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

COMPARING*HEALTH*SYSTEMS*IN*SOUTHEAST*ASIA:*A*FOCUS*

ON*INEQUITY*

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% Indicators%

• Life*expectancy*at*birth*
• GDP*per*capita*
• EducaLon*Index*
• Crude*Death*Rate*etc.*

2.%Health%System%Indicators%

• Public*Health*Expenditure*
• OutaofaPocket*Health*Expenditure*
• Physicians*per*1,000*populaLon*
• Hospital*beds*per*1,000*populaLon*

3.%Health%Outcomes%Indicators**

• Maternal*Mortality*
• Underafive*Mortality*
• HIV*Prevalence**

4.%Health%System%Performance% Indicators%

• Quality,**
• Efficiency,**
• Acceptability,*and*
• *Equity*

*

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%). 3rd 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%

• f%schooling%

index*and*the* Expected%years%

• f%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

• ccurring 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

16*

%*of*total*health*expenditure*

Out*of*Pocket*Health*Expenditure*in*SEA*(1995*to*2012)*

17*

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

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.

• Most ASEAN

countries show a negative relationship (as GDP increases

• ver 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
• n under-5 mortality

seems to be highest in Cambodia.

The relationship between GDP (US$) and Under-5 mortality over time for Southeast Asian Countries

*Prevalence*of*HIVainfected*PopulaLon*in*SEA*Countries*

24*

Number*of*people*(15a49)*living*with* HIV*

*

• Quality*
• Efficiency*
• Acceptability*
• Equity%

4.*Health*System*Performance*Indicators*

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**
• ConcentraLon*index*
• Lorenz*curve*
• Gini*coefficient*

Figure'1'Lorenz'Curve'Showing'Inequitable'Distribution'of'Doctors'Based'on' the'Population'of'States'and'Regions'in'Myanmar' ' ! ! ! ! ! ! !

0! 20! 40! 60! 80! 100! 120! 0! 20! 40! 60! 80! 100! 120! Cumulative'%'of'Doctors' Cumulative'%'of'population'

Lorenz'Curve''

Line!of!equality! Lorenz!

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*

Global%Burden%of%Disease% Local%Burden%of%Disease% By*InsLtute*of*Health*Matrix*and*EvaluaLons*(IHME)*

https://vizhub.healthdata.org/gbd-compare/

One*of*the*biggest*data*hubs*to*measure*disease* burdens***

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.

34

Source:*Stephan*Lock,*Global*PracLces,*2013*

MYANMAR%HEALTH%SYSTEM%

PAST%AND%PRESENT% % %

35*

Colonial Period: British Health System After independence: Health System was temporarily interrupted

Democratization Period

Military Regime

The first major reform to achieve UHC (Health for All)

Lack*of*government*

investment*in*healthcare*

RestricLon*of*NGO*

provision*of*health*services*

Ranked*the*second*worst*

in*terms*of*health*system* performance*(*WHO)*

✓ Increase*in*health* spending* ✓ PoliLcal*Commitment* towards*UHC* ✓ Socioaeconomic* improvements*

Health*Inequity*In*Myanmar*

Sca\er%plot%showing%discrepancy%index%of%hospital%beds%and%hospital%uIlizaIon%

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*

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)

COMMUNITY%LEVEL%INEQUITY:%% MY%OWN%STUDIES%ON%HEALTH%INEQUITIES%%%

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*

Map%of%Myanmar%

*

• Overcrowding*
• Poor*housing*and*low*socioa

economic*status**

• Unemployment,*violence,*

crime*

• Poor*schooling*faciliLes***
• Poor*health*outcomes*

Thailand% India% China%

% Slums%of%Mandalay%city%

%

Study%Design% Communityabased*crossasecLonal*study* Part*I*:QuanLtaLve*methods** Part*II:*QualitaLve*methods*

Study%se`ng%

All*resourcealimited*suburban* communiLes*in*Mandalay*city* Map of Mandalay city


 Formal%se\lements% Riverbank%se\lements% Polakee%se\lements%

#*Photo*credit*to*the*original*photographer*

A%Polakee%Child%in%the%Study%Area%

Data%collecIon%at%one%of%the%Polakee%CommuniIes%

I really want to go to

school.

