The Mdgs and Their Relation to Health and Development Policy

The MDGs and their relation to Health and Development Policy

"MDGs, Poverty and Health: Connecting Parliamentarians with Ground Realities" 12-14 December 2004, Kuala Lumpur, Malaysia

Dr Sergio Spinaci World Health Organization

World Health Organization

1 Outline

• Introduction to MDGs • Progress to date towards reaching the MDGs • Disease burden and underlying causes • Challenges to reaching the MDGs? • Strategic directions to accelerate progress • What can parliamentarians contribute? • Conclusions

World Health Organization

2 The Millennium Development Goals – a unique opportunity

• Derived from the Millennium Declaration • Common development priorities agreed upon by national governments, international agencies and the UN System • Endorsed at the 2002 Monterrey Conference on Financing for Development • Compact between North and South • 2015 goal provides critical momentum

World Health Organization

• The Millennium Development Goals (MDGs) are derived from the Millennium

Declaration which was adopted by all 191 United Nations Member States at the

Millennium Summit in September 2000.

• For the first time, National governments, international agencies and the UN

System agreed on a common set of priorities for their development efforts, and a

set of targets against which to measure progress.

• At the 2002 Monterrey Conference on Financing for Development, the rich and

the poor countries adopted a compact (James Wolfensohn; Francois

Bourguignon Development and Poverty Reduction: Looking Back, Looking

Ahead. World Bank, Washington D.C., 2004).

• developed countries reaffirmed their commitment to make concrete

efforts towards the target of 0.7 per cent of GNI as Official Development

Assistance. Countries set themselves individual targets for increasing

their ODA ranging from

• 0.17 per cent of GNI (United states by 2006)

• to 1 per cent of GNI (Norway and Luxemburg by 2005).

• In addition, developed countries committed to opening their markets to

trade, and supporting capacity building in developing countries.

• The poor countries accepted the responsibilities of good governance,

serious policy design, transparency and openness to real implementation

• The MDGs are a compact between North and South, defining the role and

responsibility of developing and developed countries

• The MDGs set targets for quantifiable improvements in key areas of human

development by 2015.

3 Millennium Development Goals

1. Eradicate extreme poverty and hunger 2. Achieve universal primary education 3. Promote gender equality and empower women 4. Reduce child mortality 5. Improve maternal health 6. Combat HIV/AIDS, Malaria and other diseases 7. Ensure environmental sustainability 8. Develop a global partnership for development

World Health Organization

The MDGs define the key areas of improvement. For each goal, more concrete, quantitative targets were set against which to measure progress. Most of the targets set for progress on the Millennium Development Goals are benchmarked for 1990 to 2015 (WHO 2004, www.who.int/mdg): Goal 1: Eradicate extreme poverty and hunger: • Health Target: Halve the proportion of people whose income is less than one dollar a day • Health Target: Halve the proportion of people who suffer from hunger Goal 4: Reduce child mortality • Health Target: Reduce by two-thirds the under-five mortality rate (probability of dying before age of 5 expressed as rate per 1000 live births) Goal 5: Improve maternal health • Health Target: Reduce by three-quaters the maternal mortality ratio (proportion of deaths of women of reproductive age from maternal causes) Goal 6: Combat HIV/AIDS, Malaria and other diseases • Health Target: Have halted by 2015 and begun to reverse the spread of HIV/AIDS • Health Target: Have halted by 2015 and begun to reverse the incidence of malaria and other major diseases. Goal 7: Ensure environmental sustainability • Health Target: Halve by 2015 the proportion of people without sustainable access to safe drinking-water and sanitation. Goal 8: Develop a global partnership for development • (Health Target: In cooperation with pharmaceutical companies, provide access to affordable essential drugs in developing countries) • The last goal identifies actions developed countries must take if targets are to be achieved (debt-relief, lowering trade barriers, allowing a freer exchange of goods and services with developing countries). Taking a broader look (also at social determinants of health), all goals are associated with health (implication of education and gender targets on health)

