Universal Health Coverage III

Designing and Financing a Primary Health System in Low-Income Settings

We have a challenge, a heavy disease burden in poor settings. We know that poverty itself is a major contributor to this disease burden. We know that most of the causes of disease are preventable or treatable. The question is how to design a delivery system in health and in the related sectors at low enough costs that it’s possible to make great headway even in the midst of poverty.

931Solving that problem has a huge, huge benefit. And not only would it tremendously improve health and we already see such improvements on the way, but it can break the poverty disease spiral and turn into a health development upward spiral. That’s our goal. The starting point for designing an appropriate health system is the science of public health. But what is public health? We know what medicine is. We think of doctors and nurses. They’re treating individual patients. Public health could be called population health. It is treating the health of a large population and partly of course through the work of doctors and nurses. But also through other tools that they don’t necessarily depend on doctors and nurses, through attention to safe drinking water, through attention to, The access of the community to anti-malaria bed nets through attention to widespread coverage of effective vaccines against the vaccine preventable diseases. So, public health looks at health from a population perspective. And scientifically addresses what should be done. The answer differs, differs by location, differs by income level because the answer in public health depends on the disease burden that needs to be addressed. I regard public health as being not not only highly effective, but quite systematic. And I would describe the public health approach this way. First, understand the Epidemiology of disease, that means understand the, nature of the diseased burden in a particular population. What is the DALY count? The disability adjusted life years. What is the prevalence of the disease that is it’s frequency in the population. What is the incidence of the disease? The number of new cases. In a given time period. Epidemiology measures the disease burden in a systematic way, and also focuses on the transmission mechanisms. Is the disease transmitted person to person, is the disease transmitted by in, intermediate vectors, so called, such as the anopheles mosquito Which bites one person infected with malaria and then later on bites another person, transferring the infection to that second person. In which case, the mosquito is serving as the vector of that disease so, the epidemiologists need to understand a lot about what kinds of diseases, who’s affected, how the diseases are transmitted. The second stage of good public health thinking is to examine the feasible and desirable interventions. What should be done? A lot of public health comes packaged, essentially, as apps. There’s an app for vaccines. There’s an app for distributing antimalaria bed nets. There’s an app for antenatal care. There’s an app for safe childbirth. Of course, that’s not the the, the way that the public health specialists might phrase it. They use the term interventions, but the, what they mean is systematic packages that address particular conditions. How to de-worm, how to control malaria, how to ensure safe childbirth, how to ensure neonatal survival how to get a new good nutritional outcome, how to face a diarrhoeal disease. How to break a cholera epidermic. These are the interventions. Based on the epidemiology, proceed to understand what are the interventions, both within the health sectors specifically and in the closely related sectors of nutrition, farming, safe water infrastructure and the like. Third is systems design. You have a list of interventions. Every child should get an immunization, every household should have bed nets, every mother should have anti-natal visits, every newborn should be visited by a health worker. Great. That’s a list. That’s a bunch of bullet points. How to deliver? That list effectively. Real implementation. That in essence is about systems design. Who should do that work? Who should give immunizations? Is that doctors? Is that nurses? Is that clinical officers? Is that community health workers? How should bed nets get distributed? Who guarantees the supply chain of medicines? Who reads the diagnostic tests? Who manages the work force? Who supervises the workers for their honesty, or for, their level of training and their competency This of course is the kind of challenge that a business faces in running an organization. Running a public health system is quite a complicated challenge. Building that system, often nearly from scratch in a very poor setting is extremely important because, comes to the question of training, recruitment, job designations and so forth. Now, part of that system, then, has to be translated into actual management and implementation. There are many things to do, especially when you’re starting in a very poor community and you’re building up a whole system, you have to invest, build an operating theater for emergency obstetrical care. And build an examination room, build a new clinic, build a new bore well for safe drinking water. You have to train a labor force, typically in a poor setting, a place where healthcare has been under invested for years, decades, or forever, there’s a tremendous amount of training to be done. Of course, there is community empowerment. The health system by it’s very core, involves the individuals in the community. They have to seek health care. They have to be. Connected with the health facilities. If they’re health workers, they have to trust the health workers into their homes, for example, or have the confidence to call the health workers. So community involvement and community empowerment is essential. Oversight, like in any business or any organization, How do you make sure the work is actually getting done, that the funds are being used properly and not being embezzled, that the disease burden