undp rba mdg-based national development planning workshop health module chandrika bahadur un...

UNDP RBAMDG-Based National Development Planning

Workshop

Health Module

Chandrika BahadurUN Millennium Project

February 27-March 3, 2006

2 www.unmillenniumproject.org

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

Public investments in Health


Public investment in Health

Source: WDI 2004 authors calculations for 2001

Region/Income groupGDP per capita

Health expenditure per capita

Public health expenditure per capita

East Asia & Pacific $993 $48 $18Europe & Central Asia $2,468 $123 $92Latin America & Caribbean $3,764 $255 $123Middle East & North Africa $2,079 $166 $95South Asia $473 $22 $4Sub-Saharan Africa $571 $29 $12

High income $29,238 $2,841 $1,667Middle income $1,996 $118 $60Low income $474 $23 $6


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


• 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

The MDG Needs Assessment Approach


• Choosing interventions• Defining and setting targets• Estimating resource needs• Checking results

MDG Needs Assessment Approach


1. Choosing Interventions

Infectious Diseases

Child Health, Maternal Health, and Reproductive Health

• IMCI package• Immunization• 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

• 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)• DOTS and DOTS Plus (as required)


1. Choosing Interventions

• 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

Health System

•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

Access to Essential Medicines


Category Intervention Package Description

Child health Neonatal integrated package

Clean delivery, newborn resuscitation, prevention of hypothermia, kangaroo care (skin-to-skin contact to promote parent/infant bonding especially for premature babies), antibiotics for infection, tetanus toxoid, breastfeeding education, hygiene education

Immunization Vaccines for polio, diptheria, pertussis, tetanus, measles, hepatitis B, Hib and yellow feverIntegrated Management of Childhood Ilnness (IMCI)

Integrated approach to child health that focuses on the well-being of the whole child. IMCI aims to reduce death, illness and disability, and to promote improved growth and development among children under 5 years of age. IMCI includes both preventive and

Maternal health Antenatal care 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

Skilled attendance and clean delivery

Presence of trained and registered midwives, nurses, nurse/midwives or doctors at birth

Emergency Obstetric Coverage (EmOc)

Treatment for ecclampsia, haemorrhage, obstructed labor and sepsis.

Reproductive health Contraception and family planning services

Universal access to family planning counselling and all forms of contraception.

Safe abortions Provision of safe abortions and counseling as well as post-abortion care.

1. Choosing Interventions:More Detail on MCH and SRH


Category Intervention Package Description

HIV/AIDS Prevention:Behavior change programs

Programs to encourage safer sexual behavor including condom social marketing, peer-based education, mass media campaigns and school based AIDS education.

STD Control Routine screening and effective treatment of sexually transmitted diseases (e.g., syphilis, gonorrhea, vaginitis)

Voluntary Counseling and Testing (VCT)

VCT includes both pre and post test counseling and is available to people testing positive or negative

Harm reduction for injecting drug users

Actions to prevent transmission of HIV and other infections that occurs through sharing of non-sterile injection equipment and drug preparations. Specific programs include provision of sterile syringes and needles and drug substitution treatment.

Prevention of Mother to Child Transmission

Prevention of transmission of the HIV virus from infected women to their infants during pregnancy, labour and delivery, as well as during breastfeeding. Includes short-term antiretroviral prophylactic treatment, infant feeding counselling and support, and

Blood safety interventions (e.g., HIV antibody screening, exlcuding high risk donors)

Measures to reduce the risk of receiving infected blood through a transfusion. Includes HIV antibody screening, avoiding unnecessary blood transfusions and excluding 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 opportunistic infections

Treatment of any infection caused by a microorganism that would not normally cause disease 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.

1. Choosing Interventions:More Detail on HIV/AIDS


Category Intervention Package DescriptionTB BCG vaccine Bacillus of Calmette and Guérin vaccine for TB in high prevalence settings.

Directly Observed Treatment Short Course (DOTS)

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.

Malaria Insecticide treated nets 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 therapy

Combination of drugs used to treat multi-drug resistant falciparum malaria, which is now widespread in Africa.

Access to Essential Medicines

Interventions to ensure availability, affordabilty, and appropriate use

Provision of procurement and distribution facilities, adequate transportation, monitoring systems to assure drug quality; elimination of user fees for essential medicines; programs to improve the 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.

Health Systems Interventions to strengthen health system

Includes, human resources, improving management capacity, enhancing monitoring and evaluation, increasing capacity for R&D, enhancing community demand, and improving infrastructure

1. Choosing Interventions:More Detail on TB, Malaria


• 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”).

2. Defining and Setting Targets: Outcome Targets


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


NO. OF CASES

COST PER CASE

Country epidemiological data

Country demographic data

Target coverage rates

Intervention components and quantities

Unit costs of components• Drugs• Hospital bed and food• Laboratory costs• Other supplies

TOTAL COSTS

3. Estimating Resource Needs:A. Direct Intervention Costs


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



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



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


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


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)


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


Building capacity for basic research and development



3. Estimating Resource Needs:Adding it All Up

Direct costs of all

interventions +

Infrastructure and HRH costs

Costs ofhealth systemstrengthening+

Total health costs


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$ 2005 2010 2015% of total

in 2015 Average 2005-15

% of total over

period

HIV/AIDS Prevention 1.93 2.75 3.25 7% 2.7$ 8%HIV/AIDS Care 1.06 1.38 1.46 3% 1.4$ 4%HIV/AIDS Treatment 0.70 6.00 9.59 22% 5.8$ 17%TB 0.33 0.33 0.33 1% 0.3$ 1%Malaria Prevention 0.28 0.51 0.73 2% 0.5$ 1%Malaria Treatment 1.98 2.03 1.58 4% 1.9$ 6%Maternal Heath 1.04 1.56 2.05 5% 1.6$ 5%Child Health 4.40 4.51 4.50 10% 4.5$ 13%Management 2.34 3.82 4.70 11% 3.7$ 11%Quality improvement 1.76 2.86 3.52 8% 2.8$ 8%Human resources (salary incr.) 4.69 7.64 9.40 22% 7.5$ 22%Community demand 0.40 0.86 1.31 3% 0.9$ 3%R&D capacity 0.23 0.38 0.47 1% 0.4$ 1%Infrastructure recurrent costs 0.78 0.72 0.66 2% 0.7$ 2%

Total cost per capita ($) 22 35 44 100% 35 100%

undp rba mdg-based national development planning workshop health module chandrika bahadur un...

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