eu and wider neighborhood ukraine. eu and wider neighborhood health gap main problem –premature...
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EU and Wider Neighborhood Ukraine
EU and Wider Neighborhood Health Gap
• Main problem– premature adult morbidity
and mortality
• Economic issue– loss of prime labor force– Cost of health services
• Social issue– Unequal opportunities
because of poor health– Poor health leads to poverty– Poverty leads to poor health
60
65
70
75
80
1970 1980 1990 2000 2010
Republic of MoldovaRussian FederationUkraineEU average CSEC average
060101 +Life expectancy at birth, in years
EU and Wider Neighborhood Shrinking Populations
5
10
15
20
25
1970 1980 1990 2000 2010
Republic of MoldovaRussian FederationUkraineEU average CSEC average
998004 +Live births per 1000 population
5
10
15
20
25
1970 1980 1990 2000 2010
Republic of MoldovaRussian FederationUkraineEU average CSEC average
998005 +Crude death rate per 1000 population
EU and Wider Neighborhood Health Gap
0
5
10
15
20
1970 1980 1990 2000 2010
Republic of MoldovaRussian FederationUkraineEU average CSEC average
060301 Reduction of life expectancy through death before 65 years, male
0
5
10
15
20
1970 1980 1990 2000 2010
Republic of MoldovaRussian FederationUkraineEU average CSEC average
060301 Reduction of life expectancy through death before 65 years, female
EU and Wider Neighborhood Health Gap
0
50
100
150
200
250
300
1970 1980 1990 2000 2010
Republic of MoldovaRussian FederationUkraineEU average CSEC average
090101 +SDR, diseases of circulatory system, 0-64 per 1000000
EU and Wider Neighborhood Health Gap
0
50
100
150
200
250
300
1970 1980 1990 2000 2010
Republic of MoldovaRussian FederationUkraineEU average CSEC average
090201 SDR, ischaemic heart disease, 0-64 per 100000, female
0
50
100
150
200
250
300
1970 1980 1990 2000 2010
Republic of MoldovaRussian FederationUkraineEU average CSEC average
090201 SDR, ischaemic heart disease, 0-64 per 100000, male
EU and Wider Neighborhood Health Gap
70
90
110
130
150
170
190
210
1970 1980 1990 2000 2010
Republic of MoldovaRussian FederationUkraineEU average CSEC average
100101 +SDR, malignant neoplasms, 0-64, per 100000
70
90
110
130
150
170
190
210
1970 1980 1990 2000 2010
Republic of MoldovaRussian FederationUkraineEU average CSEC average
100102 +SDR, malignant neoplasms, all ages per 100000
EU and Wider Neighborhood Health Gap
10
15
20
25
30
35
1980 1985 1990 1995 2000 2005 2010
Republic of MoldovaRussian FederationUkraineEU average CSEC average
110212 +SDR, transport accidents, all ages per 100000
EU and Wider Neighborhood Health Gap
0
10
20
30
40
1970 1980 1990 2000 2010
Republic of MoldovaRussian FederationUkraineEU average CSEC average
170401 +SDR, homicide and intentional injury, 0-64 per 100000
EU and Wider Neighborhood Health Gap
0
10
20
30
40
50
1970 1980 1990 2000 2010
Republic of MoldovaRussian FederationUkraineEU average CSEC average
120101 +SDR, suicide and self-inflicted injury, 0-64 per 100000
EU and Wider Neighborhood Health Gap
0
50
100
150
200
250
300
1970 1980 1990 2000 2010
Republic of MoldovaRussian FederationUkraineEU average CSEC average
110101 +SDR, external cause injury and poison, 0-64 per 100000
EU and Wider Neighborhood Health Gap
• Infant mortality follows EU trend– though on higher level
• More recently accuracy of data has been questioned– survey data in several CIS
countries significantly higher– but no survey data available
for Ukraine
• Commitment to Millennium Development Goals– MCH but no premature adult
mortality
0
10
20
30
40
1970 1980 1990 2000 2010
Republic of MoldovaRussian FederationUkraineEU average CSEC average
070100 +Infant deaths per 1000 live births
EU and Wider Neighborhood Health Gap: Behavioral Risk Factors
• We really do not know– little and fragmented
info on knowledge, behaviors, attitudes
• Makes it difficult – to recognize the
problem– design and monitor
impact of policy interventions
15
20
25
30
35
40
1990 1995 2000 2005 2010
Republic of MoldovaRussian FederationUkraineEU average CSEC average
171010 +% of regular daily smokers in the population, age 15+
EU and Wider Neighborhood Health Gap
50
100
150
200
250
1980 1985 1990 1995 2000 2005 2010
Republic of MoldovaRussian FederationUkraineEU average CSEC average
991712 +SDR, selected alcohol related causes, per 100000
200
300
400
500
600
700
800
900
1980 1985 1990 1995 2000 2005 2010
Republic of MoldovaRussian FederationUkraineEU average CSEC average
991722 +SDR, selected smoking related causes, per 100000
EU and Wider Neighborhood Infectious diseases: international PH issues
• Endemic outbreaks of vaccine preventable and waterborne diseases
• HIV/AIDS– In Ukraine: between
50,000 and 400,000 HIV positive
• TB• STIs
5
10
15
20
25
30
1970 1980 1990 2000 2010
Republic of MoldovaRussian FederationUkraineEU average CSEC average
993002 +SDR, infectious and parasitic disease, all ages per 100000
EU and Wider Neighborhood International Public Health Issues
10
20
30
40
50
60
70
80
90
100
1970 1980 1990 2000 2010
Republic of MoldovaRussian FederationUkraineEU average CSEC average
040301 +Tuberculosis incidence per 100000
EU and Wider Neighborhood International Public Health Issues
0
10
20
30
40
50
60
70
1985 1990 1995 2000 2005 2010
Republic of MoldovaRussian FederationUkraineEU average CSEC average
050303 New HIV infections reported per 100000
EU and Wider Neighborhood International Public Health Issues
0
1
2
3
4
5
6
7
1970 1980 1990 2000 2010
