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Lowering the Barriers: Innovative Solutions to Increase Access to Health Services for Women and Children Sjoerd Postma Senior Health Specialist. Overview. Socio-Economic Context MDGs (4/5/6) Overview in Asia/Pacific Identifying the Barriers to Achieving MDGs at Local Levels
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Lowering the Barriers:Innovative Solutions to Increase Access to Health Services for Women and ChildrenSjoerd PostmaSenior Health SpecialistOverview
  • Socio-Economic Context
  • MDGs (4/5/6) Overview in Asia/Pacific
  • Identifying the Barriers to Achieving MDGs at Local Levels
  • Overcoming the Barriers:Local Solutions
  • Public Health Sector Management:Lessons (to be) Learned
  • 1. Socio-Economic ContextGrowth in More, Less Developed CountriesBillionsLess Developed RegionsMore Developed RegionsSource: United Nations, World Population Prospects: The 2004 Revision (medium scenario), 2005.Population by major areaBillions5.33.92.00.80.90.70.60.5Population percentage by major areaPercentageTrends in Life Expectancy, by Region Life Expectancy at Birth, in YearsSource: United Nations, World Population Prospects: The 2004 Revision (medium scenario), 2005.Trends in Urbanization, by RegionUrban PopulationPercentSource: United Nations, World Urbanization Prospects: The 2003 Revision (medium scenario), 2004.Projected Economic GNP Growth by Region:Economic and Health Sector Challenges in Asia/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/PacificMDGs overview for selected DMCsMDG1MDG4MDG5MDG6MDG7with ADB Health SupportUW childIMR<5 MortSBAANCHIV prevTB incidTB PrevSafe H20Basic SanIndonesiaLao PDRMongoliaPapua New GuineaPakistanPhilippinesVietnamSignificant OthersChinaIndiaBangladeshSri-lankaCentral 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 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 sanitationInfected with TBLiving below $1.25/dayBirths without skilled attendanceWithout safe drinking waterChilddeathsOut of primary schoolUnderweight childrenMaternal deathsLiving with HIVSource: UNESCAP, ADB and UNDP. Accelerating Equitable Achievement of the MDGs: Closing Gaps in Health and Nutrition Outcomes, Asia-Pacific Regional MDG Report . February 2012.In many cases, disparities are wideningSources : Staff calculation based on the United Nations MDG database.From: Shila Chatterjee SDG meeting 6 May 2012Country aggregates hide sub-national regional variationsSources : Ministry of Health and Population, New Era, and Macro International Inc,. 2007. Nepal Demographic and Health Survey 2006.From: Shiladitya Chatterjee, SDG meeting 6 May 2012Country aggregates hide attainments by rich and poorChildren under 5 underweight , India 2005-06 (by wealth quintiles)Sources : Ministry of Health and Family Welfare, 2009. Nutrition in India: National Family Health Survey (NFHS-3) India 2005-06.From: Shiladitya Chatterjee ,SDG meeting 6 May 2012Health SpendingSpending on health and education (% of GDP)19Share of total health expenditures to GDP, 2009Sources : World Health Organization (2011). National Health Accounts . Geneva.From: Shiladitya Chatterjee ,SDG meeting 6 May 2012Health PersonnelPhysicians per 10,000 populationBirths attended by Skilled Health Personnel (%)21Distribution of child deaths for selected causes by selected WHO region, 20043. Identifying the Barriers to Achieving MDGs at Local LevelsThe 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)Health InsuranceFree 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)25Out 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 changeSocio-Cultural IssuesInappropriate feeding practices (under- nutrition is the underlying cause for 50% of children's deaths)Delivery at home with relativesGender of staffReverence of Medical StaffUnfamiliar with what is possible/ available4. Overcoming the Barriers:Local SolutionsImproving Access to Maternal and Child Health ServicesDemand SideMobilizing the Community: info on services, rope in community leaders, behavior change activities, health education, and organization of transportDecreasing 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 TBAsImproving 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 servicesIncluded coverage and equity targetsResult: Poorest half of population more like to receive services: immunization SBA, FP servicesWhy: part of the performance based contractCambodia: Voucher and Health Equity Fund (Demand)HEF for access to public hospitals; identified poor receive support for service fee, transport and other hospital costsMaternal Vouchers scheme done by NGOs; 5 vouchers: 3 ANC, Delivery and PNC services, but also transport costs, referral costs and free services for 5 vouchersResult: 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 costsResult: up to 25% increase in institutional deliveriesLao: Proposed CCT/Vouchers scheme (Demand)Checklist, distributed by local midwife/SBA:Thee ANC attendances Institutional deliveryPost natal careFP service introduction/HEd/ServiceFirst immunizationVital registrationCollection 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/HMISWeighing/Child ServicesMaternal ServicesFamily Planning Nutrition and Health EducationRegular days; most often linked to market daysIncluded availability of doctors from district levelPartnering for Immunization in Bangladesh (Demand/Supply)Government Partnered with NGOs to reach all immunizable childrenGovernment responsible for supplyNGO’s responsible for demand side issues: mobilization, session management, registration, monitoring and educationResults: higher immunization coverage in NGO assisted areas (90 vs. 80%)Boosted services, lead to polio eradicationLao 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 equipment2nd phase: strengthening referral function, revolving drug funds, monitoring system3rd phase: further construction for remote areas, with IFAD4th phase: further strengthening of HW skills and IMCI programLao 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) LearnedLessons 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 sustainabilityIncrease public transparency and accountability with proper audit/monitoring systems and beneficiary participationLessons 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 systemExpand capacities at decentralized levels; but technical and managerial capacity building takes time, needs a sustained program and monitoringEncourage greater involvement of private sector, civil society and communities; complementary service provision by the private sectorLink to other sectors: Better educated mothers lead to children receiving more health servicesMoving towards Universal CoveragePublic Sector Management facilitating Universal CoverageServices:Define, plan, implement service packages/standardsControl quality of services/supervision/monitoringCosts:Cost service; establish package budgetsImplement provider payments schemes/ Performance incentivesInstitute cost control and audit measures; incl anti-corruptionPopulation Coverage:Implement/subsidize insurance schemesInstitute free services for indigent, at-risk groupsThank You !Resources:World Health Report 2010 – Health Systems Financing, The Path to Universal Coverage, WHOAccelerating 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 estimatesAsia NGO Workshop, Strengthening the impact of Asia’s NGO community, MNCH interventions –ImmunizationGovernance and corruption in public health care systems, Maureen Lewis, 2006, World Bank working Paper 78Innovative 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 10Access 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 8Health service delivery, access to care, costs of health care and coping mechanisms: snapshot from three central Lao provinces, B. Jacobs, in draftCambodia: 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.
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