Closing the policy implementation gap Dr Mickey Chopra UNICEF, New York

1. Closing the policy implementation gap Dr Mickey Chopra UNICEF, New York

2. The implementation gap is costing lives

3. More training and supervision alone not the answer Each dot represents one department Source: Huicho et al, HPP, 2005

4. Distribution of 213 MES from 172 studies with adequate design (all strategies) 50% are small (<10%-points) or negative Min = -105 Median = 9 Max = 130 IQR: 3–23 No. of MES -100 to -109 -30 to -39 0 to 9 30 to 39 -20 to -29 -10 to -19 -0.1 to -9 10 to 19 20 to 29 40 to 49 50 to 59 60 or higher Magnitude of effect size (percentage-point change)

5. 3 Main ways of reducing gap 3. Legislation/ Policy changes 2. Demand/Empowerment 1. Delivery system

6. 1. Changing the delivery system

7. We have a number of cost effective treatment and prevention interventions Treatment Emergency obstetric care Acute ACTs Antibiotics for Pneumonia Supplements (e.g. Zinc, Vitamin A, folic acid) ORT Emergency neonatal care Lab-based diagnostics Malaria Severe case management Field-based diagnostics IMCI ARVs Fortified food Primary care Misoprostal For PPH DOTs Chronic Attended delivery Oxytocin For PPH Temporary Vaginal contraceptives PMTCT Microbicides Clean home delivery kits IPTp, IPTi Male contraceptives Bednets Chemo prophylaxis IRS Campaign-delivered vaccines Male circumcision EPI-delivered vaccines Long-lasting Prevention

8. Providers: Hospitals Clinics Individual practitioners (licensed or not…) Individual Oriented non-schedulable services High asymmetry of information Transaction intensive High discretion Bottlenecks: Skilled human resources Physical access Quality Cost Levers: Direct control of users Self Regulation Sophisticated purchasing capacity

9. Cross cutting bottlenecks & strategies for clinical care level in Africa ARI management Skilled delivery Stockouts of supplies Lack of access to HC Low continuity Poor quality BEOC CEOC • Strategies to remove bottlenecks • Improve supply of essential drugs & supplies • 2. Increase financial access & perceived quality • 3. Ensure quality of care: supervision & training

10. Population Oriented Schedulable Services • Providers • Integrated in clinical services (clinics, GP) • Integrated in schools, workplace • Outreach health post • Mobile Activities • Home visits, door to door activities Lower Asymmetry of information Less Transaction intensive Low discretion: standards Public good nature or network externality Bottlenecks: Low demand Low continuity Opportunity Cost Levers: Collective action: Government Primarily

11. Providers Retail Community based organizations/ associations Cooperatives Social marketing, media, Women’s groups, associations etc Family/Community based Care Low asymmetry of information Transaction light High discretion in taste/ values Bottlenecks: Knowledge Availability and cost of commodities Levers: Imitate the market Direct control of users

12. Treatment • Provider dependent interventions • Highly dependent on performance of human resources and physical infrastructure • Significant private sector involvement Acute Emergency obstetric care ACTs • Consumer directed interventions • Self diagnosis, self treatment • Significant private sector involvement Antibiotics for Pneumonia Supplements (e.g. Zinc, Vitamin A, folic acid) ORT Emergency neonatal care Lab-based diagnostics Malaria Severe case management Field-based diagnostics IMCI ARVs Fortified food Primary care DOTs Uptake Chronic Attended delivery Uptake Temporary Oxytocin For PPH Misoprostal For PPH Male contraceptives Vaginal contraceptives PMTCT Microbicides Clean home delivery kits IPTp, IPTi • Amenable to command and control • Campaign approach • Semi-skilled worker • Government run Bednets Chemo prophylaxis IRS Campaign-delivered vaccines Male circumcision EPI-delivered vaccines Long-lasting Prevention Uptake Consumer discretion Provider mediated Product Service Acknowledgement: Dan Kreis, BMGF

13. Shift existing within channel New delivery or technology approach Improve channel perfromance Potential approach Shift intervention within channel Shift intervention to different delivery channel Improve performance of delivery channel Improve intervention to increase delivery within existing channels (e.g. less need for skilled provider) Improveefficiency, capacity or equityof delivery channel New technology or policy change to deliver the intervention through a better performing channel Description • Deliver Vitamin A supplement with annual Onchocerciasis treatment campaigns • Develop a vaccine to prevent malaria • Replace lab based diagnostics with self administered test • Increase EPI coverage and expandcoldchaincapacity • Betteruseof the private sectortodeliverantimalarials • Voucher programtoincreaseuse and qualityofskilled birth attendance • Develop point-of-care diagnostic to replace lab based test • Inject for delivery of Oxytocin by midwives Examples Potential solutions Addressable through better target product profiles and customization of intervention Need to improve target product profiles to account for delivery channel Different strategies are needed for each delivery channel Formanyinterventions, improvingchannels performance is the only way toincreaseequitableuptake Addressable through better target product profiles and customization of intervention Only applies to a limited range of interventions – e.g. no vaccine for attended child birth Acknowledgement: Dan Kreis, BMGF

14. innovations for MDG 4+5

15. Thank you