Reaching the MDGs: do
we have a way forward?
Agnes Soucat, Lead Advisor, Health Nutrition Population, Africa
The World Bank
Antwerp, December 17

Why are we here today ?

Progress towards MDGs:
inadequate
25
Trend in Under-Five Deaths, 1960-2015 (Millions deaths per year)
Africa Asia Other
20
4.1
3.6
15
2.7
1.8
1.4
10 13.5 1.1
10.9 0.8
8.3 7
5.1 4.1
3
5 0.1
2.2
5.1
4.9
4.6
4.1
3.5
3.2
2.9
2
0
1960 1970 1980 1990 2000 2005 2015 with 2015 with
achievement of current Trend
MDGs

Growth is not enough
Percent living on $1 / Primary completion
day rate (
percent) Under- mortality
5
rate
Target 201 5 Targe 201 5 growth Targe 201 5 growth
growth t alone t alone
alone
East Asia 14 4 100 100 19 26
Europe and 1 1 100 100 15 26
Central Asia
Latin America 8 8 100 95 17 30
Middle East and 1 1 100 96 25 41
North Africa
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.

Yet we know that some
interventions are highly effective

Most mortality causes still avoidable
with low cost interventions
Neonatal
Cause-specific proportional
mortality in the Africa region HIV/AIDS
6%
Diarrhoeal
2%
21% diseases
Measles
21%
Malaria
7%
Respiratory
infections
Injuries
17%
17%
4% Others

Household and community level
interventions(1)
 Insecticide Treated Mosquito Breastfeeding

Nets Complementary feeding

Safe water systems
 Therapeutic Feeding

Use of sanitary latrins
 Oral Rehydration Therapy

Hand washing by mother
 Zinc for diarrhea

Indoor Residual Spraying management

(IRS) Vitamin A - Treatment for

Clean delivery and cord care measles

Early breastfeeding and Chloroquine for malaria
 
temperature management (P.vivax)
Universal extra community- Artemisinin-based
 
based care of LBW infants Combination Therapy
Antibiotics for U5 pneumonia

Community based

management of neonatal
sepsis

Population oriented interventions (2)
 PMTCT
 Family planning
 VCT
 HPV vaccination
 Cotrimoxazole prophylaxis for
 Preconceptual folate
HIV+
supplementation
 Measles immunization
 Tetanus toxoid
BCG immunization

Deworming in pregnancy

OPV immunization

Detection and treatment of

asymptomatic bacteriuria DPT immunization

 Treatment of syphilis in Hib immunization

pregnancy  Hepatitis B immunization
 Prevention and treatment of iron Yellow fever immunization

deficiency anemia in pregnancy  Meningitis immunization
 Intermittent preventive treatment
Pneumococcal immunization

(IPTp) for malaria in pregnancy
Rotavirus immunization

 Balanced protein energy
Neonatal Vitamin A

supplements for pregnant
supplementation
women
Vitamin A - supplementation

Supplementation in pregnancy

with multi-micronutrients Zinc preventive


Individual clinical interventions (3)
 Skilled attended delivery  Management of severely sick
children (referral IMCI)
 Basic emergency obstetric care (B-
EOC)  Chloroquine for malaria
(P.vivax)
Resuscitation of asphyctic

newborns at birth  Artemisinin-based Combination
Therapy
Antenatal steroids for preterm

labor  Management of complicated
malaria (2nd line drug)
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

Individual clinical interventions (3)
 Management of opportunistic  Detection and management
infections
of STI
Male circumcision

Management of opportunistic

Second-line ART

infections
Adult second-line ART

First line ART

Comprehensive emergency

obstetric care (C-EOC) Detection and treatment of

Other emergency acute care

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

Saving 1.3 million lives per year for $ 400 per
life saved: jumpstarting community care &
outreach
Expected Impact on Neonatal, Under Five and Maternal
Mortality and Additional Economic Cost
Scenario I : Africa generic
25% $1.0
Mortality reduction
20%
$ 0.66
15%
$0.5
$ 0.43
10%
$ 0.22
5%
$ 0.00
0% $0.0
Family/community Outreach/schedulable Clinical Total Services
Delivery modes
Neonatal Mortality Under Five Mortality
Maternal Mortality Incremental Economic Costs per capita/year