4 Goal 1, Target: Halve the proportion of people living on less than one dollar a day

Source: www.developmentgoals.org 5

World Health Organization

• Looking at all developing countries: Poverty level is down since 1990 and we are on track to reach the goal of reducing extreme poverty. There were at least 118 million fewer people living in extreme poverty at the decade’s end than at its beginning 1990 compared to 1999. • But progress is uneven: rapid progress in Asia will do nothing to alleviate the crushing burden of poverty in Sub-Saharan Africa (see diverting trend) and the strong diversion of the trend in Europe & Central Asia (economic breakdown of SU/ transition without social safety nets). • In 2001, most people who lived on less than one dollar a day lived in Asia and SSA: • South Asia: about 428 million people (region with greatest number of poor) • Sub-Saharan Africa about 314 million people (region with highest proportion of poor) • East Asia & Pacific (without China) about 284 million people • China alone about 212 million people (Source: (World Bank, www.developmentgoals.com/Poverty.htm)

Note: World Bank Regions are similar to WHO regions but excluding high-income countries. The major additional differences regarding the distribution of bigger developing countries are: • East Asia & Pacific: WPRO but including Indonesia, Myanmar, Thailand • Europe & Central Asia: EURO • The Latin America & Caribbean : AMRO • Middle East & North Africa: EMRO except for Afghanistan, Pakistan, Quatar, Somalia, Sudan, Syrian Arab Republic including West Bank & Gaza and Algeria. • South Asia: SEARO except for Democratic People's Republic of Korea, Indonesia, Myanmar, Thailand including Afghanistan and Pakistan. • Sub-Saharan Africa: AFRO region excepting Algeria and including Sudan and Somalia.

5 Goal 1, 4 and 5, Targets: Halve proportion of people suffering from hunger; Reduce under-five mortality rate by two-thirds; Reduce maternal mortality ratio by three-quaters

Source: World Bank, 2004 6

World Health Organization

This figure shows the percentage of people who live in countries which are "on track" for different health targets in every region • Underweight children (dark-yellow columns). Progress has been fastest for this goal, reflecting in part the lower target for this indicator (a halving of the rate between 1990 and 2015, compared with a three-quarters reduction in the case of maternal mortality ratio). • Under-five mortality (see the centre column for each region), progress has been very slow, varying between 60 percent of the people are in countries on track in the Middle East and North Africa to 0 % in SSA. • Maternal mortality (the lightest columns): progress varies between a rate of 84 percent of people in the Middle East and North Africa which are in countries on track to reach the goal for maternal mortality very low percentages in South Asia, Latin America and the Caribbean, and Sub- Saharan Africa. • We can see that progress towards these MDGs has varied across goals, across regions, but also within regions. But looking at countries "on track" on average, may hide substantial local disparities. • It shows that all region face challenges to get all countries "on track" for at least some of the goals indicated, including regions with many middle-income countries. • Additional analysis of data by income level shows that the poorest countries suffer the highest burdens of premature mortality and malnutrition and are generally least on track for reaching the related goals. (Source: Wagstaff,Adam; Claeson,Mariam, The millennium development goals for health: rising to the challenges, World Bank, 2004)

