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 Children Children Sjoerd Postma Senior Health Specialist
Jan 15, 2016
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.