Saving 2.5 million lives per year for $ 800
per life saved: Full Minimum Package at
scale:
Expected Impact on Neonatal, Under Five and Maternal
Mortality and Additional Economic Cost
Phase I : Africa generic
45% $3.0
40%
Mortality reduction
$2.5
$ 2.48
35%
30% $2.0
25%
$1.5
20% $ 1.09
15% $1.0
$ 0.72
$ 0.67
10%
$0.5
5%
0% $0.0
Family/community Outreach/schedulable Clinical Total Services
De live ry mode s
Neonatal Mortality Under Five Mortality
Maternal Mortality Incremental Economic Costs per capita/year

Saving 5.5 million lives per year for $ 1,500 per
life saved: maximum package at scale.
Expected Impact on Neonatal, Under Five and Maternal
Mortality and Additional Economic Cost
Phase III : Africa generic
80% $10
75% $ 9.26
$9
70%
65% $8
Mortality reduction
60%
$7
55%
50% $6
45%
40% $5
$ 4.11
$ 3.84
35%
$4
30%
25% $3
20%
$2
$ 1.31
15%
10% $1
5%
0% $0
Family/community Outreach/schedulable Clinical Total Services
De live ry mode s
Neonatal Mortality
Under Five Mortality
Maternal Mortality
Increm ental Econom ical Cos ts per capita/year

So why is it not happening ?

Countries use well-designed
policies to achieve growth rs
no
and human development do
s/
nt
outcomes e
m
rn
e
ov
G
Health,
But…
Education,
Poverty
es
ic
rv
e
S
*

But, what looks good
on paper seems to ent
rnm
ove
break down in G Leakage of Funds
vt.
Bad policy
practice…
Go
Poor budget handling
cal
Lo
Sub-optimal spending
(Big salary bills but insufficient
iders
textbooks & materials)
Prov Financing problems
Information & monitoring
Local govt. incentives skewed
es
iti
Local capacity issues
un
Low quality instruction
mm
Provider incentives unclear, absenteeism
Primary Hard to monitor, users helpless
Co
Quality inappropriate
education
nts
ie Lack of demand
Cl Externalities
Community norms
Budget constraints
Intra-household behavior

Financing for results

Accountability
patches… ent
rnm
ove
G Leakage of Funds
vt.
Results Based
Go
Transfers
cal
Lo
Sub-optimal spending
(Big salary bills but insufficient
iders
textbooks & materials)
Prov Results Based Financing
es
iti
un
Low quality instruction
mm
Results Based Financing
Primary
Co
education
nts
ie
Cl Condiitonal Cash Transfer

Results-based Financing
D ono r
s S ub-
N a tio na l
N a tiona l
G overnm
G overnm ent
ent
D is tric t
Results Based Aid
Results Based
Planning and
Budgeting Results Based
Contracting for
CCT, RB
bonuses
Households
Hospitals, Health Centers, Ass
or Individuals

Steps in Results-Based Budgeting
Step 1: Health Systems and
Step 2: System Bottlenecks to
High Impact Interventions
Coverage
•Analyze health systems.
•Analyze household surveys and service
•Identify major U5MR, NNMR, MMR
statistics, using six coverage determinants,
causes.
to identify system bottlenecks to coverage &
•Identify high impact health, nutrition, AIDS,
causes.
& malaria interventions (level 1-2 evidence).
•Supply side: availability of essential
•Organize interventions into 3 service
commodities, availability of human resources,
•delivery modes: Family oriented
and physical access.
community-based; Population oriented
•Demand side: initial and timely continuous
schedulable; and individual oriented
Utilization; Effective quality coverage.
clinical services.
•Analyze strategies to address bottlenecks
•Select representative tracer interventions
and set new coverage frontiers.
for each sub-package of interventions.
Step 5: Budgeting and
Fiscal Space Step 3: Estimating Impact
•Translate marginal cost into yearly •Epidemiometric model.
additional budget figures. •Estimate the impact (reduction in
Step 4: Estimating
•Link budget figures to national mortality) of overcoming the
Marginal Cost
sector plans, MTEF, PRSP, and bottlenecks based on local causes
other programs. •Estimate marginal costs to of NNMR, U5MR and MMR.
•Facilitate analysis on financing overcome the bottlenecks and •Sources include: MDG1 (Emory),
sources. achieve new performance frontiers. MDG4 (Bellagio), MDG 5 (WHO/
•Evaluate additional funding •Region/country specific inputs and WB Cochran; BMJ), and MDG 6
requirement against the fiscal space cost structures. (RBM, UNAIDS).
for health.

