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Millennium Development Goals for Health: What Will It Take to Accelerate Progress?</h1> </div> <div class="leftcol"> <div class="leftblock twocol"> <div style="display:none;visibility:hidden;" id="highlight" class="contentblock searchresults"> <form method="post" action="/web/20080829125528/http://www.dcp2.org/sdirect/_/main/ViewChapterSection,$Form.html" name="Form" id="Form"> <div style="display:none;"><input type="hidden" name="formids" value="highlighting"/> <input type="hidden" name="submitmode" value=""/> <input type="hidden" name="submitname" value=""/> </div> <label class="highlight">highlighting</label> <input type="radio" name="highlighting" value="0" onclick="this.form.submit()" id="highlighton"/>Yes <input type="radio" name="highlighting" checked="checked" value="1" onclick="this.form.submit()" id="highlightoff"/>No </form> </div> </div> <div class="leftblock twocol"> <div class="left_col"> <div class="left_col_block color"> <h3>CHAPTER INFO</h3> <div class="contentblock"> <p> Editors/Authors: Adam Wagstaff, Mariam Claeson, Robert M. Hecht, Pablo Gottret, and Qiu Fang<br/> Pages: 14<br/> </p> <div class="normal"> <ul> <li><a href="https://web.archive.org/web/20080829125528/http://files.dcp2.org/pdf/DCP/DCP09.pdf" target="_blank"> Download PDF Version</a> </li> <li><a href="javascript:popup_window();" id="howtocite"> How To Cite</a></li> </ul> <p> <strong>Region</strong> <br/> <span id="regions"> <a href="/web/20080829125528/http://www.dcp2.org/regions/1/east-asia-and-pacific" id="country_1"> East Asia and Pacific </a> <br/> <a href="/web/20080829125528/http://www.dcp2.org/regions/51/latin-america-and-the-caribbean" id="country_51"> Latin America and the Caribbean </a> <br/> <a href="/web/20080829125528/http://www.dcp2.org/regions/157/south-asia" id="country_157"> South Asia </a> <br/> <a href="/web/20080829125528/http://www.dcp2.org/regions/166/subsaharan-africa" id="country_166"> Sub-Saharan Africa </a> <br/> </span> </p> <p> <strong>Disease / Condition</strong> <br/> <span id="diseases"> <a href="/web/20080829125528/http://www.dcp2.org/diseases/2" id="disease_2"> Adolescent & Childhood Diseases</a> <br/> <a href="/web/20080829125528/http://www.dcp2.org/diseases/18" id="disease_18"> Diarrheal Disease</a> <br/> <a href="/web/20080829125528/http://www.dcp2.org/diseases/25" id="disease_25"> Helminth Infections</a> <br/> <a href="/web/20080829125528/http://www.dcp2.org/diseases/28" id="disease_28"> HIV/AIDS</a> <br/> <a href="/web/20080829125528/http://www.dcp2.org/diseases/31" id="disease_31"> Infectious Diseases</a> <br/> <a href="/web/20080829125528/http://www.dcp2.org/diseases/37" id="disease_37"> Learning & Developmental Disabilities</a> <br/> <a href="/web/20080829125528/http://www.dcp2.org/diseases/42" id="disease_42"> Malaria</a> <br/> <a href="/web/20080829125528/http://www.dcp2.org/diseases/44" id="disease_44"> Maternal Conditions</a> <br/> <a href="/web/20080829125528/http://www.dcp2.org/diseases/47" id="disease_47"> Neonatal Conditions</a> <br/> <a href="/web/20080829125528/http://www.dcp2.org/diseases/50" id="disease_50"> Nutrition</a> <br/> <a href="/web/20080829125528/http://www.dcp2.org/diseases/55" id="disease_55"> Respiratory Diseases</a> <br/> <a href="/web/20080829125528/http://www.dcp2.org/diseases/66" id="disease_66"> Tropical Diseases</a> <br/> <a href="/web/20080829125528/http://www.dcp2.org/diseases/67" id="disease_67"> Tuberculosis</a> <br/> <a href="/web/20080829125528/http://www.dcp2.org/diseases/69" id="disease_69"> Vaccine-Preventable Diseases</a> <br/> <a href="/web/20080829125528/http://www.dcp2.org/diseases/71" id="disease_71"> Women's Health</a> <br/> </span> </p> </div> </div> </div> <div class="left_col_block color" id="customBookBox"> <h3>CUSTOM BOOKS</h3> <div class="contentblock"> <p>Select, organize, download, and save your choice of chapters into a single PDF file for printing and distribution. This is a free service.</p> <p> <a href="/web/20080829125528/http://www.dcp2.org/page/main/MyDCPP.html" id="link_custombook">My DCPP</a><br/> Log in to view your saved custom books </p> </div> </div> </div> <div class="right_col"> <div class="contentblock"> <div id="content"> <h2 id="_sectiontitle">What Do Countries Need to Do?</h2> <p>If the lack of interventions is not holding countries back from achieving the goals, what is? What do countries need to do to make progress toward the MDGs?