UNDP RBA MDG-Based National Development Planning Workshop Health Module Chandrika Bahadur UN Millennium Project February 27-March 3, 2006

2 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

3 Public investment in Health Source: WDI 2004 authors calculations for 2001

4 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

5 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

6 Choosing interventions Defining and setting targets Estimating resource needs Checking results MDG Needs Assessment Approach

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)

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

Choosing Interventions: More Detail on MCH and SRH

Choosing Interventions: More Detail on HIV/AIDS

Choosing Interventions: More Detail on TB, Malaria

12 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

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

14 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

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

Estimating Resource Needs: B. Human Resources 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

Estimating Resource Needs: B. Human Resources 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

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

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)

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 15% of direct health costs including salaries Building capacity for basic research and development 2% of direct health costs including salaries

Estimating Resource Needs: Adding it All Up Direct costs of all interventions + Infrastructure and HRH costs Costs of health system strengthening + Total health costs

Checking Results Review all results to ensure that numbers are robust. Here are some sample health costs from Tanzania: