Enhancing equity in achieving health MDGs Dr Mickey Chopra, Chief of Health, UNICEF
Why focus on equity? • HUMAN RIGHTS. • QUALITY OF RESULTS • MORE THAN NUMBERS - A HUMAN FACE. MDGs are not simply a statistical exercise, but a meaningful strategy for reaching those children who risk being left behind. • OPPORTUNITY IS NOW. If we do not take advantage of the political momentum generated by the MDGs, it will be much more difficult to focus global attention and resources on hard-to-reach groups after 2015. • MEANS TO ACCELERATE ACTION ARE AVAILABLE.."
Under-five mortality in 42 developing countries after reaching MDG-4 Business as usual Mainstreaming equity Source: Gwatkin, 2007
Inequality Among and Within CountriesMILLIONS OF INFANT DEATHS45 Developing Countries, mid-1990s Gwatkin 2003
Skilled birth attendance by income quintiles, 1996-2006 Barros F et al, AJPH (in press) =
Skilled birth attendance: Inequity gaps, 1996-2006 Barros F et al, AJPH (in press) Source: New analyses
Inequity gaps in coverage, 1996-2006 Barros F et al, AJPH (in press) Source: New analyses
Poor-rich gaps in under-five mortality, 1991 and 2001-2 Barros F et al, AJPH (in press) Source: new analyses.
Reasons for Brazil’s progress (Victora et al. 2010) • Socioeconomic and demographic factors • Moderate economic growth • Reduction of socioeconomic inequalities (>2000) • Improved maternal education • Sharp decline in fertility • Urbanization • Non health-sector interventions • Huge conditional cash transfer program • Marked improvement in water supply • Rural social security
Reasons for Brazil’s progress • Health sector interventions • Vertical programs in the 1980s-1990s • Oral rehydration • Immunizations • Breastfeeding promotion • Creation of a national health system in 1989 • Strong popular participation at all levels of the NHS • Family health program with geographical targeting • High visibility of child health
Infant mortality by region Infant mortality rate, 2000 Infant mortality is highest in the Northeast and North Cedeplar/UNDP, Brazil
Family health program Brazil MOH
Problems at policy-setting level • Excessively vertical funding channels. • Existing plans remain insufficiently equity oriented. • Fragmentation and large transaction costs from misaligned aid. • Intersectoral linkages weak • Insufficient accountability for MDGs- linked to limited staffing, expertise and resources to produce results-based plans.
Problems at the system or sector level • Poor links between disease burden and choice of interventions. • Inequitable allocation of financing. • Inadequate and unpredictable funding. • Poorly trained and undersupplied human resources. • Constraints on supply chain management and capacity.
Prioritise interventions/packages Chopra et al. Lancet 2009
Bottlenecks for equity Solid evidence on high efficacy of health, nutrition, HIV/AIDS and WASH interventions Enhanced global and national commitment to MDG 1,4,5,6,7 Implementation bottlenecks poor access to healthcare, human resource constraints, inadequate supplies, low demand for and/or continuity and quality of services Insufficient and inequitable progress to MDG 1c,4,5,6,7 in many States and districts Increased govt. health spending in context of PHC mission and $ from GFATM, GAVI, PMI, PEPFAR,BMGF, bilateral aid
How UNICEF can play its role • Root causes – linkages to gender issues, protection, education, health, HIV etc • CO s engagement : understanding, follow-through • Tackling inequities – decentralization; meeting the demands of countries esp decentralized level • WASH / Nutrition /C4D thrust – and integration as effective