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Overview

Lowering the Barriers: Innovative Solutions to Increase Access to Health Services for Women and Children Sjoerd Postma Senior Health Specialist. Overview. Socio-Economic Context MDGs (4/5/6) Overview in Asia/Pacific Identifying the Barriers to Achieving MDGs at Local Levels

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Overview

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  1. Lowering the Barriers:Innovative Solutions to Increase Access to Health Services for Women and ChildrenSjoerd PostmaSenior Health Specialist

  2. Overview • Socio-Economic Context • MDGs (4/5/6) Overview in Asia/Pacific • Identifying the Barriers to Achieving MDGs at Local Levels • Overcoming the Barriers:Local Solutions • Public Health Sector Management:Lessons (to be) Learned

  3. 1. Socio-Economic Context

  4. Growth in More, Less Developed Countries Billions Less Developed Regions More Developed Regions Source: United Nations, World Population Prospects: The 2004 Revision (medium scenario), 2005.

  5. Population by major area Billions 5.3 3.9 2.0 0.8 0.9 0.7 0.6 0.5

  6. Population percentage by major area Percentage

  7. Trends in Life Expectancy, by Region Life Expectancy at Birth, in Years Source: United Nations, World Population Prospects: The 2004 Revision (medium scenario), 2005.

  8. Trends in Urbanization, by Region Urban Population Percent Source: United Nations, World Urbanization Prospects: The 2003 Revision (medium scenario), 2004.

  9. Projected Economic GNP Growth by Region:

  10. Economic and Health Sector Challenges in Asia/Pacific • General improvements but growing inequities • Economic growth, meaning higher fiscal revenues, not automatically translated into greater financing for health • Graduation to middle income leads to loss of donor funding which is not immediately replaced • Current health sector performance leaves much to be desired with regard to equity, efficiency and levels of public financing • Current health challenges remain: MDGs, NTDs, TB/HIV/AUDS/Malaria/Dengue, Stunting • Rapid demographic, epidemiological and environmental changes have health and fiscal implications: e.g., NCDs, ageing, lifestyle, food safety, (re)-emerging diseases, food security and safety

  11. 2. MDGs (4/5/6) overview in Asia/Pacific

  12. MDGs overview for selected DMCs MDG1 MDG4 MDG5 MDG6 MDG7 with ADB Health Support UW child IMR <5 Mort SBA ANC HIV prev TB incid TB Prev Safe H20 Basic San Indonesia Lao PDR Mongolia Papua New Guinea Pakistan Philippines Vietnam Significant Others China India Bangladesh Sri-lanka Central Asian Republics (Tajikistan has worst indicators, off track and reversing) Pacific Islands (TB prevalence going up; San poor) Achieved: On Track: Off Track: Reversing:

  13. MDG progress by ADB region • South Asia is off-track on 6 goals: gender equality, universal primary completion, child mortality, maternal mortality, communicable diseases and sanitation. It is on-track on water supply. • Central Asia is off track on four goals – child mortality, maternal mortality, communicable diseases, and sanitation • East Asia and Pacific are off track on child mortality, maternal mortality and communicable diseases.

  14. Despite progress, massive deprivations continue Without basic sanitation Infected with TB Living below $1.25/day Births without skilled attendance Without safe drinking water Childdeaths Out of primary school Underweight children Maternal deaths Living with HIV Source: UNESCAP, ADB and UNDP. Accelerating Equitable Achievement of the MDGs: Closing Gaps in Health and Nutrition Outcomes, Asia-Pacific Regional MDG Report . February 2012.