is as it was thought, not some completely different and unexpected mode of disease transmission. And a good system has not only monitoring, but evaluation. Assessments, how are we doing? Why did mothers die last month in childbirth in this district? What went wrong? Were those deaths preventable? Is the doctor competent? Is the ambulance broken down? Is the power not actually available in the emergency room and so forth. So, this is the systems design that is absolutely crucial for practical success. Then comes financing. It’s not surprising that money looms large in this issue, we’re talking about poverty. We’re talking about places where the absence of money plays a pervasive role in the presence of disease burden. And the question is, even if a health system is designed that With high efficiency, very smart epidemiology, very cost effective interventions. Can a poor community afford this? If not, where can the incremental funds come can make this happen. Let me discuss just a few of these aspects, and, hope that some of you. Will go on to great careers in public health. I emphasize it again because I think it’s a such a wondrous profession that actually saves lives, delivers results, has the systematic and scientific approach that is so useful. Some of the interventions that are feasible based on the local epidemiology, include malaria, a disease that is a killer. It is a pathogen, a single-celled organism called plasmodium, which is transmitted from individual to individual. By a mosquito, that as I mentioned bites an infected individual, in a subsequent bite about  two weeks later, infects a second individual unless there’s protection. What kind of protection? Well, it could be medicines that kill the pathogen in an infected individual and it could be a prevention of what’s called vector control because the mosquito is the disease vector. Vector control could be something like putting larvicide to kill the larvae of the mosquitoes before they hatch and can transmit the disease. Or it can be bed nets that block the mosquito from biting. Or, if the mosquito sits on one of these bed nets and takes up the insecticide, kills the mosquito before it can become ineffective and transmit the disease to somebody else. Vaccine preventable diseases, like measles, which otherwise claim huge numbers of lives. But we have many, many vaccines that are highly effective but often don’t reach the children in need. De-worming, as I’ve already mentioned, infections like hook worm. Which are very debilitating for children, rob children of nutrients create a loss of physical growth and many many other terrible health problems but are easily solved by very low cost de-worming medicines the problem is, the children aren’t getting them. Neonatal survival, a child is born, but doesn’t take a first breath. But it’s known there are simple interventions, that the pediatricians call helping babies breathe. Simple resuscitation techniques. That at almost no cost Could save huge numbers of new born’s lives. Famously oral re-hydration, when a child has a severe case of diarrhea and is losing water, and can, can die from the diarrhea itself, that child needs to be re-hydrated To have fluids reestablished, and the right kind of solutions can rehydrate the child and save lives. And this has been now known for many decades that even community health workers without medical degrees or nursing degrees can effectively Provide oral re-hydration and save children who would otherwise die. Antibiotics to fight respiratory infections. Many other kinds of preventions. A notable one that is a major global effort now is to prevent the transmission of an HIV virus from an infected mother to a newborn. Because it is the case that if a mother with HIV infection that may or may not yet be AIDS has a child, that child has a reasonable chance, maybe a, a third or half if no precaution is taken to contract HIV in childbirth or subsequently in breast milk during breastfeeding. And so there are now protocols to put the mother onto anti-retroviral medicines. Dramatically reducing the viral load of the HIV in the mother. And dramatically reducing the chance that the virus, thereby, is transmitted from the mother to the child in childbirth or breastfeeding. These are all examples of how a good epidemiology can be connected with a good set of interventions and the results can be very striking and hugely positive. Look at a picture, rather unpleasant but I think important for us to get a reality check. Of this very cute little girl with the kind of distended belly you would see in many villages in many parts of the world. Have a look at what came out of that belly. You see a, a horrifying plateful of worms that came out after the little girl was administered with the, the basic, very low-cost anti-worm infections. And as a result of her deworming, she and little children like her have a growth spurt afterwards, because those worms have been taking away her nutrients, her absolutely valuable nutrients necessary for her Brain development and her body development. They’d been taking them for, the worm’s growth, which is obviously the opposite of what we want. De-worming, therefore, allows a growth spurt, just like disease controls allows an economic spurt in countries that are otherwise burdened by massive disease burden. This set of interventions and others like them, properly identify through good epidemiology, can be administered at low cost in a highly effective very cost health system. In today’s dollars of say the year 2013. The cost of such a basic primary health system addressing the diseases, conditions that I just described, might reach no more than $60 per person in the community per year. A remarkably low cost to address all of those disease conditions. And you would say, 60 bucks per person per year to save all those lives and to reduce the disease. Why hasn’t it happened? And the irony is, and this is the really basic point, I sometimes call it the iron law of poverty. Even $60 is too much for a government in a very poor country. And this, I think, is the part that’s hard for us to appreciate because we assume and again, it makes sense intuitively, it’s just not correct, that if this kind of disease continues in poor  communities, maybe the government’s not trying very hard. That’s not correct. Consider the following, a country, say, is at $400 per capital, not in purchasing power, but at current market exchanges rates. That’s the kind of pricing that I’m using for this $60  example. Now, a country at $400 per capital, a country like Malawi, might collect 20% of its national income in taxes. Probably wouldn’t be able to manage more than that because a lot of the income isn’t even monetary income, it’s just the production around the farm household itself. So, as a thought experiment, consider a country at $400 per capital. Whose tax collection is 20% of the national economy. 