Mr. Shun-ichi Murata Deputy Executive Secretary of ESCAP

Mr. Bindu N. Lohani Vice President Asian Development Bank

Mr. Ajay Chhibber UN Assistant Secretary-General and UNDP Assistant Administrator and Director for Asia and the Pacific

Accelerating Equitable Achievement of the MDGs Closing Gaps in Health and Nutrition

Outcomes

Part I

Key findings

• Impressive but uneven progress • Particular challenges in achieving health and

nutrition targets • Accelerated progress crucial for countries lagging

behind – Large gaps in achievement across countries, which are

widening in some cases

• National efforts also need to target disadvantaged population groups – Within-country disparities as large as cross-country

disparities

• Eight-point strategy to close gaps

Progress in achieving MDG targets: mixed picture

Source: Staff calculations based on the United Nations MDG Database and World Population Prospects 2010; UNESCO Institute of

Statistics for the education-related indicators under Goals 2 and 3, except ‘Reaching last grade’.

Impressive progress

• Asia and the Pacific is an early achiever or is on-track for some targets: – Reduced the proportion of people living on less than $1.25 per day

from 50 to 22 per cent

– On gender, successfully reduced gender inequality in primary, secondary and tertiary education

– On health, begun to reduce the prevalence of HIV and has stopped the spread of tuberculosis

– On the environment, increased the proportion of land area that is covered by forests or has protected status, while also reduced the consumption of ozone-depleting substances

– At the household level, more than halved the proportion of people without access to safe drinking water

On the other hand, the region is still lagging in some major areas particularly

those related to health

• The region is behind schedule for ten of the 22 indicators assessed in this report.

• The region still needs to: – Eradicate hunger

– Reduce child mortality

– Improve maternal health

– Extend basic sanitation sufficiently rapidly

– Ensure that all children complete primary school

– Reduce CO2 emissions.

Scale of deprivation is large…

On most indicators, because of the region’s large population it is also home to a high proportion of the world’s deprived people.

South Asia on and off track for the MDGs

Source: Staff calculations based on the United Nations MDG Database and World Population Prospects 2010; UNESCO Institute of

Statistics for the education-related indicators under Goals 2 and 3, except ‘Reaching last grade’.

South Asia on and off track for the MDGs

There is still hope…

Source: Staff calculations based on the United Nations MDG database.

Reducing child malnutrition:

• 14 countries likely

to miss target (halving the number of 1990) if business as usual (slow, no progress or regressing)

• All will meet target

if progress accelerated by less than 2 percentage points per year

Progress in reducing the proportion of under-5 children underweight

Part II

Implications of Disparities

• Disparities are intrinsically unacceptable

• They also pose a threat to economic and social stability within countries – Wide differences in income and social attainments

can lead to discontent and provoke social and political unrest

• Uneven development between countries can provoke friction between countries and undermine regional cooperation efforts

Extent of Disparities Between Countries

Income poverty

103.00

0

20

40

60

80

100

East and Northeast

Asia

North and Central Asia South and Southwest Asia Southeast Asia The Pacific

0

20

40

60

East and Northeast

Asia

North and Central Asia South and Southwest Asia Southeast Asia

0

10

20

30

40

50

East and Northeast Asia

North and Central Asia South and Southwest Asia Southeast Asia The Pacific

Infant mortality

Underweight children

• There are wide disparities in MDG outcomes between countries. This is evident from the figures below.

Disparities between countries over time

• In many cases, such disparities are widening over time

• This is true for extreme poverty, child hunger, child mortality, maternal mortality and TB incidence - as shown in the Table below

Gini indices of inter-country distribution of selected MDG indicators

Ealier Year Gini coefficient Later Year Gini coefficient

1 $1.25 per day poverty 1997 0.426 2004 0.452

2 Underweight chi ldren 1995 0.296 2005 0.454

3 Under-5 morta l i ty 1990 0.378 2009 0.387

4 Maternal morta l i ty 1990 0.579 2008 0.593

5 TB incidence 1990 0.405 2008 0.447

Indicator

Contribution by sub-regions to disparities

• Disparities within sub-regions contribute more to overall disparities than disparities between sub-regions

• This indicates that sub-regional cooperation efforts can play a big role in reducing disparities

Why some countries do better – factors related to health sector

• Insufficient spending on health is a major cause of poor health outcomes, as demonstrated for child mortality below

• Lack of health staff is another crucial factor • Ineffective public health spending is also responsible

Sources: United Nations MDG database for child mortality and World Bank, World Development Indicators online

database for health expenditure per capita.

