Global Issues in Health Care
Jean Yan
Chief Scientist Nursing and Midwifery
World Health Organization
Geneva
1|
TITLE from VIEW and SLIDE MASTER | July 23, 2016
Healthy People, Healthy World
20
2|
TITLE from VIEW and SLIDE MASTER | July 23, 2016
The Vision
… the attainment by all peoples
of the highest possible level of health
WHO Constitution
… a state of complete physical, mental and social
well- being and not merely the absence of disease
3|
TITLE from VIEW and SLIDE MASTER | July 23, 2016
Millennium Development Goals (1990 – 2015)

Goal 4 reduce child mortality
Target: reduce by 2/3rds (under-five mortality rate)

Goal 5 improve Maternal Health
Target: reduce by ¾, the maternal mortality ratio

Goal 6 combat HIV/AIDS, malaria and other diseases
Target: halt by 2015 and begin to reverse spread
of HIV/AIDS, malaria and other major diseases
Primary Health Care – the key to attaining acceptable level of
health for all people
4|
TITLE from VIEW and SLIDE MASTER | July 23, 2016
The Essence of Primary Health Care
"health is not a commodity that is given,
it must be generated from within".
"health action should not be imposed from outside,
foreign to the people,
it must be a response of the communities to
problems they perceive, supported by an
adequate infrastructure"
5|
TITLE from VIEW and SLIDE MASTER | July 23, 2016
(Mahler, 1998)
The Global Health Situation
 Inequities in access to care and health
outcomes
 Impoverishing costs
 Erosion of trust in health care
6|
TITLE from VIEW and SLIDE MASTER | July 23, 2016
Inequities
 Access to health care
1.3 Billion individuals globally with no access to health care
58 million of women ( out of 136M) who will give birth in a year, will receive no
medical assistance during childbirth and postpartum period – endangering lives of
mothers and babies
 Health outcomes
Life expectancy : 40 years difference between the riches and poorest countries , Norway – 12 years within country
Child health (under 5 mortality rate) : vast difference exist within countries and individual cities - e.g
. Nairobi)
- below 15/1000 in high income group,
- 254/1000 in slums in the same city
In many cases – people who are well-off are generally healthier , have best access to the
best care while the poor are left to take care of themselves
7|
TITLE from VIEW and SLIDE MASTER | July 23, 2016
Infant mortality rate
(deaths per 1,000 live births)
90
80
(PAHO, 2005)
80
70
60
54
50
39
40
35 35 34
33
15 15 15 14
COR
BEL
GUY
PAN
COL
VEN
PAR
URU
TITLE from VIEW and SLIDE MASTER | July 23, 2016
VEN
MEX
ECU
ELS
BRA
PER
HON
NIC
DOR
GUA
8|
BOL
0
HAI
10
PR
10 9
8
7
6
5
CAN
20
20 19 19 19
18
CUB
22
USA
25 25
CHI
30
Growing inequalities in global health:
the widening gap in infant mortality experience
IMR: babies dying before age 1 per thousand born live
160
IMR decline
1960-1981
1981-1999
(Percent)
140
120
World
38.5
26.9
SSA
100
80
SubSaharan
Africa (SSA)
19.2
World
15.1
60
40
(UNICEF, 2003)
9|
TITLE from VIEW and SLIDE MASTER | July 23, 2016
