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Global Health Disparities: the role of health financing, donor assistance, and human resources

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All regions off track. On a regional level, SSA and SA worst off ... Malawi. Long term ... Donor funding vs. domestic resources. Kenya. Kenya. Kenya. Malawi ... – PowerPoint PPT presentation

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Title: Global Health Disparities: the role of health financing, donor assistance, and human resources


1
Global Health Disparities the role of health
financing, donor assistance, and human resources
  • CGFNS Symposium
  • Philadelphia, December 2007
  • Marko Vujicic
  • The World Bank

2
Outline
  • Global health disparities
  • Health financing disparities
  • Global action to address financing disparities -
    donor assistance for health (DAH)
  • The role of human resources for health (with
    emphasis on nursing)

3
Global Health Disparities
4
All regions off track. On a regional level,
SSA and SA worst off track in achieving health
MDGs
5
EAP MDG Attainment
P
P
P
P
P
P
P
P
P - Philippines
Source World Bank, DEC, 2006
6
(No Transcript)
7
Causes of Death Vary Greatly by Country Income
Level
8
Life Expectancy
9
MDG Attainment
  • www.gapminder.org

10
Health Financing Disparities
11
There is Tremendous Variability in Health
Outcomes But There is an Overall Trend
12
Health Financing
13
Domestic Resource Mobilization is Much More
Limited in MICs and LICs
14
Spending on Health Compared with Spending by
other Ministries
15
Percentage Point Change in Health Expenditure as
percentage of National Budget 1998-2002
Progress Towards the Abuja Target Has been Slow
Sometimes Negative
16
But the Abuja Target is Not Enough To Reach the
MDGs
US34
17
Share of Public Spending to Reach Targets
18
Donor Assistance for Health
19
Donor Funding Are Commitments Being Delivered?
ODA is Rising But is Far Short of What is Needed
to Meet the MDG (0.54) and Monterrey Commitments
(0.70)
To meet 2010 commitments (ODA of US130 billion
per year), need an average increase of about 8
per year Source OECD DAC database.
20
A Large Part of the Increase in Aid is Not
Directed to Financing the Incremental Costs of
Meeting the MDGs
Net ODA disbursements from DAC donors
106.5 billion in 2005
Debt relief
79.6 billion in 2004
Other special purpose grants
Other components of ODA
In 2005, ODA peaked at US 106.5 billion -- most
of this increase was due to debt relief and
exceptional mobilization (Tsunami, Kashmir
earthquake)
21
Donor Aid for Health has Increased Significantly
  • Most of the recent increases
  • Focus on Africa
  • Focus on specific diseases
  • Come from bilaterals and multilaterals (GAVI,
    Global Fund)

Source Michaud 2006
22
Where Does All the Aid Go?
  • On average, for every 1 disbursed by donors to
    our 14 case study countries, we estimate
  • Not recorded in balance of payment 0.30
  • Recorded in BOP but not in Govt spending
    0.20
  • Aid earmarked to specific projects 0.30
  • Budget support 0.20
  • 1990s structural adjustment provided a larger
    share of aid as general budget resources.

23
ODA is the Main Source of External Finance for
SSA, Twice as Large as FDI and Nearly Four Times
the as Large as Remittances
Total long-term flows of 41 billion in 2003
Total long-term flows of 340 billion in 2003
Source World Bank. Global Monitoring Report.
2005.
24
However, Donor Commitments for Health are
Volatile and Unpredictable
Try managing this…
25
Vertical Aid Distorts Priorities
Case management
Community Management
Drug Use
Skilled birth attendance
New born care
PMTCT
Safe and Supportive Environment
Health system
Maternal health
Source WHO, Mbewe
26
Basic Problems in Current ODA System
  • Lack of predictability of funding and large
    differences between donor commitments and
    disbursements at the country level
  • There is a growing concern about the
    verticalization of aid and the need to focus
    holistically on health systems as opposed to
    specific diseases or interventions
  • Large numbers of new actors and donors and the
    plethora of new aid instruments (e.g., SWaps,
    PRSPs, PRSCs, PRGFs, MTEFs, etc.) create problems
    of management
  • Lack of responsiveness and flexibility of aid to
    sudden problems and crises
  • Little accountability of donors for the absence
    of results and lack of ME systems which are
    needed to ensure that the additional resources
    are being used as prioritized and achieving
    results
  • A significant portion of aid is off-budget and
    often doesnt even enter into the balance of
    payments or the governments budget
  • Countries need to create fiscal space to absorb
    these large increases in external assistance, a
    potentially problematic situation given IMF
    fiscal ceiling