</p> <p>In countries with good governance, additional government health spending does reduce child mortality (<a class="text-ref" href="/web/20080829125528/http://www.dcp2.org/pubs/DCP/9/Section/1000#1036">Rajkumar and Swaroop 2002</a>). Development assistance has a stronger effect in countries with strong policies and institutions than in countries with only average-quality policies and institutions鈥攁nd an insignificant effect in countries where policies and institutions are weak. This assertion is also consistent with the findings of a study undertaken by the World Bank for the MDG report, <em>The Millennium Development Goals for Health: Rising to the Challenges</em> (<a class="text-ref" href="/web/20080829125528/http://www.dcp2.org/pubs/DCP/9/Section/1000#1048">Wagstaff and Claeson 2004</a>). The study includes other outcomes with child mortality and uses the World Bank's Country Policy and Institutional Assessment index to measure the quality of policies and institutions.</p> <p>In principle, well-governed countries with good policies and institutions could achieve the goals simply by scaling up their expenditures on existing programs in proportion to current allocations. In practice, however, the amount of extra spending required would be difficult to attain on present trends and would even be prohibitively expensive. In the case of East Asia and the Pacific, for example, if economic growth proceeds as expected and the other relevant Millennium Development Targets are attained, the region would achieve the required rates of reduction of underweight and maternal mortality鈥攁ssuming that economic growth is accompanied by the development of appropriate human resources for health鈥攅ven if government health spending continues to grow at its current rate. However, the region would miss the under-five mortality target. To reach that target, a minimum of 5 percentage points would need to be added to the annual rate of growth of the government health share of gross domestic product (GDP). That would take the projected share of GDP spent on government health programs to 3.7 percent in 2015鈥攎ore than twice what it would be if the 1990s pattern of growth continued (<a class="text-ref" href="/web/20080829125528/http://www.dcp2.org/pubs/DCP/9/Section/1000#1048">Wagstaff and Claeson 2004</a>).</p> <p>In Sub-Saharan Africa, the situation is even starker. Even if faster economic growth materializes and the other targets are achieved, the share of government health spending in GDP would need to grow nearly six fold over the coming decade, taking the share to 12.2 percent of GDP in 2015. This percentage compares with a 2000 figure of 1.8 percent and a 2015 forecast of 2.2 percent based on the 1990s annual growth in government spending for health. In conclusion, African countries will not be able to reach the MDGs simply by multiplying their health spending along the lines of historical expenditure patterns, because the multiples required are beyond any realistic expectation of what these governments will be able to do during the next 10 years.</p><a name="958">聽</a> <h3>What Are the Implications?</h3><br/> <p>Poorly governed countries cannot expect to make much progress toward the MDGs simply by scaling up their expenditures on existing programs in proportion to current allocations. Although well-governed countries could, in principle, simply scale up existing spending to reach the targets, this option is unlikely to be affordable for them or their donors.</p> <p>This situation has two implications:</p> <p><ul><li> <p>First, targeting additional government spending to activities that will have the largest effect on the MDGs is important for both sets of countries.</p></li><li> <p>Second, building good policies and institutions is important for all countries: doing so increases the productivity not just of additional spending but also of existing spending commitments. What do better policies and institutions entail in the health sector? Health systems are very broad, and weak policies and institutions can arise at several points along the pathway, from government health spending to health outcomes (<a class="text-ref" href="/web/20080829125528/http://www.dcp2.org/pubs/DCP/9/Section/1000#1005">Claeson and others 2001</a>). Countries can do a number of things, with help from donors, to build stronger policies and institutions.</p></li></ul></p><a name="961">聽</a> <h3>Improving Expenditure Allocations and Targeting</h3><br/> <p>In most countries, government spending gets stuck in the cities and disproportionately accrues鈥攊n a financial sense鈥攖o people who are better off.