6 Goal 6, Target: Have halted and begun to reverse the spread of HIV/AIDS

Estimated number of adults infected with HIV, by WHO region, 1980–2003

Source: World Health Report 2004 7

World Health Organization

The figure shows that the most explosive growth of the epidemic occurred in the mid 1990s, especially in Africa. • Area of greatest prevalence remains sub-Saharan Africa, where currently more than 25 million are living with HIV – more than ever before, amounting to two thirds of the world's people living with HIV/AIDS. • The Caribbean has the world’s second highest HIV prevalence – where in 5 countries, more than 1 in 50 adults is already infected. • The steepest increases in people living with HIV are in East Asia, driven by China’s swiftly growing epidemic; Eastern Europe, driven by Ukraine and Russia; and Central Asia. 2. According to recent estimates, none of the regions is currently "on track" in halting and reversing the spread of HIV/AIDS. • There has been slight progress in Sub-Saharan Africa, South-eastern Asia and Latin America & Caribbean, but at a rate which is insufficient to meet the target. • In Eastern Asia, Southern Asia, Oceania, Europe and Central Asia there has been negative change, increasing the spread of HIV/AIDS. • Impact of HIV/AIDS on poverty: In 2001 alone, the Asian-Pacific countries – home to over 60% the world’s population – lost $7.3 billion to HIV and AIDS, most of it borne by households who lost income because of sickness and death due to AIDS. If the current rate of infection in this region continues, by 2010, economic loses will more than double, reaching $17 billion annually. (UNAIDS, Speech by Peter Piot, 30.11.2004) (Sources: World Health Report 2004; UN Department for Economic and Social Affairs, Millennium Development Goals: Progress Report, September 2004; UNAIDS, AIDS Epidemic Update, 2004)

7 Goal 6, Target: Have halted and begun to reverse the incidence of malaria

• WHO estimates that there are about 300 million cases of malaria per year, with more than 1.5 million deaths, mostly among children less than five years old. • Almost 90 percent of all cases occur in Sub- Saharan Africa, account for about 25 percent of child mortality • In Africa, only 7 of 27 countries reported rates of bed net use greater than 5 percent

World Health Organization

• WHO estimates that there are about 300 million cases of malaria per year,

with more than 1.5 million deaths, mostly among children less than five years

old.

• Almost 90 percent of all cases occur in Sub-Saharan Africa, accounting for

about 25 percent of child mortality (8 percent of deaths occur in Southeast

Asia, 5 percent in the Eastern Mediterranean region, 1 percent in the Western

Pacific, and 0.1 percent in the Americas)

• An effective means of preventing new infections is the use of insecticide-

treated bed nets. But in Africa, only 7 of 27 countries with survey data

reported rates of bed net use greater than 5 percent

• The MDG for Malaria prevention will be hard to reach in the most affected

areas, in particular in Sub-Saharan Africa.

(Sources: WHO/HTM, World Bank: www.developmentgoals.org)

8 Goal 6, Target: Have halted and begun to reverse the incidence of tuberculosis Regional progress towards 70% case detection: Where are the missing cases? Europe low, SE Asia accelerating, Americas high 63% in top 8 countries 70 500 60 14.7 % increase in case detection 02-03 400 ) 50 Ameri cas 15.4 ) r

Afri ca y

sm+, % sm+, 300 ( 40 W Pacific '000s/ World ( 30 SE Asia 200 6.9 3.8 E Med 20 4.2 Europe orammes 5.6 -0.4 1.2 g 100 r

10 p Case detectionrate Cases not found by DOTS

0 0 1994 1996 1998 2000 2002 2004 2006 IND CHN INO NIE PAK BAN ETH RUS

Source: Tuberculosis, Monitoring and Evaluation, WHO 9

World Health Organization

The graph on the left side shows the case detection rate (SM+) in percent for different regions. • Even though the world trend for case detection (see the black dashed line) is going upward since 1999, the level of detection is still low in most regions and far from reaching the 70 percent target (DOTS detection rate?) • Regional progress has been slow in Europe, accelerating in South-East Asia and high in the Americas. • Sub-Saharan Africa has the highest tuberculosis rates and had a detection rate of only about 45% in 2003 (see light blue line) • The Europe region (including the countries of the former Soviet Union and Central Asia) where the epidemic is worsening had a detection rate of less than 20% in 2003 (see red line) • Detecting cases is crucial for expanding treatment. • Once detected, the treatment strategy developed by the World Health Organization – directly observed treatment, short course (DOTS) – can achieve cure rates of up to 95 percent, even in poor countries The diagram on the right side shows how many cases are not found by DOTS programmes in thousands each year for 8 countries which together make up for 63% of "missing cases" worldwide. In addition, it shows the rates of progress made between 2002 and 2003 in each country. (Source: Presentation by Christopher Dye, WHO/Tuberculosis, Monitoring and Evaluation) Note: Countries: India, China, Indonesia, Nigeria, Pakistan, Bangladesh, Ethiopia, Russia

