Lesson/Week 11 Distribution of Health Services and Equity of Coverage

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1 Lesson/Week 11 Distribution of Health Services and Equity of Coverage World Summary International Migration of Health Care Workers Case Study: Sub Saharan Africa Global Trends (WHO 2008 report) World Summary Health services include all services dealing with the diagnosis and treatment of disease, or the promotion, maintenance and restoration of health. Health services are the most visible functions of any health system, both to users and the general public. Service provision refers to the way inputs such as money, staff, equipment and drugs are combined to allow the delivery of health interventions. Improving access, coverage and quality of services depends on these key resources being available; on the ways services are organized and managed, and on incentives influencing providers and users. Health Service Delivery Health services are the most visible part of any health system, both to users and the general public. Health services, be they promotion, prevention, treatment or rehabilitation, may be delivered in the home, the community, the workplace, or in health facilities. Effective health service delivery depends on having some key resources: motivated staff, equipment, information and finance, and adequate drugs. Improving access, coverage and quality of health services also depends on

2 the ways services are organized and managed, and on the incentives influencing providers and users. Some Key Facts o Total global expenditure for health: US$ 4.1 trillion o Total global expenditure for health per person per year: US$ 639 o Country with highest total spending per person per year on health: United States (US$ 6103) o Country with lowest total spending per person per year on health: Burundi (US$ 2.90) o Country with highest government spending per person per year on health: Norway (US$ 4508) o Country with lowest government spending per person per year on health: Burundi (US$ 0.70) o Country with highest annual out-of-pocket household spending on health: Switzerland (US$ 1787) o Country with lowest annual out-of-pocket household spending on health: Solomon Islands (US$ 1.00) o Average amount spent per person per year on health in countries belonging to the Organisation for Economic Co-operation and Development (OECD): US$ 2716 o Percentage of the world's population living in OECD countries: 18% Percentage of the world's total financial resources devoted to health currently spent in OECD countries: 80% o Annual spending by the municipal government of New York City (population 8.2 million) on health: US$ 429 million o Annual spending by the government of Bénin (population 8.2 million) on health: US$86 million o WHO estimate of minimum spending per person per year needed to provide basic, life-saving services: US$35 to US$50 o Number of WHO Member States where health spending including spending by government, households and the private sector and funds provided by external donors is lower than US$50 per person per year: 64 o Number of WHO Member States where health spending is lower than US$20 per person per year: 30

3 o Percentage of funds spent on health in WHO's Africa Region that has been provided by donors: 14% The Global Picture

4 A Local Example Migration of Health Care Workers In the not too distant past, discussions involving "health" and "migration" would likely have focused on the physical and mental condition of immigrants, or, perhaps, the incidence of communicable diseases in a refugee camp. Today, however, the connection between health and migration can just as readily be illustrated by a hospital in AIDS-stricken Malawi, which has only 30 nurses, 26 of whom have plans to leave the country.

5 The international mobility of health workers is nothing new. In recent years, however, migration of health workers from highly skilled physicians to those in lesser skilled positions, from the developing world to wealthier destinations has increased. Moreover, the countries with the most alarming outflows include those sub-saharan African nations suffering acutely from the HIV/AIDS epidemic and dwindling numbers of health workers. Controversy surrounds the proper role of policy interventions in the global labor market of health care professionals. Emigration of health care workers weakens already failing health systems in the developing world. Yet this movement may more accurately be described as a symptom or an aggravating factor, and not the root cause of health care system failures in the developing world. At the same time, the graying of the industrialized world has placed pressures on industrialized countries to find a solution for scarce or poorly distributed health care labor to support their aging populations. Both scenarios shed light on this new global tug-of-war for health care workers. It is still unclear what the new rules of engagement will be to retain and train health care workers where they are most needed and to mitigate the grave imbalance between the rich and the poor with regard to health care. In light of these factors, experts are weighing a series of policy options that have important implications for the migration of the world's health care workers. Ethical considerations that pit the right of individuals to move against a greater public good are at stake as well. Policymakers find themselves struggling with two complex sets of issues: how can health care workers with needed skills maintain their freedom of movement and the opportunity to respond to more favorable employment offers outside their country or region of origin without damaging the