27
What is Needed?
  • A Needs Assessment which identifies systemic
    constraints and implementation bottlenecks for
    the delivery of essential services and the
    required process to address them
  • Capacity development plans linked to policy and
    institutional needs including assessing
    complementarities with other sectors, analyzing
    the role of non-state partners (NGOs, civil
    society, and the private sector), and integrating
    national health systems with global programs
  • Improve the interface between MOF and MOH as
    co-leaders working with other relevant
    ministries
  • Ensure consistency between health sector
    development plans, SWAps, the overall budget
    including cross-sectoral trade-offs and the
    macroeconomic framework, in consultation with
    the IMF
  • Apply the Paris Principles of aid effectiveness
    to the health sector in country-specific
    circumstances including harmonization and
    alignment behind government strategies and
    processes, managing for results, and mutual
    accountability
  • Strengthen systems of management for results,
    including monitoring and evaluation, appropriate
    indicators, and mutual accountability and,
  • Determine major financing gaps and potential
    additional funding resources, eventually
    adjusting the plans to available resources and
    capacity to deliver.

28
What Will Donors Have to Do?
  • Harmonize procedures (procurement, financial mgt,
    monitoring reporting) Provide increased and
    predictable long term financing
  • Finance recurrent costs
  • Assess effectiveness and appropriateness of new
    financing instruments
  • Offer consistent policy advice
  • Focus on achieving results
  • Submit to common assessment of their own
    performance

29
What Does This Mean for Countries?
  • Develop credible strategies and plans to foster
    economic growth, deal with implementation
    bottlenecks, and reach MDGs as part of PRSPs,
    SWAPs, MTEFs, and public expenditure programs
  • Improve governance
  • Enhance absorptive capacity through
    decentralization, efficient targeting mechanisms,
    and institutional reforms
  • Develop financing, management, and regulatory
    mechanisms for equitable and effective pooling of
    insurable health risks as a necessary concomitant
    to MDG and CMH intervention choices.
  • Integrate vertical programs into a well
    functioning health system to maximize
    health-specific and cross-sectoral outcomes and
    reduce transactions costs
  • Monitor and evaluate results

30
What Does This Mean for Countries?
31
Global Disparities in Human Resources for Health
Nursing Focus
32
Measuring the impact of out-migration
  • We know that having enough staff is important
    for achieving outcomes (but is at best a
    necessary condition)

33
Measuring the impact of out-migration
  • On a regional level, SSA and SA also have lowest
    staffing levels

34
Measuring the impact of out-migration
Flows of migrant nurses into selected countries
(Source OECD, 2007)
35
Measuring the impact of out-migration
  • Migration is a two way street.

(Source CIHI)
36
Measuring the impact of out-migration
(Source NCSBN)
37
Measuring the impact of out-migration
  • Developed countries relying more and more on
    migrant health workers to fill labor shortages
  • Source of migrant health workers has changed
    dramatically in recent years - developing
    countries are the main source
  • Debate on impact of out-migration
  • WHO resolution 57.19
  • UK Code of conduct
  • Bilateral agreements

38
UGANDA -Gap for attaining PEPFAR target
KENYA -Gap for attaining PEPFAR target
39
(No Transcript)
40
Measuring the impact of out-migration
  • Debate does not focus on fiscal side. i.e. are
    there enough funded positions to absorb the
    doctors and nurses who leave the country?
  • Short term
  • Vacancy data
  • Inaccurate often measured relative to norms
  • Budget execution data
  • Difficult to collect
  • Two illustrative examples
  • Kenya
  • Malawi
  • Long term
  • How easily could additional funded positions be
    created through increased fiscal space for
    health?
  • Donor funding vs. domestic resources

41
Kenya
42
Kenya
43
Kenya
44
Malawi
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