The critical role of the national health policy & strategy in strengthening health systems and delivering effective interventions in an integrated approach to accelerate progress towards the health MDGs, with a special focus on the health of women and children.
Accelerating progress towards
the health-related Millennium
Development Goals
Th e Millennium Development Goals
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● In September 2000, 189 heads of state adopted the UN Millennium Declaration and endorsed a framework for development. Th e plan was for countries and development partners to work together to reduce poverty and hunger, and tackle ill health, lack of education, gender inequality, lack of access to clean water and environmental degradation.
● Eight Millennium Development Goals (MDGs) were established, with targets for 2015, and indicators to monitor progress.
● Th ree MDGs relate directly to health; to reduce child mortality by two thirds (MDG 4), to reduce maternal deaths by three quarters and achieve universal access to reproductive health (MDG 5), and to halt and reverse the spread of HIV/AIDS, achieve universal access to treatment for HIV/AIDS by 2010, and halt and reverse the incidence of malaria and other major diseases (MDG 6).
● Other MDGs have an indirect infl uence on health; MDG 1 has a target of halving the proportion of people who suff er from hunger; MDG 7 includes a target of halving the proportion of the population without sustainable access to safe drinking water and basic sanitation; and MDG 8 has a target to provide access to aff ordable essential drugs in developing countries. Primary education (MDG 2) and empowering women (MDG 3) also lead to health gains.
● MDG goals, targets and indicators are interdependent measures of progress. Th ey are not meant to limit priorities in health, nor defi ne how programmes should be organized and funded.
Progress is being made, but huge challenges remain
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Progress
The MDGs have been a powerful
force in the fi ght to reduce poverty and inequity
Health is at the centre of the develop- ment agenda. All the MDGs infl uence health, and all causes of ill-health affect the achievement of the MDGs
The focus on specifi c goals has spurred innovation – new tools, new ways of doing business and new resources
Progress is being made, but is unequal and fragile
Challenges
Confl ict-affected and fragile states are furthest away from achieving the MDGs
More efforts and investment are necessary to prevent set backs, and to accelerate progress towards the MDGs
Better data are key – the lack of investment in health information systems at country level to assess achievements is a signifi cant problem
Time is short – urgent action is
needed
Health-related MDGs – the scorecard
● Th e number of children dying before their fi ft h birthday fell by 30% from 12.4 million in 1990 to 8.8 million in 2008, but diarrhoea and pneumonia still kill 3 million children a year.
● 40% of child deaths occur in the fi rst month of life – most in the fi rst week.
● Undernutrition is an underlying cause in about one third of child deaths.
● 99% of maternal deaths occur in developing countries.
● In Africa and South-East Asia less than 50% of women receive skilled care during childbirth.
● A woman in the wealthiest quintile is three times more likely to have a skilled birth at- tendant at the time of delivery than a woman in the poorest quintile.
● Bleeding and high blood pressure cause over 50% of deaths in pregnancy and child birth.
● Contraceptive prevalence in developing coun- tries increased from 50% in 1990 to 62% in 2005.
● New HIV infections declined by 16% between 2000 and 2008.
● 5 million of the 9.5 million people who need ARV therapy do not have access to treatment.
● Th e proportion of women receiving ARV treatment in pregnancy to prevent mother to child transmission of HIV increased by 10%
to 45% between 2007 and 2008.
● 38 of 108 malarious countries reduced malaria cases by 50% or more between 2000 and 2008.
● Th e global incidence of TB has declined since 2004, but the estimated number of multidrug- resistant cases increased to 440 000 in 2008.
● Noncommunicable diseases and injuries caused an estimated 33 million deaths in developing countries in 2004.
● 85 countries representing 66% of the world’s population do not have reliable cause of death statistics.
