Take-home messagesChallenges for all

1. The MDGs matter for poverty-reduction2. Mixed ½-time score; 2nd half better?3. Effective interventions exist; use is too low4. For countries:

– Extra govt. health necessary, not sufficient– Additional exp. needs to be targeted…– … and accompanied by broad strengthening of

policies & institutions—households, providers, HR, medicines, financing, public health, intersectoral

5. For donors: – Integrating MDGs into assistance strategies &

lending programs; intersectoral– More aid, but aid needs to be timely, MDG-

focused, coordinated, linked to PRSP & MTEF

Why the MDGs matter—i It’s the world’s poor who die earlier

0 50 100 150 200

Underweight children (percent)

Under-Five deaths/1,000 livebirths

Maternal deaths/10,000 live births

AIDS deaths/100,000 pop

TB deaths/100,000 pop

Rate/RatioPoorest 25% 2nd poorest 25%

2nd richest 25% Richest 25%

Global income quartiles

The MDGs matter for poverty-reduction

0

1

2

3

4

5

6

7

8

9

10

1 500 999 1498 1997 2496 2995 3494 3993 4492 4991 5490 5989

Households ranked by expend w/out hc payments

HH

exp

endi

ture

as

mul

tiple

of

PL

Pov line = VND 1.8m/year Expend w/out hc payments

Why the MDGs matter—iiIll health causes poverty

The MDGs matter for poverty-reduction

0

1

2

3

4

5

6

7

8

9

10

1 500 999 1498 1997 2496 2995 3494 3993 4492 4991 5490 5989

Households ranked by expend w/out hc payments

HH

exp

endi

ture

as

mul

tiple

of

PL

Pov line = VND 1.8m/year Expend w/out hc payments

0

1

2

3

4

5

6

7

8

9

10

1 500 999 1498 1997 2496 2995 3494 3993 4492 4991 5490 5989

Households ranked by expend w/out hc payments

HH

exp

endi

ture

as

mul

tiple

of

PL

Pov line = VND 1.8m/year Expend w/out hc paymentsHC payments

Out-of-pocket payments for health care pushed 2.6m Vietnamese into poverty in 1998.

Increased headcount by 23% and normalized poverty gap by 25%

Why the MDGs matter—iiIll health causes poverty

The MDGs matter for poverty-reduction

The Millennium goalsNearly half concern health & nutrition

Goal #

Goal Targetsfor 1990-2015

1 Eradication of extreme poverty & hunger

Halving of % of people who suffer from hunger

4 Reduction of child mortality

To reduce U5MR by 2/3

5 Improvement of maternal health

To reduce MMR by 3/4

6 Combating of HIV/AIDS, malaria & other diseases

To have halted & begun to reverse spread of these diseases

A mixed half-time score

A mixed half-time score—iThe news isn’t all bad

The good news… Nearly 80% of world’s

population lives in a country that’s on track to hit the malnutrition target

In 38% of countries, U5MR declined faster in 1990’s than in 1980s

E Asia & Middle East & N Africa fared well on MMR decline in 1990s

… and the bad U5MR—slow progress;

getting slower Africa—lagging badly Challenges for all regions

– Faster progress on some goals than others

– Poorest countries making slowest progress

– Within countries, poorest 20% often progressing more slowly than population as a whole

A mixed half-time score

A mixed half-time score—ii Laggards even in regions doing well

Annual rate of decline in malnutrition, E Asia

-10%

-8%

-6%

-4%

-2%

0%

2%

Chin

a

Kore

a,D

em.

Rep

.

Mal

aysi

a

Indones

ia

Vie

tnam

Thai

land

Mya

nm

ar

Cam

bodia

Lao P

DR

Phili

ppin

es

Mongolia

annual av.

% c

hange

Target rate of reduction

A mixed half-time score

A mixed half-time score—iii Poor countries progressing slowest

-8%

-7%

-6%

-5%

-4%

-3%

-2%

-1%

0%

Malnutrition U5MR MMR

pop-w

eig

hte

d

av

% r

ate

of

change in 1

990s

Low income

Lower middleincome

Upper middleincome

World Bank calculations from trend data on malnutrition (WHO) and U5MR (UNICEF), and MMR projections from 1995 data.

NB Data for Goal #6 on communicable diseases too limited to perform these calculations.

A mixed half-time score

Target

Target

Target

Prospects for the second halfSwings & roundabouts

The good news… Economic growth set to

accelerate everywhere except E Asia

Additional contributions possible from faster progress on– elimination of gender

gaps in secondary education (MDG #3)

– expanding access to drinking water (MDG #7)

… and the bad Combined contributions of

these stimuli: – appreciable, but – mostly insufficient to get

countries on track They’ll be offset—at least

in part—by slower changes within health sector

E.g. MMR likely to fall less quickly as attended deliveries rise more slowly and fertility declines more slowly

Will the second half go better?

