C OMPARING * HEALTH *S YSTEMS * IN * SOUTHEAST *A SIA :*A* FOCUS * ON - PowerPoint PPT Presentation

C OMPARING * HEALTH *S YSTEMS * IN * SOUTHEAST *A SIA :*A* FOCUS * ON *I NEQUITY * Phyu%Phyu%Thin%Zaw%(MBBS,%MPP,%PhD)%% % * 1*

Outline* 1. Regional*Level:** a. A*Brief*Overview*of*Health*Systems*in*S.E.*Asia* ◦ DefiniLon* ◦ Comparisons*of*important*indicators* ◦ Concepts*of*Equity*and*Equality* 2. Country*Level:*Myanmar*Health*System* 3. Community*Level:* ◦ Study*1* ◦ Study*2* * 2*

What*is*a*health*system?* ● The*World*Health* OrganizaLon*(2000):*“A* system*in*which*all* acLviLes’*primary*purpose* is*to*promote,*restore,* and*maintain*health.”** ● Health*systems*comprise* a*pluralisLc*mix*of*public* and*private*systems.** ● Different* types%of% healthcare * models .** *

Comparing*health*systems* 1.%Socio@economic%and%Demographic% 3.%Health%Outcomes%Indicators ** Indicators% • Maternal*Mortality* ● Life*expectancy*at*birth* • Underafive*Mortality* ● GDP*per*capita* • HIV*Prevalence** ● EducaLon*Index* 4.%Health%System%Performance% ● Crude*Death*Rate*etc.* Indicators% 2.%Health%System%Indicators% • Quality,** ● Public*Health*Expenditure* • Efficiency,** ● OutaofaPocket*Health*Expenditure* • Acceptability,*and* ● Physicians*per*1,000*populaLon* • *Equity* ● Hospital*beds*per*1,000*populaLon* *

1.*Socioaeconomic*and*Demographic*Indicators*of* Southeast*Asian*Countries* ● PopulaLon* ● GDP*per*capita* ● Poverty*Headcount** ● GINI*Index* ● EducaLon*Index* ● Life*expectancy*at*birth* ● Crude*Death*Rate* ● Crude*Birth*Rate* 5*

PopulaLons*of*Southeast*Asia* 655 million (8.5%). 3 rd most populous region

GDP*per*Capita*(PPP*Current*InternaLonal*$)*in* Southeast*Asia*from*1990*to*2015* GDP (PPP) or GDP at purchasing power parity ( PPP )

Poverty*Headcount*RaLo* The Head count ratio (HCR) is the proportion of a population that exists, or lives, below the poverty line.

GINI*Index*in*Southeast*Asian*Countries* Gini index measures the • extent to which the distribution of income (or, in some cases, consumption expenditure) among individuals or households within an economy deviates from a perfectly equal distribution. A Gini index of 0 • represents perfect equality, while an index of 100 implies perfect inequality.

EducaLon*Index*in*SEA*(1980*to*2014)* The* EducaIon% Index *is* calculated*from* the* mean%years% of%schooling% index *and*the* Expected%years% of%schooling% index .* 10*

Life*Expectancy*in*SEA*(1965*to*2015)* Life*expectancy* at*birth* expressed*as* an* index *using* a*minimum* value*of*20* years*and*a* maximum* value*of*85* years. * 11*

Crude*Death*Rate*in*SEA*(1965*to*2015)*

Crude*Birth*Rate*per*1000*PopulaLon* The number of live births occurring among the population of a given geographical area during a given year, per 1,000 mid-year total population of the given geographical area during the same year.

2.*Health*System*Indicators* ● Total*Health*Expenditure*(%*of*GDP)* ● OutaofaPocket*Health*Expenditure* ● Physicians*per*1,000*populaLon* ● Nurse*and*Midwives*per*1,000*populaLon* ● Hospital*beds*per*1,000*populaLon*

Total*Health*Expenditure*(%*of*GDP)* % of GDP

Out*of*Pocket*Health*Expenditure*in*SEA*(1995*to*2012)* %*of*total*health*expenditure* 16*

Physicians*per*1000*PopulaLon*in*SEA*Countries*(1960*to*2015)* 17*

Nurses*and*Midwives*Per*1000*PopulaLon*in*SEA*

Hospital*Beds*Per*1,000*PopulaLon*in*SEA*(1960*to*2010)*

3.*Health*Outcomes*Indicators* ● Maternal*Mortality* ● Underafive*Mortality* ● HIV*Prevalence *

Maternal*Mortality*RaLo*( modeled *esLmate,*per* 100,000*live*births)*In*Southeast*Asia* Maternal mortality ratio is the number of women who die from pregnancy -related causes while pregnant or within 42 days of pregnancy termination per 100,000 live births

Undera5*Mortality*Rate*(U5MR)* The probability per 1,000 that a newborn baby will die before reaching age 5.

The relationship between GDP (US$) and Under-5 mortality over time for Southeast Asian Countries Most ASEAN • countries show a negative relationship (as GDP increases over time, under-5 mortality decreases.) Exceptions are those • countries that already have low under-5 mortality where it can't decrease. The impact of GDP • on under-5 mortality seems to be highest in Cambodia.