During%data%collecIon%at%one%of%the%Polakee%CommuniIes%

0%% 20%% 40%% 60%% 80%% coverage%

WHO$indicators$of$MDG$5$by$type$of$se7lement$

Formal%se=lements% RB%se=lements% Polakee%se=lements%

DispariIes%even%Among%the%Poorest%%

SBA=Skilled*Birth*Atendant* ANC=*Antenatal*Care*Coverage*

Study*2*

DispariLes*in*Health*and*Healthcare*in*Myanmar*

Department%of%Health’s%State%and%Region%Budget%AllocaIon%

0.* 7500.* 15000.* 22500.* 30000.* Kachin% Kayah% Karen% Chin% Sagaing%% Tanintharyi% Bago% Magway% Mandalay% Nay%Pyi%Taw% Mon% Rakhaing% Yangon% Shan%(S)% Shan%(N)% Shan%(East)% Ayeyarwaddy%

Budget Allocation in kyats

2012a13* 2013a14* 2014a15* Source:*Department*of*Health*Planning,*Ministry*

• f*Health,*Myanmar*

Figure: Health budgets for Myanmar's regions and states are not proportionate to health needs. The lines are smooth curves fitted to the data by use of local regression and bubbles are roughly proportional to population sizes.

.

Conclusions*

• Health*InequiLes*are*seen*not*only*among*countries*but*also*within*a*

country*and*within*its*communiLes.*

• Strategies*or*policies*directed*to*the*overall*health*status*of*the*whole*

populaLon*may*not*adequately*address*health*inequiLes*because*each* community*has*its*unique*context.*

• Increasing*government*health*expenditure*along*with*equitable*resource*

allocaLon*based*on*specific*needs*is*essenLal.*

• Addressing*the*different*root*causes*of*inequiLes*is*recommended.*

Addressing*the*Root*Cause*of*Inequity*

http://elearning.tki.org.nz/Media/Images/Equity-vs-equality

References*

1.

Asian*Development*Bank*(ADB)*(1996).*Country*synthesis*of*post*evaluaLon*finding*in*Myanmar.*Manila:*ADB*Post*EvaluaLon* Office.*

2.

*Asian*Development*Bank*(ADB)*(2012).**Myanmar*in*transiLon:*opportuniLes*and*challenges.22*February*2013*

3.

Central*StaLsLcal*OrganizaLon*(CSO)*(2009).*StaLsLcal*year*book*2008.*Nay*Pyi*Taw:*CSO,*Ministry*of*NaLonal*Planning*and* Economic*Development.*

4.

Central*StaLsLcal*OrganizaLon*(CSO)*(2012).*StaLsLcal*year*book*2011.*Nay*Pyi*Taw:*CSO,*Ministry*of*NaLonal*Planning*and* Economic*Development.*

5.

Department*of*Health*NaLonal*Tuberculosis*Programme*(DOHaNTP)*(2011).*The*fiveayear*NaLonal*Strategic*Plan*(NSP)*(2011– 2015).*Nay*Pyi*Taw:*DOH.*

6.

Health*System*in*TransiLon,*The*Republic*of*Union*of*Myanmar,*Health*System*Review,*Asia*Health*Observatory*on*Health* Systems*and*Policies*

7.

World*Health*OrganizaLon*(WHO)*(2000).*The*world*health*report*2000.*Health*systems:*improving*performance.*Geneva:*WHO* (htp://*www.who.int/whr/2000/en/whr00_en.pdf,*accessed*26*November*2013].*

8.

Handler*A,*Issel*M,*Turnock*B.*A*Conceptual*Framework*to*Measure*Performance*of*the*Public*Health*System.*American%Journal%

• f%Public%Health.*2001;91(8):1235a1239.*

9.

Dhillon*PK,*Jeemon*P,*Arora*NK,*et*al.*Status*of*epidemiology*in*the*WHO*SouthaEast*Asia*region:*burden*of*disease,* determinants*of*health*and*epidemiological*research,*workforce*and*training*capacity.*InternaRonal%Journal%of%Epidemiology.* 2012;41(3):847a860.*doi:10.1093/ije/dys046.*and*many*more…………*

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