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Health MDGs scorecard for WHO Regions
World Africa Americas Eastern
MediterraneanEurope South-East Asia Western Pacifi c
Under 5 mortalityper 1000 live births
65 142 18 78 14 63 21
Measles immunization
% coverage
81 73 93 83 94 75 93
Maternal mortality
per 100 000 live births
400 900 99 420 27 450 82
Skilled birth attendant
% births
66 47 92 59 96 49 92
Contraceptive use
% married women aged 15–49
62 24 71 43 68 58 83
HIV/AIDS prevalence
% adults aged 15–45
0.8 4.9 0.5 0.2 0.5 0.3 0.1
Malaria mortality
per 100 000 population
17 104 0.5 7.5 – 2.1 0.3
TB treatment
success rate %
86 79 82 88 67 88 92
Water
% using improved sources
87 61 96 83 98 86 90
Sanitation
% using improved facilities
60 34 87 61 94 40 62
Data from World Health Statistics 2010
on track insuffi cient progress off track
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Review of progress reveals clear priorities
● Women and children are at the centre of eff orts to achieve the MDGs.
● Rapid reduction of maternal and newborn deaths is the most urgent and obvious priority.
● Ensuring safe child birth is the greatest challenge.
● Success requires access to eff ective interventions across the life course.
● Rapid progress in delivering these interventions is limited by the capacity of health care delivery systems.
● Eff orts are needed to strengthen health systems and to address the broader social and economic determinants of the health of women and children.
● Continuing investment in the fi ght against HIV/AIDS, malaria, TB, neglected tropical diseases and noncommunicable diseases is important in its own right and as a means of improving the health of women and children.
● Th e UN Secretary-General has called for a Joint Action Plan to Improve the Health of Women and Children.
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Women and children are at the centre of efforts to achieve the MDGs
Maternal mortality in 2005: estimates developed by UNFPA, UNICEF, WHO and the World Bank. Geneva, World Health Organization, 2007; www.who.int/whosis
Maternal mortality ratio by WHO region Child mortality at global level
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Africa Americas Eastern
Mediterranean Europe South-East
Asia Western Pacific
1990 2000 2010 1990 2000 2010 1990 2000 2010 1990 2000 2010 1990 2000 2010 1990 2000 2010 0
100 200 300 400 500 600
per 100 000 live births
Probability of dying by age 5 per 1000 live births
700 800
80
60
40
20 900 100
2005 2000
1995
1990 2008 2015
900
90 87
78
70 65
30 910
227 130 99
32
380 420
95 39 27 10 650
450
162 120 82
30 Goal
Trend Actual Goal
Africa Americas Eastern
Mediterranean Europe South-East
Asia Western Pacific
1990 2000 2010 1990 2000 2010 1990 2000 2010 1990 2000 2010 1990 2000 2010 1990 2000 2010 0
100 200 300 400 500 600
per 100 000 live births
Probability of dying by age 5 per 1000 live births
700 800
80
60
40
20 900 100
2005 2000
1995
1990 2008 2015
900
90 87
78
70 65
30 910
227 130 99
32
380 420
95 39 27 10 650
450
162 120 82
30 Goal
Trend Actual Goal
National health policy & strategy
● Better health outcomes depend on effective interventions delivered by better health systems.
Better health requires coherent policies and a comprehensive approach that also addresses the social, environmental and economic determinants of ill-health.
● Outcomes, interventions, programmes and systems come together in a robust national health policy & strategy.
● Systems that seek synergies between programmes get better results and can accelerate progress towards the MDGs.
● The national health policy & strategy links an analysis of needs and current performance with future objectives and priorities and details of the financial and institutional arrangements needed to achieve them.
● Development of a national health policy & strategy must be country-led and requires an inclu- sive process of consultation to ensure democratic ownership of the product.
