Russian Federation:Russian Federation:Linking Health, Poverty Linking Health, Poverty and Economic Growthand Economic Growth
Jack Langenbrunner
The World BankMoscow
July 2004
2
Why Invest In Health?Why Invest In Health? Poverty and Ill-health are intertwined
Poorer health outcomes in/within poorer countries
Poverty breeds ill-health (due to diet, education, transportation, etc)
Ill health keeps poor people poor
Invest in health: reduce ill health and poverty
3
Why Invest in Health?Why Invest in Health? Impact on Economic Growth Impact on Economic Growth
Macro-Economic Commission on Health 10% increase in life expectancy = 0.35%
growth in GDP Productivity
17% of productivity gains attributable to health status
Poor Outcomes Sick leave, absenteeism, etc.
4
Health Status Varies by IncomeHealth Status Varies by Income
0
10
20
30
40
50
60
Poorest 2ndQuintile
3rdQuintile
4thQuintile
Richest
Good
Bad/Very Bad
5
Russia vs. Canada:Russia vs. Canada: Health Status Health Status
0
10
20
30
40
50
60
70
80
90
Good or Very Good
RussiaCanada
6
Poorer Groups: More Likely to Poorer Groups: More Likely to Engage in Risky BehaviorsEngage in Risky Behaviors
Vodka Cognac Liquers Other Spirits
Several times per week or daily 0
10
20
30
40
50
60
70
80
Poorest 3rdQuintile,
Richest
7
Russian Federation:Russian Federation: General Health Status General Health Status
8
Probability of Russian Probability of Russian Man Dying, Ages 15-60Man Dying, Ages 15-60
0
5
10
15
20
25
30
35
40
45
Probability of Dying, Ages 15-60 (Males)
USDenmarkJapanGermanyUnited KingdomFrancePolandMexicoBrazilRussian FederationTurkeyKyrgz Republic
9
Re-Emergence of Infectious Re-Emergence of Infectious Diseases: AIDSDiseases: AIDS
60% 20-30 Years old 2.3 million by 2010 10% drop in GDP by 2020
Larger drops in labor supply and investments
0
50,000
100,000
150,000
200,000
250,000
300,000
10
Regional Variations GrowingRegional Variations Growing (Infant Mortality) (Infant Mortality)
0
5
10
15
20
25
30
35
40
45
1999 2001
MaximumMinimum
11
Finance and Delivery Finance and Delivery System: Reform Needed System: Reform Needed
Access to Services Social Solidarity/Risk Pooling Efficiency in Delivery Equity Protection of Poor and Vulnerable
Groups• Pensioners
12
Limited and Declining PublicLimited and Declining Public
Sector Funding for HealthSector Funding for Health
13
Selected International Comparisons:Selected International Comparisons:Levels of Funding (% Share of GDP)Levels of Funding (% Share of GDP)
0
1
2
3
4
5
6
7
8
9
10
Public Private Total
DenmarkFranceUnited KingdomRussiaPolandBrazilKyrgz Republic
14
Fragmented Funding Fragmented Funding StreamsStreams
Russia International Best Practice
Doctor Hospital
Budget Fund RayonPooled Funds
Doctor Hospital
15
Inefficiency: Inefficiency: Too Many Beds and PhysiciansToo Many Beds and Physicians
0
2
4
6
8
10
12
Beds/1000 Physicians/1000
DenmarkFranceUnited KingdomRussian FederationPolandBrazilKyrgzstan
16
Too Much Reliance on Hospital Care Too Much Reliance on Hospital Care (admissions/1,000)(admissions/1,000)
120
140
160
180
200
220
240
1992 1993 1994 1995 1996 1997 1998 1999 2000 2001
Russian Federation CIS
Eastern Europe EU
17
Geographic Inequity: Over 7-fold Geographic Inequity: Over 7-fold Regional Variation in FundingRegional Variation in Funding
(even after adjusting)(even after adjusting)
-
500
1,000
1,500
2,000
2,500
3,000
Ru
ble
s p
er c
ap
ita
18
Impact on Poor and Impact on Poor and Vulnerable GroupsVulnerable Groups
0%
20%
40%
60%
80%
100%
1994 1995 1996 1997 1998 1999 2000 2001
Out-of-Payments for Pharmaceuticals
Chargeable Health Services
Voluntary Health Insurance Premiums
Public Expenditures
19
NOBUS Survey (1): NOBUS Survey (1): Poor Pay Poor Pay More as % of ConsumptionMore as % of Consumption
0
5
10
15
20
25
30
35
Drugs Hospitals Outpatient Dental Total
TopLowest
20
NOBUS Survey (2): % of NOBUS Survey (2): % of Consumption for Paid ServicesConsumption for Paid Services
0
50
100
150
200
250
OfficialOutpatient
UnofficialOutPatient
OfficialInpatient
UnofficialInpatient
12345
21
NOBUS Survey (3):NOBUS Survey (3):Poor Can’t Afford to Follow Poor Can’t Afford to Follow Treatment RegimensTreatment Regimens
0
5
10
15
20
25
30
35
40
45
Poorest Richest
Only Free
No, Dueto Lack ofMoney
22
RecommendationsRecommendations1. Formalize informal paymentsFormalize informal payments
Standardized co-payment system Explicit protections for the poor and medically
vulnerable groups Inform and educate
2. Restructure financing and delivery systemRestructure financing and delivery system pooling, geographic formula, autonomize pooling, geographic formula, autonomize
facilities, etc.facilities, etc.
3. Improve Measures for Public HealthImprove Measures for Public Health Cross sectoral strengthening Cost-effective practices and behaviors Increase funding for AIDS and lower price of ARVs