Population change, health planning and human resource development in the health sector / W. Henry Mosley

Population change, health planning and human resource development in the health sector W Henry Mosleya Introduction ~ealth pr?grammes are driven by the demograph- ic dynamics of a population; at the same time, health interventions can and do play a major role in shaping the demographic future. Thus, while the burden of disease and, therefore, the need for health care are directly determined by the level of fertility and the epidemiological risk factors, we see that health and family planning programs not only alleviate human suffering and promote family wel- fare but over the long run reduce population growth rates and dramatically shift the age struc- ture of the population and disease burden to the elderly. These changes, referred to as the demo- graphic and epidemiological transitions, now are occurring rapidly in the less developed countries with much of the transformation typically being completed in 2 to 3 generations (60 to 90 years). Tabk 1, showing population data from the Latin American and Caribbean region for 1950 and 1990 and the projection for 2030, illustrates the demo- graphic transition that is underway ( 1). These data illustrate both the growth in total population and the ~triking shift in the age structure as fertility declmes. Over the 80-year period shown, the total population will grow from 166 million to 765 mil- li?n or 4.6 times; however, the under-5 population will only double from 27 million to 56 million while the population age 60 and over will increase more than 12 times from 9 million to 121 million. The demographic transition in the less devel- oped countries is characterized by great variation in both the timing of the onset of the transition and the pace of change. Thus, in the 1990s there is enormous heterogeneity across these countries in the levels of fertility and mortality as well as in the population age structure and in the age pattern and cause of death. This heterogeneity is summa- rized in Tabk 2 which provides selected demo- graphic indicators from seven major regions of the world ( 1). Among the less developed regions, at one extreme is sub-Saharan Africa with high fertili- ty and high mortality resulting in 46% of the popu- lation being under age 15, with 60% of all deaths found in this age group ( the vast majority of these deaths occur under the age of 5). At the other extreme is China with low fertility and a high life a De~~ent of_ Population Dynamics, The Johns Hopkins Umvers1ty, Balttmore, MD, United States of America 26 expectancy such that only 27% of the population and 13% of all deaths are in the youngest age group. The global burden of disease and cost-effective interventions The World Bank's 1993 Worl.dDevelopment R.epmt on "Investing in health" has made a major contri- bution to health policy analysis by estimating the global burden of disease, by regions of the world, and then defining the most cost-effective packages of technical interventions currently available to al- leviate this burden (1). The global burden of dis- ease, estimated on the basis of annual numbers of years of life lost due to premature death and dis- ability, is expressed in disability-adjusted life years (DALYs) lost. Of the estimated 1 362 million DALYs lost globally in 1990, 1 210 million (88%) were lost in the less developed regions of the world. O~this, 610 million DALYs (55%) were lost among children under 15, while the second greatest con- tri~ution to premature death and disability was paid by 1:11en and women in the age group 15 to 44, accounung for 313 million DALYs lost, or 26% of the total. Taking into account this burden of disease and the available cost-effective interventions, the 1993 Worl.d Development R.epmt proposed a minimum package of public health measures and essential clinical interventions as a top priority for govem- me.nt finance ( 1). This package of interventions, which would cost as little as $12/capita/year in a low income country, is estimated to reduce the burden of disease by 31 %. This noteworthy pack- age of interventions is primarily directed toward preventing and treating diseases and promoting health among children, young people, and their parents. The technical interventions for children include immunizations, micronutrient supple- mentation, treatment of worm infections, and management of the sick child, while technical in- terventions for adults include prenatal and deliv- ery care, family planning, short-course chemother- apy for tuberculosis, treatment of STDs (sexually- transmitted diseases) and limited care of other conditions. These technical interventions are built on a foundation of school health programs and public information and social development activi- ties designed to increase knowledge about family planning, nutrition, hygiene and self care; reduce the consumption of tobacco, alcohol, and other Rapp. trimest. statist sanit. mond., 47 (1994) Table 1 Population change in Latin America, 1950-1990-2030 Tableau 1 Evolution de la population en Amerique latine, 1950-1990-2030 1950 Total: 166 By age group (years)- Par groupe d'age (annees) <5 27 5-14 40 15-49 90 60+ 9 Source: Ref. Ref. (1). Table 2 Population (millions) 1990 444 56 103 254 31 2030 765 56 114 474 121 Selected demographic indicators, by major region, 1990 Tableau 2 lndicateurs demographiques par grandes regions, 1990 Sub-Saharan Africa Middle East India- Afrique Moyen-Orient lnde sub-saharienne Population (millions) 510 503 850 % by age - % par age <15 46 41 37 15-59 49 53 56 60+ 5 6 7 Deaths (millions) Deces (millions) 7.9 4.4 9.3 % by age - % par age <15 60 45 40 15-59 24 20 25 60+ 16 35 35 Total fertility rate - 6.4 5.0 1.9 Somme des naissances reduites Life expectancy - Esperance de vie 52 61 58 Increase (%) -Accroissement (%) 1950-1990 1990-2030 1950-2030 Other Asia 167 107 157 182 244 & islands - Autres Latin America & Caribbean- pays et nes d 'Asie Amerique latine et Carai"bes 683 444 37 36 57 57 7 7 5.5 3.0 36 27 27 31 35 42 4.0 3.3 62 70 72 0 11 87 290 China - Chine 1134 27 64 9 8.9 13 26 61 3.3 69 361 107 185 426 1244 FSE & EME"- AESE et EMEa 1 144 21 62 17 10.9 2 18 80 2.5 75 a FSE: Former socialist economies