</p><a name="962">聽</a> <h3>Geographic Targeting</h3><br/> <p>Resource allocation formulas can be used to reduce government spending gaps across regions and ideally to favor geographic zones that are furthest behind. These formulas have been used, for example, as part of Bolivia's decentralization efforts since 1994 and have been associated with some large鈥攁nd pro-poor鈥攊mprovements in maternal and child health indicators. Targeting resources to poor regions and provinces may be most effectively implemented through nontraditional mechanisms for priority setting and implementation, such as social investment funds. In Bolivia, a recent impact evaluation concluded that such funds were responsible for a decline in under-five mortality from 88.5 to 65.6 per 1,000 live births over a five-year period (<a class="text-ref" href="/web/20080829125528/http://www.dcp2.org/pubs/DCP/9/Section/1000#1030">Newman and others 2002</a>).</p><a name="963">聽</a> <h3>Changing the Allocation of Spending across Care Levels</h3><br/> <p>Spending on health in developing countries is characterized by a high concentration of spending on secondary and tertiary infrastructure and personnel. Some governments have tried to scale back the share of hospital spending. Tanzania, for example, reduced the share of hospital spending from 60 percent in 2000 to 43 percent in 2002. Chapter 3 deals with the issue of how to couple expenditure reallocations across levels of care with measures to improve performance at each level of the health care system.</p><a name="964">聽</a> <h3>Targeting Specific Programs</h3><br/> <p>Programs such as those delivering directly observed treatment short course (DOTS) for tuberculosis or integrated management of infant and childhood illness (IMCI) for child health are good examples of programs that may yield high returns to government spending at the margin. A recent World Bank study in India provides further support for the idea that the way government spending is allocated across programs makes a difference to its effect on the Millennium Development Indicators (<a class="text-ref" href="/web/20080829125528/http://www.dcp2.org/pubs/DCP/9/Section/1000#1054">World Bank 2003a</a>). Successful public health programs鈥攍arge-scale programs with a measurable health effect over at least a five-year period鈥攁re further discussed in chapter 8. All successful programs have several factors in common: technical innovation and stakeholder consensus, strong political leadership, coordination across agencies and management, effective use of information and financial resources, and participation of the beneficiary community.</p><a name="965">聽</a> <h3>Targeting Specific Population Groups</h3><br/> <p>Many countries subsidize all government health services for everyone. These blanket subsidy schemes not only fail to target interventions that give rise to externalities but also fail to disproportionately benefit the poor鈥攄espite the stronger equity case for subsidizing their care and the fact that they tend to bear a disproportionate burden of malnutrition as well as child and maternal mortality. There are many proven ways to target the poor鈥攆or example, by delivering essential services in clinics or health posts that only poor families attend or by promoting and delivering services in a way that segments the market and appeals to those in low-income households.</p><a name="966">聽</a> <h3>Targeting Spending to Remove Bottlenecks</h3><br/> <p>A planning and budgeting approach is to assess鈥攆or a country鈥攖he health sector impediments to faster progress, to identify ways of removing them, and to estimate both the costs of removing them and the likely effects of their removal on MDG outcomes (<a class="text-ref" href="/web/20080829125528/http://www.dcp2.org/pubs/DCP/9/Section/1000#1042">Soucat and others 2002</a>). MDG analysis along these lines鈥攔eferred to sometimes as <em>marginal budgeting for bottlenecks</em> (MBB)鈥攈as begun in several African countries and in some states of India (UNICEF and World Bank 2003). In Mali, key bottlenecks were identified for supporting home-based practices and delivering periodic and continual professional care. They included low access to affordable commodities and the need for community-based support for home-based care; low geographical access to preventive professional care (immunization, vitamin A supplementation, and prenatal care); shortages of qualified nurses and midwives; and an absence of effective third-party payment mechanisms for the poor for professional continuous care. Important health systems bottlenecks, such as human resources, drug availability, and health care management, are discussed in chapters 71-73.