1. 1 African Development Bank Agnes Soucat, MD, Ph.D Director Department of Human Development African Development Bank Agnes Soucat, MD, Ph.D Director Department of Human Development The promise of RBF to reach the Health MDGs and the Evidence Gap: How Impact Evaluation Can Inform Policy Dialogue

2. 2 Progress towards the health MDGs is inadequate Number of children dying before the age of 5

3. 33 Source: Demographic and Health Surveys Treated fever among children under 5 by wealth quintile

4. 44 Most mortality causes still avoidable with low cost interventions

5. 55 The Health MDGs are within reach…. Source : high Level Task Force on Innovative Financing, 2009

6. 66 And money is here… Africa is growing at 5% a year and external aid is an important source of health spending in Sub-Saharan Africa…

7. 77 But increasing public spending is also not enough * Percent deviation from rate predicted by GDP per capita Source: Spending and GDP from World Development Indicators database. Under-5 mortality from Unicef 2002 But more money does not always give better results

8. 88 Countries use well-designed policies to achieve growth and human development outcomes Health, Education, Poverty But… * Services Governments/donors

9. 99 Communities Government Providers Local Govt. Clients Leakage of Funds Bad policy Poor budget handling Primary education Sub-optimal spending (Big salary bills but insufficient commodities) Financing problems Information & monitoring Local govt. incentives skewed Local capacity issues Low quality services Provider incentives unclear, absenteeism Hard to monitor, users helpless Lack of demand Externalities Community norms Budget constraints Intra-household behavior But, what looks good on paper seems to break down in practice…

10. 10 Expenditure incidence Health Source: Filmer 2003b Public Money Benefits Richer Groups

11. 11 Nonwage funds not reaching health services: Evidence from PETS (%) CountryMean Chad 200495 Senegal 200360 Cameroon 200470 Rwanda 200340 Source: World Bank Health Public Money Does Not Reach the Frontline

12. 12 And the Results Chain to achieving the MDGs 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, ORT ARI treatment, Exclusive Breastfeeding, Vitamin A supplementation, ITNs, Antimalarial treatment, Attended Deliveries, Antenatal Care, 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 Education Access to water Income School Health

13. 13 “ 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 water Female education Income 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 ORT ARI treatment Exclusive breastfeeding Vitamin A supplementation ITNs Antimalarial treatment Attended Deliveries Antenatal Care Contraception etc…