of Europe. - AESE: Anciennes economies socialistes d'Europe. EME: Established market economies. - EMBE: Economie de marche bien etablies. Source: Ref. (1 ). drugs; and prevent the transmission of AIDS and STDs. Expanding female education and the in- creasing empowerment of women is recognized as a critical underpinning in a health development strategy. Wld hlth statist. quart., 47 (1994) A family-centered health development strategy The health strategy envisioned in the 1993 World Deve!bpmmt Report recognizes that sustainable health development strategies must begin with households (families) as the basic productive (and 27 reproductive) units in societies. In families, women are the cornerstone: the number of children and their initial survival and development as healthy or disabled members of society are critically depen- dent upon the knowledge, skills, motivations and resources women have, along with the freedom to control their life situation. Key choices, decisions and actions that women must make in this process of health "production" relate to: • control of their reproduction: this encompasses marriage and divorce as well as the numbers and spacing of their children; • means taken to protect their health and the health of their children: these include care dur- ing pregnancy and childbirth, breastfeeding and dietary practices, specific preventive inter- ventions such as immunizations and curative actions; and • measures taken to reduce environmental haz- ards in the home: these include personal hy- giene, household smoke abatement, food prep- aration and storage, protection of water and sanitation. Government policies, strategies and programs to promote the development of a healthy, produc- tive society (along with slowing population growth and improving the environment) must have an over-arching goal to bring the advances of science and technology to every household where the "primary production" of human health and wel- fare takes place. To be most effective, these inter- ventions must encourage individual initiative and private sector entrepreneurship as well as commu- nity involvement and leadership. Health sector reform Traditionally, health systems in developing coun- tries have largely been institution-based, with re- sources directed toward building hospitals and health centres and training the personnel most concerned with one-on-one sickness care (physi- cians, nurses and supporting personnel). The model has been Western, high-technology medical care. The 1993 World Development R.eport puts priori- ty on a population-based health development strat- egy that will require major reform of the health system in many countries. Investments will be re- quired in a very different set of program activities, and correspondingly distinctive institutional, pro- fessional and technical capacities will be needed if sustainable programs are going to be established. The essential program elements in a popula- tion-based health development strategy include: • effective communication and motivation activi- ties using all the techniques of modern media to reach every woman with information about pregnancy and childbirth care, breastfeeding and nutrition, personal and household hy- giene, health risks and sickness care, contracep- 28 tion and safe sexual practices, tobacco, alcohol and substance abuse, etc.; • rationalized health care provider training pro- grams for physicians, nurses, midwives, para- medics, etc., based on high-priority health problems, along with restructured academic curricula covering both basic professional edu- cation and continuing education which pre- pares them to effectively organize and manage the delivery of primary health care at the dis- trict and community levels; • a variety of essential health care commodity marketing and service delivery systems, both public and private, developed in a way that en- sures that every family has access to a basic package of essential preventive and curative technologies and services at affordable cost. An important feature of these systems, both public and private, would be decentralized manage- ment with local accountability; • the policy, legal and regulatory basis for public- sector cost recovery and private-sector health care financing, including systems for quality control and cost containment; • institutions with the technical capacity and reg- ulatory authority to ensure that minimum stan- dards of safety and effectiveness are being met by the commercial sector in such areas as food and drug production and distribution, and en- vironmental and occupational protection; • strong institutional capacities in data collec- tion, management, analysis, interpretation and dissemination, and use of these data for plan- ning, monitoring and evaluation; and • public and private research institutions which take a problem-solving approach to health and family planning research and have the ability to carry out policy analysis, to develop and/ or adapt technologies to local conditions, to con- duct operations research, and to implement innovative pilot studies. Human resource needs As implied by the program elements listed above, a wide range of scientific, analytical, and technical capabilities are required for the policy analysis, strategic planning, program design, implementa- tion and evaluation of population-based health programs that currently are rare in most ministries of health in less developed countries. These are the capabilities provided by epidemiologists, demogra- phers, sociologists, economists, anthropologists, communications specialists, management special- ists, financial analysts, operations research special- ists and environmental health scientists. Building up these capabilities, either in health ministries, universities, or the private sector will be an essen- tial ingredient of health sector reform. In the first instance, support for this professional develop- ment may often require assistance from the inter- Rapp. trimest. statist. sanit. mond., 47 (1994) national donor community, although in the long run, developing countries can only achieve sustain- ablity by building up their own research and train- ing resources. For some types of professional training it may be best to redirect