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Health

AIDS: translating scientific discoveries into sustainable, affordable programs

David Wilson's picture

Red ribbon for World AIDS Day, Thailand (credit: Trinn Suwannapha).

We’re entering a phase where AIDS is moving from emergency crisis financing to sustainable development financing—which is a major challenge, but one that we’re continuing to tackle, with the goal of stronger national ownership and responsibility.

 

One of the Bank’s international mandates is to support countries to develop better national health plans and budgets. Today, the Bank released an important study, The Fiscal Dimension of HIV/AIDS in Botswana, South Africa, Swaziland, and Uganda, which is a part of this mandate. The study helps countries do the long-range planning that we so desperately need in HIV programs.

 

The Bank has a long-established partnership with ministries of finance and planning, and we understand country systems. We stand ready to help countries integrate HIV into their programs and plan for it in a sustainable way.

 

We’ve seen extraordinary progress in AIDS. Today, we have more antiretroviral drugs to treat HIV than every other virus in history combined. We’ve reduced treatment costs from tens of thousands of dollars to as little as $100. And we’ve expanded our understanding of effective HIV prevention, including the role of male circumcision and the important role that treatment can play in prevention under the right circumstances.

 

Many of us involved in HIV remember the days when 70% of beds in health facilities in Africa were occupied by people with AIDS. Our successes in treatment and prevention have removed this specter and have allowed health systems to focus on other important health priorities.

Les « Maman Lumière » de Djibouti donnent l’exemple pour changer de comportement et améliorer la santé

Marie Chantal Messier's picture

Mothers discuss child rearing in Djibouti (credit: Marie Chantal Messier).

Nous étions assises sur des tapis de sol, dans la chaleur et la poussière du quartier Moustiquaire, le plus pauvre de Djibouti, pour parler des pratiques d’alimentation des enfants. Des voix se sont soudainement élevées dans le groupe. Plusieurs femmes insultaient et montraient du doigt l’une d’entre elles qui baissait honteusement la tête.

Mes homologues djiboutiennes m’ont expliqué que la femme embarrassée était critiquée parce que son fils ne parlait pas encore à 5 ans. Au lieu de donner de l’eau à boire à son nouveau-né comme le veut la tradition, elle avait choisi d’allaiter son dernier enfant au sein exclusivement jusqu’à l’âge de six mois.  Le groupe pensait que ce choix expliquait les problèmes de développement de l’enfant.

Ma première réaction a été de me dire : « la pression du groupe est un véritable obstacle à la promotion des méthodes d’allaitement optimales à Djibouti ! »

Djibouti’s "Shining Mothers": Role models for behavior change, better health

Marie Chantal Messier's picture

Also available in: FrançaisMothers discuss child rearing in Djibouti (credit: Marie Chantal Messier).

We were sitting on floor mats in the hot and dusty Quartier Moustiquaire, the poorest neighborhood of Djibouti City, observing a group of new mothers and their children discussing child feeding practices. All of a sudden, there was an uproar in the group. One woman had her head bent down in shame, and several other women shouted and pointed fingers at her.  

My Djiboutian counterparts told me the embarrassed woman was being criticized because her 5-year-old son still doesn’t speak.  Rather than follow the ancestral tradition of giving water to her newborn, she chose to exclusively breastfeed her last child until he was 6 months old. The group asserted that this choice had led to the child’s developmental problems. 

My immediate reaction to the scene was, “Peer pressure is a true obstacle to promoting optimal breastfeeding in Djibouti!”

Are all medical procedures, drugs good for the patient?

Patricio V. Marquez's picture

Also available in: РусскийPatients waiting at health center in Angola (credit: UN/Evan Schneider).

When healthcare professionals take the Hippocratic Oath, they promise to prescribe patients regimens based on their “ability and judgment” and to “never do harm to anyone”.

Although extraordinary progress in medical knowledge during the last 50 years, coupled with the development of new technologies, drugs and procedures, has improved health conditions and quality of life, it has also created an ever-growing quandary regarding which drugs, medical procedures, tests and treatments work best.

And for policy makers, administrators and health economists, the unrestrained acquisition and use of new medical technologies and procedures (e.g., open heart surgery to replace clogged arteries, ultrasound technology scanners to aid in the detection of heart disease, and life-saving antiretroviral drugs for HIV/AIDS) is increasing health expenditures in an era of fiscal deficits.

In many countries, I’ve see how ensuring value for money in a limited-resources environment is not only difficult but requires careful selection and funding of procedures and drugs. It also comes with serious political, economic and ethical implications—and with new drugs and technologies appearing every day, this challenge isn’t going away. What should countries do?

Все ли методы лечения и лекарства хороши для пациента?

Patricio V. Marquez's picture

Patients waiting at health center in Angola (credit: UN/Evan Schneider).

Принимая клятву Гиппократа, профессионалы из области здравоохранения обязуются лечить пациентов, основываясь на своих «способностях и суждениях», а так же «никогда и никому не навредить».

Впечатляющий прорыв в области врачебных знаний за последние 50 лет, сопровождаемый развитием новых высоких технологий, лекарств и методик лечения, значительно улучшил средний уровень здоровья и качества жизни в целом. Однако при этом зачастую это приводит к ситуации, когда все труднее и труднее становится определять, какие же лекарственные средства, методики, тесты и процедуры окажутся самыми эффективными.

