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Partners for Health: MDG and beyond

Jacques Baudouy

The 6th Global Conference on Health Promotion Bangkok, Thailand, 7-11 August 2005

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Abstract The Millennium Development Goals commit the international community to an expanded vision of development-- one that vigorously promotes health and human development as key to sustaining social and economic progress in all countries, and recognizes the importance of creating a global partnership for development. The goals have been accepted as a common framework for development progress. The first seven goals are mutually reinforcing and are directed at reducing poverty in all its forms. The last goal - global partnership for development - is about the means to achieve the first seven. Achieving the targets set by the MDGs will require more focus on development outcomes. It also will require continuous monitoring of national and global progress towards meeting the MDGs, and more close engagement among partners in helping governments improve human development. All of the poorest countries will need additional monetary assistance and must collaborate with donors in developing effective frameworks through which additional resources can be delivered and performance can be measured and evaluated. For the poorest countries many of the goals seem far out of reach. Even in better-off countries, there may be regions or groups that lag behind. Countries need to set their own strategies and work, together with the global partners, to ensure that poor people are included in the benefits of development. As proposed by the Monterrey Consensus and the recent G8 summit, debt management and debt relief to countries that are poor and heavily indebted needs to be a top priority in the development agenda in order to accelerate progress towards attainment of the MDGs. This paper will set the stage for discussion by providing a very brief general overview of what the MDGs are and their importance in relation to global health. It will also review progress in regions so far, highlighting variation among countries, as well as stressing the importance of addressing the equity gap within countries. The paper will present strategies for achieving the MDG agenda, highlighting the importance of policy and institutional reforms that increase absorptive capacity within countries so that they can effectively use additional resources to improve health service delivery. The importance of cross-sectoral actions and the need for good monitoring and surveillance will also be stressed. The importance of effective partnerships will be highlighted and issues of donor harmonization and the need for NGO/Civil Society engagement and public-private partnerships will be addressed. In addition, the relationship between globalization and trade in products potentially harmful to health as well as awareness of different lifestyles, and impacts on health related behavior and NCDs will be discussed. The paper will conclude with a recommendation to

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broaden the MDG agenda to include Non-communicable Diseases (NCDs), given that health impacts in some regions may be larger by focusing in this area.

Positioning Health in Development:Public Policies to Reach the MDGs and Beyond

Dr. Jacques Baudouy, DirectorHealth, Nutrition and PopulationHuman Development NetworkThe World Bank

Cycle of health & wealthand economic growth

Buys more health services

Improves life styles

Reduces job-related risks

Buys more education and other human capital-related services

Buys more health services

Improves life styles

Reduces job-related risks

Buys more education and other human capital-related services

Source: Salehi, 2004

HealthIncomeWealthGrowth

Improves political stability, investment climate, and productivity

Reduces medical spending

Reduces fertilityIncreases labor supply and

female labor force participationIncreases saving

Increase in the years of healthy life expectancy

Improves political stability, investment climate, and productivity

Reduces medical spending

Reduces fertilityIncreases labor supply and

female labor force participationIncreases saving

Increase in the years of healthy life expectancy

Some empirical evidence

Poor health reduces GDP per capita by reducing both labor productivity and the relative size of the labor force (Ruger, Jamison, Bloom and Canning)

10% increase in life expectancy at birth leads to 0.35% increasein the economic growth rate (CMH)

Increases in health status accounted for 17% of the increase in productivity gains (NBER)

One year increase in life expectancy raises GDP per capita by about 4% (Bloom, Canning and Sevilla)

Reductions in adult mortality explain 10-15% of the economic growth that occurred between 1960-90 (Jamison, Lau and Wang)

Ill health and povertyThe case of Vietnam (1)

0

1

2

3

4

5

6

7

8

9

10

1 500 999 1498 1997 2496 2995 3494 3993 4492 4991 5490 5989

Households ranked by expend w/out hc payments

HH e

xpen

ditu

re a

s m

ultip

le o

f PL

Pov line = VND 1.8m/year Expend w/out hc paymentsSource: World Bank

Ill health and povertyThe case of Vietnam (2)

0

1

2

3

4

5

6

7

8

9

10

1 500 999 1498 1997 2496 2995 3494 3993 4492 4991 5490 5989

Households ranked by expend w/out hc payments

HH

exp

endi

ture

as

mul

tiple

of

PL

Pov line = VND 1.8m/year Expend w/out hc paymentsHC payments

Out-of-pocket payments for health care pushed 2.6m Vietnamese into poverty in 1998.

Increased poverty gap by 25%

Source: World Bank

0 50 100 150 200

Underweight children (percent)

Under-Five deaths/1,000 live births

Maternal deaths/10,000 live births

AIDS deaths/100,000 pop

TB deaths/100,000 pop

Rate/RatioPoorest 25% 2nd poorest 25%

2nd richest 25% Richest 25%

The world’s poor fare worse

Global income quartiles

Source: World Bank

Coverage rates of basic MCH services by income quintile in Asia

0

10

20

30

40

50

60

70

80

90

100

Antenatal Care OralRehydration

Thereapy

FullImmunization

Med. Treatmentof Ac. Res. Inf.