*Prevalence*of*HIVainfected*PopulaLon*in*SEA*Countries* Number*of*people*(15a49)*living*with* HIV* 24*

4.*Health*System*Performance*Indicators* * • Quality* • Efficiency* • Acceptability* • Equity%

Equality%vs%Equity% Equality is Sameness Equity is Fairness http://elearning.tki.org.nz/Media/Images/Equity-vs-equality

Health*Inequity* ● Health*inequiLes*can*be*defined*as*systemaLc*differences*in*the* health*status*of*different*populaLon*groups* [WHO] .* ● Inequity*is*an*avoidable*unfairness*of*resource*allocaLon*due*to* poor*policies,*mismanagement*or*corrupLon.* ● Inequality*simply*means*an*uneven*distribuLon*of*healthcare* resources* *

Measuring*inequity* • Determine*whether*two*or*more*groups*(e.g.*rich*and*poor)* receive*the*same*service* • Determine*if*their*needs*are*equal* • Only*allocaLon*of*services*according*to*need*is*equitable.* • Horizontal%equity :*equal*treatment*of*those*with*equal* needs** • VerIcal%equity :*people*with*greater*clinical*needs*should* have*more*intervenLon*

Methods :** * • ConcentraLon*curve** Figure'1'Lorenz'Curve'Showing'Inequitable'Distribution'of'Doctors'Based'on' the'Population'of'States'and'Regions'in'Myanmar' ' • ConcentraLon*index* ! Lorenz'Curve'' • Lorenz*curve* 120! Cumulative'%'of'Doctors' 100! • Gini*coefficient* 80! 60! Line!of!equality! 40! Lorenz! 20! 0! 0! 20! 40! 60! 80! 100! 120! Cumulative'%'of'population' ! ! ! ! ! !

How*to*measure*needs?* Data%from%WHO,%World%Bank,%IHME% In*some*studies,*need*is*measured*as* ● selfareported*morbidity* Need*refers*to*either*selfaperceived*or* ● professionally*evaluated*Need* SLll*a*debate* ●

One*of*the*biggest*data*hubs*to*measure*disease* burdens*** Global%Burden%of%Disease% Local%Burden%of%Disease% By*InsLtute*of*Health*Matrix*and*EvaluaLons*(IHME)* https://vizhub.healthdata.org/gbd-compare/

Ranking*of*Health*Systems* ● WHO*and*IHME:** ! Composite*Index*(health*inequality,*responsivenessalevel,* responsivenessadistribuLon,*and*fairafinancing*)* ! France*is*ranked*the*best*and*Myanmar*is*ranked*the*second*worst* ● OECD:*Indicators*(healthcare*spending,*number*of*hospital*beds,*doctors* &*nurses*and*life*expectancy)* ● Bloomberg*Healthcare*Efficiency*Index:*(*life*expectancy,*relaLve*and* absolute* health *expenditures)* ! Hong%Kong%is%ranked%#1%ahead%of%Singapore%(#2).%

Universal*Health*Coverage* ● All*healthcare*systems’*primary*objecLve*is*to*get*Universal*Health*Coverage.* ● UHC*has*two*dimensions*–*access*to*needed*health*care,*and*financial*protecLon* Fig: Coverage of health insurance in ASEAN countries 2012.

%%Comparing%UHC%in%Southeast%Asia% Singapore’s health system is the best based on international assessments. Thailand’s Universal Health Coverage: the most successful story (98% coverage). In general, Increased government health spending: the more significant gains. Source:*Stephan*Lock,*Global*PracLces,*2013* 34

M YANMAR %H EALTH % SYSTEM % P AST % AND %P RESENT % % % 35*

Democratization Period The first major reform to achieve UHC (Health for Military Regime All) After independence: Health System was temporarily interrupted Colonial Period: ✓ Increase*in*health* British Health Lack*of*government* spending* System investment*in*healthcare* ✓ PoliLcal*Commitment* RestricLon*of*NGO* towards*UHC* provision*of*health*services* ✓ Socioaeconomic* Ranked*the*second*worst* improvements* in*terms*of*health*system* performance*(*WHO)*

Health*Inequity*In*Myanmar*

InequiIes%in%DistribuIon%of%Health%Care%FaciliIes% Looking*at*the*distribuLon*of* ● health*care*faciliLes*and*beds* across*the*country,*inequiLes*are* evident.** A*discrepancy*index*lower*than* ● 1.0*means*that*a*region*or*state* has*fewer*beds*per*1000* populaLon*than*the*naLonal* average*(1.0).* 38* Sca\er%plot%showing%discrepancy%index%of%hospital%beds%and%hospital%uIlizaIon%

Root*Causes*of*Healthcare*Inequity*in*Myanmar* ● Poverty*is*a*cause*of*health*inequity*in*its*own*right** ● Health*inequity*results*from*low*levels*of*investment* and*inappropriate*policies**

Current*strategies*to*reduce*inequiLes*** Myanmar*is*fully*aware*of*its* ● health*inequiLes.* Since*2010,*health*care*spending* ● has*been*steadily*on*the*rise.** Policies*are*now*directed*to* ● reduce*health*inequiLes*across*the* country.* Universal*Health*Coverage*in*2030* ● Health Budget Growth in Myanmar (2010-2014)

C OMMUNITY %L EVEL %I NEQUITY :%% M Y %O WN %S TUDIES % ON %H EALTH %I NEQUITIES %%% 1. Equity of Access to Health Services Among Poor Communities 2. Health and Healthcare Disparities in Myanmar

Study*1* ● Equity*of*access*to*healthcare*in*resource*limited*areas* in*Myanmar*

India% China% % Slums%of%Mandalay%city% * % • Overcrowding* Thailand% • Poor*housing*and*low*socioa economic*status** • Unemployment,*violence,* crime* • Poor*schooling*faciliLes*** • Poor*health*outcomes* Map%of%Myanmar%