Transcript www.unmillenniumproject.org

UNDP RBA
MDG-Based National Development Planning
Workshop
Health Module
Chandrika Bahadur
UN Millennium Project
February 27-March 3, 2006
Public investments in Health
Low- and middle-income countries shoulder 85% of
the total global burden of disease, yet account for
only 11 % of global health spending
Sources: WB
2
www.unmillenniumproject.org
Public investment in Health
Region/Income group
East Asia & Pacific
Europe & Central Asia
Latin America & Caribbean
Middle East & North Africa
South Asia
Sub-Saharan Africa
High income
Middle income
Low income
GDP per
capita
$993
$2,468
$3,764
$2,079
$473
$571
$29,238
$1,996
$474
3
Health
Public health
expenditure expenditure
per capita
per capita
$48
$18
$123
$92
$255
$123
$166
$95
$22
$4
$29
$12
$2,841
$118
$23
$1,667
$60
$6
Source: WDI 2004
authors calculations for 2001
www.unmillenniumproject.org
What Needs to happen
• Governments have credible health strategies, grounded
in a real needs assessment of what it will cost to reach
the health MDGs
• Governments undertake necessary structural and
institutional reforms to enhance absorptive capacity
• Donors provide increased and predictable long term
financial support from donors, including support for
recurrent costs
• Donors harmonize aid coordination and provide
consistent, evidenced-based policy advice
• Donors, government and civil society monitor and
evaluate results regularly
4
www.unmillenniumproject.org
The MDG Needs Assessment Approach
• Reaching the MDGs will require investing in an
outcome focused health system that can deliver an
integrated set of quality essential health services
to all of the population
• Such a strengthened system of health care
delivery includes prevention and treatment
activities carried out in the community, the clinic
and up to the district, referral hospital
5
www.unmillenniumproject.org
MDG Needs Assessment Approach
•
•
•
•
Choosing interventions
Defining and setting targets
Estimating resource needs
Checking results
6
www.unmillenniumproject.org
1. Choosing Interventions
Child Health,
Maternal
Health, and
Reproductive
Health
• IMCI package
• Immunization
Infectious
Diseases
• Antiretroviral therapy
• UNAIDS HIV prevention and care package
• Artemisinin combination treatment for malaria (as appropriate)
• Insecticide treated nets and IRS as appropriate (other vector control
as appropriate)
•
•
•
•
•
•
Neonatal package
Antenatal care
Skilled attendance and clean delivery
Emergency obstetric care (EmOC)
Contraception and family planning services
Safe abortions and care of complications of abortion
• DOTS and DOTS Plus (as required)
7
www.unmillenniumproject.org
1. Choosing Interventions
Health
System
•
•
•
•
New infrastructure and O&M of existing infrastructure at district level
Adequate health personnel salaries
Pre- and in-service training
Community demand interventions
• Management systems and monitoring & evaluation
• Research and development
Access to
Essential
Medicines
• Interventions to ensure availability, e.g.:
• Incentives to direct research and development
• Establishment of national essential medicines lists, including
preventive, curative, and reproductive health commodities,
equipment, and supplies
• Ensuring reliable procurement and distribution systems
• Interventions to ensure affordability, e.g.:
• Equity pricing
• Reduction of tariffs and duties
• Reduction of mark-ups
• Interventions to ensure appropriate use, e.g.:
• Programs to improve the way drugs are prescribed,
dispensed, and used
• Public media campaigns and education of providers
8
www.unmillenniumproject.org
1. Choosing Interventions:
More Detail on MCH and SRH
Category
Child health
Intervention Package Description
Clean delivery, newborn resuscitation, prevention of hypothermia, kangaroo care (skin-toNeonatal integrated
skin contact to promote parent/infant bonding especially for premature babies), antibiotics for
package
infection, tetanus toxoid, breastfeeding education, hygiene education
Vaccines for polio, diptheria, pertussis, tetanus, measles, hepatitis B, Hib and yellow fever
Immunization
Integrated approach to child health that focuses on the well-being of the whole child. IMCI
Integrated Management
aims to reduce death, illness and disability, and to promote improved growth and
of Childhood Ilnness
development among children under 5 years of age. IMCI includes both preventive and
(IMCI)
Maternal health
Antenatal care
Skilled attendance and
clean delivery
Emergency Obstetric
Coverage (EmOc)
Reproductive health Contraception and family
planning services
Safe abortions
Visits with skilled personnel during pregnancy to check that all is well with mother and baby.
