Agnès Soucat - Reaching the MDGs: do we have a way forward?
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Transcript of Agnès Soucat - Reaching the MDGs: do we have a way forward?
Reaching the MDGs: do we have a way forward?
Agnes Soucat, Lead Advisor, Health Nutrition Population, Africa
The World Bank
Antwerp, December 17
Why are we here today ?
Progress towards MDGs: inadequate
Trend in Under-Five Deaths, 1960-2015 (Millions deaths per year)
2.9 3.2 3.5 4.1 4.6 4.92
5.1
13.510.9
8.3 7 5.1 4.1
2.2
3
4.1
3.6
2.71.8
1.41.1
0.8
0.1
0
5
10
15
20
25
1960 1970 1980 1990 2000 2005 2015 withachievement of
MDGs
2015 withcurrent Trend
Africa Asia Other
Growth is not enough
15159561003524Africa
6943991001522South Asia
41259610011Middle East and North Africa
30179510088Latin America
261510010011Europe and Central Asia
2619100100414East Asia
2015 growth alone
Target
2015 growth alone
Target
2015 growth alone
TargetUnder-5 mortality
rate
Primary completion rate (percent)
Percent living on $1/day
Sources: World Bank 2003a, Devarajan 2002. Notes: Average annual growth rates of GDP per capita assumed are: EAP 5.4; ECA 3.6; LAC 1.8; MENA 1.4; SA 3.8; AFR 1.2. Elasticity assumed between growth and poverty is –1.5; primary completion is 0.62; under-5 mortality is –0.48.
Yet we know that some interventions are highly effective
Most mortality causes still avoidable with low cost interventionsCause-specific proportional mortality in the Africa region
21%
17%
4%
21%
6%2%
7%
17%
Neonatal
HIV/AIDS
DiarrhoealdiseasesMeasles
Malaria
RespiratoryinfectionsInjuries
Others
Household and community level interventions(1) Insecticide Treated Mosquito
Nets Safe water systems Use of sanitary latrins Hand washing by mother Indoor Residual Spraying
(IRS) Clean delivery and cord care Early breastfeeding and
temperature management Universal extra community-
based care of LBW infants
Breastfeeding Complementary feeding Therapeutic Feeding Oral Rehydration Therapy Zinc for diarrhea
management Vitamin A - Treatment for
measles Chloroquine for malaria
(P.vivax) Artemisinin-based
Combination Therapy Antibiotics for U5 pneumonia Community based
management of neonatal sepsis
Population oriented interventions (2) Family planning HPV vaccination Preconceptual folate
supplementation Tetanus toxoid Deworming in pregnancy Detection and treatment of
asymptomatic bacteriuria Treatment of syphilis in
pregnancy Prevention and treatment of iron
deficiency anemia in pregnancy Intermittent preventive treatment
(IPTp) for malaria in pregnancy Balanced protein energy
supplements for pregnant women
Supplementation in pregnancy with multi-micronutrients
PMTCT VCT Cotrimoxazole prophylaxis for
HIV+ Measles immunization BCG immunization OPV immunization DPT immunization Hib immunization Hepatitis B immunization Yellow fever immunization Meningitis immunization Pneumococcal immunization Rotavirus immunization Neonatal Vitamin A
supplementation Vitamin A - supplementation Zinc preventive
Individual clinical interventions (3) Skilled attended delivery Basic emergency obstetric care (B-
EOC) Resuscitation of asphyctic
newborns at birth Antenatal steroids for preterm
labor Antibiotics for Preterm/Prelabour
Rupture of Membrane (P/PROM) Detection and management of
(pre)ecclampsia (Mg Sulphate) Management of neonatal infections Antibiotics for U5 pneumonia Antibiotics for diarrhea and enteric
fevers Vitamin A - Treatment for measles Zinc for diarrhea management Clinical management of neonatal
jaundice
Management of severely sick children (referral IMCI)
Chloroquine for malaria (P.vivax)
Artemisinin-based Combination Therapy
Management of complicated malaria (2nd line drug)
Individual clinical interventions (3) Management of opportunistic
infections Male circumcision Second-line ART Adult second-line ART Comprehensive emergency
obstetric care (C-EOC) Other emergency acute care
Detection and management of STI
Management of opportunistic infections
First line ART Detection and treatment of
TB with first line drugs (category 1 and 3)
Re-treatment of TB patients with first line drugs (category 2)
MDR treatement with second line drugs
Saving 1.3 million lives per year for $ 400 per life saved: jumpstarting community care &
outreachExpected Impact on Neonatal, Under Five and Maternal
Mortality and Additional Economic Cost
$ 0.66
$ 0.00
$ 0.43
$ 0.22
0%
5%
10%
15%
20%
25%
Family/community Outreach/schedulable Clinical Total ServicesDelivery modes
Mo
rtal
ity
red
uct
ion
$0.0
$0.5
$1.0
Neonatal Mortality Under Five Mortality
Maternal Mortality Incremental Economic Costs per capita/year
Scenario I : Africa generic
Saving 2.5 million lives per year for $ 800 per life saved: Full Minimum Package at scale:
Expected Impact on Neonatal, Under Five and Maternal Mortality and Additional Economic Cost
$ 2.48
$ 0.72
$ 1.09
$ 0.67
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
Family/community Outreach/schedulable Clinical Total ServicesDelivery modes
Mo
rtal
ity
red
uct
ion
$0.0
$0.5
$1.0
$1.5
$2.0
$2.5
$3.0
Neonatal Mortality Under Five Mortality
Maternal Mortality Incremental Economic Costs per capita/year
Phase I : Africa generic
Saving 5.5 million lives per year for $ 1,500 per life saved: maximum package at scale.