Cross-country variation in child mortality explained by differences in health spending

Why some countries do better – factors outside the health sector

• Differences in health outcomes also result from factors outside the health sector indicating need for a multi-disciplinary approach

• For example, differences in access to basic infrastructure play a crucial role. • Better roads improve the proportion of births attended by skilled health staff as

shown below.

Births attended by skilled health personnel and the extent of paved roads

Sources : The World Bank, World Development Indicators online database for GDP per capita, electricity consumption, and

percent of paved road networks; and the United Nations MDG database for skilled birth attendance, access to sanitation and

safe drinking water.

Why some countries do better – other factors

• Countries doing better in health were associated with several other attributes such as

– Effectiveness in controlling corruption and addressing other governance issues

– High state of women’s development

– Spread of education and literacy, particularly among women

– Extent of access to clean water and improved sanitation, and

– Access to reproductive health services

One country, many worlds

Gaps in MDG achievements among citizens within national borders can be as large as gaps between people from different countries

Source: Demographic and Health Survey.

• Overall disparities tend to be larger in countries with relatively lower levels of attainment (large red bubbles)

• Attainments are generally higher with low disparities

Reducing disparities and raising attainments: Same issue?

Economic status as a marker of within-country disparities

• Child malnutrition less prevalent in urban than in rural areas

• Prevalence levels similar among children of same economic status

Percentage of children under 5 underweight

Rural

Urban

Additional drivers of within country disparities

• Education of mother

• For under-5 mortality

– Breast-feeding reduces risk

– High risk for girls in some countries

• Castes, ethnic and linguistic groups

– Need to remove cultural and institutional discrimination

Part III

An Eight-Point Agenda to Reduce Health Disparities

Bring together health policy options encompassing three inter-related aspects:

• Address social determinants of health

• Health sector interventions

• Strategies outside health ministries that have a big impact on health, and cut-across sectors

• Inclusive economic growth complemented by social protection policies to manage health risks and vulnerabilities

• Gender aware policies that raise the status of women

• Rights based framework that treats human health as a norm, counters stigma

Address the social determinants of health to reduce health inequities

Sri Lanka, where health is

treated as a social right;

Kerala (India), with higher female

literacy, hold important lessons

• Channel resources towards primary health care system

• Integrated fragmented services and minimize out-of-pocket expenditures

• Strengthen basic infrastructure such as better roads and electricity

Expand access to responsive and efficient primary health care systems

Bangladesh and Indonesia

have successfully delivered to

the poor and vulnerable, an

integrated primary health care

package which includes

essential services

• Address the risks and vulnerabilities of women and children

• Adopt a life-cycle approach including reproductive and child health services

• Promote appropriate breastfeeding practices to reduce under-5 mortality

Integrate Child and Maternal health into a continuum of care

Mongolia, Indonesia and Tamil

Nadu (India) demonstrate that a

package of preventive, promotive

and curative services is an

effective shield against maternal

and child deaths

• Health indicators of the growing urban poor need attention—they are not much better than those of the rural poor

• Promote inclusive urban governance with a focus on rights to health, education and other social services

Focus on the health needs of the urban poor in a rapidly urbanizing region

In India, as part of slums

improvement, the urban poor

are now being included in

reproductive and child health

care

• Expand fiscal space for public health-- better tax governance, expanding the tax base, and tapping into innovative revenue sources

• Minimize waste by controlling systemic inefficiencies: wastage is known to range between 20 and 40 per cent of all health spending

• Expand health insurance options

Devise sustainable financing strategies

China, Thailand--health insurance to

deal with out-of-pocket expenses

India-- 2% education cess on income

tax is an innovative way to expand

sources of finance

• Strengthen checks on corruption and waste

• Check counterfeit and sub-standard medicines

• Regulate to ensure quality and fair pricing of health services

• Promote generics as a lower cost alternative to patented medicines

Improve the governance of health systems

Generics in HIV/AIDS reduced

treatment costs from $10,000-15,000

per patient/year to under $80 now in

about a decade

• Promote systematic exchange of information, R&D, to leverage varied knowledge and experiences

• Enhance regional cooperation

• Supplement official development assistance with innovative international financing mechanisms

Coordinate national strategies with regional and global cooperation--leverage diversity

-UNITAID-bulk medicine purchase facility for low income countries -International Finance Facility for Immunization / Global Alliance for Vaccines and Immunization -Solidarity levies on airline tickets

In conclusion: Tackling barriers is within reach

• Right to health is an essential ingredient of inclusive and equitable societies

– benefits the private sector and economic growth

• Locally tailored approaches do better than generic strategies; yet much can be gained from cooperation and experience sharing

• The MDG Acceleration agenda--a timely reminder of the urgency to bridge persisting health deficits in this fast growing region

THANK YOU ALL