1960
1981
1999
Under 5 mortality (per 1000 live births)
by wealth group
Poorest
Less poor
Middle
Less rich
Richest
350
300
250
200
150
100
50
0
Mali
India
(Houweling et al, 2007)
10 |
TITLE from VIEW and SLIDE MASTER | July 23, 2016
Morocco
Peru
Kyrgyz
Republic
All cause mortality (per 1000 person yrs)
Mortality over 25 years according to level in
the occupational hierarchy: Whitehall
Admin
Prof/Exec
Clerical
Other
80
70
60
50
40
30
20
10
0
40-64yrs
65-69yrs
70-89yrs
(Marmot & Shipley, BMJ, 1996)
11 |
TITLE from VIEW and SLIDE MASTER | July 23, 2016
Life expectancy of Indigenous Peoples
(Bramley et al, 2005)
12 |
TITLE from VIEW and SLIDE MASTER | July 23, 2016
P ercent P o pulatio n with access to health care services
1996-1998
65.2
Ecuado r (98)
39.8
54.8
B o livia (97)
29.9
Access
to health
services
according
to ethnicity
(IDB, 2004)
56.9
P eru (96)
13 |
33.9
0
20
No Indigenas
TITLE from VIEW and SLIDE MASTER | July 23, 2016
Indigenas
40
60
80
14 |
(Murphy et al, 2005)
(probability of living to 65 yrs when aged 20 yrs)
The widening trend in mortality by
education in Russia,1989-2001
TITLE from VIEW and SLIDE MASTER | July 23, 2016
Infant mortality in Brazil by race and mother's
education, 1990
(Pinto da Cunha, 1997)
15 |
TITLE from VIEW and SLIDE MASTER | July 23, 2016
Social exclusion in health and environment
•152 million people without access to safe
drinking water and basic sanitation
16 |
TITLE from VIEW and SLIDE MASTER | July 23, 2016
The social determinants of health
17 |
TITLE from VIEW and SLIDE MASTER | July 23, 2016
Impoverishing Costs
 Annual government health expenditures
$20 per person in low income
$6,000 per person in high income countries
 Out of pocket health expenditures
40% in low income countries ( 5.6 billion)
20% in high income countries
Result: 100M people below the poverty line each year ( due to
rising HC costs , system for financial protection in disarray)
18 |
TITLE from VIEW and SLIDE MASTER | July 23, 2016
Erosion of trust in health care:
health as a commodity and care driven by profitability
HC often delivered according to a disease model , high technology, specialist care and the
power of prevention ignored
 unnecessary tests and procedures, frequent and longer hospitalization
 higher overall costs, exclusion of people who can't pay
 fragmented health care focused on national disease and projects with little attention to
coherence, decrease investment in infrastructures , services and staff
 People reduced to program targets
 Health workforce deployment: ½ of physicians and ¾ of nurses and midwives working in
hospitals
 Specialist perform tasks that are better managed by general practitioners, family doctors
and nurses – leading to inefficiency, limited access to comprehensive health care.
Health care failing to respond to expectations of the public –
patient-centered, fair, affordable and efficient
19 |
TITLE from VIEW and SLIDE MASTER | July 23, 2016
Towards a health system that …

