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Reaching the MDGs Evidence on High Impact Interventions- Agnes Soucat, World Bank and Netsanet Walelign, UNICEF Kigali June 23-27 Why are we here today ? Progress towards MDGs: inadequate Trend in Under-Five Deaths, 1960-2015 (Millions deaths per year) Growth is not enough

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reaching the mdgs evidence on high impact interventions

Reaching the MDGs Evidence on High Impact Interventions-

Agnes Soucat, World Bank

and Netsanet Walelign, UNICEF

Kigali June 23-27


Progress towards MDGs: inadequate

Trend in Under-Five Deaths, 1960-2015 (Millions deaths per year)

growth is not enough
Growth is not enough

Sources: World Bank 2003a, Devarajan 2002. Notes: Average annual growth rates of GDP per capita assumed are: EAP 5.4; ECA 3.6; LAC 1.8;

MENA 1.4; SA 3.8; AFR 1.2. Elasticity assumed between growth and poverty is –1.5; primary completion is 0.62; under-5 mortality is –0.48.

household and community level interventions 1
Insecticide Treated Mosquito Nets

Safe water systems

Use of sanitary latrins

Hand washing by mother

Indoor Residual Spraying (IRS)

Clean delivery and cord care

Early breastfeeding and temperature management

Universal extra community-based care of LBW infants


Complementary feeding

Therapeutic Feeding

Oral Rehydration Therapy

Zinc for diarrhea management

Vitamin A - Treatment for measles

Chloroquine for malaria (P.vivax)

Artemisinin-based Combination Therapy

Antibiotics for U5 pneumonia

Community based management of neonatal sepsis

Household and community level interventions(1)
population oriented interventions 2
Family planning

HPV vaccination

Preconceptual folate supplementation

Tetanus toxoid

Deworming in pregnancy

Detection and treatment of asymptomatic bacteriuria

Treatment of syphilis in pregnancy

Prevention and treatment of iron deficiency anemia in pregnancy

Intermittent preventive treatment (IPTp) for malaria in pregnancy

Balanced protein energy supplements for pregnant women

Supplementation in pregnancy with multi-micronutrients



Cotrimoxazole prophylaxis for HIV+

Measles immunization

BCG immunization

OPV immunization

DPT immunization

Hib immunization

Hepatitis B immunization

Yellow fever immunization

Meningitis immunization

Pneumococcal immunization

Rotavirus immunization

Neonatal Vitamin A supplementation

Vitamin A - supplementation

Zinc preventive

Population oriented interventions (2)
individual clinical interventions 3
Skilled attended delivery

Basic emergency obstetric care (B-EOC)

Resuscitation of asphyctic newborns at birth

Antenatal steroids for preterm labor

Antibiotics for Preterm/Prelabour Rupture of Membrane (P/PROM)

Detection and management of (pre)ecclampsia (Mg Sulphate)

Management of neonatal infections

Antibiotics for U5 pneumonia

Antibiotics for diarrhea and enteric fevers

Vitamin A - Treatment for measles

Zinc for diarrhea management

Clinical management of neonatal jaundice

Management of severely sick children (referral IMCI)

Chloroquine for malaria (P.vivax)

Artemisinin-based Combination Therapy

Management of complicated malaria (2nd line drug)

Individual clinical interventions (3)
individual clinical interventions 310
Management of opportunistic infections

Male circumcision

Second-line ART

Adult second-line ART

Comprehensive emergency obstetric care (C-EOC)

Other emergency acute care

Individual clinical interventions (3)
  • Detection and management of STI
  • Management of opportunistic infections
  • First line ART
  • Detection and treatment of TB with first line drugs (category 1 and 3)
  • Re-treatment of TB patients with first line drugs (category 2)
  • MDR treatement with second line drugs
countries use well designed policies to achieve growth and human development outcomes
Countries use well-designed policies to achieve growth and human development outcomes

Services Governments/donors

Health, Education, Poverty




But, what looks good on paper seems to break down in practice…


Leakage of Funds

Bad policy

Poor budget handling

Local Govt.

Sub-optimal spending

(Big salary bills but insufficient textbooks & materials)


Financing problems

Information & monitoring

Local govt. incentives skewed

Local capacity issues


Low quality instruction

Provider incentives unclear, absenteeism

Hard to monitor, users helpless

Quality inappropriate



Lack of demand



Community norms

Budget constraints

Intra-household behavior

results based financing
Results-based Financing


Sub-National Government


National Government

Results Based Aid

Results Based Planning and Budgeting

Results Based Contracting for

CCT, RB bonuses

Hospitals, Health Centers, Ass


or Individuals


Steps in Results-Based Budgeting

  • Step 1: Health Systems and
  • High Impact Interventions
  • Analyze health systems.
  • Identify major U5MR, NNMR, MMR
  • causes.
  • Identify high impact health, nutrition, AIDS,
  • & malaria interventions (level 1-2 evidence).
  • Organize interventions into 3 service
  • delivery modes: Family oriented
  • community-based; Population oriented
  • schedulable; and individual oriented
  • clinical services.
  • Select representative tracer interventions
  • for each sub-package of interventions.
  • Step 2: System Bottlenecks to
  • Coverage
  • Analyze household surveys and service
  • statistics, using six coverage determinants,
  • to identify system bottlenecks to coverage &
  • causes.
  • Supply side: availability of essential
  • commodities, availability of human resources,
  • and physical access.
  • Demand side: initial and timely continuous
  • Utilization; Effective quality coverage.
  • Analyze strategies to address bottlenecks
  • and set new coverage frontiers.
  • Step 5: Budgeting and
  • Fiscal Space
  • Translate marginal cost into yearly
  • additional budget figures.
  • Link budget figures to national
  • sector plans, MTEF, PRSP, and
  • other programs.
  • Facilitate analysis on financing
  • sources.
  • Evaluate additional funding
  • requirement against the fiscal space
  • for health.
  • Step 3: Estimating Impact
  • Epidemiometric model.
  • Estimate the impact (reduction in
  • mortality) of overcoming the
  • bottlenecks based on local causes
  • of NNMR, U5MR and MMR.
  • Sources include: MDG1 (Emory),
  • MDG4 (Bellagio), MDG 5 (WHO/
  • WB Cochran; BMJ), and MDG 6
  • (RBM, UNAIDS).
  • Step 4: Estimating
  • Marginal Cost
  • Estimate marginal costs to
  • overcome the bottlenecks and
  • achieve new performance frontiers.
  • Region/country specific inputs and
  • cost structures.
linking flow of funds to impacts

Inputs (Health & WSS Inputs) to Release


Health Output

MDGs Outcome


Essential drugs commodities, safe water system, and/or human resources etc.


∆Cof health & nutrition interventions delivered by Family/Community

Support for community meeting, inputs for a mobile team, construction of health post etc.

Impact on MDG health indicators: Reduction in U5MR and MMR


∆Cof health & nutrition interventions delivered by Outreach team

Drugs and supplies, subsidies for insurance for referral care per user etc.


Demand side subsidy, performance-based incentives for health workers, doctors, and IEC inputs etc.

∆Cof health & nutrition inter-ventions delivered by Clinics/Hospitals


Cost of removing bottlenecks to achieve certain MDG target

Training, supervision and monitoring of community mobilizers, primary and referral clinical care etc.


Aggregate Cost of Inputs

Linking Flow of Funds to Impacts
the challenge of scaling up in rwanda
The Challenge of Scaling Up in Rwanda

Current Health Expenditures