</p><a name="967">聽</a> <h3>Improving Policies toward Households as Producers and Demanders of Care</h3><br/> <p>Households are at the center of any efforts to scale up; they not only demand and consume care, but they are also important producers of prevention and care. Policies to increase coverage of cost-effective interventions to reach the health MDGs, therefore, need to identify and influence the key constraints to both the production and the demand for those services at the household and community levels.</p><a name="968">聽</a> <h3>Lowering Financial Barriers</h3><br/> <p>Low income is a barrier to the use of most health interventions, and economic growth is an important weapon in the war against malnutrition and mortality. However, social protection programs are also important. Successful schemes aimed at households and communities are discussed in chapter 56.</p> <p>One part of the affordability equation is price. User charges for MDG interventions are to be discouraged. Why? Many of those interventions involve benefits that spill over to people who do not receive the intervention; high coverage of immunization is a classic example. However, an equity case also can be made for reducing prices facing the poor and near poor, even where no spillovers occur. Subsidies should be targeted to services with spillovers and to the poor. In practice, subsidies are often badly targeted in at least one respect if not both. Exceptions exist. In Ifakara, Tanzania, a voucher program for mosquito nets was launched successfully for pregnant women and children under five (<a class="text-ref" href="/web/20080829125528/http://www.dcp2.org/pubs/DCP/9/Section/1000#1039">Schellenberg and others 2001</a>).</p> <p>Some recent programs, especially in Latin America, have not only made health care affordable for the poor but have also made it profitable. Rather than simply reducing the cost of using specific interventions, these programs provide users with cash payments, which are linked to specific interventions and restricted to certain groups鈥攐ften poor mothers and their children. The experience with these programs in targeting and achieving results is encouraging (<a class="text-ref" href="/web/20080829125528/http://www.dcp2.org/pubs/DCP/9/Section/1000#1024">Mesoamerica Nutrition Program Targeting Study Group 2002</a>; <a class="text-ref" href="/web/20080829125528/http://www.dcp2.org/pubs/DCP/9/Section/1000#1028">Morris and others 2003</a>; <a class="text-ref" href="/web/20080829125528/http://www.dcp2.org/pubs/DCP/9/Section/1000#1032">Palmer and others 2004</a>).</p> <p>Risk aversion coupled with the unpredictability of illness provides a motivation for pooling risks through an insurance scheme. The Arab Republic of Egypt, for example, introduced a school health insurance program for all children attending school. The program resulted in larger increases in coverage among the poor and achieved considerable effect on use and out-of-pocket expenditures (<a class="text-ref" href="/web/20080829125528/http://www.dcp2.org/pubs/DCP/9/Section/1000#1058">Yip and Berman 2001</a>). However, insurance in the developing world is very limited, and those who are least able to smooth consumption without insurance are the least likely to have insurance coverage (<a class="text-ref" href="/web/20080829125528/http://www.dcp2.org/pubs/DCP/9/Section/1000#1029">Musgrove, Zeramdini, and Carrin 2002</a>). Another problem is that many of the schemes are small scale, and evaluations of these schemes do not generally measure health effect or effect on equity, thus resulting in limited evidence (<a class="text-ref" href="/web/20080829125528/http://www.dcp2.org/pubs/DCP/9/Section/1000#1032">Palmer and others 2004</a>).</p><a name="969">聽</a> <h3>Providing Information鈥擡nhancing Knowledge</h3><br/> <p>Lack of knowledge is a major factor behind poor health. It results in people not seeking care when needed, despite the absence of price barriers, and it also results in people鈥攅specially poor people鈥攚asting limited resources on inappropriate care. Ignorance may also result in people not getting the maximum health gain out of inputs they have available to them and use. Many people do not know that hand washing confers much of the health benefit of piped water (see chapter 41). Not surprisingly, piped water has a much greater effect on the prevalence of diarrhea among the children of the better off and better educated. Better-educated women鈥攅specially those with a secondary education鈥攁chieve better health outcomes for themselves and their children not by using health-specific knowledge that they acquire at school, but by using general numeracy and literacy skills learned at school to acquire health-specific knowledge later in life. Although better-educated girls will mean healthier women and healthier children in years to come, a shorter and more direct route to increasing health-specific knowledge and skills is through information dissemination, health promotion, and counseling in the health sector.