Health system design and natural disasters Lessons from Haiti and Rwanda Paul Farmer, MD, PhD Harvard Medical School Brigham and Women s Hospital Partners In Health The Current Situation of Health in China Harvard Center Shanghai May 8, 2012
Health system design in the 21 st century Community-based Hospital-linked Health center-enriched
China s Cooperative Medical System Barefoot doctors Primary health care, including control of vaccine-preventable and vector-borne diseases Sanitation Life expectancy: 35 years in 1952 68 years in 1982 1980s economic reforms affect coverage? 1979: 80-90% covered by CMS 1984: 40-45% Sidel VW. The barefoot doctors of the People's Republic of China. New England Journal of Medicine1972;286:1292 99.; David Blumenthal and William Hsiao, Privatization and Its Discontents The Evolving Chinese Health Care System New England Journal of Medicine 353, no.11, (2005): 1165.;
Accompaniment A cornerstone of care June 1999 1 year later With accompagnateur 10 years later
Public-private partnerships Boucan Carré, 2003
Public-private partnershipsp
10 000 Building platforms for control of complex, chronic diseases 10 billion 9000 8.9 billion 8000 8.3 billion 7000 6000 US$ millio on 5000 4000 3000 2000 1000 0 Resources for AIDS 59 212 PEPFAR UNGASS World Bank MAP BMGF Global Fund FOKAL/OSI 1623 UNAIDS 257 292 Harvard Consensus Statement HEI UNAIDS & WHO unpublished estimates, 2007. 1987 1990 1993 1996 1997 1998 2000 2001 2002 2003 2004 2005 2006 2007
From Haiti to Rwanda
(Re)building infrastructure Rwinkwavu, 2005
(Re)building infrastructure Bt Butaro, 2011 GoR covered 25% construction costs and 48% operating costs
Horizontal, vertical, diagonal 100000 90000 80000 70000 60000 50000 40000 30000 20000 10000 People on ART nationwide 6000 5000 4000 3000 2000 1000 People on ART at PIH/IMB sites 0 Year 2002 2003 2004 2005 2006 2007 2008 2009 2010 0 2000 2002 2004 2006 2008 2010 2012 More than 90,000000 Rwandans on ART (>80% of PLWA) Source: National AIDS Control Commission. Annual Report for the Fight Against AIDS. Annual Report 2008. Available: http://www.cnls.gov.rw/spip.php?article66.
Horizontal, vertical, diagonal 250 200 150 100 50 0 Child mortality 1995200320082010 <5 deaths per 1,000 live births Maternal mortality 3,500 3,000 2,500 2,000 Deaths per 1,500 100,000 1,000 500 live births 0 Source: UNICEF Rwanda Health Statistics 2011. Available: http://www.unicef.org/infobycountry/rwanda_statistics.html; WHO World Health Statistics 2005. Available: http://www.who.int/whosis/whostat/whostat2005en.pdf
Platforms for control of complex, chronic diseases PACT: community-based care in the US U.S. Enrollment 35% savings
Global Health Delivery Professional/ Medical Publisher, Media 7% Trade Association 3% Academia 25% Non Governmental Organization 30% For Profit Organization 6% Medical Institution 9% International Agency 6% Government 13% More than 6,800 members representing more than 2,149 organizations across 158 countries
Partners In Health, 2012 Research, Training, Service
Natural disasters and the limitations of health system design
Natural disasters and the limitations of health system design General Hospital nursing school collapse
Haiti s earthquake in context 30000 People killed per million inhabitants Damages (US Millions, 2009) 25000 20000 15000 10000 5000 0 Haiti 2010 Nicaragua 1972 Guatemala 1976 Myanmar 2008 Honduras 1974 Honduras 1998 Sri Lanka 2004 Venezuela 1999 Bangladesh Earthquake Earthquake Earthquake Cyclone Cyclone Cyclone Tsunami Flood 1991 Cyclone Solomon Is. Indonesia 2004 1975 Tsunami Tsunami Cavallo E., A. Powell, and O. Becerra, Estimating the Direct Economic Damage of the Earthquake in Haiti, Inter-American Development Bank Working Paper Series #IDB-WP-163, 2010.
Haiti earthquake: acute response Source: US Comfort image from Grant Traverse Herald Archives: archives.gtherald.com.
Diagnosis: acute-on-chronic Over 3 million people affected by earthquake At peak, 1.3 million in resettlement camps April, 2012: ~450,000 still in camps Source: OCHA. Humanitarian Bulletin: Haiti, November 17; USAID. Haiti Earthquake. Fact Sheet #10, Fiscal Year (FY) 2011. February 4, 2011; OCHA. Haiti: One Year Later. Available at: http://ochaonline.un.org/haitiearthquakeresponse/tabid/7331/language/en-us/default.aspx; USAID. Fact Sheet #7 Haiti Earthquake and cholera. June 13, 2011. Available: http://reliefweb.int/node/419780
Tangshan, 1976
Sichuan, 2008
Disasters natural and unnatural Sichuan, 2008 >150 aircraft mobilized: largest non-military airlift in Chinese history Total damages estimated ~$20 billion; overall economic costs ~$75 billion GDP per capita: $4,046 (2011, 24 th out of 31 Provinces)
Building back better Mirebalais Hospital, 2012