Taking an equity focused approach to achieving the MDGs:approach to achieving the MDGs: right in principle; right in practice?

Unequal progress2/3 countries that have made progress inmade progress in reducing U5MR have shown worsening inequalitiesinequalities(i.e gaps between better off and worse off have increased)increased)

Indicates : delivery and financing of health andfinancing of health and nutrition services as well as demand / use of these favor the better offese a o e be e o

UNICEF Progress for Children 2010

HYPOTHESISC ti l i d h b th t it i t tl• Conventional wisdom has been that it is too costly and too difficult to go into poor, hard to reach communities; reaching better off easier to reachcommunities; reaching better off, easier to reach children has been considered more cost effective.

• Hypothesis tested : Because the needs are greatestHypothesis tested : Because the needs are greatest amongst the unreached, and new, innovative, efficient strategies and tools exist to reach them, the g ,benefits of concentrating on them could outweigh the additional costs of reaching them.

• This would mean a greater equity focus would :a) be more cost effective and b) accelerate progress towards MDG’s

R i f lit t h d d f i

Testing the Hypothesis• Review of literature: hundreds of rigorous

controlled studies on equity focused strategiesR i d ff ti l l• Reviewed effective large scale programmes

• Devised an equity-focused approach building on the literature and Alma Ata Declaration(1978)the literature and Alma Ata Declaration(1978)

• Designed an analytical framework for modelingU d t k d li i• Undertook modeling exercise - used data from 15 out of 60 countries reviewed

l d 180 000 d i- analyzed 180,000 data points- compared equity focused approach and the

t th i t f t ff ti b 2015current path in terms of cost effectiveness by 2015 and contribution to health related MDG’s

Two model strategies were compared -Current and Equity-focused approach q y pp

Modeled equity-focused approach - adds ways to ensure the most deprived children are reachedensure the most deprived children are reached

(a) Different ways of delivering services: Shifting treatment of main child killers to communitiesProviding maternal and newborn services closer to communitiesIncentives for improved distribution and performance of health workers

(b) Reducing financial barriers for the poor(b) Reducing financial barriers for the poorReducing costs of drugs and other commoditiesInsurance or free provision of services for the poorSubsidizing indirect costs for using services e.g. through cash transfersSubsidizing indirect costs for using services e.g. through cash transfers

(c) Empowering communities Community participation and organizationC it b d ti f iti h lth l t d tiCommunity based promotion of positive health-related practicesIntensified communication e.g face to face

Cost effective proven interventions are known p- strategies differ in the way these are

delivered, promoted and financed

Child 2003

Nutrition series

Maternal

Child develop

ment series 2007

Newborn 2005

2003 series 2008

Series2006

Repro-ductive Health

2007

Series2006

E it T l A Equity Typology B1

Distribution patterns for mortality and deprivation in 15 countries – 4 typologies

150

200

250

60%

80%

100%

lity

per 1

,00

hsrage

Def

icit

Equity Typology A

6080 100 120 140

60%

80%

100%

ality

per

1,0

0 hse

Def

icit

Equity Typology B1

-

50

100

0%

20%

40%

Lowest Second Middle Fourth Highest Und

er 5

mor

tabi

rth

% C

over

-20 40 60

0%

20%

40%

Lowest Second Middle Fourth Highest Und

er 5

mor

tabi

rth

% C

over

ag

Wealth Quintiles Wealth Quintiles

70100%Equity Typology C

*Niger, Mali, Rwanda, Uganda *Benin, Kenya, Nigeria,,Zimbabwe, Ghana

Equity Typology B2

30 40 50 60 70

40%

60%

80%

100%

rtal

ity p

er 1

,00

rths

vera

ge d

efic

it4050 60 70 80 90 100

40%

60%

80%

100%rt

ality

per

1,0

0 irt

hs

erag

e de

ficit

Equity Typology B2

-10 20

0%

20%

Lowest Second Middle Fourth Highest Und

er 5

mor bi

% C

ov

-10 20 30 40

0%

20%

40%

Lowest Second Middle Fourth Highest

Und

er 5

mor bi

% C

ove

Coverage Deficit score Under five Mortality rate

Wealth Quintiles

*Philippines, Vietnam South Africa*Honduras, Bangladesh, Pakistan

Using MBB (WB-UNICEF) Supply and Demand bottlenecks for most / least deprived areas analyzed100%

p y

Supply Bottleneck 

75% (esp. midwives shortage)   Demand  Bottleneck (esp. 

50%Financial access) 

25%

0%COMMODITIES: % HUMAN RES: % ACCESS: % UTILISATION: % CONTINUITY: % EFFECTIVE COV: health centres with no perinatal supply

stock-outs

facilities with sufficient workers

families living near health facility with

daily service provision

deliveries assisted by trained worker

deliveries with i) SBA ii) weighed &

iii) receive 3 postnatal care visits

% of SBA deliveries occur within a ANC-

qualified health facility

Mortality: causes in poor compared to rich children

250(Under Five Mortality Rate per 1000 Live Births)

Others

4.9

21.6 200

InjuriesAIDS

6.6

36.7

150

AIDS Pneumonia

Measles56.3

1 68.8

100

MeaslesMalariaDiarrhea

50

11

22.1 1.6

13.9 1.6

50

DiarrheaNeonatal

40.7 26.9

0Nigeria: Nigeria Q1 Nigeria: Nigeria Q5 (richest)

Analytical FrameworkCoverage

35%

30%

25%

Coverage

25%

20%

15%

10%

35 30 25 20 15 10 5 0 5% 10% 15% 20% 25% 30% 35%

10%

5%Inputs/costs Impact

10

102

103

Low

103

104

105

106

107High MDG progress

Impact on child mortality in most

100 sand least deprived areas

7080 90

live

birt

h

Baseline

4050 60 70

per 1

,000

Current

20 30 40

mor

talit

y p

Equity Focused

-10

Most Deprived Areas Least Deprived AreasUnd

er 5

mU

Progress towards MDG 4

140

160

hs

141

100

120

00 li

ve b

irth

Historical path

88

80

100

ity p

er 1

,00

Current Path

Equity

40

60

er 5

mor

tali q y

Focused

MDG Target

20 Und

e

-1990 1995 2000 2005 2010 2015

Per $1m additional invested - equity-focused strategies can avert more child deaths

120

140

Equity Typology A

100

120

Equity Typology B1

20

40

60

80

100

20

40

60

80

-

20

Current Equity Focused-

20

Current Equity Focused*Niger, Mali, Rwanda, Uganda *Benin, Kenya, Nigeria, Zimbabwe, Ghana

60 70

Equity Typology B2

25

30

Equity Typology C

10

20

30

40

50

5

10

15

20

-

Current Equity Focused

-

Current Equity Focused*Philippines, Vietnam South Africa*Honduras, Bangladesh, Pakistan

Conclusion• An equity-focused approach improves returns on

investment, averting many more child and maternal deaths d i d f t ti th th t thand episodes of stunting than the current path.

• Using an equity focused approach a US $1 million• Using an equity focused approach, a US $1 million investment in reducing under-five deaths in a low-income, high-mortality country would avert an estimated 60% more d th th th t hdeaths than the current approach.

• Because national burdens of disease ill health and• Because national burdens of disease, ill health and malnutrition are concentrated in the most excluded and deprived child populations, providing these children with essential services can accelerate progress towards the health related MDGs and reduce disparities within nations.