</p> <p>Several success stories exist. In Brazil, after health workers trained by IMCI provided information and counseling at health facilities and in the community, health knowledge among mothers improved, as did feeding practices (<a class="text-ref" href="/web/20080829125528/http://www.dcp2.org/pubs/DCP/9/Section/1000#1038">Santos and others 2001</a>). After only 18 months, the nutritional status of children in the area improved as well. Social marketing and media campaigns鈥攆or example, malaria and social marketing of insecticide-treated nets (see chapter 21)鈥攈ave also proved effective in some circumstances.</p><a name="970">聽</a> <h3>Reducing Time Costs</h3><br/> <p>Transportation systems, road infrastructure, and geography influence the demand for care delivered by formal providers through their effect on time costs, which can be substantial. In rural communities, where the roads are poor and the transportation unreliable, the time spent waiting for the transportation is also a major cost. Time costs tend to be a major issue for maternal mortality: health centers are unable to provide essential obstetric care for a complicated delivery, and women would have to travel to distant hospitals to get such services. Road rehabilitation and other transportation projects are important here, but so are subsidies linked to the use of health services. Malaysia and Sri Lanka provide free or subsidized transportation to hospitals in emergencies (<a class="text-ref" href="/web/20080829125528/http://www.dcp2.org/pubs/DCP/9/Section/1000#1033">Pathmanathan and others 2003</a>). Other options for tackling inaccessibility include using outreach and establishing partnerships between government and nongovernmental organizations (NGOs), private providers, or community organizations.</p><a name="971">聽</a> <h3>Providing Access to Water and Sanitation</h3><br/> <p>The availability of adequate supplies of water and improved sanitation is associated with better maternal and child health outcomes, at least among the better educated, even after controlling for other influences. This result is not altogether surprising. Hand washing is easier if the household has piped water that provides readily available quantities of safe water. The safe disposal of feces is easier if the household has an improved form of sanitation. The developing world lags well behind the industrial world in both; the poorer people fare especially badly. They are less likely to be connected to a network, and the sources they rely on tend to be more costly per liter than the networked services used by the better off.</p> <p>The challenge from a health perspective is to get maximum health benefits from investments in access to water and sanitation infrastructure. Efforts to work across sectors on water and health, in order to influence the health MDGs, are under way in Ethiopia, Peru, and Rwanda.</p><a name="972">聽</a> <h3>Improving Health Service Delivery</h3><br/> <p>Health providers鈥攊n the public and private sectors, as well as in both formal and informal sectors鈥攕hould deliver interventions of relevance to the MDGs. Many are efficient, deliver high quality services, and are responsive to their patients. Many, however, are not; many are not even there to deliver any services at all. As a result, resources鈥攑ublic and private鈥攁re often nonexistent, underused, or wasted.</p> <p>Two things can make a difference. One is the quality of management. Better management means a clearer delineation of responsibilities and accountabilities inside organizations, a clearer link between performance and reward, and so on. Management means getting accountabilities right within an organization. The other thing that can make a difference is getting accountabilities right between the organization and the public (<a class="text-ref" href="/web/20080829125528/http://www.dcp2.org/pubs/DCP/9/Section/1000#1057">World Bank 2003d</a>).</p><a name="973">聽</a> <h3>Improving Management鈥擨ncreasing Accountability within Provider Organizations.