health workers, drugs, equipment (all S), service demand (D), waiting time (S), wages/ incentives (S), quality of staff (S), price of goods (S), Information on choices/providers (D), education (D)

• Affordability: costs and prices (S), HH resources and willingness to pay (D), informal fees (S) and opportunity costs (D)

• Acceptability: HW attitude and service provision (S), user/HH attitude and expectations (D), management of services and HR (S), technology (S), community and cultural preferences, attitudes and norms (D)

25

Health Insurance

• Free service to fully paid services continuum (75% of private expenditure is out of pocket)

• Different models:– Health care for the poor funded entirely by

government (e.g. Thailand)– Mix of public provision and subsidized health

insurance for poor

• ‘Competition’ between schemes (CBHI, HEF, vouchers, etc); unclear demarcation (scheme and geographically)

Out of Pocket (private financing)

Grey: low <65%)Yellow: med 65-80%Orange: high 80-90%Red: very high>95%

Small circle: negative changeLarge circle: zero or positive change

Socio-Cultural Issues

• Inappropriate feeding practices (under- nutrition is the underlying cause for 50% of children's deaths)

• Delivery at home with relatives• Gender of staff• Reverence of Medical Staff• Unfamiliar with what is possible/

available

4. Overcoming the Barriers:

Local Solutions

Improving Access to Maternal and Child Health

Services• Demand Side

– Mobilizing the Community: info on services, rope in community leaders, behavior change activities, health education, and organization of transport

– Decreasing financial barriers: CCT, Emergency loan fund, fee exemption, vouchers schemes, cost sharing, SHI, CHI, Prepayment, other incentives (e.g. loss of income or transport)

• Supply Side:– Decreasing

geographical barriers: more facilities, maternity waiting homes, outreach, transport facilities, delegation to lower level staff, collaboration with TBAs

– Improving management and organization: improve quality (training supervision, audits), increase productivity (monetary incentives, performance based financing), decreasing costs, increasing service time

Cambodia: Contracting for PHC (Supply)

• Private sector contracts for provision of PHC services besides government health services

• Included coverage and equity targets

• Result: Poorest half of population more like to receive services: immunization SBA, FP services

• Why: part of the performance based contract

Cambodia: Voucher and Health Equity Fund

(Demand)• HEF for access to public hospitals;

identified poor receive support for service fee, transport and other hospital costs

• Maternal Vouchers scheme done by NGOs; 5 vouchers: 3 ANC, Delivery and PNC services, but also transport costs, referral costs and free services for 5 vouchers

• Result: increased deliveries up 45%, with 25% of women paying themselves reduced with 25%, and nearly 60% of the poor covered for health services

India: Conditional Cash Transfer scheme

(Demand)• Women below poverty line

attending 3 ANCs and institutional delivery received cash after delivery to take care of direct and indirect costs

• Result: up to 25% increase in institutional deliveries

Lao: Proposed CCT/Vouchers scheme

(Demand)• Checklist, distributed by local

midwife/SBA:– Thee ANC attendances – Institutional delivery– Post natal care– FP service introduction/HEd/Service– First immunization– Vital registration

• Collection of stamps and signatures and single payment of 200,000 kip ($25 dollars) to offset costs (primarily transport and relatives accommodation)

Integrated Service Delivery in Indonesia: ‘Posyandu’

(Supply)• Five table service provision:

– Registration/HMIS– Weighing/Child Services– Maternal Services– Family Planning – Nutrition and Health Education

• Regular days; most often linked to market days

• Included availability of doctors from district level

Partnering for Immunization in

Bangladesh (Demand/Supply)• Government Partnered with NGOs to reach

all immunizable children• Government responsible for supply• NGO’s responsible for demand side issues:

mobilization, session management, registration, monitoring and education

• Results: higher immunization coverage in NGO assisted areas (90 vs. 80%)