● There is an urgent need to align external support around the national health policy & strategy to reduce fragmentation and the burden on countries.
is the basis for improving health outcomes
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National
National development policy and plan Poverty reduction strategy Legislative framework
Policy framework National health
policy & strategy National health
system Better health
outcomes Interventions &
programmes
Global
Millennium Declaration and Development Goals
Primary Health Care reforms Paris declaration on aid
effectiveness Abuja declaration (2001)
International Health
Regulations (2005) Framework Convention on Tobacco Control
The comprehensive national health plan which describes the
• context, needs and priorities
• structure and governance
• functions and fi nancing
• targets and monitoring Based on the Three Ones;
• one plan
• one coordinating framework
• one monitoring system
Service delivery &
infrastructure Health workforce Health information Medical products Financing Leadership &
governance
Reduced mortality and morbidity Reduced risks and threats to health Reduced inequities in health
Improved health of women and children Counselling and
education
Clinical interventions e.g. diagnosis and treatment of disease Protective
interventions e.g. vaccination Enabling environment e.g. water and sanitation, public health legislation Socioeconomic interventions e.g.
housing, education
Linking policy to outcomes
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Strengthening health systems
● A health system consists of all the organizations, institutions, resources and people whose primary purpose is to improve health.
● Th e six building blocks of a health system are health services and infrastructure, the health workforce, a health information system, medical products, vaccines & technologies, health fi nancing, and leadership & governance.
● A well functioning health system responds in a balanced way to the population’s health needs and expectations by addressing key constraints in the six building blocks, to provide equitable access to people-centred care, with a special focus on women, girls and children.
● Coverage of interventions that depend on a functioning health care system, such as skilled care during delivery, tends to be lower than interventions delivered through specifi c programmes, such as immunization. Th erefore, a comprehensive range of eff ective public health and clinical interventions, targeted at mothers, newborn and children, delivered in an integrated approach, is urgently needed to improve the health of women and children.
● Th ere is a direct relationship between the ratio of health workers to population and survival of women during childbirth and children in early infancy.
● Sub-Saharan Africa has 11% of the world’s population, 24% of the global burden of disease, but only 3% of the world’s health workers.
● A monitoring and evaluation plan with mechanisms to assess quality of care, monitor progress against indicators and targets, and measure health system performance is essential for accountability.
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Women and children are dipping in and out of the health care system
at least 1 ANC visit
at least 4 ANC visits
Skilled birth attendant BCG
Measles
ORT Family planning
Pneumonia care DPT
Full immunization
100 90 80 70 60 50 40 30 20 10 0
PRE-PREGNANCY PREGNANCY BIRTH POSTNATAL CHILDHOOD ADOLESCENCE ADULT / OLDER AGE
Percentage
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Delivering eff ective interventions over
● Health systems are designed to deliver a set of effective clinical and public health interventions over the life course to achieve better health outcomes.
● Interventions can be grouped into five tiers; counselling & education; clinical interventions;
protective interventions; enabling environment; and socioeconomic interventions.
● Creating an enabling environment and socioeconomic interventions have the greatest popu- lation impact, such as legislation to promote safe driving, and efforts to reduce poverty and increase employment. Some preventive and clinical interventions also have a population im- pact, such as vaccination and treatment of communicable diseases. Counselling and education require the greatest individual effort, such as advice to stop smoking.
● Essential protective and clinical interventions such as immunization and treatment of disease are necessary but insufficient to reach the MDGs – addressing socioeconomic factors and creating an enabling environment is crucial.
● Different interventions often contribute to multiple outcomes and frequently have linkages to one another. For example, immunization can be bundled with growth monitoring, distribution of bed nets, micronutrient supplements and other interventions for mothers and children.
● Many highly effective interventions that have a significant impact on the health of women and children are the severely under-resourced.
Based on: Frieden TR A Framework for Public Health Action: The Health Impact Pyramid. Am J Public Health 2010; 100:590-595
the life course to improve health
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Early childhood development
Empowerment of women and gender equity Housing
Education Employment
PRE-PREGNANCY PREGNANCY BIRTH POSTNATAL CHILDHOOD ADOLESCENCE ADULT / OLDER AGE
Increasing population impact Increasing individual effort needed
Safe water and improved sanitation Family planning
Early detection, diagnosis and treatment of NCDs:
cardiovascular disease, diabetes, cancer and asthma
Intermittent preventive malaria treatment
Preventing mother-to-child transmission of HIV Promoting breastfeeding
Sexual & reproductive health counselling Sexual & reproductive health counselling Promotion of healthy life style (alcohol, diet, smoking, physical activity, etc.)
