Accelerating progress towards the health-related Millennium Development Goals The critical role of the national health policy & strategy in strengthening health systems and delivering effective interventions in an integrated approach to accelerate progress towards the health MDGs, with a special focus on the health of women and children.
The Millennium Development Goals In September 2000, 189 heads of state adopted the UN Millennium Declaration and endorsed a framework for development. The plan was for countries and development partners to work together to reduce poverty and hunger, and tackle ill health, lack of education, gender inequality, lack of access to clean water and environmental degradation. Eight Millennium Development Goals (MDGs) were established, with targets for 2015, and indicators to monitor progress. Three MDGs relate directly to health; to reduce child mortality by two thirds (MDG 4), to reduce maternal deaths by three quarters and achieve universal access to reproductive health (MDG 5), and to halt and reverse the spread of HIV/AIDS, achieve universal access to treatment for HIV/AIDS by 2010, and halt and reverse the incidence of malaria and other major diseases (MDG 6). Other MDGs have an indirect influence on health; MDG 1 has a target of halving the proportion of people who suffer from hunger; MDG 7 includes a target of halving the proportion of the population without sustainable access to safe drinking water and basic sanitation; and MDG 8 has a target to provide access to affordable essential drugs in developing countries. Primary education (MDG 2) and empowering women (MDG 3) also lead to health gains. MDG goals, targets and indicators are interdependent measures of progress. They are not meant to limit priorities in health, nor define how programmes should be organized and funded. 2
Progress is being made, but huge challenges remain Progress The MDGs have been a powerful force in the fight to reduce poverty and inequity Health is at the centre of the development agenda. All the MDGs influence health, and all causes of ill-health affect the achievement of the MDGs The focus on specific goals has spurred innovation new tools, new ways of doing business and new resources Progress is being made, but is unequal and fragile Challenges Conflict-affected and fragile states are furthest away from achieving the MDGs More efforts and investment are necessary to prevent set backs, and to accelerate progress towards the MDGs Better data are key the lack of investment in health information systems at country level to assess achievements is a significant problem Time is short urgent action is needed 3
Health-related MDGs the scorecard 4 The number of children dying before their fifth birthday fell by 30% from 12.4 million in 1990 to 8.8 million in 2008, but diarrhoea and pneumonia still kill 3 million children a year. 40% of child deaths occur in the first month of life most in the first week. Undernutrition is an underlying cause in about one third of child deaths. 99% of maternal deaths occur in developing countries. In Africa and South-East Asia less than 50% of women receive skilled care during childbirth. A woman in the wealthiest quintile is three times more likely to have a skilled birth attendant at the time of delivery than a woman in the poorest quintile. Bleeding and high blood pressure cause over 50% of deaths in pregnancy and child birth. Contraceptive prevalence in developing countries increased from 50% in 1990 to 62% in 2005. New HIV infections declined by 16% between 2000 and 2008. 5 million of the 9.5 million people who need ARV therapy do not have access to treatment. The proportion of women receiving ARV treatment in pregnancy to prevent mother to child transmission of HIV increased by 10% to 45% between 2007 and 2008. 38 of 108 malarious countries reduced malaria cases by 50% or more between 2000 and 2008. The global incidence of TB has declined since 2004, but the estimated number of multidrugresistant cases increased to 440 000 in 2008. Noncommunicable diseases and injuries caused an estimated 33 million deaths in developing countries in 2004. 85 countries representing 66% of the world s population do not have reliable cause of death statistics.
