Partners for Health: MDG and beyond

Transcription

1 Partners for Health: MDG and beyond Jacques Baudouy The 6 th Global Conference on Health Promotion Bangkok, Thailand, 7-11 August

2 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 publicprivate 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 2

3 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. 3

4 Positioning Health in Development: Public Policies to Reach the MDGs and Beyond Dr. Jacques Baudouy, Director Health, Nutrition and Population Human Development Network The World Bank

5 Cycle of health & wealth and economic growth Buys Buys more more health health services services Improves Improves life life styles styles Reduces Reduces job-related job-related risks risks Buys Buys more more education education and and other other human human capital-related capital-related services services Health Source: Salehi, 2004 Improves Improves political political stability, stability, investment investment climate, climate, and and productivity productivity Reduces Reduces medical medical spending spending Reduces Reduces fertility fertility Increases Increases labor labor supply supply and and female female labor labor force force participation participation Increases Increases saving saving Increase Increase in in the the years years of of healthy healthy life life expectancy expectancy Income Wealth Growth

6 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% increase in 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 (Jamison, Lau and Wang)

7 HH expenditure as multiple of PL Ill health and poverty The case of Vietnam (1) Households ranked by expend w/out hc payments Source: World Bank Pov line = VND 1.8m/year Expend w/out hc payments

8 Ill health and poverty The case of Vietnam (2) HH expenditure as multiple of PL Source: World Bank Out-of-pocket payments for health care pushed 2.6m Vietnamese into poverty in Increased poverty gap by 25% Households ranked by expend w/out hc payments Pov line = VND 1.8m/year HC payments Expend w/out hc payments

9 The world s poor fare worse TB deaths/100,000 pop AIDS deaths/100,000 pop Maternal deaths/10,000 live births Under-Five deaths/1,000 live births Underweight children (percent) Global income quartiles Poorest 25% 2nd poorest 25% 2nd richest 25% Richest 25% Source: World Bank Rate/Ratio

10 Coverage rates of basic MCH services by income quintile in Asia Antenatal Care Oral Rehydration Thereapy Full Immunization Med. Treatment of Ac. Res. Inf. Att. Delivery Med. Treatment of Fever Modern Contra. Use (Women) Lowest 20% of Population Highest 20% of Population

11 The world responds to the challenge: The Millennium Development Goals 189 member states adopt the goals at the UN General Assembly: Goal 1: Eradicate extreme poverty and hunger Goal 2: Achieve universal primary education Goal 3: Promote gender equality and empower women Goal 4: Reduce child mortality Goal 5: Improve maternal health Goal 6: Combat HIV/AIDS, malaria, and other diseases. Goal 7: Ensure environmental sustainability Goal 8: Develop a global partnership for development.

12 Assessing progress on the MDGs: U5 Mortality U5M - EAP U5M - ECA U5M - LAC Actual Goal Actual Goal Actual Goal U5M - MNA U5M - SAS U5M - SSA Actual Goal Actual Goal Actual Goal

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

14 Global trends in underweight (Children 0-4 Years) Prevalence of underweight (%) Bangladesh India China No. of underweight children (million) Africa Asia LAC Developing Data Source: de Onis et al (2004)

15 The poorest countries are progressing the slowest Malnutrition U5MR MMR pop-weighted av % rate of change in 1990s 0% -1% -2% -3% -4% -5% -6% -7% -8% Target Target Target Low income Lower middle income Upper middle income

16 Progress varies by country: Annual rate of decline in malnutrition, Africa Botswana Mauritania Uganda Nigeria Kenya Ethiopia Tanzania Burkina Faso 6% 4% 2% 0% -2% -4% -6% -8% Target rate of reduction annual av. % change

17 Progress varies within countries: Rate of U5 mortality by income quintile: Bangladesh deaths per 1000 live births Lowest 20% Second Middle Fourth Highest 20% U5 Mortality Rate

18 Achieving the Agenda: What is needed to reach the health MDGs? Financing Policies, Institutions, and Governance Multi-sectoral Approaches Partnerships

19 Global health spending and ODA Region/income group Population, 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, Europe & Central Asia 476 2, Latin America & Caribbean 527 3, Middle East & North Africa 306 2, South Asia 1, Sub-Saharan Africa World 6,201 5, High income , N/A Middle income 2,742 1, Low income 2, Source: WDI, 2002

