Health in Africa

Health in Africa

Anja SmithStellenbosch University13 September 2013

What issues/topics come to mind when you think of “health in Africa”?

Which of these are most important and why?

Objectives:1. Exposure to economic frameworks to think through

implications of diseases in Africa2. Understand key concepts used to prioritise health

decision-making and track health outcomes3. To understand why more health expenditure does not

always lead to better health outcomes

What makes health different from other development topics (e.g. employment, education, housing, etc.)?

• Health an outcome of many inputs: health services, nutrition, sanitation, housing, education, etc.

• Health has both a stock and flow component• Loss of health imposes two sets of cost:

1. healthcare costs2. loss of income when ill

• Demand for health services not constant but “irregular and unpredictable”

• Severe market entry restrictions: high educational costs, licensing for medical doctors

• Information asymmetries:– Information asymmetry between doctor and patient:

“product uncertainty”, agency problem– Insurance information asymmetries: 1) Moral hazard: riskier behaviour due to fact of being insured2) Adverse selection: selection of poor(er) risks into insurance pool

What makes health different? (2)Arrow’s (1963) perspective: Uncertainty and medical care

Why does health matter?Health and economic growth

• Macroeconomic evidence: – impact is small, evidence is ambiguous, many

identification and measurement problems

Why does health matter?Health and economic growth

• Microeconomic evidence:– “clear[er] causal relationship from health to earning

potential and income” (Jack & Lewis, 2011)– “Some dimensions of health status and some health

inputs do affect labour supply and worker productivity. In several cases, the effect tends to be largest for the poorest.” (Strauss and Thomas, 1998 : 798)

WHY?

Why does health matter?Health and economic growth (2)

– Taller men earn higher wages (Strauss & Thomas, 1998)

– Household surveys show that poor health reduces number of hours worked but evidence of impact on productivity and wages less clear:

“…the health indicators used in those studies tend to reflect shorter-term health problems but wages tend to adjust relatively slowly.” (Jack & Lewis, 2011)

Health cycle

Burden of disease (BOD) & causes of death

Health services:

access and quality

(Improved) health

outcomes

Health expenditure prioritisation: how should we decide which ill person to help when we have limited resources?

Disability-adjusted life-years: -Number of years lost due to death, disability or illness-Because it emphasises “years lost” if disease strikes it places greater emphasis on the value of young life

What summary measures can we use to track health outcomes?

Health outcomes

Key concepts:• Life expectancy at birth• Under-five mortality rate: probability per

1,000 that a newborn baby will die before age five

• Maternal mortality rate/ratio: number of maternal deaths during a given period per 100,000 live births

Themes

• Public vs. private sector• Expenditure• Financing• Efficiency• Supply: facilities, staff, medication, etc.• Demand: information, need, responsiveness

Health and developmentCase study: Economic and social burden of malaria

Health and developmentCase study: Economic and social burden of malaria

• How does malaria prevalence influence development?

• Are all these channels valid? Which are likely to have the biggest impact?

• Immediate vs. long-term impacts?

Health outcomes in AfricaLife expectancy at birth in years by WHO region by gender, 2009

Americas

Europe

Western Pacific

Global

Eastern Mediterranean

South-East Asia

Africa

0 10 20 30 40 50 60 70 80 90

79

79

77

71

68

67

56

73

71

72

66

64

64

52

Male Female

Health outcomes in AfricaMaternal mortality ratio per 100,000 live births by WHO region

1990 1995 2000 2005 20100

100

200

300

400

500

600

700

800

900

820 800

720

600

480

AfricaSouth-East AsiaEastern MediterraneanGlobalWestern PacificAmericasEurope

Burden of diseaseDistribution of burden of diseases as % of total DALYs by broader causes by WHO region, 2004

Europe

Americas

Western Pacific

Sout-East Asia

Eastern Mediterranean

Africa

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

10

17

18

42

44

71

77

69

69

44

41

21

13

14

13

14

15

8

Communicable diseases Non-communicable diseases Injuries

Burden of disease (2)Leading (10) causes of burden of diseases as % of total disability-adjusted life years (DALYs), African region, 2004

Road traffic accidents

Protein-energy malnutrition

Tuberculosis

Prematurity and low birth weight

Neonatal infections and other

Birth asphyxia and birth trauma

Malaria

Diarrhoeal disease

Lower respiratory infections

HIV/AIDS

0 2 4 6 8 10 12 14

1.9

1.9

2.9

3

3.6

3.6

8.2

8.6

11.2

12.4

Broad causes of death (males)Western Cape 2010

Source: Western Cape Mortality Profile 2010

Causes of death (females)Western Cape 2010

Source: Western Cape Mortality Profile 2010

Burden of disease (3): malariaClassification of countries by stage of malaria elimination (December 2012), WHO Malaria Report 2012