6 fundamental right of others in a population to a basic standard of health care? The Care Drain: A Global Phenomenon with Local Implications While the flight of health care workers from sub-saharan Africa to the United Kingdom, Australia, and North America captures the spotlight in current discussions on "health care brain drain," mapping out medical migration as a global phenomenon highlights the interconnections of flows across regions. Notable source regions for health care-related migration are Africa, the Caribbean, South Asia, and Southeast Asia. According to the Organization for Economic Cooperation and Development (OECD), the primary destinations are the Anglophone countries of Canada, the US, the UK, Australia, and New Zealand. Across these countries, an average of 23 to 24 percent of physicians are trained abroad. Other recipients of significant numbers of medical migrants include Western Europe and the oil-exporting Gulf States. Nurses, in particular, are leaving their home countries in greater numbers. The number of nurses in the UK from non-eu countries grew from approximately 2,000 in to more than 15,000 in In the US, the percentage of nurses trained abroad increased from six percent in 1998 to 14 percent in Even the Philippines, a traditional sending country, sent more than three times the number of nurses abroad in 2001 than in 1996, primarily to the UK, Ireland, and Saudi Arabia. Such trends persist despite severe or emerging shortages in home countries. In fact, long-time source countries like India and the Philippines face health worker shortages themselves in rural and underserved areas. Some developing countries, too, are becoming both destinations and sources of skilled workers.

7 While an estimated 5,000 doctors have moved from South Africa to the US, UK, Canada, and Australia, South Africa has become a destination for health professionals in its own right, as indicated in a 2002 study by the Southern Africa Migration Project (SAMP). Neighboring Botswana shares a similar position in the Southern Africa region. Among industrialized countries, too, there is an ever-shifting pattern of movement. The United Kingdom has replaced its health professionals who have gone to North America with entrants from Germany. Germany, in turn, hosts a significant and growing number of physicians from the Czech Republic. In anticipation of a mass exodus after EU expansion in May 2004, Czech health systems identified recruitment from neighboring Slovakia as a coping strategy. The downstream effects of such recruitment strategies have a profound effect on source countries. Impact of Health Care Migration on Source Countries Outflows of health care workers are not necessarily a sign of health system malfunction. In fact, in some countries, such flows have been part of an overall strategic labor export plan. The Philippines, India, and Cuba have intentionally invested in the training of health workers for export. In return, some migrants contribute to their home countries with remittances and enhanced skills when they return. However, for some countries, even limited migration can have a big impact. Indeed, a study by the Joint Learning Initiative at Harvard University notes that "while the absolute numbers may not be large, the outflows can be 'fatal' for disadvantaged people in source countries." Health care migration from countries that are involuntary or reluctant sources tends to have more wide-spread negative reverberations. This is especially true in the case of sub-saharan African countries, whose health systems are already compromised by an HIV/AIDS epidemic that claimed

8 77 percent of the disease's deaths worldwide in Approximately 37 of 47 sub-saharan African countries do not have 20 doctors per 100,000 people, as recommended by the World Health Organization (WHO) minimum standards. In contrast, the average among OECD countries was approximately 222 physicians per 100,000 people in Malawi filled only 28 percent of vacant nursing positions in South Africa had up to 4,000 doctor vacancies and 32,000 nurse vacancies in Migration is not solely responsible for the shortages but it is an active factor. For instance, the main cause of attrition among health workers in Malawi is not migration but death, mainly from HIV/AIDS. South Africa has 35,000 registered nurses documented as being in the country who are inactive or unemployed, despite 32,000 vacancies in the public sector. At the same time, however, a 2003 WHO report found that 60 percent of South African institutions had trouble replacing nurses who had emigrated; a significant number of pharmacies in Zimbabwe have closed due to the outflow of pharmacists. International migration flows have also exacerbated rural health shortages, as vacancies in urban areas left by migrating workers are filled by those leaving rural tracts. For example, in South Africa, rural areas account for 46 percent of the population, but only 12 percent of doctors and 19 percent of nurses. These internal disparities have also been noted in countries whose governments support the emigration of health care personnel. The dearth of health care workers has hampered not only the expansion of AIDS treatment programs in Botswana and South Africa, but also routine services for tuberculosis and immunizations throughout sub-saharan Africa. On the ground, such shortages lead to unqualified employees performing critical services, overburdened staff, lack of popular confidence in the health care sector, and loss of institutional knowledge.

9 International migration also tends to disproportionately involve those most likely to contribute in managerial and training roles, further weakening a country's health system. The financial loss figures are significant as well. Because many developing countries pay for health training through public medical schools, they lose a substantial amount in training investments when health workers migrate. Estimates range from $500 million per year on average for a developing country to $1 billion per year for South Africa. Although the home country may gain from remittances, such transfers do not necessarily go to the health system or to public coffers. Furthermore, as a nation's economic productivity is linked to the health of its citizens, the economic impact of poor health systems may become significant. Contributing Factors to Health Care Migration: Salaries, Training, Distribution Beyond the fundamental challenges facing many source countries of health care migrants, such as political and economic instability and poor governance, there are other starting points for appropriate policy responses. Salaries and benefits are an obvious factor, given extreme wage differentials across countries. A 2002 survey led by human resource management and development expert Tim Martineau listed monthly salaries for physicians that range from US$50 in Sierra Leone to US$1,242 in South Africa. Wages in Canada and Australia are approximately four times those in South Africa. However, many experts emphasize that pay is not the sole motive for leaving the country. Other factors include poor work environments characterized by heavy workloads, lack of supervision, and limited organizational capacity. There are also environmental considerations; workplaces may be dangerous due to lack of sanitation and supplies to protect workers from diseases like HIV/AIDS and tuberculosis.

