Let me start with a disclaimer: I am overweight. My kids and my wife keep telling me that I need to be mindful of what and how much I eat and be more disciplined with my exercise regime. Why do people like me have to listen and heed this advice?
While much of the health focus in sub-Saharan Africa has been directed toward communicable diseases, particularly HIV/AIDS, there has been less acknowledgement that non-communicable diseases (NCDs) are a growing problem. These diseases already account for about 30% of deaths and are expected to become the leading cause of ill health and death by 2030 (see chart).
Health systems are under pressure in Asia. Epidemiological and demographic transitions are taking place much faster than in Europe and America, in the span of a single generation. With the transition comes the non-communicable disease (NCD) epidemic that requires more sophisticated and expensive interventions provided by hospitals, inpatient or outpatient. Rapid economic development in Asia has lifted millions out of poverty and raised peoples’ expectations for services. Between China, India, Thailand, Philippines, Indonesia and Vietnam, expansion of health insurance coverage during the last decade has reached an additional one billion people, making services more affordable and thus increasing demand. Advancing medical technology eagerly awaited by specialist doctors sitting on top of health professional hierarchies further expands possibilities for treatment. The middle class votes with their feet and takes their health problems to medical tourism meccas like those in Bangkok and Singapore, voiding their own countries of additional income to health care providers. Policymakers are scrambling to expand hospital capacity, boost the pay of health professionals, and encourage investment to meet the demand.
But governments do not wait. They are exploring hospital autonomy, decentralization, user fees and private sector participation. These policies often pose risks that need to be mitigated by policies and institutional arrangements. For example, health care providers sometimes order unnecessary procedures to earn additional revenue, thanks to the powerful incentive of the fee-for-service payment mechanism and information asymmetry between the patient and health care provider. This can mean financial ruin for both the patient and new, relatively weak health insurance agencies.
Despite these challenges, hospitals aren’t high on the international health development agenda, save a few initiatives to improve quality and provider payment reform.
As a World Bank staff member, I feel privileged to have participated in two landmark global public health events.
In June 2001 at a UN General Assembly Special Session, world leaders collectively acknowledged—for the first time—that a concerted global response was needed to arrest the HIV/AIDS pandemic. This led to the establishment of the Global Fund and bilateral initiatives such as PEPFAR, which helped fund a scaled-up response to HIV/AIDS, as well as to malaria and tuberculosis. The net result for the most part has been impressive: a dramatic expansion in access to treatment that has saved millions of lives, a significant reduction in the vertical transmission of HIV (mother to child), technological progress resulting in cheaper, more effective treatments, and better knowledge about HIV transmission to guide prevention efforts—while highlighting the need to revamp health systems to make the effort sustainable.
I’m in New York this week at the UN Summit on Non Communicable Diseases (NCDs), where more than 30 heads of state, 100 ministers, international agencies, and civil society organizations are discussing a pressing global health issue: NCDs. This is a policy nod in the right direction, as NCDs have been largely ignored in development circles even though they cause two-thirds of all deaths in the world (most of them prematurely) and long-lasting ill health and disability, and due to NCDs’ chronic nature, increase the risk of impoverishing millions of people who lack or have limited access to health systems.