9 Goal 7, Target: Halve proportion of people without sustainable access to safe drinking-water and sanitation

Source: WHO/UNICEF, 2004

World Health Organization

The figure on the left side shows population without access to improved drinking water sources in 2002 • In 2002, 83 per cent of the world’s population – around 5.2 billion people – used improved drinking water sources. But 1.1 billion people were still using water from unimproved sources in 2002. Of those, nearly two thirds live in Asia. (all three dark blue parts) • In sub-Saharan Africa, 42 per cent of the population is still unserved. The figure on the right side shows population without improved sanitation in 2002 • Global sanitation coverage rose from 49 per cent in 1990 to 58 per cent in 2002. Still, some 2.6 billion people – half of the developing world – live without improved sanitation. • Though major progress was made in South Asia from 1990 to 2002, little more than a third of its population are currently using improved sanitation. (dark green part at the bottom) • In sub-Saharan Africa as well, coverage is a mere 36 per cent. • Over half of those without improved sanitation – nearly 1.5 billion people – live in China and India. If the current trend continues, sub-Saharan Africa will not reach the MDG target (Source: WHO/UNICEF, Meeting the MDG drinking-water and sanitation target: A mid-term assessment of progress, 2004)

10 Goal 8: A global partnership for development

World Bank, 2004 11

World Health Organization

• Taking a look to the trend of ODA since 1990: going upwards since 2001 but still on a very low level compared. • The Monterrey Declaration (2002) called for a substantial increase in official development assistance (ODA) and for donors to ensure that debt relief did not detract from ODA resources. • OECD estimated that if all donor countries were to meet these pledges, the ratio of ODA to GNI (Gross national Income) would increase to 0.29 percent by 2006—(see the dashed horizontal line) being a return to 1994 levels but still be substantially below pre–Cold War levels. • But the increase of ODA to GNI of about 30% between 2001 and 2003 is nominal. • Correcting for exchange rates (weakening of the dollar) and inflation leaves the real increase in aid of only13 percent. • Even this real increase is not leading to new “net cash inflows” since strategic (political) motives, technical cooperation, and debt relief account for the majority of it. (In 2002, $2.9 billion of the $5.9 billion nominal increase in ODA was due to debt relief, and another $1 billion was for just two countries (Afghanistan and Pakistan). • Although the recent commitments and actual increases are somewhat encouraging, they fall far short of what is likely needed to reach the MDGs. • The Millennium Project estimates total ODA needs for reaching MDGs at 0.53% of GNI (A Global Plan to Achieve the Millennium Development Goals, UN Millennium Project 2004) • The IMF quotes the estimated ratio of ODA to GDP (Gross domestic product) necessary to reach MDGS to be more than 0.40%. (Sources: James Wolfensohn; Francois Bourguignon Development and Poverty Reduction: Looking Back, Looking Ahead. World Bank, Washington D.C., 2004; Catherine Michaud, Development Assistance for Health (DAH): Recent Trends and Resource Allocation (unpublished), 2004).

11 Are we "on track" to reach the Health MDGs by 2015 ?

• If trends over the last decade continue, the majority of poor countries will not meet the health MDGs • Each country should review its priorities based on progress towards reaching the MDGs and disease burden • Only 10 years left to reach the MDGs

World Health Organization

• If trends observed in the nineties continue, the majority of poor countries will not meet the health MDGs • No region of the developing world is currently on track to meet the child mortality target • For maternal mortality, evidence indicates that declines have been limited to countries with lower levels of mortality • Each country should review its priorities based on progress towards reaching the MDGs and disease burden. Within this, countries need to take a broad look at the disease burden to include emerging diseases (SARS, epidemiological transition) and preventable risks into their health strategies. • There are only ten years left until 2015 to reach the MDGs, getting "on track" is a prerequisite for achieving the goals.