10 This is occurring when much of the current international funding is narrowly focused on disease-specific programs rather than capacity-building to improve salaries, human resource management, and the procurement of basic medical supplies and much-needed in-country training. In many developing countries, health care needs require a broad grounding in public health. Training, however, in some source countries for medical professionals especially for physicians has tended to focus on advanced medical techniques. Graduates are unlikely to use such training or to make professional advances in these areas without moving to countries where medical technology is more readily accessible and used. Other factors in destination countries act as magnets for health workers in the developing world. With fewer people having children and individuals living longer, there has been a profound change in the industrialized world's age distribution, from Japan to Italy. As a result, there is a growing demand for health care workers, especially those who can provide assistance to the elderly. In some instances, inappropriate or poor distribution of health care professionals and not a shortage is at the root of increased demand. Although some estimates suggest that the US produces more medical doctors than it needs, there is a shortage of general practitioners. Furthermore, 20 percent of Americans live in rural areas, but fewer than nine percent of physicians live in these areas. All of these factors have contributed to the emergence of a robust, international recruitment industry. Recruitment drives by actors as diverse as the provincial governments in Canada to Wal-Mart pharmacies in America have been important facilitators of the medical migration process. Recruitment practices include retaining third-party recruitment agencies, aggressive advertising in professional medical publications, and relocation

11 services for migrants. Proposed Policy Responses As outlined above, several players and conditions have conspired to deplete developing countries of their important health care providers. At issue is not only the availability of healthcare workers but also the long-term viability of health care systems. Shoring-up crumbling systems has emerged as a critical policy challenge. As might be imagined, policy responses are controversial and not easy to implement. A major study in 2004 by the nongovernmental organization Physicians for Human Rights (PHR) sets forth some guidelines for rich countries in search of additional health care labor. A similar report by the Joint Learning Initiative at Harvard University carefully documents the spectrum of challenges, including migrations that developing countries face. The recommendations focus on changing the conditions for native health care workers, including increasing wages and opportunities for training and improving working conditions. In addition, they suggest that developed countries should work to minimize their reliance on foreign health professionals by placing native health professionals in underserved areas (e.g., through programs focused on loan repayment and recruitment from rural areas). Several actors ranging from sending and destination countries to advocacy groups in Africa and around the world have promoted recommendations to deal explicitly with managing the migration of health workers.

12 Rather than restricting the movement of health professionals, such schemes emphasize minimizing the factors that foster migration. In light of the disparities between sending and receiving countries and the critical need for health workers in poor countries, the WHO and other global actors are giving high-level consideration to such actions. Regulating Active Recruitment Host countries as well as representatives from organizations such as Physicians for Human Rights and the International Council of Nurses have called for regulated recruitment from developing countries facing a critical shortage of health care workers. South Africa, for example, did just that through a government mandate issued in 1995 that prohibited South Africa from recruiting doctors from the 14 member countries of the Southern African Development Community. The effort has reportedly been successful, with implementation carried out through professional registration controls. Similarly, the UK has implemented a "code of practice" renewed in 2001 to reflect concerns about Africa that prohibits its National Health Service organizations from recruiting health workers from certain countries. While the code has been well respected in the public sector, it is not binding on the private sector. As a result, the number of nurses from abroad increased in Consequently, the focus has centered on the accountability of private actors. It is unclear, however, how to manage such private recruitment. Several ideas have been floated. These include requiring recruitment agencies to report their practices publicly; creating an independent watch-dog type agency to oversee the process and to monitor and promote compliance with a code, and taxing employers and recruitment agencies that import medical workers without following codes of conduct. Bilateral agreements are another mechanism for promoting health worker flows that are more beneficial to source countries. For instance, Norway's