 

 Для тех, кто принимает решения и управляет экономикой здравоохранения, бесконечное приобретение и внедрение новых медицинских технологий и процедур (например, операции на открытом сердце, ультразвуковая сканеры для выявления болезней сердца, а так же антиретровирусная терапия против ВИЧ/СПИД) ведет к существенному росту расходов на здравоохранение, особенно заметного в эпоху бюджетных дефицитов.

Putting Humpty Dumpty back together again

Cristian Baeza's picture

2012 is off to a sobering start for those of us in the global health community, against a backdrop of continuing global financial volatility coupled with complex reforms at the Global Fund to Fight AIDS, Tuberculosis and Malaria. New research from the Institute for Health Metrics and Evaluation (IMHE) shows a slowdown—and perhaps a plateauing—of the historical growth in global health funding to which we have been accustomed during the past decade. This new reality is, rightly, leading to questions about whether substantial—if not radical—changes are needed in the highly fragmented global health ecosystem. And yet, at the same time, there are signs of new initiatives.

I believe the slowdown in global health funding requires adjusting our expectations in the coming years. Last fall, after participating in a number of inspiring discussions during the UN General Assembly, I reflected about each one of the critical global health priorities to which we have all pledged our support in recent years: the Millennium Development Goals (MDGs) for nutrition, child and maternal health, and HIV/AIDS, TB, and malaria, as well as non-communicable diseases. It struck me that while most of these health interventions are destined to help the same mother or child, we have created very separate initiatives and institutions to deliver on each. We have been able to elevate the awareness and commitments for each of these priorities, but now the challenge is, like Humpty Dumpty, how do we now put them all back together again?

Reforming hospitals in East Asia — engagement by development partners wanted

Toomas Palu's picture

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.

Ethics, values and health systems

Patricio V. Marquez's picture

It’s widely accepted nowadays that the ultimate goals of a health system are to improve the health conditions of the population; minimize the risk of impoverishment due to catastrophic health events; and increase the level of satisfaction of the citizens of a country with the quality of services received.

What kind of health system needs to be developed to achieve these goals?

Professor Uwe E. Reinhardt, a distinguished Princeton University health economist, urges us to focus on broader social goals, including the distributive ethic or moral values in a country.   In essence, this means that the “structural parameters” of a health system—financing health care, risk pooling to protect individuals from the cost of illness, producing and delivering health services, purchasing or commissioning health care on behalf of patients, stewardship and governance, and production and distribution of health care resources--should be determined by the shared ethic or moral values in a society.

As Professor Reinhardt points out, alternative “distributive social ethics” or “moral values” may offer three broad health care organization models to choose from:  (i) a one-tier system, where health care is a social good available to all on equal terms; (ii) a two-tiered system, where health care is a social good for all with exception of the rich; and (iii) a multi-tiered system, where health care is a private consumption good like other services such as food and housing.

So which one of these models should governments adopt, adapt and develop? Which model should international organizations recommend as part of policy dialogue with governments? Is there an appropriate “government” versus “private market” combination that should prevail in a health system?

Out-of-pocket in the Caucasus

Owen Smith's picture

I am partway through a trip to the countries of the South Caucasus (Armenia, Azerbaijan and Georgia), where winter is settling in—snow in Tbilisi and Yerevan, and a raw wind on Baku’s seafront.

It is a diverse region at the proverbial crossroads, but one common trait is a bleak health financing environment. All three countries rely on out-of-pocket (OOP) expenditures for about two-thirds of total health spending, well above their peer groups, including other countries of the former Soviet Union or middle-income countries around the world. As a result, the incidence of “impoverishing” and “catastrophic” health spending by households—both common indicators of financial protection—are among the highest in the world. Besides costing some households dearly, OOP expenditures also keep many others away from the hospital or clinic: Utilization rates are among the lowest in Europe and Central Asia.

How did the Caucasus become such OOP outliers? The proximate causes are clear enough: large formal or informal payments for health care and high prices and overconsumption of pharmaceuticals. Many of these issues, in turn, can be traced to low levels of government spending on health, around 1.8% of GDP in all three countries, roughly half the regional average. Health spending is low as a share of government budgets, as well. As a result, providers recover costs directly from patients, and can have more latitude to engage in rent-seeking in the absence of stronger pooling and purchasing mechanisms.

The imperative of integrated health care delivery systems

Patricio V. Marquez's picture

DL-PH002 World Bank

In the past decade we have witnessed a noticeable zigzag internationally on how to improve health system performance. While some have advocated for the primacy of primary health care (reinforced by a major 2008 WHO report), others have stressed the importance of hospital autonomy initiatives.

This zigzag clearly illustrates another false dichotomy in the health sector that merits urgent revision. More and more, we’re recognizing why a cohesive and integrated health care delivery model needs to be in place to better organize and respond to the changing needs of the population, particularly given the raising importance of noncommunicable diseases and injuries as the main causes of death and disability worldwide. A recent report on NCDs in China demonstrates how the chronic nature of these conditions—different from acute episodes of ill health resulting from infectious diseases—demands a well-coordinated combination of hospital, ambulatory and physician response, in some cases over the lifetime of an individual.

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