Att. Delivery Med. Treatmentof Fever

Modern Contra.Use (Women)

Lowest 20% of Population Highest 20% of Population

The world responds to the challenge:The Millennium Development Goals

Goal 1: Eradicate extreme poverty and hungerGoal 2: Achieve universal primary educationGoal 3: Promote gender equality and empower

womenGoal 4: Reduce child mortalityGoal 5: Improve maternal healthGoal 6: Combat HIV/AIDS, malaria, and other

diseases.Goal 7: Ensure environmental sustainabilityGoal 8: Develop a global partnership for

development.

189 member states adopt the goalsat the UN General Assembly:

Assessing progress on the MDGs:U5 Mortality

U5M - EAP

41

59

20

0

50

100

150

200

1990 1995 2000 2005 2010 2015Actual Goal

U5M - ECA

3615

46

0

50

100

150

200

1990 1995 2000 2005 2010 2015Actual Goal

U5M - LAC

33

53

18

0

50

100

150

200

1990 1995 2000 2005 2010 2015Actual Goal

U5M - MNA

53

77

26

0

50

100

150

200

1990 1995 2000 2005 2010 2015Actual Goal

U5M - SAS

92

43

130

0

50

100

150

200

1990 1995 2000 2005 2010 2015Actual Goal

U5M - SSA

171

62

187

0

50

100

150

200

1990 1995 2000 2005 2010 2015Actual Goal

Assessing progress on the MDGs: Share of people living on less than $1 (or $2) a day (%)

Global trends in underweight (Children 0-4 Years)1980-2005

Data Source: de Onis et al (2004)

0

15

30

45

60

75

1980 1985 1990 1995 2000 2005

Prev

alen

ce o

f und

erw

eigh

t (%

)

BangladeshIndiaChina

0

40

80

120

160

200

1980 1985 1990 1995 2000 2005

No.

of u

nder

wei

ght c

hild

ren

(mill

ion)

AfricaAsiaLACDeveloping

The poorest countries are progressing the slowest

-8%-7%-6%-5%-4%-3%-2%-1%0%

Malnutrition U5MR MMR

pop-

wei

ghte

d av

% ra

te o

f cha

nge

in 1

990s

Low incomeLower middle incomeUpper middle income

Target

Target

Target

Progress varies by country:Annual rate of decline in malnutrition, Africa

-8%-6%-4%-2%0%2%4%6%

Botswana

Maurit

aniaUgandaNigeri

aKen

ya

EthiopiaTan

zania

Burkina Fas

o

annu

al a

v. %

cha

nge

Target rate of reduction

Progress varies within countries: Rate of U5 mortality by income quintile: Bangladesh

0

20

40

60

80

100

120

140

160

Lowest 20% Second Middle Fourth Highest 20%

deat

hs p

er 1

000

live

birt

hs

U5 Mortality Rate

Achieving the Agenda:What is needed to reach the health MDGs?

FinancingPolicies, Institutions, and GovernanceMulti-sectoral ApproachesPartnerships

Region/income groupPopulation,

millions (2002)

Per capita GDP (2002

$US)

Health expenditure per capita,

(2000)

Public health expenditures as % of total health exp.

(2000)Aid as a % of GNI (2001)

East Asia & Pacific 1,838 980 44 38 0.5Europe & Central Asia 476 2,384 108 73 1Latin America & Caribbean 527 3,176 262 47 0.3Middle East & North Africa 306 2,265 171 62 0.7South Asia 1,401 467 21 20 1Sub-Saharan Africa 688 463 29 43 4.6World 6,201 5,201 482 58 0.2High income 965 26,942 2735 59 N/AMiddle income 2,742 1,870 115 51 0.4Low income 2,495 453 21 25 2.4

Source: WDI, 2002

Global health spending and ODA

Accelerating progress to reach the health MDGs: U5 Mortality

Target

Accelerating progress to reach the health MDGs: Maternal Mortality

Target

ODA for health is increasing, but…

DAH (in millions of US$)

01000200030004000500060007000

1990 average1997-99

2002

Private non-profit

Multilateralexcluding UN

Bilateral

External Funding is unreliable

ODA is NOT the solution

Donors are unable to make long term commitments

Donor Com m itm ents as a percentage of Total Health Expenditure

02040

6080

100

1997 1998 1999 2000 2001

Mauritania

Tanzania

Mali

Eritrea

Percentage of Total Health Expenditure Financed by External Sources

0

510

1520

25

1997 1998 1999 2000 2001

Guinea

Benin

Burundi

Liberia

Government health spendingNecessary, but not sufficient

Absorptive capacity of funds

Equitable targeting of funding needed

Policies and Institutions are crucial

Proportional scaling-up across programsLeads to bigger decline in MMR than U5MRImpact is greater in countries with good policies & institutions