Removing Coverage Bottlenecks
in Ethiopia: scaling up ITN
trained and
deployed
about 20,000
procurrred policy
HEW
>20,000 ITN de cis ion: long
100% las ting ITN
80% 80%
75%
72%
65%
75%
50%
36%
20%
25%
16%
2007
4% 1%
2005
0%
ITN in HEWs Fam ilie s w ith Us ing ne t Us ing tr e ate d
dis tr icts ne t ne t
2005 2007

Linking Flow of Funds to Impacts
Inputs (Health & WSS
Bottlenecks MDGs Outcome
Health Output
Inputs) to Release
1
Essential drugs commodities,
Availability
∆C of health &
safe water system, and/or
human resources etc.
nutrition interventions
Support for community delivered by
Impact on MDG
meeting, inputs for a mobile Family/Community
Accessibility
team, construction of health health
post etc. indicators:
∆C of health & Reduction in
Drugs and supplies, subsidies U5MR and
nutrition interventions
Utilization
for insurance for referral care
MMR
delivered by Outreach
per user etc. team
Demand side subsidy,
∆C of health & Cost of
performance-based incentives Continuity
for health workers, doctors, removing
and IEC inputs etc. nutrition inter-ventions bottlenecks to
delivered by
achieve certain
Clinics/Hospitals
Training, supervision and
MDG target
monitoring of community Quality
mobilizers, primary and
referral clinical care etc.
Aggregate Cost of Inputs

The Challenge of Scaling Up in Ethiopia
US$
(2004 constant $)
35
Strategy
30
Step 5: Expansion and upgrade of referral
25
care
Step 4: Expansion and upgrade of emergency
Step 5
obstetrical care
20
Step 3: First level clinical upgrade
Step 4
15
Step 3
Step 2: Health services extension program
10 Step 2
Step 1
Step 1: Information and social mobilization for
5
behavior change
Current Health
Expenditures
0
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

The Challenge of Scaling Up in Rwanda
Per Capita Cost of Strategy
Scaling Up to Reach MDGs
$40
Step 6: Scaling up HAART
$35
Step 5: strengthening national hospitals
$30
Step 4: upgrading district hospitals
$25
Step 3: Mutuelles for indigents
$20
$15 Step 2: Performance Based Financing
at health centres
$10
Current Health Step 1: Information and mobilisation at
community level
Expenditures
$5
$0
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Results ?

Dramatic decrease of malaria in
Rwanda
 Malaria out patient
 Non Malaria out patient
Sheet 1 Sheet 1
Age group Age group
5 years and above 5 years and above
220K
Under 5 years Under 5 years
25K
200K
180K
20K
Sum of Conf# outpatient malaria
160K
Sum of Non malaria OPD
140K
15K
120K
100K
10K
80K
60K
5K
40K
20K
0K
0K
2001 2002 2003 2004 2005 2006 2007
2001 2002 2003 2004 2005 2006 2007
The trend of sum of Conf# outpatient malaria for Year G#C. Color shows details
The trend of sum of Non malaria OPD for Year G#C. Color shows details about
about Age group . The data is filtered on Country , which keeps Rwanda. The
Age group . The data is filtered on Country , which keeps Rwanda. The view is
view is filtered on Age group , which keeps 5 years and above and Under 5
filtered on Age group , which keeps 5 years and above and Under 5 years.
years.

Rwanda 2005-2007
Indicators DHS-2005 DHS-2007
Contraceptive prevalence: 10% 27%
Modern methods
Delivery in Health Centers 39% 52%
Fertility 6.1 children 5.5 children
Use of Insecticide treated nets 4% 67%
among children less than 5
Anemia Prevalence : Children 56% 48%
Anemia Prevalence : Women 33% 27%
Vaccination : All 75% 80.4%
Vaccination : Measles 86% 90%
Infant Mortality rate 86 per 1000 62 per 1000
Under-Five Mortality rate 152 per 1000 103 per 1000

Rwanda: back on track for the MDGs
Progress towards the MDGs
80% $35
70% $30
$29.35
60%
$25
50%
$19.98 $20
40%
$15
30%
$10
$8.83
20%
$5
10%
0% $0
Phase I Phase II Phase III
MDG 1 MDG5 MDG 6 MDG 7
MDG4
Anaemia Reduction of Low Birth weight Estimated reduction in stunting
IMR reduction NNMR reduction MMR reduction
Total fertility rate (TFR) Reduction of Malaria Mortality Reduction in AIDS mortality
Quality of drinking water Use of sanitary laterin Hand washing by mother