13 public health sector limits recruitment from most developing countries. However, it has signed agreements allowing nationals from Poland and the Philippines to work there. Likewise, China has initiated agreements to send medical professionals to England for training purposes. Such arrangements have also been initiated by countries with health worker shortages. South Africa has proposed bilateral agreements which aim to stop active recruitment of its health workers with several countries. Similar to mandates and codes of practice, bilateral agreements face challenges of private sector enforcement. In light of the difficulty in enforcing such agreements, as well as the resulting shift in migration that would likely occur to and from countries that do not have such practices in place, some groups have called for an international standard to be set forth by the WHO or an international treaty. Some analysts believe that such a standard could be an important advocacy tool for those within a country pushing their government to codify ethical recruitment policies. Promoting Training Through Short-Term Visas Other recommendations under consideration include changing the visa policies of wealthy countries to promote skills development through shortterm visas. The hope is that such training could improve health care treatment and retention in the health care profession within origin countries. Others are dubious of such efforts, pointing to the importance of understanding more clearly the kinds of skills shortages and the distribution of current health care workers. They argue that increased numbers are unlikely to solve these mismatches. Furthermore, many believe it will be difficult to enforce the departure of those on temporary training visas. Such new visa programs will also have to

14 ensure that training is appropriate for the needs in the origin country. Compensating Countries for Losses Associated with Health Care Worker Migration One of the most controversial issues within the health care field as well as the international migration management field as a whole is the idea of compensation. In 2004, the World Health Assembly the decision-making body of the World Health Organization recommended that its director general examine reimbursement by destination to source countries for the investments lost when health professionals migrate. Critics of such a plan counter that individuals search out opportunities outside their country of origin because of poor in-country opportunities for professional growth and remuneration. Governments, therefore, should not be rewarded for their failure to provide meaningful employment for their own citizens and for domestic economic mismanagement. Others have suggested that any compensation should be invested directly in the health care system, potentially through foreign aid streams. One possible source of reimbursement under consideration is taxing employers of foreign health care workers. Noting the traditional resistance of importing countries towards compensation measures, some observers have alternatively proposed large-scale reinvestment efforts funded by rich countries to develop human resources in sending countries. Case Study: Sub Saharan Africa Africa suffers a number of health service delivery issues First, there is a severe shortage of health care workers in Africa to support the continent s population. Africa was estimated to have 2.3 health care workers per 1,000 populations, compared to 4.3 in south-east Asia, 18.9 in Europe, and 24.8 in the Americas.

15 To some extent this shortage was due to the difficulty of recruiting and training qualified workers in hard-to reach locations and for low wages. However, qualified health workers were also difficult to retain and often quit their positions because they found it difficult to fulfill their duties without the necessary supplies, support, and access to patients. Africa s health workforce was underrepresented by nurses and support staff, placing additional strain on skilled doctors to perform routine procedures like vaccinations as well as administrative work. These shortages were exacerbated by the fact that a greater percentage of the population required medical attention. Second, the continent had a severely underdeveloped physical infrastructure system. For example, most African nations lacked a modern sewage collection and treatment system. These systems, implemented in developed nations in the second half of the nineteenth century, had been directly responsible for the elimination of water-transmitted diseases such as cholera. By comparison, their absence in Africa contributed to the prevalence of several diseases. Although major African cities were connected by paved roads, much of the population lived in remote communities that were accessible only by singlelane sand or dirt paths. According to the United Nations, 62 percent of Africans lived in rural communities compared with 19 percent in North America and 28 percent in Europe. In many African countries, only percent of the rural population lived within 2 kilometers of a road. Furthermore, there was limited existing infrastructure, such as postal services or railroads, reaching into these communities. As a result, health workers could not easily reach the vast population living in remote locations. People requiring medical attention had to devise their own ways to travel to the closest health clinic. Without motor transportation, they were often forced to walk or rely on a relative to push them in a wheelbarrow. Tragically, those who lived five miles or more from a health clinic and were sick, malnourished, or pregnant had significantly lower survival rates than those who lived closer to a clinic.

16 Third, cultural barriers sometimes disrupted access to medical treatment. For example, drugs and vaccines that were imported into African countries were received by the ministry of health or customs office. In some cases, local officials expected foreign organizations to pay bribes or facilitating payments to accelerate processing of paperwork; failure to make such payments could delay access. Disease or infection often carried a social stigma, with a patient being shunned by his or her community. As a result, an individual who suspected s/he might be sick often chose to put off seeking medical attention until the condition became impossible to ignore. Such a practice not only led to higher risk for the patient but also increased infection rates for those nearby.

17 Within country variation: Example Flash presentation: Africans doctors/nurses abroad Ghana trains 150 doctors annually; five years after graduation, 80 percent have left, according to Ghanaian data reported by the World Bank. For pharmacists, the proportion is about 40 percent; for nurses and midwives, it's about 75 percent -- which is why half the nursing posts in Ghana are vacant. Meanwhile, South African doctors emigrate at a rate of about 1,000 annually. In 2001, Zimbabwe graduated 737 nurses; 437 left for one country, Britain.