Guarantees social protection in health for all citizens

Contributes to the elimination of inequities in access to
health services

Guarantees quality health services

Assures excluded social groups equal opportunity to
receive integral health care

Satisfies the population’s health needs, demands &
expectations

Eliminates the inability to pay as a barrier to access to
health care
20 |
TITLE from VIEW and SLIDE MASTER | July 23, 2016
PAHO/WHO XLIII Directing Council, Washington DC 2002
Link PHC with Millennium Development
Goals
PHC
renewal
Provides a framework for
achieving MDGs by:
•Strengthening the entire
health system
•Providing a focus on equity
•Integrating different
approaches to service
delivery
•Addressing social
determinants of health
21 |
MDGs
Outcomes
•Equity : Access
Strategy:
TITLE from VIEW and SLIDE MASTER | July 23, 2016
• Alliances
•Quality: efficient, effective
•Solidarity : Community
participation
• Networks
MDG targets
The renewed PHC : 4 reform areas
(WHR 2008)
Universal
Coverage
Service
Delivery
Leadership
Public
Policy
Health care responsive to the expectations of the public –
patient-centered, fair, affordable and efficient
22 |
TITLE from VIEW and SLIDE MASTER | July 23, 2016
Progress can be achieved in short time periods
In 7 years
LIFE
EXPECTANCY
56 yrs
ACCESS TO
POTABLE
WATER
In 9 years
In 15 years
POVERTY
PRIMARY SCHOOL
ENROLMENT
15m
33%
7m
48 yrs
Sri Lanka
South Africa
1946 - 1953
1994 - 2001
18%
23 |
TITLE from VIEW and SLIDE MASTER | July 23, 2016
China
1990 - 1999
89%
46%
Botswana
1970 - 1985
Renewed PHC
Progress is not a given: child deaths in 1975 and 2006
24 |
TITLE from VIEW and SLIDE MASTER | July 23, 2016
PHC’s Impact on Population Health
 PHC was a significant contributor to improved population health in
OECD countries
10000
PYLL
Low PC Countries
5000
High PC Countries
PYLL= Potential
Years of Life Lost
0
(Measure
1970 of
premature mortality)
25 |
1980
1990
2000
Lost Premature Mortality and PHC Performance
In 18 OECD Countries, 1970-1998
TITLE from VIEW and SLIDE MASTER | July 23, 2016
Macinko et al., 2003
PHC’s Impact on Population Health
 PHC reforms in Costa Rica significantly reduced mortality in adults and
children
–– With reform
++ Without reform
For every 5 additional years
after PHC reform, child
mortality was reduced by
13%
… and adult mortality was
reduced by 4%
Trends in Under-5 Mortality in Districts With and Without PHC Reform
Costa Rica, 1985-2001
26 |
TITLE from VIEW and SLIDE MASTER | July 23, 2016
Rosero-Bixby, 2004
Health Systems with Strong PHC Are More Efficient
Stronger PHC 2
Primary Care Score
UK
DK
1.5
1
0.5
NTH
FIN
SP
CAN
AUS
SWE
0
Weaker PHC 1000
JAP
GER
BEL
1500
US
FR
2000
2500
3000
3500
4000
Per Capita Health Care Expenditures
27 |
TITLE from VIEW and SLIDE MASTER | July 23, 2016
Starfield & Shi, 2002
The HRH Challenge
 Unequal distribution -the parts of the world experiencing the greatest
burden of disease have the lowest numbers of health care providers
 The highest density of health workers is in urban settings leaving
rural areas underserved
 Lack of national policy and plan on human resources for health in
most countries
 Inadequate capacity to train more
 Member states not able to provide basic services because of the
HRH crisis
28 |
TITLE from VIEW and SLIDE MASTER | July 23, 2016
Worker Density by Region
0. 8
Sub - Sahar an A f r ica
2. 3
A sia
2. 6
S&C ent r al A mer ica
4. 2
Glo b al
6. 9
M id d le East
8. 7
W est er n Pacif ic
9. 9
N o r t h A mer ica
10. 3
Eur o p e
0
2
4
6
Workers per 1,000 population
29 |
TITLE from VIEW and SLIDE MASTER | July 23, 2016
8
10
12
The Health Workforce
Nurses and midwives : The main providers of health care , urban and
rural
(improved access and coverage)
Source: Australia's Health Workforce. Productivity Commission Position
Paper. Canberra, 2005.
30 |
TITLE from VIEW and SLIDE MASTER | July 23, 2016
Contributions of Nursing and Midwifery to
Primary Health Care ( improved health outcomes)
Skilled attendant at birth saves
mothers and babies

Trained N& M can deliver approximately 80% of
the health care and up to 90% of the
pediatric care currently provided by primary
care physicians at equal or better quality and
lower costs
Under utilization of nurse practitioners in the
US – cost the country as much as
$ 8.7 B
annually (Tournquist ' 97)