Health MDGs scorecard for WHO Regions Under 5 mortality per 1000 live births Measles immunization % coverage Maternal mortality per 100 000 live births Skilled birth attendant % births Contraceptive use % married women aged 15 49 HIV/AIDS prevalence % adults aged 15 45 Malaria mortality per 100 000 population TB treatment success rate % Water % using improved sources Sanitation % using improved facilities World Africa Americas Eastern Mediterranean Europe South-East Asia Western Pacific 65 142 18 78 14 63 21 81 73 93 83 94 75 93 400 900 99 420 27 450 82 66 47 92 59 96 49 92 62 24 71 43 68 58 83 0.8 4.9 0.5 0.2 0.5 0.3 0.1 17 104 0.5 7.5 2.1 0.3 86 79 82 88 67 88 92 87 61 96 83 98 86 90 60 34 87 61 94 40 62 on track insufficient progress off track Data from World Health Statistics 2010 5
Review of progress reveals clear priorities Women and children are at the centre of efforts to achieve the MDGs. Rapid reduction of maternal and newborn deaths is the most urgent and obvious priority. Ensuring safe child birth is the greatest challenge. Success requires access to effective interventions across the life course. Rapid progress in delivering these interventions is limited by the capacity of health care delivery systems. Efforts are needed to strengthen health systems and to address the broader social and economic determinants of the health of women and children. Continuing investment in the fight against HIV/AIDS, malaria, TB, neglected tropical diseases and noncommunicable diseases is important in its own right and as a means of improving the health of women and children. The UN Secretary-General has called for a Joint Action Plan to Improve the Health of Women and Children. 6
Women and children are at the centre of efforts to achieve the MDGs Maternal mortality ratio by WHO region Child mortality at global level Africa Americas Eastern Mediterranean Europe South-East Asia Western Pacific Probability of dying by age 5 per 1000 live births 900 800 910 900 Trend Goal 100 90 87 Actual Goal 700 650 80 78 per 100 000 live births 600 500 400 380 420 450 60 70 65 300 200 227 130 162 120 99 100 82 32 95 39 27 30 10 0 1990 2000 2010 1990 2000 2010 1990 2000 2010 1990 2000 2010 1990 2000 2010 1990 2000 2010 40 20 30 1990 1995 2000 2005 2008 2015 Maternal mortality in 2005: estimates developed by UNFPA, UNICEF, WHO and the World Bank. Geneva, World Health Organization, 2007; www.who.int/whosis 7
National health policy & strategy is the basis for improving health outcomes Better health outcomes depend on effective interventions delivered by better health systems. Better health requires coherent policies and a comprehensive approach that also addresses the social, environmental and economic determinants of ill-health. Outcomes, interventions, programmes and systems come together in a robust national health policy & strategy. Systems that seek synergies between programmes get better results and can accelerate progress towards the MDGs. The national health policy & strategy links an analysis of needs and current performance with future objectives and priorities and details of the financial and institutional arrangements needed to achieve them. Development of a national health policy & strategy must be country-led and requires an inclusive process of consultation to ensure democratic ownership of the product. There is an urgent need to align external support around the national health policy & strategy to reduce fragmentation and the burden on countries. 8
Linking policy to outcomes Policy framework National health policy & strategy National health system Interventions & programmes Better health outcomes National National development policy and plan Poverty reduction strategy Legislative framework Global Millennium Declaration and Development Goals Primary Health Care reforms Paris declaration on aid effectiveness Abuja declaration (2001) International Health Regulations (2005) Framework Convention on Tobacco Control The comprehensive national health plan which describes the context, needs and priorities structure and governance functions and financing targets and monitoring Based on the Three Ones; one plan one coordinating framework one monitoring system Service delivery & infrastructure Health workforce Health information Medical products Financing Leadership & governance Counselling and education Clinical interventions e.g. diagnosis and treatment of disease Protective interventions e.g. vaccination Enabling environment e.g. water and sanitation, public health legislation Socioeconomic interventions e.g. housing, education Reduced mortality and morbidity Reduced risks and threats to health Reduced inequities in health Improved health of women and children 9
Strengthening health systems A health system consists of all the organizations, institutions, resources and people whose primary purpose is to improve health. The six building blocks of a health system are health services and infrastructure, the health workforce, a health information system, medical products, vaccines & technologies, health financing, and leadership & governance. A well functioning health system responds in a balanced way to the population s health needs and expectations by addressing key constraints in the six building blocks, to provide equitable access to people-centred care, with a special focus on women, girls and children. Coverage of interventions that depend on a functioning health care system, such as skilled care during delivery, tends to be lower than interventions delivered through specific programmes, such as immunization. Therefore, a comprehensive range of effective public health and clinical interventions, targeted at mothers, newborn and children, delivered in an integrated approach, is urgently needed to improve the health of women and children. There is a direct relationship between the ratio of health workers to population and survival of women during childbirth and children in early infancy. Sub-Saharan Africa has 11% of the world s population, 24% of the global burden of disease, but only 3% of the world s health workers. 10 A monitoring and evaluation plan with mechanisms to assess quality of care, monitor progress against indicators and targets, and measure health system performance is essential for accountability.