Diagnosis and treatment of HIV/AIDS, TB, Malaria, NTDs, and other infectious diseases Antenatal care Safe delivery Postpartum and
newborn care Management of childhood illness
Insecticide-treated nets and indoor residual spraying
Road safety, including speed controls, motorcycle helmets, seat belts, drink-driving laws, and child seats Providing facilities, parks, cycle ways to encourage physical activity
Better nutrition including policies to reduce salt, trans fats and sugar in foods
Health legislation including tobacco taxation, smoke free workplace, licensing of doctors, hospitals, pharmacies and labs, food, etc.
Reducing stigma and discrimination
Insecticide-treated nets and indoor residual spraying Immunization
De-worming and other preventive treatment for NTDs Vit A, micronutrients
Counselling and education
Clinical interventions
Protective interventions
Enabling environment
Socioeconomic interventions
Cancer screening Family planning
Growth monitoring
Delivering effective interventions over the life course
Note: this is not a comprehensive list of all health interventions to achieve the MDGs
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Financing for the MDGs should promote
sustainability and enhance fairness
The facts
● Direct out-of-pocket payments prevent mil- lions of people from using needed services and can lead to impoverishment.
● People can be protected from fi nancial hard- ship through national health fi nancing policies that promote pooling of risk and resources.
● Extending health protection through insur- ance and tax-fi nanced systems aims to achieve universal coverage.
● Most expenditure for the MDGs will continue to come from domestic sources. Th e poorest and least stable countries will continue to need external aid for the foreseeable future.
● Aid for health must be predictable, aligned with nationally-defi ned priorities, provided in ways that minimize transaction costs, designed to enhance sustainability and limit dependen- cy on external funds.
The evidence
● A basic package of health services costs US$ 35–
50 per person per year.
● Low-income countries currently spend on average US$ 25 per person per year on health, of which US$ 10 is out of pocket expenditure.
● In 47 countries, out of pocket payments account for over 50% of total health expenditure.
● 100 million people are driven below the pov- erty line every year due to catastrophic health care payments.
● Spending on health in low-income countries needs to increase from US$ 31 billion now to US$ 67–76 billion by 2015.
● Development assistance for health increased from US$ 6.8 billion in 2000 to US$ 16.7 billion in 2008.
● External resources in low-income countries have increased from 12% of total health ex- penditure in 2000 to 17% in 2006.
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Estimated fi nancial gap for 49 low-income countries
Note: additional resources are needed to meet the funding gap in high burden middle income countries Source: WHO and Taskforce on Innovative Financing for Health Systems, 2009
Health financing Governance / regulation Health info systems Supply chain / logistics Infrastructure
Human resources Other essential drugs
Family planning Maternal health Immunization Childhood illness Tuberculosis Malaria HIV/AIDS
0 10 20 30 40 50
Billions (US$)
2015 45
2014 42
2013 40
2012 42
2011 36
2010 2009
19
27 Scale up period
Programme costs for women’s & children’s health US$ 5 billion
Health systems costs US$ 31 billion Programme costs for other health topics US$ 9 billion
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● The MDGs have been a powerful force in the fi ght to reduce poverty and inequity.
● Progress towards the health MDGs is being made, but is unequal and fragile.
● The need to reduce maternal and newborn deaths emerges as the most urgent and obvious priority.
● Improving the health of women and children requires (a) effective interventions;
(b) health systems to deliver those interventions; and (c) policies & strategies that set out how the resources needed to deliver results will be mobilized and deployed.
● A comprehensive national health policy & strategy is therefore the foundation for improving the health of women and children.
●
The national health policy & strategy identifi es health system and programme needs to deliver effective interventions that achieve health outcomes.
●
There is an urgent need to increase investment in the health of women and children…
●
... and to align fi nancial and technical support with the national health policy
& strategy.
Conclusions
© World Health Organization 2010. All rights reserved.
WHO/DGO/2010.2 http://www.who.int/topics/millennium_development_goals