Effective interventions existThey need to reach more people

Maternal deaths would fall by 73% if coverage of key interventions rose to 99%

0% 10% 20% 30% 40%

Drugs for preventing malaria

Treatment for iron deficiency

Magnesium sulphate for pre-eclampsia

Active management in third stage oflabor

Improved access to safe abortion services

Improved access to comprehensiveessential obstetric care

deaths averted (as % current total)

Hemorrhage

Puerperal Infection

Eclampsia

Obstructed Labour

Abortion Complications

Malaria

Anemia

Tetanus

Cause of death

Plenty of effective interventions

Extra govt. health spendingNecessary, but not sufficient

Proportional scaling-up across programs– Leads to bigger decline in MMR than U5MR– Impact is:

• Greater in countries with good policies & institutions, as measured by the Bank’s Country Policies and Institutions Assessment (CPIA)

• Negligible when CPIA is very low

But… even in countries with high CPIA– relying on across-the-board scaling-up to get

to MDGs would require much faster growth in share of GDP devoted to govt. health spending

Rising to the challenges—countries

Proportional scaling-upExpensive way of reaching MDGs

Calculations assume CPIA of 4 and a proportional scaling-up of programs

0

2

4

6

8

10

12

14

eap eca lac mna sar ssa

share

of

GD

P d

evo

ted t

o

govt

. healt

h e

xpend.

(%)

2000

2015 on currenttrend

2015 requiredfor U5MR MDG

Calculations show how far share of GDP devoted to government health spending would need to rise by to achieve U5MR MDG, if current spending patterns were scaled

up proportionately

Rising to the challenges—countries

0% 2% 4% 6% 8% 10%

Baseline*

Gujarat

Orissa

Madagascar

Mali

Rajastan

Benin

Estimated % reduction in U5MR if spending rose by 10%

* Baseline is optimistic estimate for a country with below-average quality policies & institutions. Actual change may be a good deal smaller.

Rising to the challenges—countries

Targeting for bigger returns Returns to removing bottlenecks

Stronger policies & institutions Households & providers Lower all household barriers

– Households key actors—as demanders & deliverers – Lower financial barriers, especially for the poor; empower

women; better knowledge; increase accessibility Improved service delivery—accountability

– Within organizations (management)• Examples where performance improved through clearer

responsibilities, accountability, links between performance & rewards, etc.

– Between organizations and public:• Directly (patient-provider)—e.g. governance participation,

information dissemination• Indirectly (policymaker-provider)—e.g. contracting,

partnerships, social marketing

Rising to the challenges—countries

Stronger policies & institutions HR, drugs, public health, finance Tackling HR and drugs constraints

– HR: Improve returns to employment; training to focus on MDG-specific; etc.

– Drugs: better logistics and incentives to get drugs to frontline; behavior change against poor quality drugs; etc.

Strengthening core public health functions– Strategies for disease prevention, treatment & control;

govt.-led M&E; intersectoral—beyond MOH Sustainable health financing

– Work out what’s affordable; where appropriate mobilize extra domestic resources

– Better PRSPs and MTEFs; align goals & resources– Rely less on out-of-pocket expenditures

Rising to the challenges—countries

HR recruitment & retentionMoney isn’t everything

What health workers in Andra Pradesh want from their job, and whether they get it

0

20

40

60

80

100

Good physical workingconditions

Training opportunities

Challenging work

Tools and materials to useskills fully on the job

Good opportunities to advance

Good working relationship withcolleagues

Desirable location

Time for personal/family life

Good employment benefits

Good income

% saying is important

% saying is present in job

Rising to the challenges—countries

Intersectoral agenda is keyInfrastructure and behavior change

Impact of piped water on diarrhea prevalence among children by income quintile, India

-80%

-60%

-40%

-20%

0%

Poore

st

2nd

Mid

dle

4th

Ric

hest

I ncome quintiles

change in d

iarr

hea

pro

babilit

y x

100

Rising to the challenges—countries

Spending what’s affordableWho does it? Who doesn’t?

Czech Republic

Uruguay

Oman

Hungary

Argentina

Saudi Arabia

St. Kitts And Nevis

Slovak Republic

Estonia

Poland

Mauritius

South Africa

Chile

Croatia

Malaysia

Trinidad And TobagoMexico

Costa RicaLithuania

BotswanaLatviaBrazilGrenada

Russian Federation

Macedonia, Fyr

Thailand

Tunisia

Panama

Namibia

Turkey

Tonga

Bulgaria

Gabon

Colombia

Dominica

Dominican Republic

I ran, I slamic Rep.

Romania

Venezuela, Rb

Belize

St. Lucia

St. Vincent And The Grenadines

Algeria

Bosnia And Herzegovina

Samoa

Fiji

Belarus

Peru

Cape Verde

El Salvador

KazakhstanParaguaySwaziland

Lebanon

Ukraine

Guyana

Guatemala

J ordan

Philippines

China

Jamaica

AlbaniaEgypt, Arab Rep.

