Take-home messages Challenges for all

2. Take-home messagesChallenges for all • The MDGs matter for poverty-reduction • Mixed ½-time score; 2nd half better? • Effective interventions exist; use is too low • For countries: • Extra govt. health necessary, not sufficient • Additional exp. needs to be targeted… • … and accompanied by broad strengthening of policies & institutions—households, providers, HR, medicines, financing, public health, intersectoral • For donors: • Integrating MDGs into assistance strategies & lending programs; intersectoral • More aid, but aid needs to be timely, MDG-focused, coordinated, linked to PRSP & MTEF

3. The MDGs matter for poverty-reduction Why the MDGs matter—i It’s the world’s poor who die earlier Global income quartiles

4. The MDGs matter for poverty-reduction Why the MDGs matter—iiIll health causes poverty

5. The MDGs matter for poverty-reduction Why the MDGs matter—iiIll health causes poverty Out-of-pocket payments for health care pushed 2.6m Vietnamese into poverty in 1998. Increased headcount by 23% and normalized poverty gap by 25%

6. A mixed half-time score The Millennium goalsNearly half concern health & nutrition

7. The good news… Nearly 80% of world’s population lives in a country that’s on track to hit the malnutrition target In 38% of countries, U5MR declined faster in 1990’s than in 1980s E Asia & Middle East & N Africa fared well on MMR decline in 1990s … and the bad U5MR—slow progress; getting slower Africa—lagging badly Challenges for all regions Faster progress on some goals than others Poorest countries making slowest progress Within countries, poorest 20% often progressing more slowly than population as a whole A mixed half-time score A mixed half-time score—iThe news isn’t all bad

8. A mixed half-time score A mixed half-time score—ii Laggards even in regions doing well Target rate of reduction

9. A mixed half-time score A mixed half-time score—iii Poor countries progressing slowest Target Target Target World Bank calculations from trend data on malnutrition (WHO) and U5MR (UNICEF), and MMR projections from 1995 data. NB Data for Goal #6 on communicable diseases too limited to perform these calculations.

10. The good news… Economic growth set to accelerate everywhere except E Asia Additional contributions possible from faster progress on elimination of gender gaps in secondary education (MDG #3) expanding access to drinking water (MDG #7) … and the bad Combined contributions of these stimuli: appreciable, but mostly insufficient to get countries on track They’ll be offset—at least in part—by slower changes within health sector E.g. MMR likely to fall less quickly as attended deliveries rise more slowly and fertility declines more slowly Will the second half go better? Prospects for the second halfSwings & roundabouts

11. Plenty of effective interventions Effective interventions existThey need to reach more people Cause of death

12. Rising to the challenges—countries Extra govt. health spendingNecessary, but not sufficient • Proportional scaling-up across programs • Leads to bigger decline in MMR than U5MR • Impact is: • Greater in countries with good policies & institutions, as measured by the Bank’s Country Policies and Institutions Assessment (CPIA) • Negligible when CPIA is very low • But… even in countries with high CPIA • 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

13. Rising to the challenges—countries Proportional scaling-upExpensive way of reaching MDGs Calculations show how far share of GDP devoted to government health spending would need to rise by to achieve U5MR MDG, if current spending patterns were scaled up proportionately

14. Rising to the challenges—countries Targeting for bigger returns Returns to removing bottlenecks * Baseline is optimistic estimate for a country with below-average quality policies & institutions. Actual change may be a good deal smaller.

15. Rising to the challenges—countries Stronger policies & institutions Households & providers • Lower all household barriers • 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) • Examples where performance improved through clearer responsibilities, accountability, links between performance & rewards, etc. • Between organizations and public: • Directly (patient-provider)—e.g. governance participation, information dissemination • Indirectly (policymaker-provider)—e.g. contracting, partnerships, social marketing

16. Rising to the challenges—countries Stronger policies & institutions HR, drugs, public health, finance • Tackling HR and drugs constraints • HR: Improve returns to employment; training to focus on MDG-specific; etc. • Drugs: better logistics and incentives to get drugs to frontline; behavior change against poor quality drugs; etc. • Strengthening core public health functions • Strategies for disease prevention, treatment & control; govt.-led M&E; intersectoral—beyond MOH • Sustainable health financing • Work out what’s affordable; where appropriate mobilize extra domestic resources • Better PRSPs and MTEFs; align goals & resources • Rely less on out-of-pocket expenditures

17. Rising to the challenges—countries HR recruitment & retentionMoney isn’t everything

18. Rising to the challenges—countries Intersectoral agenda is keyInfrastructure and behavior change

19. Rising to the challenges—countries Spending what’s affordableWho does it? Who doesn’t?

20. Rising to the challenges—development community The World Bank What’s it doing vis-à-vis the MDGs? Country assistance strategies Using the goals to assess country assistance strategies Lending & Technical Assistance Dialogue Helping incorporate the MDGs in government policies & budgets Integrating MDGs in sectorwide and programmatic instruments Reorienting and increasing Bank loans & grants to achieve MDG outcomes Analytical work Analyzing MDG trends, prospects, and challenges M&E Using the goals for building M&E capacity

21. Rising to the challenges—development community Learning the lessons of DAHImplications for MDGs • Aid is too unpredictable, and the transaction costs are too high • Aid works better the better the policy environment • Aid can help foster good policies, and facilitate transition to them • Aid is fungible; points towards enhanced coordination, aid pooling, and putting countries in the driver seat • Global partnerships can add value, but contain risks

22. Take-home messagesChallenges for all • The MDGs matter for poverty-reduction • Mixed ½-time score; 2nd half better? • Effective interventions exist; use is too low • For countries: • Extra govt. health necessary, not sufficient • Additional exp. needs to be targeted… • … and accompanied by broad strengthening of policies & institutions—households, providers, HR, medicines, financing, public health, intersectoral • For donors: • Integrating MDGs into assistance strategies & lending programs; intersectoral • More aid, but aid needs to be timely, MDG-focused, coordinated, linked to PRSP & MTEF

23. Additional Slides – ECA focus

24. Why the MDGs matter for all- including ECA countries • Progress can be quickened, irrespective of targets • Progress needs to be for everyone, not just the better off • Goals help focus on outcomes

25. The good news… Low child malnutrition rates, and most countries reducing malnutrition quickly Low maternal mortality rates in many countries … and the bad Slow progress in reducing child mortality and maternal mortality, especially in Central Asia Sharp increase in HIV incidence in some countries; TB burden remains high ECA has a mixed half-time score—Good news and bad

26. Why the MDGs matter for ECAThe poor are lagging

27. Tuberculosis and HIV/AIDSRapidly increasing in some countries

28. Reaching MDGs will not be enoughHigh returns from reducing adult mortality – MDG+ approach

29. Adult mortality rates are highand increasing in some countries

30. Adult male mortality, 2000