18 More on doctors abroad Since 1996, 37% of South African doctors and 7% of nurses have migrated to Australia, Canada, Finland, France, Germany, Portugal, United Kingdom, and United States compared with 34% of educators, 29% of engineers, and 24% of accountants. It is estimated that 23,407 South African doctors are in Australia, New Zealand, Canada, United Kingdom, and the United States (8,999 in the United Kingdom alone); there are also in excess of 10,000 South African nurses in the United Kingdom, with large numbers in New Zealand, Australia, Canada and United States. The greatest challenges to health stem from the global liberalization of trade, with its resultant movement of goods and services (including health workers) within the world economy. With the exception of a few countries, such as the Philippines and South Africa,1 which have had collaborative health worker migration schemes for some years, migration is seriously affecting the sustainability of health systems of many developing countries. The Organisation of Economic Cooperation and Development (OECD) has estimated that 18% of all doctors and 11% of all nurses working in OECD countries are foreign born. Furthermore, in some European countries the average annual growth rate in the number of foreign-trained doctors in the past 25 years is <10%.

19 Doctors in Africa (2008)

20 What is the Scope of the Crisis? UCGH.pdf The World Health Organization (WHO) estimates that sub-saharan Africa faces a shortage of more than 800,000 doctors, nurses, and midwives and an overall shortage of 1.5 million healthcare workers. In Africa, a mere 3% of the world s health workers struggle against all odds to combat 24% of the global disease burden1 In Malawi, only 10% of the physician slots are filled while 10 people die every hour of AIDS in the country3 Out of the 1200 physicians trained in Zimbabwe from 1990 to 2001, only 360 remain3 More than 3000 nurses from African nations migrated and registered in the United Kingdom in Ghana has lost 69% of physicians, 25% of nurses, and 42% of pharmacists which graduated between Ethiopia s public health sector is losing about 9.6% of their physicians every year to both the private healthcare sector and to other countries. Although particular causes of shortages vary by country, there are common threads: Brain-Drain, or the emigration of trained and talented individuals to other nations or jurisdictions, is a major and complex issue, and is driven by systemic failures of policy and practice. In Ghana, research indicates that 50% of graduates of medical schools emigrate within 5 years, and 75% within 10 years. Active recruiting by wealthy nations pull trained health care workers out of Africa. Broken Health Systems, though, are the key factor in the shortage. Faced with very overwhelming patient loads, poor and unsafe working conditions, and not enough supplies and technology to do their jobs, is it a surprise that many who would like to stay feel they must leave Africa? And wealthy countries are not investing the resources to change this situation or replace the health workers recruited to meet our needs. Low Prioritization of Community Health Workers these family and community members do the bulk of care-giving in many nations and fill some of the massive gaps, but receive little or no compensation.

21 Poor Economic Policy is a major driver of this brain drain. For decades international economic institutions have forced impoverished nations to adapt policies that dismantle existing public health systems and prevent the development of new infrastructure. The International Monetary Fund (IMF) is among the most problematic imposing policies that require a public sector ceiling that prevents countries from hiring enough health workers or paying them enough to retain them. HIV/AIDS also has a massive direct effect the health workforce. In South Africa, it is conservatively estimated that 16% of the existing health worker force is HIV+ and in Malawi the government figures they will lose nearly 3% of their workforce each year to the disease. Durbin Senate Bill 805 Dick Durbin (D-IL) introduced the African Health Capacity Investment Act of 2007 (S. 805) in March, which focuses on recruiting and training an expanded health workforce and assembling a coordinated US plan to address the issue. This bill recently passed the Senate Foreign Relations Committee unanimously, but must pass on the Senate and House floors and be signed by the President. While the current version of this bill entails a smaller financial commitment than the total need, its articulation of principles in tackling these issues is commendable and a crucial first step in educating the rest of Congress on a comprehensive approach to addressing the health care worker shortage. More on the scope of the problem WHO recommends a minimum of 2 physicians per 10,000 population; 29 of the 46 sub-saharan countries are below this level, and an additional 7 are at this bare minimum; only 10 are above. Interestingly, 4 of the 5 North African countries are well above the WHO minimum. Effect on Source Country Doctors and nurses are the linchpins of any healthcare system. In countries already severely deprived of health professionals, the loss of each one has serious implications for the health of the citizens. Senior officials in Ethiopia, Nigeria, and Uganda have cited lack of health personnel as the main constraint to mobilizing responses to health challenges. The United Nations Conference on Trade and Development has estimated