12 Disease burden and underlying causes

• Burden of disease changes with economic and demographic transition • The determinants of ill health are broad • Prevention of major risk-factors and noncommunicable diseases must be included in health strategies

World Health Organization

• The burden of disease changes with economic and demographic transition (epidemiological transition) • The determinants of ill health are broad, to understand the lack of progress in reaching health targets, we need to consider that • Mortality is influenced by social determinants of health (such as Poverty, food security, social exclusion and discrimination, housing, early childhood conditions and occupational status) and risk factors which lie outside the health system (such as conflict) and education. (Commission on Social Determinants of Health, WHO) • Therefore, improvements of health outcomes are not only a direct result of health inputs • Broader health (and development) strategies must include the prevention of major risk-factors - including injuries and other non-communicable diseases

13 The global role of non-communicable diseases and injuries Adult mortality: probabilities of death between 15 and 60 years of age by cause, 2002

Source: World Health Report 2003 14

World Health Organization

• This slide shows premature adult mortality worldwide. Besides the burden of

communicable diseases (the dark grey bar, which is particularly high Africa, we

can see that the share of noncommunicable diseases, represented in the light

grey bars is substantial in all regions. In addition, we can see that injuries

explain a major part of premature death in all regions (look at the green bars)

• Surprisingly, almost 50% of the adult disease burden in the high mortality

regions of the world is now attributable to noncommunicable diseases.

Population ageing and changes in the distribution of risk factors have

accelerated the epidemic of noncommunicable diseases in many developing

countries.

• A demographic revolution is under way throughout the world. Today, there are

around 600 million people in the world aged 60 years and over. This total will

double by 2025 and by 2050 will reach two billion, the vast majority of whom

will be in the developing world.

14 Countries in transition are suffering from a double burden of disease

GDP in US$ billion for Brazil, Russia, Years of life lost due to cardiovascular diseases in India, China vs. the G6 countries population aged 35 – 64 years

Source: Goldman Sachs, Source: Global Forum Update on Global Paper No 99, 2003 Research for Health 2005 15

World Health Organization

• The figure on the left side shows projections of growth for the so called BRIC countries, Brazil, Russia, India China. According to these estimates these economies could be larger than the G6 by 2039. By 2025 they could account for over half the size of the G6. Currently they are worth less than 15% of the G6. Now, we want to look at the possible impact of such economic transition on health: • The figure on the right side shows estimates for the impact of health transition on the burden of CVD in the future for the growing economies India, China and Russia compared to others. (Source K. Srinath Reddy, Health research for cardiovascular disease in developing countries, Global Forum Update on Research for Health 2005) • It shows years of life lost (Potentially Productive Years of Life Lost) due to CVD in populations aged 35 – 64 years. The orange bars are the actual levels of 2000 whereas the white bars are estimates for the year 2030. Looking at these white bars, we can see that a major increase of CVD is expected for India and China, • Accounting for nearly half of the global burden of disease (all ages) today, the group of NCD have undergone a 10% increase from estimated levels in 1990. While the proportion of burden from noncommunicable diseases in developed countries remains stable at over 80% in adults aged 15 years and over, the proportion in middle-income countries has already exceeded 70%. • The economic transition, and, related to it, the demographic transition, will bring with it a number of major challenges for health and social policy planners. (rise in demand for health care)

• The slide shows the global distribution of mortality attributable to 20 leading selected risk factors for the year 2000. • The red color indicates which are the main risk factors for developing countries with higher mortality (these are underweight, unsafe sex, high blood pressure, unsafe water and high cholesterol. • The yellow colour shows the main risk factors for developing countries with lower mortality (these are: high blood pressure, tobacco, alcohol and high cholesterol) • Taking a broader look at underlying causes of mortality it becomes clear that efforts to reach the specific health MDGs must be underpinned by broader health strategies taking into account these risk factors and the increase of certain risks with the economic development of a country bringing (changes in diet and lifestyle).

