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

� e Millennium Development Goals

2

● In September 2000, 189 heads of state adopted the UN Millennium Declaration and endorsed a framework for development. � 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.

● � 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 in� uence on health; MDG 1 has a target of halving the proportion of people who su� 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 a� 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. � ey are not meant to limit priorities in health, nor de� ne how programmes should be organized and funded.

Progress is being made, but huge challenges remain

3

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● � e number of children dying before their

� � 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 � rst month of life – most in the � 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.

● � 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.

● � 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 Mediterranean

Europe South-East Asia

Western Pacifi c

Under 5 mortality per 1000 live births 65 142 18 78 14 63 21

Measles immunization% coverage 81 73 93 83 94 75 93

Maternal mortalityper 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 mortalityper 100 000 population 17 104 0.5 7.5 – 2.1 0.3

TB treatmentsuccess 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 2010on track insuffi cient progress off track 5

Review of progress reveals clear priorities● Women and children are at the centre of e� 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 e� ective interventions across the life course.

● Rapid progress in delivering these interventions is limited by the capacity of health care delivery systems.

● E� 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 � 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.

● � 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 effortsto 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

7

Africa Americas Eastern Mediterranean

Europe South-EastAsia

Western Pacific

1990 2000 2010 1990 2000 2010 1990 2000 2010 1990 2000 2010 1990 2000 2010 1990 2000 20100

100

200

300

400

500

600

per 1

00 0

00 li

ve b

irths

Probability of dying by age 5 per 1000 live births

700

800

80

60

40

20

100900

2005200019951990 2008 2015

900

9087

78

70

65

30

910

227

99130

32

380420

9510

39 27

650

450

162 12082

30

GoalTrend GoalActual

Africa Americas Eastern Mediterranean

Europe South-EastAsia

Western Pacific

1990 2000 2010 1990 2000 2010 1990 2000 2010 1990 2000 2010 1990 2000 2010 1990 2000 20100

100

200

300

400

500

600

per 1

00 0

00 li

ve b

irths

Probability of dying by age 5 per 1000 live births

700

800

80

60

40

20

100900

2005200019951990 2008 2015

900

9087

78

70

65

30

910

227

99130

32

380420

9510

39 27

650

450

162 12082

30

GoalTrend GoalActual

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 healthpolicy & strategy

National healthsystem

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.

● � 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 � 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 speci� c programmes, such as immunization. � erefore, a comprehensive range of e� 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.

● � 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 outof 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 e� 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

Incr

easi

ng p

opul

atio

n im

pact

Incr

easi

ng in

divi

dual

eff

ort

need

ed

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 andnewborn 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

ImmunizationDe-worming and other preventive treatment for NTDsVit A, micronutrients

Counselling and education

Clinicalinterventions

Protective interventions

Enabling environment

Socioeconomic interventions

Cancer screening

Family planningGrowth 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 promotesustainability 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 � nancial hard-ship through national health � nancing policies that promote pooling of risk and resources.

● Extending health protection through insur-ance and tax-� nanced systems aims to achieve universal coverage.

● Most expenditure for the MDGs will continue to come from domestic sources. � 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-de� 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 countriesSource: 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

20102009

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 topicsUS$ 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/2010.2http://www.who.int/topics/millennium_development_goals