22 that each migrating African professional represents a loss of $184,000 to Africa,12 and the financial cost to South Africa is estimated at $37 million. Moreover, Africa spends $4 billion a year on the salaries of foreign experts. The migrating doctor leaves a vacuum. Medical students and young doctors in training need motivated, well educated, articulate champions of both the health service and their specialty. Loss of well-trained, experienced personnel is perhaps the most serious aspect for the future in many countries and one that monetary compensation cannot replace. Global Trends (WHO 2008 report) Some Indicators Pregnancy and childbirth are still dangerous for most women The target for monitoring progress towards Millennium Development Goal 5 (MDG 5) (improve maternal health) is to reduce the maternal mortality ratio in all countries so that by 2015 it is one quarter of its 1990 level. This indicator is often described as the most seriously off track of all the healthrelated MDG indicators. The latest estimate is that women died in 2005 as a result of complications of pregnancy and childbirth, and that 400 mothers died for every live births (this is the maternal mortality ratio, the main indicator of the safety of pregnancy and childbirth). The maternal mortality ratio was 9 in developed countries, 450 in developing countries and 900 in sub-saharan Africa. This means that 99% of the women who died in pregnancy and childbirth were from developing countries. Slightly more than half of these deaths occurred in sub-saharan Africa and about a third in southern Asia: together these regions accounted for over 85% of maternal deaths worldwide.

23 Gaps in coverage range from 20% to over 70% The coverage gap is an aggregate index of the difference between observed and ideal or universal coverage in four intervention areas: family planning, maternal and neonatal care, immunization, and treatment of sick children. Estimates from the most recent surveys showed that the mean overall gap across all 54 countries was 43%, with values for individual countries ranging from more than 70% in Chad and Ethiopia to less than 20% in Peru and Turkmenistan. In 18 of the 54 countries, the gap was 50% or more; it was between 30% and 49% in 29 countries and less than 30% in the remaining 7 countries.

24 . In the 40 countries that had been subject to at least two surveys since 1990, the coverage gap fell in all except four Chad, Kenya, Zambia and Zimbabwe where it increased. On average, the gap fell by about 0.9 percentage points per year. Only in Cambodia ( ), Mozambique ( ) and Nepal ( ) was the decline more than 2 percentage points. There are large within-country differences in the coverage gap between the poorest and wealthiest population quintiles. In India and the Philippines, the wealthiest groups are three times more likely to receive care than the poorest.

25 In terms of absolute difference, Nigeria has the largest inequity in coverage: the difference between maximum and actual coverage is 45 percentage points larger for the poorest than for the best-off population quintile. Some countries, including the formerly points per year. Analysis of change by intervention area showed that collectively, in countries where a positive trend was recorded, the largest contribution to the decline in the coverage gap came from immunization (33%), closely followed by maternal and neonatal care (30%), family planning (20%) and treatment of sick children (17%). Socialist republics Azerbaijan and Turkmenistan have remarkably small differences by wealth quintile. Inequalities between population groups are particularly high for maternal and neonatal care, which includes antenatal care and the presence of a skilled attendant at delivery. For these interventions, the coverage gap for the poorest and best-off quintiles differs by 33.9%. The difference is smallest for the treatment of sick children and family planning. HIV/AIDS estimates are revised downwards HIV/AIDS is one of the most urgent threats to global public health. Most of the infections with HIV and deaths due to the disease could be prevented if people everywhere had access to good services for preventing and treating HIV infection. Estimates of the size and course of the HIV epidemic are updated every year by UNAIDS and WHO.4 In 2007, improved survey data and advances in estimation methodologies led to substantially revised estimates of numbers of people living with HIV, of HIV-related deaths and of new infections worldwide.

26 The number of people living with HIV continues to rise but is lower than previously estimated The number of people living with HIV worldwide in 2007 was estimated at 33.2 million; there may be as few as 30.6 million or as many as 36.1 million. The latest estimates cannot be compared directly with estimates published in previous years. For instance, the new best estimate for 2006 is now 32 million and not 39.5 million as published in For 2000, UNAIDS and WHO now estimate that 27.6 million people were infected, compared with 36.1 million estimated at that time. The new data and improved methods used in 2007 also led to a substantial revision of the estimates Sub-Saharan Africa continues to be the region most affected by HIV/AIDS. In 2007, two in every three people in the world living with HIV lived in sub-saharan Africa, a total of 22.5 million. Although the total number of people living with HIV has increased significantly over the years, the proportion infected has not changed since the end of the 1990s. In fact, the number of people who become infected every day (over 6800) is greater than the numbers who die of the disease (around 6000). Worldwide, 0.8% of the adult population (aged years) is estimated to be infected with HIV, with a range of %. In sub-saharan Africa, the estimated proportion of the population infected has actually fallen steadily since Current data indicate that HIV prevalence reached a peak of nearly 6% around 2000 and fell to about 5% in This reflects significant changes in high-risk forms of behavior in a number of countries but is also a result of the maturity of the pandemic, especially in sub-saharan Africa where HIV first took hold among the general population. There have also been improvements to the methods used for estimating HIV prevalence in countries without survey-based data. For example, it is now