16 Challenges to reaching the MDGs?

There are many constraints to scaling-up essential health services … • Financial constraints – Domestic and external resources – Share of public health spending in low-income countries – Impoverishing out-of pocket payments – The burden of debt • Health systems constraints – Supply of health services – Health sector policy and strategic management • Political constraints – Governance and overall policy framework

World Health Organization

• There are many constraints to scaling-up essential health services (Report of Working Group 5 of the Commission on Macroeconomics and Health, WHO 2001) • Financial constraints – Domestic and external resources for reaching health MDGs – Share of public health spending in low-income countries – Impoverishing out-of pocket payments – The burden of debt • Health systems constraints – Supply of the appropriate degree of intervention – Health sector policy and strategic management level • Political constraints – Governance and overall policy framework

17 The financing gap to reaching health MDGs

• CMH estimates essential health services cost $30 -$40 per capita per year • Based on this, scaling up essential health services in developing countries would require: – Additional increase of domestic budgetary resources of $23 billion by 2007 and $40 billion by 2015 (1% of GNI by 2007 and of 2% of GNI by 2015) – Total grant resources for health of $27 billion by 2007 and $38 billion by 2015. Current spending ($8.1 billion in 2002) needs to be more than tripled • External flows for health in SSA have increased by 40% between 1996 and 2002 - still short of the real 5 fold increase required (Millennium Project's estimates)

World Health Organization

• The Commission on Macroeconomics and health, estimates the cost of essential health services at $30 - $40 per capita per year. • Based on this, scaling-up essential health services in developing countries would require: • An increase of annual domestic budgetary resources of $23 billion by 2007 and $40 billion by 2015. To achieve this, low-income countries would need to increase their current annual public expenditures on health of GNI of 1% of GNI by 2007 and of 2% of GNI by 2015. • The need for total annual grant resources for health: $27 billion by 2007 and $38 billion by 2015. To achieve this, the current spending ($8.1 billion in 2002) needs to be more than tripled. The increase between 1999 and 2002 has been $1.7 billion, most of it was due to new funds committed by both public and private sources to the Global Fund to fight AIDS, tuberculosis and malaria (GFATM) • External flows for health in SSA have increased by 40% between 1996 and 2002 but this is still short of the real 5 fold increase required based on the Millennium Project's Estimates (Sources: Report of the Commission on Macroeconomics and Health: Macroeconomics and Health: Investing in Health for Economic Development, WHO, 2001; A Global Plan to Achieve the Millennium Development Goals, UN Millennium Project, 2004)

18 Sources of health expenditure in countries grouped by income

19 Source: World Bank, 2004

World Health Organization

• The lighter orange colour at the top of each column indicates, that the share of GDP spent on health by the government is lowest in low-income countries (less than 1% of GDP) compared to an average of approximately 6% of GDP in OECD countries. • The dark orange part at the bottom of each column shows the share of private health spending in % of GDP. • For the Non-OECD countries, we can see that this share is greatest in low-income countries (left column) showing that more than 75% of total health expenditures are coming from private spending • Low income countries therefore tend to shift the burden of health expenditures on individuals. This is particularly anti-poor, because private spending is mostly out-of pocket, since social and private health insurances still play a small role in most developing countries. • (Parallel to an increase of tax-funded government spending on health, these insurances could reduce the financial risk of individuals caused by health expenditure • Social and private health insurances are alternatives to tax-based and out-of pocket funding. Whereas social insurance has can be designed in order to share the financial risk between the rich and the poor of a country, private insurances just protect the individual from the risk of catastrophic health expenditures over time.) (Source: Wagstaff,Adam; Claeson,Mariam, The millennium development goals for health: rising to the challenges, World Bank, 2004)

