Reaching the MDGs Evidence on High Impact Interventions-

1. Reaching the MDGs Evidence on High Impact Interventions- Agnes Soucat, World Bank and Netsanet Walelign, UNICEF Kigali June 23-27

2. Why are we here today ?

3. Progress towards MDGs: inadequate Trend in Under-Five Deaths, 1960-2015 (Millions deaths per year)

4. Growth is not enough 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.

5. Yet we know that some interventions are highly effective

6. Most mortality causes still avoidable with low cost interventions

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

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

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

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

11. Saving 1.3 million lives per year for $ 400 per life saved: jumpstarting community care & outreach

12. Saving 2.5 million lives per year for $ 800 per life saved: Full Minimum Package at scale:

13. Saving 5.5 million lives per year for $ 1,500 per life saved: maximum package at scale.

14. So why is it not happening ?

15. Countries use well-designed policies to achieve growth and human development outcomes Services Governments/donors Health, Education, Poverty But… *

16. But, what looks good on paper seems to break down in practice… Government Leakage of Funds Bad policy Poor budget handling Local Govt. Sub-optimal spending (Big salary bills but insufficient textbooks & materials) Providers Financing problems Information & monitoring Local govt. incentives skewed Local capacity issues Communities Low quality instruction Provider incentives unclear, absenteeism Hard to monitor, users helpless Quality inappropriate Primary education Lack of demand Clients Externalities Community norms Budget constraints Intra-household behavior

17. Budgeting for results

18. Results-based Financing Donors Sub-National Government District National Government Results Based Aid Results Based Planning and Budgeting Results Based Contracting for CCT, RB bonuses Hospitals, Health Centers, Ass Households or Individuals

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

20. Removing Coverage Bottlenecksin Ethiopia: scaling up ITN

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

22. The Challenge of Scaling Up in Ethiopia

23. The Challenge of Scaling Up in Rwanda Current Health Expenditures

24. Results ?

25. Malaria out patient Non Malaria out patient Dramatic decrease of malaria in Rwanda

26. Rwanda 2005-2008

27. Rwanda: back on track for the MDGs