But… even in countries with better policies and institutionsrelying on across-the-board scaling-up to get to MDGs would require much faster growth in share of GDP devoted to govt. health spending

Making money workPolicies and Institutions are critical

-0.74-0.75-0.375.00-0.52-0.72-0.084.00-0.31-0.690.223.00

MalnutritionMMRUnder-5 mortalityCPIA Index*

•CPIA: Country Policy and Institutional Assessment; ratings used by World Bank to allocate IDA credits

Elasticities of public health expenditures and MDGs

Stronger policies & institutionsImproving demand and service delivery

Policies need to address lowering all household barriers to access to care

Households key actors—as demanders & deliverers Lower financial barriers, especially for the poor; empower women; better knowledge; increase accessibility

Improved service delivery—accountabilityWithin organizations (management)

Performance improved through clearer responsibilities and accountability linking performance & rewards

Between organizations and public:Directly (patient-provider): governance participation, information disseminationIndirectly (policymaker-provider): contracting, partnerships, social marketing

Stronger policies & institutionsHR, drugs, public health, financing

Tackling HR and drugs constraintsHR: Improve returns to employment; training to focus on MDG-specific servicesDrugs: better logistics and incentives to get drugs to frontline; behavior change against poor quality drugs

Strengthening core public health functionsStrategies for disease prevention, treatment & control; govt.-led M&E

Sustainable health financingWork out what’s affordable; mobilize extra domestic resources where appropriate Better planning and budgeting to align goals & resourcesRely less on out-of-pocket expendituresMove toward risk pooling

The human resources challengeSub-Saharan Africa needs in health

800,000

80,000

1,140,000

470,000

0

200,000

400,000

600,000

800,000

1,000,000

1,200,000

Physicians Nurses

HR Requirements (HRR)Average of low andlower-middle incomecountries

HR Availability (HRA) inSSA

Effective Policies and institutions to Achieve the MDGs:PROGRESA: an example of effective targeting

Benefit:

125-Peso Monthly Food Transfer per Family

IF Each Child Receives 2-4 Checkups annually, Adults Receive One Annual Checkup, Pregnant Women Receive Seven Pre- and Post-natal Checkups

Accomplishments:

Serves over 20 million people (1/5 pop of Mexico)Provides 20% of income of participating familiesKeeps administrative expenses under 10% of total program costHas survived a landmark shift in power away from the political party that established it.

PROGRESA: Effective Targeting

0102030405060708090

Bottom 20% ofNational Population

Bottom 40% ofNational Population

Perc

ent o

f Tot

alPr

ogra

m B

enef

its

Health impact often requires a multi-sectoral approach

Impact of piped water on diarrhea prevalence among children by income quintile, India

-80%

-60%

-40%

-20%

0%

Poore

st

2nd

Middle

4th Riches

t

Income quintiles

chan

ge in

dia

rrhe

a pr

obab

ility

x 1

00

Even with good infrastructure, other activities such a behavior change, are needed

Partnerships

Key to achieving the MDGs Broadens scope beyond government capacity to deliver servicesIncreases transparency and accountabilityGovernment can take on a more stewardship roleTypes:

International alliances to bring needed commodities to marketGov./Business/ Civil Society: targeted efforts to tackle specific public health issuesGov-NGO: give voice to population and access hard-to-reach populations

PartnershipsNGOs and Civil Society

Essential link at the grassroots level that can be in getting services to the hardest-to-reach populations

Can increase participation by tapping into social capital at the community level

Partnerships:Cambodia contracting

05

1015202530354045

Government Areas Contracted-InAreas

Contracted-OutAreas

19972001

Percentage of Poorest 20% Benefited by Intervention

Partnerships:Donor Harmonization

Donors need to use country owned and led initiatives as the basis for aligning and harmonizing assistance

Partners need to work together to improve the quality of aid by supporting activities that increase absorptive capacity within countries to effectively use assistance

The MDG+ Agenda

While the MDGS are important goals the focus on those targets is not the full picture for some regions

The epidemiologic transition in many countries calls for a agenda that is broader than the MDGs and needs to address non-communicable diseases (NCDs)

Deaths, by broad cause group and WHO Region, 2003

InjuriesNoncommunicableconditions

Communicable diseases, maternal and perinatal conditions and nutritional deficiencies

AFR EMR EURSEAR WPR AMR

25

50

75

%

Sour

ce: W

HO

Reaching MDGs will not be enoughHigh returns from reducing adult mortality – MDG+ approach in Europe and Central Asia

Increase in life expectancy from reaching MDGs 4 and 5, or reducing CVD and external causes

0.0 2.0 4.0 6.0 8.0 10.0 12.0

Remaining FSU

E. and S. Europe

Central Asia & Caucasus

Regional average

Increase in life expectancy (years)

Reaching MDGs 4 and 5 Reaching EU levels for CVD and external causes

The MDG+ Agenda- Implications for Health Promotion

Work multisectorallyTarget effectivelyStrengthen prevention efforts Build on existing HP modelsBuild partnerships with the private sector