19 Catastrophic health expenditure and impoverishment due to health spending

EM R impoverishment AFR catastrophic

EUR

SEA

AMR

WP R

- 306090 Number of people (million)

Source: Evidence and Information for Policy, WHO. Calculations from various sources. 20

World Health Organization

• This figure shows the financial burden to access health services. • In the red bars the number of people burdened by catastrophic health expenditure in million for all WHO regions (including high-income countries). Catastrophic being defined as more than 40% of subsistence income. • The grey bar show the number of people who were pushed below the poverty line due to the payment of catastrophic health expenditure – measuring the impoverishing effect of out-of-pocket expenditures for health. • Besides financial barriers, geographical and social barriers are decreasing the demand for health services at community and local level. (The exact year is not known since data of several years was compiled by EIP).

20 Debt relief: The crucial (and neglected) variable

Debt Service and ODA by Region, 2000

Sub-Saharan Africa

South Asia

Middle East, North Africa Development assistance Latin America, Caribbean Debt service Europe, Central Asia

East Asia & Pacific

-200 -150 -100 -50 0 50 US $ billion

Source: Pettifor, A. & Greenhill, R. (2002) 21

World Health Organization

• Many governments are burdened by debt payments as can be seen in the green bars stating a debt service from 12.6 bn US$ for SSA up to 144.3 bn US$ for Latin America % Caribbean. • The pink bars show that development assistance is not able to make up for the outflows due to debt services and shows the relevance of debt relief for reducing poverty and setting countries on a growth path • The HIPC initiative is an important step toward debt relief. 13 countries have reached their completion point under the HIPC Initiative and been granted US$ 26 billion in nominal debt service reduction over time. • But the actual impact of debt relief on freeing resources for social spending depends also on the share of total debt which is incurred from bi- and multilateral donors, since only this, not the share of private debts can be mitigated by multilateral and bi-lateral mechanisms of debt relief. Once debt is relieved, policies are needed to ensure that resources are channeled to social sectors. (HIPC countries are countries heavily indebted for most or all of the past decade, more than half of the population living on less than $1 a day and highly depending on development assistance.) (Sources: Pettifor, A. & Greenhill, R. (2002). Debt relief and the Millennium Development Goals, Background Paper for Human Development Report 2003. New York: Human Development Report Office, United Nations Human Development Programme, December)

21 Health systems constraints: Supply of health services

• Shortage and distribution of appropriately qualified staff • Weak technical guidance, programme management and supervision • Inadequate supplies of drugs and medical equipment • Lack of infrastructure

World Health Organization

• Shortage and distribution of appropriately qualified staff • Weak technical guidance, programme management and supervision • Inadequate supplies of drugs and medical supplies and equipment • Lack of infrastructure • Many of these constraints result from chronic underinvestment in health systems, but some are rooted in a lack of management, governance and overall stewardship.

22 Workforce for health in Africa is low and declining

Source: High-Level Forum on the Health MDGs, Abuja, 2004 23

World Health Organization

• To achieve the Millennium Development Goals, the minimum level of health workforce density is estimated at 2.5 health workers per 1,000 people. Out of 46 countries in Africa, only 6 have workforce density over 2.5 per population. Indeed, Africa’s health workforce density averages 0.8 workers per 1000 population; significantly lower compared to the other regions and to the world median density of 5 per 1,000 populations. • The low density of health workforce, thus, the absolute shortage is severely threatened by high attrition rates underscored by four key "hot buttons": • Insufficient Training Opportunities. • Deteriorating Health of the Workforce. • Rural/Urban Imbalance. • The "Brain Drain", • As European and American demand for health services increases, so does active recruitment from selected countries in Africa and Asia (Policy coherence of donor countries?) • The graph on the right side shows projections for Africa's health workforce until 2015 based on current trends. The already low level of workforce is expected to further decrease. For nurses the rate is even faster than for physicians. (Source: High-Level Forum on the health MDGs, Adressing Africa's health workforce crisis: an avenue for action, Background Paper, Abuja, 2004)