27 clear that pregnant women attending antenatal clinics in major cities are more likely to be infected with HIV than adults in general. Therefore, reliance on testing women in urban antenatal clinics tends to overestimate the prevalence of HIV. The new estimates have been adjusted to reflect this. Estimating mortality due to AIDS is difficult in developing countries, where most deaths occur but where systems for counting deaths and recording cause of death are weak or nonexistent. Currently, new infection rates and deaths due to HIV/AIDS are estimated from the application of statistical models using data on HIV prevalence, average time between HIV infection and death in the absence of treatment, and survival rates of people receiving treatment. In the absence of antiretroviral treatment, the net median survival time after infection with HIV is now estimated to be 11 years, instead of the previously estimated 9 years. These changes are based on recent information generated by longitudinal research studies. For the same level of prevalence, this longer average survival period has resulted in lower estimates of new infections and deaths due to AIDS. The contribution of the number of people on antiretroviral treatment to the total number of people living with HIV/AIDS is still small. In the future, however, as more people benefit from treatment and live longer with HIV infection, this will increasingly affect the number of people in the world living with HIV/AIDS. Progress in the fight against malaria Malaria is endemic in many of the world s poorest countries. The MDG target aims to have halted and begun to reverse the incidence of the disease by Indicators for monitoring progress include the proportion of the population in risk areas using effective prevention and treatment measures, and the incidence and death rates associated with malaria.

28 In Africa, where 80% of the global burden of malaria occurs,5 new data from household surveys and research analysis based on surveillance data allow one to assess changes in intervention coverage in the fight against malaria in the region. Nevertheless, further efforts are needed to accurately monitor progress towards the MDG target and evaluate the intensified efforts against malaria.6 Most countries in the region still lack good standard measurement tools. Use of insecticide-treated nets has increased substantially MDG goal 6 for malaria requires the measurement of two indicators: prevalence and mortality rate. Measuring trends in these indicators requires health information systems that produce timely and comparable population-level statistics, complete surveillance systems with well-functioning laboratories, and civil registration systems with notification and assignment of cause of death. In resource-poor settings, such systems are either nonexistent or seriously inadequate. As a result, analyses in high-burden countries are based on multiple sources, mainly household surveys and surveillance data from health facilities. Insecticide-treated nets (ITNs) are a cheap and highly effective way of reducing the burden of malaria. They prevent malaria transmission and reduce the need for treatment, thus lessening pressure on health services and averting deaths, especially in young children. In the majority of the 21 African countries with data from at least two national surveys, the proportion of children sleeping under ITNs increased five to ten times within five years. These observed increases reflect trends in the production of nets and in resources available for their procurement, which have both increased substantially in the past five years.

29 The poor do not benefit as much from malaria intervention coverage Studies are increasingly showing the impact of control measures Intervention indicators at national level often hide important within-country disparities. A malaria indicator survey (MIS) from Zambia, a country with endemic malaria, showed that children living in the wealthiest households are better protected by bednets; they have a lower chance of carrying the malaria parasite, and when they fall sick they are more likely to be treated with antimalarial medication. Similarly, pregnant women A recent study in Zanzibar showed that, following deployment of antimalarial combined therapy, malaria associated morbidity and mortality decreased dramatically: crude under-five mortality decreased by 52% while infant and child mortality declined by 33% and 71%, respectively. Similarly, in Eritrea, following implementation of multiple intervention coverage, malaria morbidity and case fatality fell by 84% and 40%, respectively.

30 The pattern is not consistent across Africa, however; in Eritrea and Gabon, for instance, there is no difference in bednet use between different geographical or income groups, while in Ghana the direction of the relationship is unclear. A recent study in Zanzibar showed that, following deployment of antimalarial combined therapy, malaria associated morbidity and mortality decreased dramatically: crude under-five mortality decreased by 52% while infant and child mortality declined by 33% and 71%, respectively. Similarly, in Eritrea, following implementation of multiple intervention coverage, malaria morbidity and case fatality fell by 84% and 40%, respectively. A more recent review of data from selected clinics in Rwanda suggested a similarly large impact, whereby death rates and malaria cases in children under five fell by about 66% and 64%, respectively.12 The trend observed from inpatient records was consistent with outpatient laboratory reports obtained for all ages. The proportion of positive cases among those suspected of having malaria (slide positivity rate) declined sharply over time, from a high of about 50% in September 2002 to below 20% five years later. Reducing Deaths from Tobacco Tobacco use is the single largest cause of preventable death in the world today. The WHO report on the global tobacco epidemic, 2008 provides a comprehensive analysis, based on data from 135 countries, of patterns of tobacco use, the deaths that result and the measures to reduce deaths. Tobacco use is a risk factor for six of the eight leading causes of death Tobacco kills a third to a half of all those who use it. On average, every user of tobacco loses 15 years of life.