Burden of disease (4): HIVAdult (15-49 years) HIV prevalence in 2011 by WHO region, WHO 2013

Burden of disease (5): TBEstimated TB incidence rates, 2011, WHO

TB prevalence in South Africa relative to international context

Brazil Cambodia China DRC India MozambiqueSouth Africa Zimbabwe0

200

400

600

800

1000

1200

46

817

104

512

249

490

768

547

42

424

75

327

181

548

993

603

Prevalence/100,000 Incidence/100,000

Case

s pe

r 100

,000

Source: Western Cape DoH HIV &TB M&E presentation as derived from WHO Global Tuberculosis report 2012

Why focus on TB?• Costs of tuberculosis:

– Mortality– Reduced productivity due to morbidity

• (Global) public intervention (and coordination) required as at least three externalities associated with TB (Jack, 2000):– Highly contagious disease that spreads through social contact,

individuals unable to fully absorb the cost of the disease– Diagnosis externality: Early in disease individuals may be unaware

of need for TB diagnosis and treatment as symptoms are similar to those of other diseases

– Drug-resistance externalities: Incomplete treatment leads to exposure of community to the disease as well as exposure to more severe strains of the disease over time

• Tuberculosis viewed as “disease of the poor”: control and cure of the disease can make contribution to poverty reduction (Jack, 2000)

Human resources for healthNursing and midwifery personnel-to-population ratio, 2005-2010

Source: Health Situation Analysis in the African region, Atlas of Health Statistics 2012, WHO

Translating expenditure into outcomesLife expectancy vs. total per capita healthcare expenditure for 175 countries (WHO, 2011)

0 1000 2000 3000 4000 5000 6000 7000 8000 900045

50

55

60

65

70

75

80

85

South Africa

Equitorial Guineau

US$

Translating expenditure into outcomes (2)Maternal mortality vs. total per capita healthcare expenditure, 161 countries - WHO, 2010 (maternal mortality) & 2011 (healthcare expenditure)

0 1000 2000 3000 4000 5000 60000

100

200

300

400

500

600

700

800

900

South Africa

Equitorial Guineau

US$

Links in the chain in translating expenditure into outcomes in developing countriesFilmer, Hammer & Pritchett, 2000

Expenditure

Choices

Incentives

Outcomes

• Impact of primary healthcare often estimated as if translating healthcare expenditure into outcomes is simple technical process.

• “But individuals are guided by their own knowledge and resources in judging the quality of their health care (and that of their children).”

• “’…service delivery and overall effectiveness both depend on the demand for specific services, the price of services and the existing (and potential) supply in the private sector”. (emphasis added)

• Case for primary care is often made by assuming that “the public sector could deliver whatever the government (or some international forum) decided ought to be delivered”

• BUT • “Often, health service failures result from a

systemic mismatch between the traditional civil service incentive structure and the tasks required in the health sector”.

Links in the chain in translating expenditure into outcomes in developing countries (2)Filmer, Hammer & Pritchett, 2000

Expenditure

Choices

Incentives

Outcomes

1. Composition of expenditure, e.g. primary vs. secondary vs. tertiary care, HIV vs. TB, HIV vs. malaria, preventative vs. curative care

2. Output of the public sector: efficiency in translating inputs into outputs

3. Net impact of public sector supply on overall consumption: do people use more of the service simply because government is spending more? e.g. crowding-out of private services

4. Health production function: the impact of health inputs is mitigated by biological and medical facts, i.e. the effectiveness/appropriateness of certain treatments

Additional resourcesArrow, K. 1963. Uncertainty and the Welfare Economics of Medical Care. American Economic Review. 53(5): 941-973.Economist Intelligence Unit, 2011. Future of healthcare in Africa.Filmer, D., Hammer, J.S. & Pritchett, L.H., 2000. Weak links in the chain: a diagnosis of health policy in poor countries. World Bank Research Observer. 15(2): 199-224. August.Lagomarsino, G., Garabran, A. Adyas, A., Muga, R. & Otoo, N. 2012. Moving towards universal health coverage: health insurance reforms in nine developing countries in Africa and Asia. Lancet. 380(9845): 933–943.Strauss, J. & Thomas, D. 1998. Health, nutrition, and economic development. Journal of Economic Literature. 36(2), 766-817.William, J. & Lewis, M. 2010. Health investments and economic growth: macroeconomic evidence with microeconomic foundations. In Spence, M. and Lewis, M. Health and Growth, World Bank, Commission on Growth and Development. World Health Organization website: www.who.org World Health Organization. 2012. Atlas of African Health Statistics.