Women and children are dipping in and out of the health care system PRE-PREGNANCY PREGNANCY BIRTH POSTNATAL CHILDHOOD ADOLESCENCE ADULT / OLDER AGE 100 Percentage 90 80 70 60 50 40 30 20 10 0 at least 1 ANC visit Skilled birth attendant Measles Full immunization Pneumonia care at least 4 ANC visits BCG DPT ORT Family planning 11
Delivering effective interventions over the life course to improve health Health systems are designed to deliver a set of effective clinical and public health interventions over the life course to achieve better health outcomes. Interventions can be grouped into five tiers; counselling & education; clinical interventions; protective interventions; enabling environment; and socioeconomic interventions. Creating an enabling environment and socioeconomic interventions have the greatest population impact, such as legislation to promote safe driving, and efforts to reduce poverty and increase employment. Some preventive and clinical interventions also have a population impact, such as vaccination and treatment of communicable diseases. Counselling and education require the greatest individual effort, such as advice to stop smoking. Essential protective and clinical interventions such as immunization and treatment of disease are necessary but insufficient to reach the MDGs addressing socioeconomic factors and creating an enabling environment is crucial. Different interventions often contribute to multiple outcomes and frequently have linkages to one another. For example, immunization can be bundled with growth monitoring, distribution of bed nets, micronutrient supplements and other interventions for mothers and children. Many highly effective interventions that have a significant impact on the health of women and children are the severely under-resourced. 12 Based on: Frieden TR A Framework for Public Health Action: The Health Impact Pyramid. Am J Public Health 2010; 100:590-595
Delivering effective interventions over the life course PRE-PREGNANCY PREGNANCY BIRTH POSTNATAL CHILDHOOD ADOLESCENCE ADULT / OLDER AGE Counselling and education Clinical interventions Protective interventions Family planning Promoting breastfeeding Sexual & reproductive health counselling Promotion of healthy life style (alcohol, diet, smoking, physical activity, etc.) Diagnosis and treatment of HIV/AIDS, TB, Malaria, NTDs, and other infectious diseases Antenatal care Safe delivery Postpartum and newborn care Preventing mother-to-child transmission of HIV Intermittent preventive malaria treatment Immunization Management of childhood illness Sexual & reproductive health counselling Early detection, diagnosis and treatment of NCDs: cardiovascular disease, diabetes, cancer and asthma Growth monitoring Family planning Vit A, micronutrients Cancer screening De-worming and other preventive treatment for NTDs Increasing individual effort needed Increasing population impact Enabling environment Socioeconomic interventions Insecticide-treated nets and indoor residual spraying Safe water and improved sanitation Reducing stigma and discrimination Providing facilities, parks, cycle ways to encourage physical activity Better nutrition including policies to reduce salt, trans fats and sugar in foods Road safety, including speed controls, motorcycle helmets, seat belts, drink-driving laws, and child seats Health legislation including tobacco taxation, smoke free workplace, licensing of doctors, hospitals, pharmacies and labs, food, etc. Housing Education Employment Early childhood development Empowerment of women and gender equity Note: this is not a comprehensive list of all health interventions to achieve the MDGs 13
Financing for the MDGs should promote sustainability and enhance fairness 14 The facts Direct out-of-pocket payments prevent millions of people from using needed services and can lead to impoverishment. People can be protected from financial hardship through national health financing policies that promote pooling of risk and resources. Extending health protection through insurance and tax-financed systems aims to achieve universal coverage. Most expenditure for the MDGs will continue to come from domestic sources. The poorest and least stable countries will continue to need external aid for the foreseeable future. Aid for health must be predictable, aligned with nationally-defined priorities, provided in ways that minimize transaction costs, designed to enhance sustainability and limit dependency on external funds. The evidence A basic package of health services costs US$ 35 50 per person per year. Low-income countries currently spend on average US$ 25 per person per year on health, of which US$ 10 is out of pocket expenditure. In 47 countries, out of pocket payments account for over 50% of total health expenditure. 100 million people are driven below the poverty line every year due to catastrophic health care payments. Spending on health in low-income countries needs to increase from US$ 31 billion now to US$ 67 76 billion by 2015. Development assistance for health increased from US$ 6.8 billion in 2000 to US$ 16.7 billion in 2008. External resources in low-income countries have increased from 12% of total health expenditure in 2000 to 17% in 2006.
Estimated financial gap for 49 low-income countries Billions (US$) 50 Tuberculosis 40 30 Scale up period 27 36 42 40 42 45 Programme costs for other health topics US$ 9 billion Programme costs for women s & children s health US$ 5 billion Malaria HIV/AIDS Other essential drugs Childhood illness Immunization Maternal health Family planning 20 19 Human resources 10 Health systems costs US$ 31 billion Infrastructure Supply chain / logistics Health info systems Governance / regulation Health financing 0 2009 2010 2011 2012 2013 2014 2015 Note: additional resources are needed to meet the funding gap in high burden middle income countries Source: WHO and Taskforce on Innovative Financing for Health Systems, 2009 15
Conclusions The MDGs have been a powerful force in the fight to reduce poverty and inequity. Progress towards the health MDGs is being made, but is unequal and fragile. The need to reduce maternal and newborn deaths emerges as the most urgent and obvious priority. Improving the health of women and children requires (a) effective interventions; (b) health systems to deliver those interventions; and (c) policies & strategies that set out how the resources needed to deliver results will be mobilized and deployed. A comprehensive national health policy & strategy is therefore the foundation for improving the health of women and children. The national health policy & strategy identifies health system and programme needs to deliver effective interventions that achieve health outcomes. There is an urgent need to increase investment in the health of women and children... and to align financial and technical support with the national health policy & strategy. http://www.who.int/topics/millennium_development_goals World Health Organization 2010. All rights reserved. WHO/DGO/2010.2