It includes being offered a range of tests and should be implemented in accordance with the
new WHO antenatal care model
Presence of trained and registered midwives, nurses, nurse/midwives or doctors at birth
Treatment for ecclampsia, haemorrhage, obstructed labor and sepsis.
Universal access to family planning counselling and all forms of contraception.
Provision of safe abortions and counseling as well as post-abortion care.
9
www.unmillenniumproject.org
1. Choosing Interventions:
More Detail on HIV/AIDS
Category
HIV/AIDS
Intervention Package
Prevention:
Behavior change
programs
STD Control
Description
Programs to encourage safer sexual behavor including condom social marketing, peer-based
education, mass media campaigns and school based AIDS education.
Routine screening and effective treatment of sexually transmitted diseases (e.g., syphilis,
gonorrhea, vaginitis)
Voluntary Counseling VCT includes both pre and post test counseling and is available to people testing positive or
and Testing (VCT)
negative
Harm reduction for
Actions to prevent transmission of HIV and other infections that occurs through sharing of
injecting drug users
non-sterile injection equipment and drug preparations. Specific programs include provision
of sterile syringes and needles and drug substitution treatment.
Prevention of Mother to Prevention of transmission of the HIV virus from infected women to their infants during
Child Transmission
pregnancy, labour and delivery, as well as during breastfeeding. Includes short-term
antiretroviral prophylactic treatment, infant feeding counselling and support, and
Blood safety
Measures to reduce the risk of receiving infected blood through a transfusion. Includes HIV
interventions (e.g., HIV antibody screening, avoiding unnecessary blood transfusions and excluding high risk
antibody screening,
donors.
exlcuding high risk
donors)
Care and Treatment:
Antiretroviral therapy
Combination of protease inhibitors taken with reverse transcriptase inhibitors used in treating
AIDS and HIV.
Treatment of
Treatment of any infection caused by a microorganism that would not normally cause disease
opportunistic infections in individual but occurs in persons with abnormally functioning immune systems (as in AIDS
patients)
Orphan support
Provision of support to orphans to minimize the impact of AIDS on their lives. Includes
school fee support, provision of orphanages and community support.
10
www.unmillenniumproject.org
1. Choosing Interventions:
More Detail on TB, Malaria
Category
TB
Malaria
Access to Essential
Medicines
Health Systems
Intervention Package
BCG vaccine
Directly Observed
Treatment Short Course
(DOTS)
Insecticide treated nets
Description
Bacillus of Calmette and Guérin vaccine for TB in high prevalence settings.
Internationally-recommended TB control strategy combining five elements: political commitment,
microscopy services, drug supplies, surveillance and monitoring systems, and use of highly
efficacious regimes with direct observation of treatment.
Mosquito nets that are treated with insecticide, which can provide a physical and chemical barrier
to mosquitos. The chemical halo that extends beyond the mosquito net itself also shortens the
mosquito's life span.
Artemisinin combination
Combination of drugs used to treat multi-drug resistant falciparum malaria, which is now
therapy
widespread in Africa.
Interventions to ensure
Provision of procurement and distribution facilities, adequate transportation, monitoring systems
availability, affordabilty,
to assure drug quality; elimination of user fees for essential medicines; programs to improve the
and appropriate use
way drugs are prescribed, dispensed, and used, including development and implementation of
national essential medicines lists and clinical treatment guidelines, public media campaigns and
education of providers.
Interventions to strengthen Includes, human resources, improving management capacity, enhancing monitoring and evaluation, increasing
capacity for R&D, enhancing community demand, and improving infrastructure
health system
11
www.unmillenniumproject.org
2. Defining and Setting Targets:
Outcome Targets
• Some health MDGs have quantified targets, such as the
goal on child mortality
• Others allow for interpretation of targets, such as
HIV/AIDS
• Each country will need to adopt specific numeric
outcome targets to guide its MDG health strategy.
• Health MDGs offer no specific guidance on coverage
levels for health services. Overall aim should be to
achieve universal coverage of essential health services
(or “essential health package”).