31 Total tobacco-attributable deaths from ischaemic heart disease, cerebrovascular disease (stroke), chronic obstructive pulmonary disease and other diseases are projected to rise from 5.4 million in 2004 to 8.3 million in 2030, almost 10% of all deaths worldwide. More than 80% of these deaths will occur in developing countries. Tobacco use is highly prevalent in many countries. According to estimates for 2005, 22% of adults worldwide currently smoke tobacco. Some 36% of men smoke compared to 8% of women. Over a third of adult men and women in eastern and central Europe currently smoke tobacco. Adult smoking prevalence is also high in south-east Asia and northern and western parts of Europe. However, nearly two thirds of the world s smokers live in just 10 countries: Bangladesh, Brazil, China, Germany, India, Indonesia, Japan, the Russian Federation, Turkey and the United States, which collectively comprise about 58% of the global population. Breast cancer mortality and screening Globally, cancer is one of the top ten leading causes of death. It is estimated that 7.4 million people died of cancer in 2004 and, if current trends continue, 83.2 million more will have died by Among women, breast cancer is the most common cause of cancer mortality, accounting for 16% of cancer deaths in adult women. There is evidence that early detection through mammography screening and adequate follow-up of women with a positive result could significantly reduce mortality from breast cancer. The World Health Survey provides the first and a unique opportunity to examine the prevalence of screening in a broad range of countries comprising two thirds of the world s population. Less than a quarter of women had breast cancer screening

32 At present, breast cancer, along with cervical, colorectal and possibly oral cancers, is the only type for which early screening has been shown to reduce mortality from the disease. There is sufficient evidence to show that mammography screening among women aged years could reduce mortality from breast cancer by 15 25%. Data from the surveys indicate that screening is almost universal in Finland, Luxemburg, the Netherlands and Sweden, with 85% or more women aged years having had mammography in the previous three years. This observation is consistent with recent findings on cancer screening in the region. By contrast, screening prevalence is extremely low in most lowincome countries, being less than 5% in Overall, in the 66 countries surveyed, only 22% of women aged years had had a mammogram in the previous three years. Even in countries where screening is common, there are huge differences according to wealth status Estimates from the surveys show that the prevalence of mammography varies significantly by wealth. In the 25 Member States of the WHO European Region surveyed, where breast screening is generally higher than in low-income countries, screening among women in the lowest wealth quintile was lower than among their wealthier counterparts. In the Russian Federation, women in the wealthiest group are seven times more likely to have had a mammogram than women in the poorest group. By contrast, in countries such as Austria, Belgium and the Netherlands, women in the lowest income quintile are as likely to have had mammography as their wealthier counterparts. This is also the case in countries such as Kazakhstan and Portugal, although overall prevalence of screening in these two countries is relatively low.

33 Breast cancer is a major cause of death among adult women in much of the world. Using data from the 2004 Global Burden of Disease (GBD),5 lifetime risk of dying from breast cancer is estimated at about 33 per thousand among women in high-income countries compared with 25 per thousand in upper/middle-income countries and less than 15 per thousand in low- and lower/middle-income countries. These higher rates in wealthier countries reflect a combination of factors, including increasing longevity and a lower risk of dying from other causes, higher exposure to breast cancer risk factors such as overweight and hormone replacement therapy, and lower protective factors such as breastfeeding practices and fertility. Among women in their late 30s in high-income countries, about 10% of deaths are due to breast cancer; this proportion rises to 14% among women in their 50s. Divergent Trends In Mortality Slow Down Improvements In Life Expectancy In Europe Half a century ago, a child born in Europe could expect to live for about 66 years, a life expectancy at birth that was the highest of any region in the world except North America. By contrast, average life expectancy at birth 50 years ago was 38 years in sub-saharan Africa, 41 years in Asia, 45 years in the Middle East, 51 years in Latin America and the Caribbean and 60 years in Oceania. Over the following 50 years, average life expectancy at birth improved all over the world, increasing by almost 27 years in Asia, 23 years in the Middle East, 21 years in Latin America, 14 years in Oceania and 11 years in sub- Saharan Africa. The smallest increase was in Europe, where life expectancy increased by only 8 years, albeit starting from a higher baseline than in most other regions. Analysis of death registration data suggests that the reason for the relative stagnation in life expectancy in Europe as a whole lies in the very slow pace of change in some parts of the continent of Europe.