Strengthening Health Systems to Reach the Poor: What Can Mohs Do?

Woodrow Wilson Center Washington, 15 July 2008

Strengthening health systems to reach the poor: what can MOHs do?

Cesar Victora Federal University of Pelotas, Brazil Visiting Professor, Johns Hopkins University Inequalities in child health

Distal determinants (social, political, economic)

Social stratification

Access to preventive and curative interventions

Child health and nutrition Types of inequities

• Other types of inequalities are also important, such as – Gender – Urban/rural – Ethnic group – Education • These inequalities interact and overlap with socioeconomic inequalities What can countries do?

• Recognize that health services often contribute to increasing inequities • Prioritize diseases of the poor • Consider the pattern of inequity • Deploy/improve services where the poor live • Employ appropriate delivery channels • Remove financial barriers (user fees, etc) • Monitor implementation, coverage and impact with an equity lens What can countries do?

• Recognize that health services often contribute to increasing inequities Skilled attendant at delivery by region, recent DHS

100 90 80 70 60 50 40 30 20 10 0 Poorest 2nd 3rd 4th Least poor

East Asia. Pacific Europe. Central Asia Latin America. Caribbean Middle East. North Africa South Asia Sub-Saharan Africa

Gwatkin et al, 2007 What can countries do?

• Recognize that health services often contribute to increasing inequities • Prioritize diseases of the poor Causes of death, Mozambique

Countdown to 2015 Matching budget to disease burden

Tanzania MOH/ IDRC/ TEHIP project What can countries do?

• Recognize that health services often contribute to increasing inequities • Prioritize diseases of the poor • Consider the pattern of inequity Co-coverage

Is each underfive child getting the preventive interventions s/he should receive?

Victora et al, Lancet 2005 Percent of underfive children receiving six or more child survival interventions

100%

80%

60%

40%

20%

0% Poorest 2nd 3rd 4th Least poor

Cambodia

Victora et al, Lancet 2005 Percent of underfive children receiving six or more child survival interventions

100%

80%

60%

40%

20%

0% Poorest 2nd 3rd 4th Least poor

Brazil Cambodia

Victora et al, Lancet 2005 Percent of underfive children receiving six or more child survival interventions

100%

80%

60%

40%

20%

0% Poorest 2nd 3rd 4th Least poor

Bangladesh Benin Brazil Cambodia Eritrea Haiti Malawi Nepal Nicaragua

Source:Victora Victora et al, Lancet et al, 2005 Lancet 2005 Percent of underfive children receiving six or more child survival interventions

100% Bottom inequity 80%

60%

40%

20%

0% Top inequity Poorest 2nd 3rd 4th Least poor

Bangladesh Benin Brazil Cambodia Eritrea Haiti Malawi Nepal Nicaragua

Victora et al, Lancet 2005 Percent of underfive children receiving six or more child survival interventions

100% Target the poor 80%

60%

40%

20% Continue to disseminate Disseminate 0% widely, give special attention to the poor interventions widely Poorest 2nd 3rd 4th Least poor (perhaps with Bangladesh Benin geographicalBrazil targeting) Cambodia Eritrea Haiti Malawi Nepal Nicaragua

Victora et al, Lancet 2005 What can countries do?

PANCHAGARH

THAKURGAON NILPHAMARILALMONIRHAT drive program implementation

KURIGRAM DINAJPUR RANGPUR 2002 2003 GAIBANDHA INDIA * 2004 JOYPURHAT SHERPUR JAMALPUR NAOGAON SUNAMGANJ SYLHET 2005 NETRAKONA BOGRA

NAWABGANJ MYMENSINGH 2006

RAJSHAHI MAULVIBAZAR SIRAJGANJ HABIGANJ NATORE TANGAIL KISHOREGANJ

GAZIPUR INDIA PABNA NARSINGDI BRAHAMANBARIA KUSHTIA MANIKGANJ MEHERPUR DHAKA RAJBARI NARAYANGANJ CHUADANGA INDIA FARIDPUR MUNSHIGANJ JHENAIDAH MAGURA COMILLA By 2006, 148 of 159

SHARIATPURCHANDPUR * MADARIPUR NARAIL KHAGRACHHARI sub-districts in the JESSORE GOPALGANJ FENI LAKSHMIPUR BARISAL RANGAMATI NOAKHALI “red” areas had IMCI

INDIA KHULNA JHALOKATI CHITTAGONG SATKHIRA BAGERHAT

PIROJPUR BHOLA PATUAKHALI BARGUNA Source: Bangladesh Maternal * BANDARBAN Mortality Survey, 2001: Bay of Bengal Provided District Under-5 COX'S BAZAR Mortality Estimates

MYANMAR

Bangladesh MOH and partners: slide by S Arifeen Infant mortality by region, Brazil

Infant mortality rate, 2000

Cedeplar/UNDP, Brazil Tetravalent vaccine, Brazil

Cobertura de imunização Qtd % nos municípios abs

Até 70% 412 7,5% Acima de 70% até 95% 1659 30,1%

Acima de 95% 3436 62,4% Brazil MOH Family health program, Brazil

Brazil MOH Peru: introduction of new vaccines

• Pentavalent vaccine was first introduced to 40% of the country population, living in the poorest districts of Peru. – It took 4 years to reach universal coverage • 2008: rotavirus vaccine being introduced to about 20% of the population, again in the poorest districts. • Conjugated pneumococcal vaccine to follow the same pattern.

C. Lanata, personal communication What can countries do?

Johns Hopkins University/ UNICEF: ACSD Evaluation What can countries do?

• Recognize that health services often contribute to increasing inequities • Prioritize diseases of the poor • Consider the pattern of inequity • Deploy/improve services where the poor live • Employ appropriate delivery channels • Remove financial barriers (user fees, etc) Coverage in the poorest quintile by the public and private sectors

Medical treatment of ARI

Skilled delivery

Medical Private Treatment of Fever Public Medical Treatment of >50 countries Diarrhoea with DHS surveys 0 5 10 15 20 25 30 Coverage (%)

Gwatkin, Bhuiya, Victora - Lancet 2005 What can countries do?

100% ACSD (before) Comp (before) ACSD (after) Comp (after) 80%

60%

40% Coverage (%) Coverage

20%

0% Poorest 2nd 3rd 4th Richest Wealth quintiles

Johns Hopkins University/ UNICEF: ACSD Evaluation What can countries do?