23 Health systems constraints: Health sector policy and strategic management

• Weak, overly centralized systems for planning and Management • Lack of intersectoral action and partnership for health between government and civil society • Weak incentives to use inputs efficiently and respond to user needs and preferences • Aid dependency

World Health Organization

• Weak, overly centralized systems for planning and Management (e.g. drug policies, supply systems, regulation of pharmaceutical sector) • Lack of intersectoral action and partnership for health between government and civil society • Weak incentives to use inputs efficiently and respond to user needs and preferences • Reliance on donor funding that reduces flexibility and ownership

24 Political constraints: Governance and overall policy framework

• Low priority attached to social sectors • Fragile states • Corruption and weak rule of law • Political instability and insecurity • Weak structure of public accountability

World Health Organization

• Low priority attached to social sectors • Health sector has a key role in reaching health MDGs in fragile states • In most fragile states, progress to achieve MDG health targets by 2015 is rather stagnating or even reversing. (Source: Presentation David Nabarro, WHO: "Imperative and Obligation: realising Health MDGs in fragile states at the High-level forum on the health MDGs, Abuja, 2004) • Improving access to basic health services is crucial, in particular in rural areas • Stewardship of local and central government for health policy and priority setting is very limited/weak • Corruption, weak rule of law and enforceability of contracts • Political instability and insecurity • Weak structure of public accountability

25 What can parliamentarians contribute?

• Advocate MDGs as an opportunity to call for equitable access to effective health interventions for constituents • Support mobilization of resources for health – Debating the need – Discussing the budgeting process – Advocating alternative options for financing • Review and monitor existing health policies and strategies – Involve local capacity to plan and build a strong decentralized health system • Influence legislation and support pro-poor health policies • Foster a partnership between government and civil society for better health 26

World Health Organization

• MDGs as an opportunity to call for equitable access to effective health interventions for their constituents as contribution to poverty reduction • Support the mobilization resources for health • Advocating the scaling up of domestic resources for health by debating it in parliament and with Ministries of Finance in particular (linking public health spending to overall growth) • Encourage dialogue between parliamentary committees, the treasury and the health sector to increase transparency of the budgeting process • Advocate the creation of alternative and sustainable ways of health care financing, in both, the public and the private sector • Review and monitor existing health policies and strategies • Setting up review committees composed of Ministers, government officials of different sectors, community representatives, service providers and consumers to review existing health policies and strategies related to reaching MDGs and the health needs of the vulnerable • Involving local capacity to plan and build a strong decentralized health system • Influence legislation and support pro-poor health policies • Advocate regulations and incentives to increase human resources for health in rural areas and introduce laws to regulate the quality of public and private health services • Foster a partnership between government and civil society for better health. Civil society is vital to local health delivery and research.

Conclusions

• If trends continue, most poor countries will not reach the health MDGs • Health must be addressed within the broad development framework • Greater investment in public health and strengthened health systems are prerequisites • Equity concerns should underpin health strategies and policies

World Health Organization

• If trends of the nineties continue, most poor countries will not reach the health MDGs (e.g. no country of the developing world is currently on track to meet the child mortality target) • Address health within the broad development framework • Health strategies must be rooted in efforts to strengthen overall public policy and the capacity for its implementation • Greater investment in public health and strengthened health systems are needed • Increase domestic and external funding for health • Increase absorptive capacity of health systems to deliver services to the poor effectively. In particular, the lack of human resources in health needs to be addressed • Equity concerns should underpin health strategies and policies, ensuring financial, social and geographical accessibility to services of equal quality.