20% of $400 is 80 dollars per year. What that means is that the governments revenue out of its domestic revenue collection would be $80 per person per year in the country. What is that $80 per person have to go towards? Well, it has to run the government, the parliament, the courts, the president, the national defense, the police, the roads, the power, the infrastructure, water, sanitation. I, the it has to go for the schools, it has to go for construction for environmental conservation, and yes, part of it has to go for the public health system. But think of it, you have $80 in total You have to allocate it to all of those purposes, and experts that have looked at this repeatedly say that a country really focusing on health, but also on education, infrastructure, courts, decency, rule of law, might be able to stretch and devote 15% of the total budget. to the health sector what’s 15% of $80 per capital? Yikes. That’s just $12 per capital per year devoted to health. How much healthcare can you get for just $12 per capital? And keep in mind that in Europe and the United States, the public health budget is $3,000 per person per year. Or $4,000 per person, per year. The point is the following: for a poor country, even trying hard out of its own revenues, it can’t reach the $60 per person per year. On its own. This is why development assistance, ODA as we talked about it, Official Development Assistance, is so important for health. And now you can see the complexity of this challenge. On the one hand, we need good epidemiology to describe what should be done. Next, we need to identify effective interventions. Third, we need to identify the kind of system that can bring about those interventions. Fourth, we need to manage and implement such a system. And now, I’m saying, we have to pay for it, not a fortune, but an amount that is beyond the means of the poor country itself. The answer, in my view, is official development assistance Carefully, scientifically, professionally targeted towards improving the health of poor people. Helping them to build primary health systems. This is what I advocated when I chaired the commission on macroeconomics and health for the World Health Organization. And what I have championed for a dozen years as special adviser to UN Secretary General, Coffee Annan first, and now to UN Secretary General Ban Ki Moon, on how we can achieve the millenium development goals. We’ve taken the targets of reducing child mortality, maternal mortality, and the burdens of infectious diseases. To do the work, we now see scientifically how it can be done. We see, even, that the budget is very, very small, but too big for the poor countries. That’s why I am a strong believer in organizations like the global fund to fight AIDS, tuberculosis, and malaria, which I’ve participated in the design and launch, now a dozen years ago. We need extra funding to fight those three diseases. That’s why I’m a great fan of the global alliance for vaccines and immunization. GAVI, which provides extra financing for immunization coverage. That’s why I’ve been a great fan of the United States Pepfire program, the emergency program for Aids, and the USPMI Program the Presidents Malaria Initiative that has given extra income to Poor, malaria stricken countries to fight malaria. These kinds of targeted focus, official development aid programs have been hugely effective, very successful. Because you know how the money should be used. You can monitor it, you can watch it, you can assess it, you can evaluate it. And the results are very strong. And what’s heartening is the figure that you are looking at of the take off of official development assistance, especially bilateral assistance. That is from governments to other to low income country governments. Especially after the year 2000, because it is with the millennium development goals that these great breakthroughs are being achieved. Malaria is coming down, the AIDS  urden is coming down, a treatment for tuberculosis is expanding. Under five mortality rates have come down considerably, maternal mortality rates have come down considerably. We’re seeing that public health works, but we’re not yet at the full system to deliver it in part because the budget gap remains significant even if it has declined. This has made a big difference, but there still is an important gap that needs to be closed so that we can truly achieve our long-standing and crucial objective of health for all.

Pedro Pereira Leite

Researcher and professor. He had his PhD. on museology in 2011, with the title “Muss-amb-ike Homeland: The commitment on musicological process”, that was published in 2011. In 2012 he finishes a Post-PhD Research on "Biographical Glances: The intersubjectivity poetry on museology, at Lusófona University (Lisbon). Presently he is working in his Post PhD. Research about: “Global Heritages" with the aims to build a network on local cognizance and memory manager has a tool to build the will of action in 3 different communities, linked by past communed heritages.” He works at CES. He participates on different Research network, presented papers in national and international conferences, and had published books on research subjects.

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