Health Prevention and promotion– better use
of existing preventive measures reduces the
global health burden of disease by 70%
(WHR 08)
Nurses – a valuable resource for global health
31 |
TITLE from VIEW and SLIDE MASTER | July 23, 2016
The renewed PHC : 4 reform areas
(WHR 2008)
32 |
Universal
Coverage
Service
Delivery
Leadership
Public
Policy
TITLE from VIEW and SLIDE MASTER | July 23, 2016
Now More than Ever : Nursing and
Midwifery Contributing to PHC
Source: Compendium of PHC studies : 38 teams from 29 countries across 6 regions
 Universal Coverage: rural and remote  Service delivery
areas
- Korea : utilization of nurses as community health practitioners
(CHP) – a total of 1850 , each responsible for 1500 – 2000
population. High satisfaction level from clients, improved health
status and decreased risk behaviors ( smoking and drinking
alcohol)
- Belize : Community – based psychiatric/mental health program
by trained nurse practitioners ( 10 months). Mental health
hospital – closed ( only six beds in acute hospital), .National
program staffed by nurse practitioners, only two psychiatrist
needed at national level..
- Bahrain – Adequate number of nurses and midwives trained to work
in the 4 tiered health system. Results: 22 health centers opened
through out the kingdom providing 12-24 hours of care. 2.8
million visits to health centers, increased diabetic visits, children
screening and immunizations
33 |
TITLE from VIEW and SLIDE MASTER | July 23, 2016
- Yemen . Use of community midwives , increase in clinic attendance
- Botswana : nurses providing family health . Sustained intervention
for care of stroke patients resulting in families assuming
responsibility for own health
- Brazil : nurse – led care during deliveries … no maternal deaths
from pregnancy or childbirth
- Australia : Renal replacement therapy provided by nurse
practitioners, no medical officers needed
- Denmark : Care of the elderly provided by nurses . Health
assessment, activities of daily living higher, average bed days
lower, running costs for care- lower and life expectancy
increased by 30%
Now More than Ever : Nursing and
Midwifery Contributing to PHC
Source: Compendium of PHC studies : 38 teams from 29 countries across 6 regions
 Leadership
- Haiti – nurse –led care in ambulatory
and clinic care ,
resulted in gains in controlling malnutrition, malaria and TB
 Public Policy
- Oman : government commitment to increase access to basic
health care brings long-term improvements, five year national
health plan. Includes use of 1400 nurses, resulting in 85%
increase in clinic visits, 1 PHC per 10,000 population, high
immunizations coverage, fall in infant mortality rate
( from
170/1000 in 1970 to 16/1000 in 2006)
- China – nurse –led innovation in community health
( rehab
and palliative care) : Nurse coordinated the care provided by
multi-disciplinary teams – physiotherapists, nutritionists,
optometrist, psychologist, music therapist , Results : improved
aged persons ability to manage own well –being, decrease in
hospitalization
- Canada – nurse-managed care for medically deprived
communities. Nurses coordinate and supervise the work of
volunteers, community partners, town councils, business
organizations , referrals to physicians. . 16 sites, 24 nurse
managers, 18,500 clients( 1 nurse per 800 clients, average of 825 clients per day)
34 |
TITLE from VIEW and SLIDE MASTER | July 23, 2016
-
Thailand : one PHC per every village, Nurses of the
Community Program 33 educational institutions, 300
administrative organizations , 60 community hospitals. Provide
essential services : maternal and children, elderly, disease
surveillance and control, involve in local policy development to
improve quality life. All graduates are working in their own or
nearby community .
Health Professionals : a Valuable Resource
for Global Health
Nursing and midwifery , a solution to today's increasingly
complex needs in health care delivery and PHC provision
Nation of Healthy People
Healthy World (MDGs)
 Nursing and Midwifery Practitioners: 16 million nurses and midwives,
60% of health care providers
 Better trained member of the team, coordinate and manage health
services, support and supervise other team members, well trusted
by the community, delivers services with scarce resources.
 Shown rapid transformation of nursing practice and the reorientation of professional training to support PHC.
