Reaching the MDGs Evidence on High Impact Interventions-

Agnes Soucat, World Bankand Netsanet Walelign, UNICEF

Kigali June 23-27

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 4.9

2

5.1

13.510.9

8.3 75.1 4.1

2.2

3

4.1

3.6

2.7

1.8

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

Percent living on $1/day Primary completion rate (percent) Under-5 mortality rate

Target 2015 growth alone

Target 2015 growth alone

Target 2015 growth alone

East Asia 14 4 100 100 19 26

Europe and Central Asia

1 1 100 100 15 26

Latin America 8 8 100 95 17 30

Middle East and North Africa

1 1 100 96 25 41

South Asia 22 15 100 99 43 69

Africa 24 35 100 56 59 151

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 interventions

Cause-specific proportional mortality in the Africa region

21%

17%

4%

21%

6%2%

7%

17%

Neonatal

HIV/AIDS

Diarrhoealdiseases

Measles

Malaria

Respiratoryinfections

Injuries

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 Services

Delivery modes

Mo

rtali

ty r

ed

ucti

on

$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 Services

Delivery modes

Mo

rtali

ty r

ed

ucti

on

$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

rtali

ty r

ed

ucti

on

$0

$1

$2

$3

$4

$5

$6

$7

$8

$9

$10

Neonatal MortalityUnder Five MortalityMaternal MortalityIncremental Economical Costs 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

Gover

nments/

donors

Comm

uniti

es

Government

Providers

Loca

l Gov

t.Clie

nts

Leakage of Funds

Bad 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…

Budgeting for results

Results-based Financing

Donors

National Government

Households or Individuals

Results Based Aid

Results Based Contracting for

CCT, RB bonuses

Hospitals, Health Centers, Ass

Sub-National Government

District

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 Families 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 Outcome

1

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 $)

Strategy

Step 5: Expansion and upgrade of referral care

Step 4: Expansion and upgrade of emergency obstetrical care

Step 3: First level clinical upgrade

Step 2: Health services extension program

Step 1: Information and social mobilization for behavior change

The Challenge of Scaling Up in RwandaThe Challenge of Scaling Up in Rwanda

Per Capita Cost of Scaling Up to Reach MDGs

$0

$5

$10

$15

$20

$25

$30

$35

$40

2006 20072008 20092010 20112012 20132014 2015

Strategy

Step 6: Scaling up HAART

Step 5: strengthening national hospitals

Step 4: upgrading district hospitals

Step 3: Mutuelles for indigents

Step 2: Performance Based Financing at health centres

Step 1: Information and mobilisation at community level

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 Conf# outpatient malaria

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 malaria 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 2005-2008Indicators DHS-2005 DHS-2008

Contraceptive prevalence: Modern methods

10% 27%

Delivery in Health Centers 39% 52%

Infant Mortality rate 86 per 1000 62 per 1000

Under-Five Mortality rate 152 per 1000 103 per 1000

Anemia Prevalence : Children 56% 48%

Anemia Prevalence : Women 33% 27%

Vaccination : All 75% 80.4%

Vaccination : Measles 86% 90%

Use of Insecticide treated nets among children less than 5

4% 67%

Fertility 6.1 children 5.5 children

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