• Boosted services, lead to polio eradication

Lao District Health Program (1)

(Demand/Supply)• 1st phase: capacity building of district

team and staff, incl TBAs; development of mobile and fixed MCH services; construction and equipment

• 2nd phase: strengthening referral function, revolving drug funds, monitoring system

• 3rd phase: further construction for remote areas, with IFAD

• 4th phase: further strengthening of HW skills and IMCI program

Lao District Health Program (2)

(Demand/Supply)• Results: 90% access (national 60%),

IMR/CMR only 1/3 of national, 50% reduction in MMR (all at $1 pppa)

• Why: long term sustained support (SCF Australia; only 1 expat), integrated with regular health services, capacity building of staff and communities key.

5. Public Health Sector Management:

Lessons (to be) Learned

Lessons learned (1)

First and Foremost: Reducing peri-natal infant and

maternal deaths needs a ‘whole’ health care system offering appropriate and affordable quality antenatal and delivery care, including emergency obstetric care in a so-called continuum of care (mother and infant/child health services)

Lessons learned (2)• Address service, financial and socio-

cultural barriers together, not in isolation;• Better allocation of national and local

resources to match greatest needs; Target usually excluded groups; Prioritization for MCH services

• Address supply and demand side; a combination of measures for greater success and sustainability

• Increase public transparency and accountability with proper audit/monitoring systems and beneficiary participation

Lessons learned (3)• Improve service delivery standards and monitor

those by clinical and other audits through regular supervision and establishment of a (local) decision focused information system

• Expand capacities at decentralized levels; but technical and managerial capacity building takes time, needs a sustained program and monitoring

• Encourage greater involvement of private sector, civil society and communities; complementary service provision by the private sector

• Link to other sectors: Better educated mothers lead to children receiving more health services

Moving towards Universal Coverage

Public Sector Management facilitating Universal

Coverage• Services:

– Define, plan, implement service packages/standards

– Control quality of services/supervision/monitoring

• Costs:– Cost service; establish package budgets– Implement provider payments schemes/

Performance incentives– Institute cost control and audit measures; incl

anti-corruption• Population Coverage:

– Implement/subsidize insurance schemes– Institute free services for indigent, at-risk groups

Thank You !• Resources:

– World Health Report 2010 – Health Systems Financing, The Path to Universal Coverage, WHO

– Accelerating Equitable Achievement of the MDGs, Asia-Pacific regional MDG report 2011/12

– Trends in Maternal Mortality 1990-2010, WHO, UNICEF, UNFPA and the World Bank estimates

– Asia NGO Workshop, Strengthening the impact of Asia’s NGO community, MNCH interventions –Immunization

– Governance and corruption in public health care systems, Maureen Lewis, 2006, World Bank working Paper 78

– Innovative approaches to reducing financial barriers to obstetric care in low-income countries, F. Richard et al, American Journal of Public Health, Oct 2010 vol 100 no 10

– Access to maternal and perinatal health services: lessons from successful and less successful examples of improving access to safe delivery and care of the newborn, V. de Brouwere, et al, 2010 , Tropical Medicine and International Health, vol 15 no 8

– Health service delivery, access to care, costs of health care and coping mechanisms: snapshot from three central Lao provinces, B. Jacobs, in draft

– Cambodia: Using contracting to reduce inequity in PHC delivery, the World Bank, HNP discussion paper, reaching the poor program paper no.3. Oct 2004

– Enabling the rural poor access to health services through innovative health interventions in Cambodia, B. Jacobs, PHD thesis, 2011, Vrije Universiteit Brussels,

– District health programs and health sector reform: case study in the Lao People’s Democratic Republic, C. Perks et al, Bulletin of the World Health Organization, Feb 2006, 84 (2)

– Review of ongoing health financing reform in Lao PDR and challenges in expanding the current social protection schemes, study report, MoH Lao PDR, UNESCAP, WHO, ILO, April 2008.