  15. In many cases, disparities are widening Sources : Staff calculation based on the United Nations MDG database. From: Shila Chatterjee SDG meeting 6 May 2012

  16. Country aggregates hide sub-national regional variations Sources : Ministry of Health and Population, New Era, and Macro International Inc,. 2007. Nepal Demographic and Health Survey 2006. From: Shiladitya Chatterjee, SDG meeting 6 May 2012

  17. Country aggregates hide attainments by rich and poor Children under 5 underweight , India 2005-06 (by wealth quintiles) Sources : Ministry of Health and Family Welfare, 2009. Nutrition in India: National Family Health Survey (NFHS-3) India 2005-06. From: Shiladitya Chatterjee ,SDG meeting 6 May 2012

  18. Health Spending Spending on health and education (% of GDP) 19

  19. Share of total health expenditures to GDP, 2009 Sources : World Health Organization (2011). National Health Accounts . Geneva. From: Shiladitya Chatterjee ,SDG meeting 6 May 2012

  20. Health Personnel Physicians per 10,000 population Births attended by Skilled Health Personnel (%) 21

  21. Distribution of child deaths for selected causes by selected WHO region, 2004

  22. 3. Identifying the Barriers to Achieving MDGs at Local Levels

  23. The 4 ‘A’ Dimensions of Barriers (Geographic) Accessibility: service location (S), HH location (D), transport costs (D) Availability: Health workers, drugs, equipment (all S), service demand (D), waiting time (S), wages/ incentives (S), quality of staff (S), price of goods (S), Information on choices/providers (D), education (D) Affordability: costs and prices (S), HH resources and willingness to pay (D), informal fees (S) and opportunity costs (D) Acceptability: HW attitude and service provision (S), user/HH attitude and expectations (D), management of services and HR (S), technology (S), community and cultural preferences, attitudes and norms (D)

  24. Health Insurance Free service to fully paid services continuum (75% of private expenditure is out of pocket) Different models: Health care for the poor funded entirely by government (e.g. Thailand) Mix of public provision and subsidized health insurance for poor ‘Competition’ between schemes (CBHI, HEF, vouchers, etc); unclear demarcation (scheme and geographically) 25

  25. Out of Pocket (private financing) Grey: low <65%) Yellow: med 65-80% Orange: high 80-90% Red: very high>95% Small circle: negative change Large circle: zero or positive change

  26. Socio-Cultural Issues Inappropriate feeding practices (under- nutrition is the underlying cause for 50% of children's deaths) Delivery at home with relatives Gender of staff Reverence of Medical Staff Unfamiliar with what is possible/ available

  27. 4. Overcoming the Barriers:Local Solutions

  28. Improving Access to Maternal and Child Health Services Demand Side Mobilizing the Community: info on services, rope in community leaders, behavior change activities, health education, and organization of transport Decreasing financial barriers: CCT, Emergency loan fund, fee exemption, vouchers schemes, cost sharing, SHI, CHI, Prepayment, other incentives (e.g. loss of income or transport) Supply Side: Decreasing geographical barriers: more facilities, maternity waiting homes, outreach, transport facilities, delegation to lower level staff, collaboration with TBAs Improving management and organization: improve quality (training supervision, audits), increase productivity (monetary incentives, performance based financing), decreasing costs, increasing service time

  29. Cambodia: Contracting for PHC (Supply) Private sector contracts for provision of PHC services besides government health services Included coverage and equity targets Result: Poorest half of population more like to receive services: immunization SBA, FP services Why: part of the performance based contract

  30. Cambodia: Voucher and Health Equity Fund (Demand) HEF for access to public hospitals; identified poor receive support for service fee, transport and other hospital costs Maternal Vouchers scheme done by NGOs; 5 vouchers: 3 ANC, Delivery and PNC services, but also transport costs, referral costs and free services for 5 vouchers Result: increased deliveries up 45%, with 25% of women paying themselves reduced with 25%, and nearly 60% of the poor covered for health services

  31. India: Conditional Cash Transfer scheme (Demand) Women below poverty line attending 3 ANCs and institutional delivery received cash after delivery to take care of direct and indirect costs Result: up to 25% increase in institutional deliveries

  32. Lao: Proposed CCT/Vouchers scheme (Demand) Checklist, distributed by local midwife/SBA: Thee ANC attendances Institutional delivery Post natal care FP service introduction/HEd/Service First immunization Vital registration Collection of stamps and signatures and single payment of 200,000 kip ($25 dollars) to offset costs (primarily transport and relatives accommodation)

  33. Integrated Service Delivery in Indonesia: ‘Posyandu’ (Supply) Five table service provision: Registration/HMIS Weighing/Child Services Maternal Services Family Planning Nutrition and Health Education Regular days; most often linked to market days Included availability of doctors from district level