Republic of MoldovaRussian FederationUkraineEU average CSEC average
050312 +Clinically diagnosed AIDS incidence per 100000
EU and Wider Neighborhood Health Financing Gap
• Public financing of health lower than expected
• High level of out-of-pocket payments– informal and formal
• People can not access health services– in Ukraine 30% of
population reports no access (2001)
• Leads to poverty and ill health vicious circle 0 10000 20000 30000 40000 50000 60000
0
5
10
15
Republic of MoldovaRussian FederationUkraineEU average CSEC average
Y = 0.000176X+3.44Y
X
X - 990002 Real gross domestic product, PPP$ per capita, 2000Y - 340102+Total health expenditure as % of gross domestic product (GDP), Last Available
EU and Wider Neighborhood Health Care Services: Structural Imbalances
500
600
700
800
900
1000
1100
1200
1300
1400
1980 1985 1990 1995 2000 2005 2010
Republic of MoldovaRussian FederationUkraineEU average CSEC average
270205 +Hospital beds per 100000
EU and Wider Neighborhood Health Care Services Structural Imbalances
20
30
40
50
60
70
80
90
100
110
1980 1985 1990 1995 2000 2005 2010
Republic of MoldovaRussian FederationUkraineEU average CSEC average
992733 +General practitioners (PP) per 100000
EU and Wider Neighborhood Health Care Services: Structural Imbalances
10
15
20
25
30
1970 1980 1990 2000 2010
Republic of MoldovaRussian FederationUkraineEU average CSEC average
992902 +In-patient care admissions per 100
EU and Wider Neighborhood Ukraine response to health sector challenges
(1)• Health system has been resisting reform so far
– Para 49 in Constitution guarantees free health care and forbids optimization of health services
• Strategic health reform documents– “Concept of the Development of Health Care in
Ukraine” President’s Decree 2000– “The Health of Nation,” Government program, 2002;
based on WHO Health for All strategy– But no effective implementation, decision making
barriers, strategies not funded
EU and Wider Neighborhood Ukraine response to health sector challenges
(2)• Emerging health system reform directions
– Family Doctor based PHC services
– Health financing system reform, attempts to introduce social health insurance
• Joint Government, WB, GFATM effort to tackle HIV/AIDS and TB epidemic– annually 1 million workers seek temporary
employment abroad
EU and Wider Neighborhood Ukraine – evidence on EU convergence
• “European Way” – overarching development objective declared by the President of Ukraine
• Public health, safety, occupational health– Sanitary Epidemiology Service – largely unchanged Soviet model,
incremental changes planned
• Pharmaceutical industry– domestic industry supplies60% of local market, first
manufacturers GMP certified
• Medical training and qualifications– undergraduate and graduate training still far from Europe– still 138 recognized specialties
EU and Wider Neighborhood World Bank Program in Ukraine
• Tuberculosis and AIDS Project; 2003; cost US$ 77M (WB loan US$ 60 M)– TB (US$ 28.7 M) training, diagnosis, treatment, public
awareness, monitoring and evaluation; – HIV/AIDS component (US$ 32.2 M) treatment protocols, training,
harm reduction, public awareness, strengthening regional capacity Prisons component (US$ 12.7 M) both HIV/AIDS and TB;
– Implemented in parallel and complementary to the GFATM grant of US$ 90 M
• Policy dialogue under Programmatic Adjustment Loan Program (PAL 2 2003)– Health financing reform– PHC reform
EU and Wider Neighborhood World Bank Program in Russia
• Health Reform Pilot Project; 1997; (cost $83.2 mill (WB loan $66 million)– Kaluga oblast reform (Restructuring delivery system and provider
incentives; Maternal and Child health and Family Planning) – Tver oblast reform (Restructuring cardiovascular health services;
Family medicine; Restructuring provider incentives)– National Training Program in Family Medicine
• Health Reform Implementation Project; 2003; cost $41 mill (WB loan $30 mill)– Rationalization of health services– Strengthening financial and economic management– Improving policy and governance
EU and Wider Neighborhood World Bank Program in Russia
• Tuberculosis and AIDS Control Project; 2003; cost $286 mill (WB loan $150 mill)– Control of TB ($217M) policies, strategies and protocols;
strengthening surveillance, monitoring, quality control; improvement of TB case detection and diagnosis; improvement of TB treatment)
– Control of HIV/AIDS ($65.3) policies, strategies and public information; surveillance and monitoring; targeted prevention of HIV/AIDS and STIs in high risk groups; prevention of mother-to-child transmission)
• Health policy analysis and dialogue– studies, advisory services
EU and Wider Neighborhood World Bank Program in Moldova
• Tuberculosis and AIDS Project; 2003; cost US$ 15M (WB grant US$5 M, GFATM grant US$ 9.5M)– HIV/AIDS/STI component (US$ 6.9M): strategic planning and
institution building, surveillance system, training, laboratory capacity; prevention and harm reduction programs among high risk groups; treatment and care for PLWHA;
– TB (US$ 6.8M) policies, strategies and protocols; surveillance, monitoring, quality control; improvement of TB case detection and diagnosis; improvement of TB treatment
• Health Investment Fund Project; 2000; cost US$ 20M (WB credit US$ 10M; Netherlands US$ 8.4M)– Policy and institutional strengthening of MOH (US$ 1.7 M)– Health Investment Fund (US$ 17.7M) – emergency and primary health
care; hospital capacity rationalization