20 Accelerating progress to reach the health MDGs: U5 Mortality Target

21 Accelerating progress to reach the health MDGs: Maternal Mortality Target

22 ODA for health is increasing, but DAH (in millions of US$) average Private non-profit Multilateral excluding UN Bilateral

23 External Funding is unreliable ODA is NOT the solution Donors are unable to make long term commitments Donor Commitments as a percentage of Total Health Expenditure Percentage of Total Health Expenditure Financed by External Sources Mauritania Tanzania Mali Eritrea Guinea Benin Burundi Liberia

24 Government health spending Necessary, but not sufficient Absorptive capacity of funds Equitable targeting of funding needed Policies and Institutions are crucial Proportional scaling-up across programs Leads to bigger decline in MMR than U5MR Impact is greater in countries with good policies & institutions But even in countries with better policies and institutions relying on across-the-board scaling-up to get to MDGs would require much faster growth in share of GDP devoted to govt. health spending

25 Making money work Policies and Institutions are critical Elasticities of public health expenditures and MDGs CPIA Index* Under-5 mortality MMR Malnutrition CPIA: Country Policy and Institutional Assessment; ratings used by World Bank to allocate IDA credits

26 Stronger policies & institutions Improving 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 accountability Within organizations (management) Performance improved through clearer responsibilities and accountability linking performance & rewards Between organizations and public: Directly (patient-provider): governance participation, information dissemination Indirectly (policymaker-provider): contracting, partnerships, social marketing

27 Stronger policies & institutions HR, drugs, public health, financing Tackling HR and drugs constraints HR: Improve returns to employment; training to focus on MDG-specific services Drugs: better logistics and incentives to get drugs to frontline; behavior change against poor quality drugs Strengthening core public health functions Strategies for disease prevention, treatment & control; govt.-led M&E Sustainable health financing Work out what s affordable; mobilize extra domestic resources where appropriate Better planning and budgeting to align goals & resources Rely less on out-of-pocket expenditures Move toward risk pooling

28 The human resources challenge Sub-Saharan Africa needs in health 1,200,000 1,140,000 1,000, , , , ,000 HR Requirements (HRR) Average of low and lower-middle income countries 400, ,000 80,000 HR Availability (HRA) in SSA 0 Physicians Nurses

29 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 families Keeps administrative expenses under 10% of total program cost Has survived a landmark shift in power away from the political party that established it.

30 PROGRESA: Effective Targeting Percent of Total Program Benefits Bottom 20% of National Population Bottom 40% of National Population

31 Health impact often requires a multisectoral approach Even with good infrastructure, other activities such a behavior change, are needed Impact of piped water on diarrhea prevalence among children by income quintile, India Income quintiles change in diarrhea probability x 100 0% -20% -40% -60% -80% Poorest 2nd Middle 4th Richest

32 Partnerships Key to achieving the MDGs Broadens scope beyond government capacity to deliver services Increases transparency and accountability Government can take on a more stewardship role Types: International alliances to bring needed commodities to market Gov./Business/ Civil Society: targeted efforts to tackle specific public health issues Gov-NGO: give voice to population and access hardto-reach populations

33 Partnerships NGOs and Civil Society Essential link at the grassroots level that can be in getting services to the hardestto-reach populations Can increase participation by tapping into social capital at the community level

34 Partnerships: Cambodia contracting Percentage of Poorest 20% Benefited by Intervention Government Areas Contracted-In Areas Contracted-Out Areas

35 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

36 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 noncommunicable diseases (NCDs)

37 Deaths, by broad cause group and WHO Region, 2003 % AFR EMR SEAR WPR AMR EUR Noncommunicable conditions Injuries Communicable diseases, maternal and perinatal conditions and nutritional deficiencies Source: WHO

38 Reaching MDGs will not be enough High 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 Regional average Central Asia & Caucasus E. and S. Europe Remaining FSU Increase in life expectancy (years) Reaching MDGs 4 and 5 Reaching EU levels for CVD and external causes

39 The MDG+ Agenda- Implications for Health Promotion Work multisectorally Target effectively Strengthen prevention efforts Build on existing HP models Build partnerships with the private sector