Expected Impact on Neonatal, Under Five and Maternal Mortality and Additional Economic Cost
$ 9.26
$ 1.31
$ 4.11 $ 3.84
0%5%
10%15%20%25%30%35%40%45%50%55%60%65%70%75%80%
Family/community Outreach/schedulable Clinical Total Services
Delivery modes
Mo
rtal
ity
red
uct
ion
$0
$1
$2
$3
$4
$5
$6
$7
$8
$9
$10
Neonatal MortalityUnder Five MortalityMaternal MortalityIncremental Economical Cos ts per capita/year
Phase III : Africa generic
So why is it not happening ?
Countries use well-designed policies to achieve growth and human development outcomes
Health, Education,
PovertyBut…
* Service
s
Govern
ments/donors
Commun
ities
Government
Providers
Loca
l Gov
t.Clien
ts
Leakage of FundsBad policyPoor budget handling
Primary education
Sub-optimal spending(Big salary bills but insufficient textbooks & materials)
Financing problemsInformation & monitoringLocal govt. incentives skewedLocal capacity issues
Low quality instructionProvider incentives unclear, absenteeismHard to monitor, users helplessQuality inappropriate
Lack of demandExternalitiesCommunity normsBudget constraintsIntra-household behavior
But, what looks good on paper seems to break down in practice…
Financing for results
Commun
ities
Government
Providers
Loca
l Gov
t.Clien
ts
Leakage of Funds
Results Based Transfers
Primary education
Sub-optimal spending(Big salary bills but insufficient textbooks & materials)
Results Based Financing
Low quality instruction
Results Based Financing
Condiitonal Cash Transfer
Accountability patches…
Results-based Financing
Donors
N ationa l G overnm
ent
Households or Individuals
Results Based Aid
Results Based Contracting for
CCT, RB bonuses
Hospitals, Health Centers, Ass
S ub-N ationa l
G overnmentD is tric t
Results Based Planning and Budgeting
Steps in Results-Based BudgetingStep 1: Health Systems and High Impact Interventions•Analyze health systems.•Identify major U5MR, NNMR, MMR causes.•Identify high impact health, nutrition, AIDS,& malaria interventions (level 1-2 evidence).•Organize interventions into 3 service •delivery modes: Family oriented community-based; Population oriented schedulable; and individual oriented clinical services.•Select representative tracer interventions for each sub-package of interventions.
Step 4: Estimating Marginal Cost•Estimate marginal costs to overcome the bottlenecks and achieve new performance frontiers.•Region/country specific inputs and cost structures.
Step 3: Estimating Impact•Epidemiometric model.•Estimate the impact (reduction in mortality) of overcoming the bottlenecks based on local causes of NNMR, U5MR and MMR.•Sources include: MDG1 (Emory), MDG4 (Bellagio), MDG 5 (WHO/WB Cochran; BMJ), and MDG 6 (RBM, UNAIDS).
Step 2: System Bottlenecks to Coverage•Analyze household surveys and service statistics, using six coverage determinants,to identify system bottlenecks to coverage & causes.•Supply side: availability of essential commodities, availability of human resources, and physical access.•Demand side: initial and timely continuous Utilization; Effective quality coverage.•Analyze strategies to address bottlenecks and set new coverage frontiers.
Step 5: Budgeting and Fiscal Space•Translate marginal cost into yearly additional budget figures.•Link budget figures to national sector plans, MTEF, PRSP, and other programs.•Facilitate analysis on financing sources.•Evaluate additional funding requirement against the fiscal space for health.
