Reaching the MDGs Evidence on High Impact Interventions-

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Reaching the MDGs Evidence on High Impact
Interventions-

• Agnes Soucat, World Bank
• and Netsanet Walelign, UNICEF
• Kigali June 23-27

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Why are we here today ?
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Progress towards MDGs inadequate Trend in
Under-Five Deaths, 1960-2015 (Millions deaths per
year)
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Growth is not enough
Percent living on 1/day Percent living on 1/day Primary completion rate (percent) Primary completion rate (percent) Under-5 mortality rate 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.
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Yet we know that some interventions are highly
effective
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Most mortality causes still avoidable with low
cost interventions
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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

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Population oriented interventions (2)

• 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

• 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

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Individual clinical interventions (3)

• Management of severely sick children (referral
  IMCI)
• Chloroquine for malaria (P.vivax)
• Artemisinin-based Combination Therapy
• Management of complicated malaria (2nd line drug)

• 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

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Individual clinical interventions (3)

• 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

• Management of opportunistic infections
• Male circumcision
• Second-line ART
• Adult second-line ART
• Comprehensive emergency obstetric care (C-EOC)
• Other emergency acute care

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Saving 1.3 million lives per year for 400 per
life saved jumpstarting community care outreach
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Saving 2.5 million lives per year for 800 per
life saved Full Minimum Package at scale
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Saving 5.5 million lives per year for 1,500 per
life saved maximum package at scale.
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So why is it not happening ?
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Countries use well-designed policies to achieve
growth and human development outcomes
Services
Governments/donors
Health, Education, Poverty
But

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But, what looks good on paper seems to break down
in practice
Government
Leakage of Funds
Bad policy Poor budget handling
Local Govt.
Sub-optimal spending (Big salary bills but
insufficient textbooks materials)
Providers
Financing problems Information monitoring Local
govt. incentives skewed Local capacity issues
Communities
Low quality instruction
Provider incentives unclear, absenteeism Hard to
monitor, users helpless Quality inappropriate
Primary education
Lack of demand
Clients
Externalities Community norms Budget
constraints Intra-household behavior
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Budgeting for results
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Results-based Financing
Donors
Sub-National Government District
National Government
Results Based Aid
Results Based Planning and Budgeting
Results Based Contracting for
CCT, RB bonuses
Households or Individuals
Hospitals, Health Centers, Ass
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Steps in Results-Based Budgeting

• Step 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 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.

• 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 4 Estimating
• Marginal Cost
• Estimate marginal costs to
• overcome the bottlenecks and
• achieve new performance frontiers.
• Region/country specific inputs and
• cost structures.

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Removing Coverage Bottlenecksin Ethiopia
scaling up ITN
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Linking Flow of Funds to Impacts
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The Challenge of Scaling Up in Ethiopia
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
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The Challenge of Scaling Up in Rwanda
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
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Results ?
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Dramatic decrease of malaria in Rwanda

• Non Malaria out patient

• Malaria out patient

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Rwanda 2005-2008
Indicators 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
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Rwanda back on track for the MDGs