12
www.unmillenniumproject.org
3. Estimating Resource Needs
To assist countries in undertaking a Needs
Assessment, the Millennium Project suggests the
following four-point approach:
A. Direct intervention costs (drugs, supplies,
hospital beds, diagnostic tests)
B. Human resources
C. Infrastructure
D. Health systems strengthening
13
www.unmillenniumproject.org
3. Estimating Resource Needs:
A. Direct Intervention Costs
Country epidemiological data
Country demographic data
NO. OF CASES
Target coverage rates
TOTAL
COSTS
Intervention components
and quantities
COST PER CASE
Unit costs of components
• Drugs
• Hospital bed and food
• Laboratory costs
• Other supplies
14
www.unmillenniumproject.org
3. Estimating Resource Needs:
B. Human Resources
Countries need to calculate the number and cost of health
workers at all levels of the health system needed to deliver
the interventions at scale. Health workers include (among
others):
•
doctors
•
nurses and midwives
•
clinical officers
•
lab technicians and technologists
•
pharmacists and pharmacy technicians
•
community health workers
•
health managers
15
www.unmillenniumproject.org
3. Estimating Resource Needs:
B. Human Resources
Human resource cost categories include
•
salary and benefits
•
in-service training
•
pre-service training
•
retention and distribution incentives
Human resource needs should be carefully estimated
by each country for the desired level of service
coverage
16
www.unmillenniumproject.org
3. Estimating Resource Needs:
B. Human Resources
Suggested costing methods
•
Health workers per facilities
•
Doctor or nurse to population ratio
•
Conducting a comprehensive human resources needs
survey
Country example: Yemen Human Resources Needs, 2015
17
www.unmillenniumproject.org
3. Estimating Resource Needs:
C. Infrastructure
Number and cost of building or refurbishing health facilities
from health posts to first level referral hospitals (including
capital costs, maintenance, and overhead).
Country example: Ethiopia Infrastructure Needs, 2015
18
www.unmillenniumproject.org
3. Estimating Resource Needs:
D. Health Systems Strengthening
Two methods:
1. Bottom-up costing of health system components
•
Costs of managers at all levels (training and
salaries)
•
Quality control and audit systems
•
Basic financial and accounting systems
•
Health information systems (and required ICT)
•
Public health functions (such as epidemiologic
surveillance)
•
Enhancing community demand for services (health
education and community mobilization)
19
www.unmillenniumproject.org
3. Estimating Resource Needs:
D. Health Systems Strengthening
2. Overhead mark-up to direct cost of services
•
Estimate a percentage of direct cost of services as
follows:
Strengthening
management systems
(including financial
management)
20% of direct health
costs including salaries
Improving monitoring,
evaluation, and quality
assurance
15% of direct health
costs including salaries
Building capacity for
basic research and
development
2% of direct health
costs including salaries
20
www.unmillenniumproject.org
3. Estimating Resource Needs:
Adding it All Up
Direct costs
of all
interventions
+
Infrastructure
and HRH costs
+
Costs of
health system
strengthening
Total health costs
21
www.unmillenniumproject.org
4. Checking Results
Review all results to ensure that numbers are robust. Here
are some sample health costs from Tanzania:
Per capita total cost estimates in 2000 US$
HIV/AIDS Prevention
HIV/AIDS Care
HIV/AIDS Treatment
TB
Malaria Prevention
Malaria Treatment
Maternal Heath
Child Health
Management
Quality improvement
Human resources (salary incr.)
Community demand
R&D capacity
Infrastructure recurrent costs
Total cost per capita ($)
2005
1.93
1.06
0.70
0.33
0.28
1.98
1.04
4.40
2.34
1.76
4.69
0.40
0.23
0.78
22
2010
2.75
1.38
6.00
0.33
0.51
2.03
1.56
4.51
3.82
2.86
7.64
0.86
0.38
0.72
35
22
2015
3.25
1.46
9.59
0.33
0.73
1.58
2.05
4.50
4.70
3.52
9.40
1.31
0.47
0.66
44
% of total
in 2015
7%
3%
22%
1%
2%
4%
5%
10%
11%
8%
22%
3%
1%
2%
100%
Average
2005-15
$
2.7
$
1.4
$
5.8
$
0.3
$
0.5
$
1.9
$
1.6
$
4.5
$
3.7
$
2.8
$
7.5
$
0.9
$
0.4
$
0.7
35
% of total
over
period
8%
4%
17%
1%
1%
6%
5%
13%
11%
8%
22%
3%
1%
2%
100%
www.unmillenniumproject.org