Removing Coverage Bottlenecksin Ethiopia: scaling up ITN
ITN indistricts
HEWs Fam ilies w ithnet
Using net Using treatednet
2005
2007
80% 80%
65%
72%75%
36%
20%
1%4%
16%
0%
25%
50%
75%
100%
2005 2007
procurrred >20,000 ITN
trained and deployed about 20,000 HEW policy
decision: long lasting ITN
Linking Flow of Funds to Impacts
∆C of health & nutrition inter-ventions delivered by Clinics/Hospitals
Impact on MDG health
indicators: Reduction in U5MR and
MMR
Availability ∆C of health & nutrition interventions delivered by Family/CommunityAccessibility
Utilization
Continuity
Quality
Essential drugs commodities, safe water system, and/or human resources etc.
Support for community meeting, inputs for a mobile team, construction of health post etc.
Drugs and supplies, subsidies for insurance for referral care per user etc.
Demand side subsidy, performance-based incentives for health workers, doctors, and IEC inputs etc.
Training, supervision and monitoring of community mobilizers, primary and referral clinical care etc.
Inputs (Health & WSS Inputs) to Release Bottlenecks
∆C of health & nutrition interventions delivered by Outreach team
Health Output
Cost of removing
bottlenecks to achieve certain
MDG target
Aggregate Cost of Inputs
MDGs Outcome1
The Challenge of Scaling Up in EthiopiaThe Challenge of Scaling Up in Ethiopia
Current Health Expenditures
Step 1
Step 2
Step 3
Step 4
Step 5
0
5
10
15
20
25
30
35
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
US$ (2004 constant $)
Step 1: Information and social mobilization for behavior change
Step 2: Health services extension program
Step 3: First level clinical upgrade
Step 4: Expansion and upgrade of emergency obstetrical care
Step 5: Expansion and upgrade of referral care
Strategy
The Challenge of Scaling Up in RwandaThe Challenge of Scaling Up in RwandaPer Capita Cost of Scaling Up to Reach MDGs
$0
$5
$10
$15
$20
$25
$30
$35
$40
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Step 1: Information and mobilisation at community level
Step 2: Performance Based Financing at health centres
Step 3: Mutuelles for indigents
Step 4: upgrading district hospitals
Step 5: strengthening national hospitals
Step 6: Scaling up HAART
Strategy
Current Health Expenditures
Results ?
Malaria out patient Non Malaria out patient
2001 2002 2003 2004 2005 2006 2007
0K
5K
10K
15K
20K
25K
Sum
of Con
f# o
utpa
tient
mal
aria
Sheet 1
Age group
5 years and above
Under 5 years
The trend of sum of Conf# outpatient malaria for Year G#C. Color shows details about Age group . The data is filtered on Country , which keeps Rwanda. The view is filtered on Age group , which keeps 5 years and above and Under 5 years.
2001 2002 2003 2004 2005 2006 2007
0K
20K
40K
60K
80K
100K
120K
140K
160K
180K
200K
220K
Sum
of Non
mal
aria
OPD
Sheet 1
Age group
5 years and above
Under 5 years
The trend of sum of Non malaria OPD for Year G#C. Color shows details about Age group . The data is filtered on Country , which keeps Rwanda. The view is filtered on Age group , which keeps 5 years and above and Under 5 years.
Dramatic decrease of malaria in Rwanda
Rwanda 2005-2007
67%4%Use of Insecticide treated nets among children less than 5
103 per 1000152 per 1000Under-Five Mortality rate 62 per 100086 per 1000Infant Mortality rate
5.5 children6.1 childrenFertility
90%86%Vaccination : Measles80.4%75%Vaccination : All27%33%Anemia Prevalence : Women48%56%Anemia Prevalence : Children
52%39%Delivery in Health Centers
27%10%Contraceptive prevalence: Modern methods
DHS-2007DHS-2005Indicators
Rwanda: back on track for the MDGs
Progress towards the MDGs
$8.83
$19.98
$29.35
0%
10%
20%
30%
40%
50%
60%
70%
80%
Phase I Phase II Phase III
$0
$5
$10
$15
$20
$25
$30
$35
Anaemia Reduction of Low Birth weight Estimated reduction in stunting U5MR reduction
IMR reduction NNMR reduction MMR reduction Lifetime Risk of Dying
Total fertility rate (TFR) Reduction of Malaria Mortality Reduction in AIDS mortality Reduction in TB Mortality
Quality of drinking water Use of sanitary laterin Hand washing by mother Cost per capita per year in US$
MDG 1 MDG4 MDG 7MDG 6MDG5