( made possible by their versatility , numbers and capacity )
35 |
TITLE from VIEW and SLIDE MASTER | July 23, 2016
Global Response
 Strengthening nursing and midwifery (WHA 59.272006)_ acknowledges the crucial contribution of nursing
and midwifery to efforts for improved health outcomes.
 Rapid Scaling Up of health workforce production
(WHA 59.23-2006)- aims to achieve a rapid
increase in the number of qualified health
workers in countries experiencing shortages
36 |
TITLE from VIEW and SLIDE MASTER | July 23, 2016
Islamabad Declaration 4-6 March, 2007
 Founded on belief that efficient, effective nursing and
midwifery services are critical to achieving the MDGs,
health systems strengthening, and the general health of all
nations.
 Three themes:
scaling up nursing and midwifery capacity
skill mix of existing and new cadres of workers
positive workplace environments.
37 |
TITLE from VIEW and SLIDE MASTER | July 23, 2016
Scaling –up N&M Capacity Initiatives
Policy to Action
WHA Resolution
Strengthening
N&M
Global Work Plan
& Launch
Geneva
Geneva
Islamabad Declaration
Pakistan
Action Plan
Zambia
38 |
TITLE from VIEW and SLIDE MASTER | July 23, 2016
Global Work plan for Scaling-up Nursing and
Midwifery Capacity to contribute to the MDGs
Better Health Outcomes
Strengthened Health Service (PHC)
Adequate and appropriate #s of
Satisfied, motivated N%M
workforce
Global Program of Work
39 |
TITLE from VIEW and SLIDE MASTER | July 23, 2016
Global Work plan for Scaling-up Nursing and
Midwifery Capacity to contribute to the MDGs
Global Program of Work
Outputs
Commitment
&
Support
( political &
Constituencies)
Core Elements
Education and Training•
Health Service Provision•
Workplace environment•
Talent management•
Partnership •
Resources
40 |
TITLE from VIEW and SLIDE MASTER | July 23, 2016
Adequate # of tutors to
Scale-up production of
N&M workforce
PHC accessible in
Areas of greatest
Health needs
Productivity and retention
Of N&M workforce
Increased
Leadership and management
skills strengthened in
support of N&M PHC
services
Success Measures
 Adequate number of competent N&M – increased production and
Increased capacity of educational institutions – tutors, IPE
 Enhanced access to competent nurses and midwives who provide
care, supervision and support in all settings.
 Leaders effective in integrated N&M in the national health program
 A positive workplace environment – C149 , healthy workforce
 Coordinated, integrated, collaborative, sustainable approach to
planning, policy and health care delivery
 Expansion of partnerships and networks
41 |
TITLE from VIEW and SLIDE MASTER | July 23, 2016
Participating GPW countries
Serbia
Qatar
Bhutan
Nicaragua
Somalia
India
Zambia
Argentina
42 |
TITLE from VIEW and SLIDE MASTER | July 23, 2016
Action Now !
 Investment in nursing and midwifery
 Active engagement in policy and decision-making at all
levels
 Updated and scale-up training : PHC focused
 Innovative practice models
 Leadership – shared, collective, multi-disciplinary and
multi-sectoral
 Alliances and Networks
43 |
TITLE from VIEW and SLIDE MASTER | July 23, 2016
VOLUNTEER OPPORTUNITIES AT WHO
 SCHOLAR PROGRAM
- PhD
- mid-career to senior level nursing leaders
- three months
 INTERNSHIP PROGRAM
- Masters level
- work experience
- 8 weeks ( on –site or off –site)
44 |
TITLE from VIEW and SLIDE MASTER | July 23, 2016
World of Global Health : Nursing and
Midwifery Services
Great
Good
Leadership
Innovation
Action (partnerships
and team work )
Policymakers' continued investment and support for N&M are vital
in making PHC a reality
45 |
TITLE from VIEW and SLIDE MASTER | July 23, 2016
A Message
 Good it is
To receive peace from the World
 Better it is
To give peace to the world
 Best, by far the best , it is
To become the peace of the World
Sri Chinmoy
46 |
TITLE from VIEW and SLIDE MASTER | July 23, 2016
A Final Message for PHC
 Good it is
To receive ( health ) from the World - HFA
 Better it is
To give (health) to the world
 Best, by far the best , it is
To become the healthy people for the Healthy World
Sri Chinmoy
47 |
TITLE from VIEW and SLIDE MASTER | July 23, 2016
Our world, Our health…
20
48 |
TITLE from VIEW and SLIDE MASTER | July 23, 2016
All TOGETHER
49 |
TITLE from VIEW and SLIDE MASTER | July 23, 2016
50 |
TITLE from VIEW and SLIDE MASTER | July 23, 2016