traditional academic programs in universities. This has been successfully accom- plished in the population field by establishing pop- ulation centres in departments of sociology or eco- nomics in many less developed countries and this might be a good mechanism for training health economists or specialists in communications, man- agement and finance. For most professional disci- plines, however, the development or strengthen- ing of schools of public health will likely be the best route, as these institutions encompass all the major disciplines required for health sector reform. This approach is already under way in countries as di- verse as China, Mexico, Indonesia, Zaire and Nige- ria, among others. Recognizing that medical practice will have to adapt to these new conditions, the critical institu- tions to be reoriented in developing countries (and developed countries as well) are those con- cerned with medical education. Effective strategies for change in medical education will likely be evo- lutionary, not revolutionary. Key elements in this process will include steps to curtail specialist train- ing and promote primary care. One model is that adopted by the International Network of Commu- nity-Oriented Educational Institutions in the Health Sciences, whose members have introduced curriculum reforms that emphasize community- based and problem-based learning. At the recent international Conference on a Future Partnership for the Acceleration of Health Development, the issue of capacity development was considered by the participants who recognized the critical lack of appropriate capabilities for un- dertaking health sector reform in most less devel- oped countries.h In addition to endorsing the concept of institution-building in developing countries, a key recommendation was the establish- ment of an international network to facilitate countries' access to information, technical assis- tance, and experiences in health development and health sector reform; to mobilize donor support; and to help develop, refine and promote the use of tools for health policy analysis and reform. A key principle was partnership among collaborating insti- tutions worldwide, joining in a network designed to be catalytic, enhancing communication among institutions and groups committed to reform in both the less developed and more developed coun- b Conference on a Future Partnership for the Acceleration of Health Development convened in Ottawa, Canada by the International Development Research Corporation, the World Bank, and the World Health Organization, October lS-20, 1993. Wld hlth statist. quart, 47 (1994) tries, identifying common problems and issues, ex- changing experiences, and searching together for innovative solutions. Summary As a result of the demographic and epidemiological transitions now occurring rapidly in many developed countries, a dramatic shift in the age structures of populations and the burden of disease towards the middle-aged and elderly is expected to take place over the next several decades. In the 1990s, however, there remains great diversity across countries in fertility levels and mortality patterns. The World Bank's 1993 World Development Report assessed the global burden of disease in order to define the minimum packages of public health measures and clinical interventions that would improve health conditions in low-income coun- tries in a cost-effective and affordable way. Strategically implementing these programmes will require that gov- ernment investments be directed toward a limited num- ber of cost-effective health interventions, delivered eq- uitably to the entire population. At the same time, steps must be taken to improve the efficiency and contain the costs of health care delivery in the public and private sectors. Such a population-based health strategy will require the development of a wide range of scientific, analytical and technical capacities, currently rare in most ministries of health. This will require the involve- ment of epidemiologists, demographers, sociologists, analysts, operations research specialists and environ- mental health scientists. Building up these capabilities in health ministries, universities or the private sector will be an essential ingredient of health system reform. Resume Evolution demographique, planification sanitaire et developpement des ressources humaines dans le secteur de la sante En raison des rapides transitions demographique et epidemiologique par lesquelles passent actuellement de nombreux pays developpes, on s'attend au cours des prochaines decennies a un deplacement spectacu- laire de la structure d'age des populations et du fardeau de la morbidite vers les groupes d'age moyen et eleve. Toutefois, dans les annees 1990, les taux de fecondite et les tableaux de mortalite demeurent tres divers d'un pays a l'autre. Le Rapport sur le developpement dans le monde 1993de la Banque mondiale evalue la morbidite mondiale pour definir les programmes minimaux de mesures de sante publiques et d'interventions cliniques permettant aux pays a faible revenu d'ameliorer leur situation sanitaire de fa9on rentable et a un coat aborda- ble. Les gouvernements devraient consacrer leurs in- vestissements a un nombre limite d'interventions sani- taires rentables, offertes equitablement a !'ensemble de la population. Des mesures devront aussi etre prises pour ameliorer l'efficience et maftriser les coats des prestations dans les secteurs public et prive. Une telle strategie sanitaire basee sur la population necessitera la 29 mise en oouvre d'une gamme etendue de moyens scien- tifiques, analytiques et techniques, qui sont actuelle- ment rares dans la plupart des ministeres de la sante. II faudra aussi mobiliser des epidemiologistes, des demo- graphes, des sociologues, des analystes et des specia- listes de la recherche operationnelle ainsi que de !'hy- giene de l'environnement. Le developpement de telles capacites au sein des ministeres de la sante, des 30 universites et du secteur prive constituera un element essentiel de la reforme du systeme de sante. Reference - Reference 1. World Bank. 1993 World DevelbfJmmt &port. New York, Oxford University Press for the World Bank, 1993. Rapp. trimest. statist. sanit. mond., 47 (1994)