Turkmenistan

Morocco

Sri LankaSyrian Arab Republic

EcuadorVanuatu

Indonesia

Azerbaijan

Zimbabwe

Honduras

India

Papua New Guinea

Bolivia

Armenia

Lesotho

Vietnam

DjiboutiGuinea

Georgia

Ghana

Pakistan

Angola

Solomon I slands

Sudan

Gambia, The

HaitiCameroon

Mauritania

Mongolia

Comoros

Cote D'I voire

Kyrgyz Republic

Bangladesh

Uzbekistan

Cambodia

Senegal

TogoNepal

Moldova

Uganda

Central African Republic

RwandaKenya

Congo, Rep.

Benin

Burkina Faso

Chad

Nigeria

Guinea-BissauMadagascar

Eritrea

TajikistanMaliYemen, Rep.

Zambia

NigerEthiopiaCongo, Dem. Rep.

MalawiBurundi

TanzaniaSierra Leone

0

1

2

3

4

5

6

7

8

0 2,000 4,000 6,000 8,000 10,000 12,000 14,000

Per capita income PPP

dom

est

ically

-fin

an

ced g

overn

men

t h

ealt

h s

pen

din

g a

s %

GD

P

Rising to the challenges—countries

The World Bank What’s it doing vis-à-vis the MDGs?

Rising to the challenges—development community

Analytical work

Dialogue

Country assistance strategies

M&E

Lending & Technical

Assistance

Analyzing MDG trends, prospects, and challenges

Helping incorporate the MDGs in government policies &

budgets

Using the goals to assess country assistance strategies

Integrating MDGs in sectorwide and programmatic instruments

Reorienting and increasing Bank loans & grants to achieve

MDG outcomes

Using the goals for building M&E capacity

Learning the lessons of DAHImplications for MDGs

Aid is too unpredictable, and the transaction costs are too high

Aid works better the better the policy environment

Aid can help foster good policies, and facilitate transition to them

Aid is fungible; points towards enhanced coordination, aid pooling, and putting countries in the driver seat

Global partnerships can add value, but contain risks

Rising to the challenges—development community

Take-home messagesChallenges for all

1. The MDGs matter for poverty-reduction2. Mixed ½-time score; 2nd half better?3. Effective interventions exist; use is too low4. For countries:

– Extra govt. health necessary, not sufficient– Additional exp. needs to be targeted…– … and accompanied by broad strengthening of

policies & institutions—households, providers, HR, medicines, financing, public health, intersectoral

5. For donors: – Integrating MDGs into assistance strategies &

lending programs; intersectoral– More aid, but aid needs to be timely, MDG-

focused, coordinated, linked to PRSP & MTEF

Additional Slides – ECA focus

Why the MDGs matter for all- including ECA countries

Progress can be quickened, irrespective of targets

Progress needs to be for everyone, not just the better off

Goals help focus on outcomes

ECA has a mixed half-time score—Good news and bad

The good news…

Low child malnutrition rates, and most countries reducing malnutrition quickly

Low maternal mortality rates in many countries

… and the bad

Slow progress in reducing child mortality and maternal mortality, especially in Central Asia

Sharp increase in HIV incidence in some countries; TB burden remains high

Why the MDGs matter for ECAThe poor are lagging

Under-Five Mortality by Wealth Quintile

0

20

40

60

80

100

120

Armenia,2000

Kazakhstan,1999

Kyrgyzstan,1997

Turkey, 1998 Turmenistan,2000

Uzbekistan,1996

Un

de

r-5

mo

rta

lity

ra

te

Poorest 20% Population average Wealthiest 20%

Tuberculosis and HIV/AIDSRapidly increasing in some countries

Tuberculosis incidence

0

20

40

60

80

100

120

140

160

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000

per

100

,000

po

pu

lati

on

Romania Russia Ukraine Kazakhstan Uzbekistan

Reaching MDGs will not be enoughHigh returns from reducing adult mortality – MDG+ approach

Increase in life expectancy from reaching MDGs 4 and 5, or reducing CVD and external causes

0.0 2.0 4.0 6.0 8.0 10.0 12.0

Remaining FSU

E. and S. Europe

Central Asia & Caucasus

Regional average

Increase in life expectancy (years)

Reaching MDGs 4 and 5 Reaching EU levels for CVD and external causes

Adult mortality rates are highand increasing in some countries

Bulgaria

0

50

100

150

200

250

300

1960 1965 1970 1975 1980 1985 1990 1995 2000

Ad

ult

mo

rtal

ity

rate

(x1

000)

Adult mortality, males Adult mortality, females

Adult male mortality, 2000

<150 (19)150-200 (7)200-300 (6)>300 (6)