  34. Partnering for Immunization in Bangladesh (Demand/Supply) Government Partnered with NGOs to reach all immunizable children Government responsible for supply NGO’s responsible for demand side issues: mobilization, session management, registration, monitoring and education Results: higher immunization coverage in NGO assisted areas (90 vs. 80%) Boosted services, lead to polio eradication

  35. Lao District Health Program (1)(Demand/Supply) 1st phase: capacity building of district team and staff, incl TBAs; development of mobile and fixed MCH services; construction and equipment 2nd phase: strengthening referral function, revolving drug funds, monitoring system 3rd phase: further construction for remote areas, with IFAD 4th phase: further strengthening of HW skills and IMCI program

  36. Lao District Health Program (2) (Demand/Supply) Results: 90% access (national 60%), IMR/CMR only 1/3 of national, 50% reduction in MMR (all at $1 pppa) Why: long term sustained support (SCF Australia; only 1 expat), integrated with regular health services, capacity building of staff and communities key.

  37. 5. Public Health Sector Management:Lessons (to be) Learned

  38. Lessons learned (1) First and Foremost: Reducing peri-natal infant and maternal deaths needs a ‘whole’ health care system offering appropriate and affordable quality antenatal and delivery care, including emergency obstetric care in a so-called continuum of care (mother and infant/child health services)

  39. Lessons learned (2) Address service, financial and socio-cultural barriers together, not in isolation; Better allocation of national and local resources to match greatest needs; Target usually excluded groups; Prioritization for MCH services Address supply and demand side; a combination of measures for greater success and sustainability Increase public transparency and accountability with proper audit/monitoring systems and beneficiary participation

  40. Lessons learned (3) Improve service delivery standards and monitor those by clinical and other audits through regular supervision and establishment of a (local) decision focused information system Expand capacities at decentralized levels; but technical and managerial capacity building takes time, needs a sustained program and monitoring Encourage greater involvement of private sector, civil society and communities; complementary service provision by the private sector Link to other sectors: Better educated mothers lead to children receiving more health services

  41. Moving towards Universal Coverage

  42. Public Sector Management facilitating Universal Coverage Services: Define, plan, implement service packages/standards Control quality of services/supervision/monitoring Costs: Cost service; establish package budgets Implement provider payments schemes/ Performance incentives Institute cost control and audit measures; incl anti-corruption Population Coverage: Implement/subsidize insurance schemes Institute free services for indigent, at-risk groups

  43. Thank You ! Resources: World Health Report 2010 – Health Systems Financing, The Path to Universal Coverage, WHO Accelerating Equitable Achievement of the MDGs, Asia-Pacific regional MDG report 2011/12 Trends in Maternal Mortality 1990-2010, WHO, UNICEF, UNFPA and the World Bank estimates Asia NGO Workshop, Strengthening the impact of Asia’s NGO community, MNCH interventions –Immunization Governance and corruption in public health care systems, Maureen Lewis, 2006, World Bank working Paper 78 Innovative approaches to reducing financial barriers to obstetric care in low-income countries, F. Richard et al, American Journal of Public Health, Oct 2010 vol 100 no 10 Access to maternal and perinatal health services: lessons from successful and less successful examples of improving access to safe delivery and care of the newborn, V. de Brouwere, et al, 2010 , Tropical Medicine and International Health, vol 15 no 8 Health service delivery, access to care, costs of health care and coping mechanisms: snapshot from three central Lao provinces, B. Jacobs, in draft Cambodia: Using contracting to reduce inequity in PHC delivery, the World Bank, HNP discussion paper, reaching the poor program paper no.3. Oct 2004 Enabling the rural poor access to health services through innovative health interventions in Cambodia, B. Jacobs, PHD thesis, 2011, Vrije Universiteit Brussels, District health programs and health sector reform: case study in the Lao People’s Democratic Republic, C. Perks et al, Bulletin of the World Health Organization, Feb 2006, 84 (2) Review of ongoing health financing reform in Lao PDR and challenges in expanding the current social protection schemes, study report, MoH Lao PDR, UNESCAP, WHO, ILO, April 2008.

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