1 African Development Bank Agnes Soucat, MD, Ph.D Director Department of Human Development African Development Bank Agnes Soucat, MD, Ph.D Director Department.

1

African Development BankAfrican Development BankAgnes Soucat, MD, Ph.D Agnes Soucat, MD, Ph.D

DirectorDirectorDepartment of Human DevelopmentDepartment of Human Development

The promise of RBF to reach the The promise of RBF to reach the Health MDGs and the Evidence Gap: Health MDGs and the Evidence Gap: How Impact Evaluation Can Inform How Impact Evaluation Can Inform

Policy Dialogue Policy Dialogue

2

2.9 3.2 3.5 4.1 4.6 4.9

2

5.1

13.510.9

8.3 75.1 4.1

2.2

3

4.1

3.6

2.7

1.8

1.41.1

0.8

0.1

0

5

10

15

20

25

1960 1970 1980 1990 2000 2005 2015 withachievement of

MDGs

2015 withcurrent Trend

Africa Asia Other

Progress towards the health MDGs is Progress towards the health MDGs is inadequate inadequate

Number of children dying before the age of 5

33

Source: Demographic and Health Surveys

Treated fever among children under 5 by wealth quintile

44

Most mortality causes still avoidable with low Most mortality causes still avoidable with low cost interventionscost interventions

Cause-specific proportional mortality in the Africa region

21%

17%

4%

21%

6%2%

7%

17%

Neonatal

HIV/AIDS

Diarrhoealdiseases

Measles

Malaria

Respiratoryinfections

Injuries

Others

55

$151.0

$89.0

$48.0

$-

$20.0

$40.0

$60.0

$80.0

$100.0

$120.0

$140.0

$160.0

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Comprehensive Medium Focussed

Billio

ns o

f US$

2009

-15

Progress towards MDGs, Marginal Cost, and Fiscal Space

MDG 1 MDG7MDG 6MDG 5MDG 4

The Health MDGs are within reach…. The Health MDGs are within reach….

Source : high Level Task Force on Innovative Financing, 2009

66

And money is here… Africa is growing at 5% a And money is here… Africa is growing at 5% a year and external aid is an important source of year and external aid is an important source of health spending in Sub-Saharan Africa…health spending in Sub-Saharan Africa…

External aid as % of total health spending (2002)

0

2

4

6

8

10

12

14

16

18

20

East Asia &Pacific

Eastern Europe& Central Asia

Latin America &the Caribbean

Middle East &North Africa

South Asia Sub-SaharanAfrica

Region

Pe

rce

nt

of

tota

l he

alt

h e

xp

en

dit

ure

77

But increasing public spending is also not enough

* Percent deviation from rate predicted by GDP per capitaSource: Spending and GDP from World Development Indicators database. Under-5 mortality from Unicef 2002

But more money does not always give better results

88

Countries use well-designed Countries use well-designed policies to achieve growth and policies to achieve growth and human development outcomeshuman development outcomes

Health, Education,

PovertyBut…

* Service

s

Gover

nments/

donors

99

Comm

uniti

es

Government

Providers

Loca

l Gov

t.Clie

nts

Leakage of Funds

Bad policyPoor budget handling

Primary education

Sub-optimal spending(Big salary bills but insufficient commodities)

Financing problemsInformation & monitoringLocal govt. incentives skewedLocal capacity issues

Low quality servicesProvider incentives unclear, absenteeismHard to monitor, users helpless

Lack of demandExternalitiesCommunity normsBudget constraintsIntra-household behavior

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

1010

Expenditure incidenceExpenditure incidence

Health

Source: Filmer 2003b

Public Money Benefits Richer Groups

1111

Nonwage funds not reaching health services: Nonwage funds not reaching health services: Evidence from PETS (%)Evidence from PETS (%)

Country MeanChad 2004 95

Senegal 2003 60 Cameroon 2004 70

Rwanda 2003 40

Source: World Bank

Health

Public Money Does Not Reach the Frontline

1212

And the Results Chain to achieving the MDGs And the Results Chain to achieving the MDGs has missing links… has missing links…

Upstream diagnostic

Country Status Report on Health, Poverty, Health Systems and the MDGs

Policy dialogue

One country, one costed plan for country supported by all partners (IHP+)

Financing Programs

Focused funds:,Malaria HIV/AIDS, Tuberculosis etc.

Problem specific and health system focused operations (eg: SWAPs, PBS, PRSC)

Joint Bank-Partners Programs (eg: Results-based financing)

Health Systems

Health Financing Human Resources For Health

Supply Chain and Pharmaceuticals

Governance and Service Delivery

Infrastructure and ICT

Health Systems Outcomes

Immunization, ORTARI treatment, ExclusiveBreastfeeding, Vitamin A supplementation,ITNs,Antimalarial treatment,Attended Deliveries, AntenatalCare, Contraception, etc…

Health Outcomes

Nutrition (MDG1)Child health (MDG4)

Maternal Health and mortality (MDG5)

Malaria,AIDS, TB, prevalence and mortality (MDG6)

Financial protection

Control of Non Communicable Diseases

Control of Neglected Tropical Diseases

Multisectoral Outcomes

Female EducationAccess to waterIncomeSchool Health

1313

“ “ the missing middle” problem….the missing middle” problem….

MDGs

Other outcomes

Health systems Outcomes

Nutrition (MDG1)

Child health (MDG4)

Maternal Health and mortality (MDG5)

Malaria,AIDS, TB, prevalence and mortality (MDG6)

Financial protection

Non Communicable Diseases

Access to safe waterFemale educationIncome

Other sectors Outcomes

Education

Water

Social Protection

Financing

Focused funds:,Malaria HIV/AIDS, Tuberculosis etc.

Problem specific and health system focused operations (eg: SWAPs, PBS, PRSC)

Joint Bank-Partners Programs (eg: Results-based financing)

Health systems

Human Resources For Health

Supply chain

Governance and Service Delivery

Public finance and health insurance

Infrastructure and ICT

Immunization ORTARI treatment Exclusivebreastfeeding Vitamin A supplementationITNsAntimalarial treatmentAttended Deliveries AntenatalCare Contraception etc…