</h3><br/> <p>Management styles in government-funded and government-implemented health schemes have recently begun to change, focusing on performance鈥攖hat is, on outputs and outcomes鈥攔ather than on inputs and processes. Good performance is rewarded, financially or in some other way. The focus is on clients and on the belief that an organization is ultimately accountable to its clients. A client-oriented strategy emphasizes customer choice and satisfaction. Business techniques enhance performance and are a standard part of strategic planning.</p> <p>This new approach is evident in several countries, and elements of the approach are visible in successful nutrition and child health programs (see chapter 56). For example, in Tamil Nadu's Integrated Nutrition Program, community nutrition workers were given clearly defined duties. Information on outputs not only enabled the community to keep the workers accountable but also enabled the nutrition workers to see how their program was working. In Ceara's Programa de Agentes de Saude, which is credited with a substantial reduction in child mortality (<a class="text-ref" href="/web/20080829125528/http://www.dcp2.org/pubs/DCP/9/Section/1000#1047">Victora and others 2000</a>), health agents and nurse-supervisors were assigned clear tasks and given clear responsibilities. The intended outcomes of the program were emphasized to health workers and members of the public, and the health agents were held accountable through community-based monitoring and rewarded for good performance.</p><a name="974">聽</a> <h3>Governance</h3><br/> <p>The accountability of provider organizations to the public can be improved through enhanced governance or contracting. Having community representatives participate in the governance and oversight of providers can improve the productivity and quality of public sector providers. In Burkina Faso, participation of community representatives in public primary health care clinics increased immunization coverage, the availability of essential drugs, and the percentage of women with two or more prenatal visits. In Peru, comparisons of primary health care clinics with and without community participation in governance suggested decreases in staff absenteeism and waiting times and suggested increases in perceived quality by patients (<a class="text-ref" href="/web/20080829125528/http://www.dcp2.org/pubs/DCP/9/Section/1000#1008">Cotlear 1999</a>). The approach probably works best for primary care and in situations in which strong technical and advisory support is provided to community representatives who are close to the service being delivered.</p><a name="975">聽</a> <h3>Contracting</h3><br/> <p>Evidence on the effect of contracting within the public sector is mixed, and the experiences are mainly based on lessons learned from middle-income countries. In several countries in Europe and Central Asia, evidence shows a positive effect from performance-based payment, but that is not necessarily the same as contracting, which can occur without performance-related pay. The best evidence relates to the use of target payments for the attainment of a given level of coverage鈥攆or example, for immunization or cervical cytology at the primary care level (<a class="text-ref" href="/web/20080829125528/http://www.dcp2.org/pubs/DCP/9/Section/1000#1021">Langenbrunner 2003</a>). In Argentina and Nicaragua, social security institutes have increased productivity by establishing capitation-based payments for an integrated package of inpatient and ambulatory services (<a class="text-ref" href="/web/20080829125528/http://www.dcp2.org/pubs/DCP/9/Section/1000#1002">Bitran 2001</a>). Key influences on the success of contracts within the public sector include whether the provider has the ability to respond, whether service commitments are congruent with funding levels, whether output and key components of performance expectations are easily measurable, and how far capacity strengthening of the payer or funder is addressed.</p> <p>Contracting with nonprofit organizations is most common in low-income countries (see chapter 12, which contains a longer discussion of contracting with NGOs). Most cases have had positive effects on target outcome or output variables. In Bangladesh, contracts with nonprofit organizations for planning and implementing an expanded program on immunization project were credited with a dramatic increase in immunization. In Haiti, contracting for a primary health care package also significantly increased immunization coverage (<a class="text-ref" href="/web/20080829125528/http://www.dcp2.org/pubs/DCP/9/Section/1000#1010">Eichler, Auxilia, and Pollock 2001</a>). In Bangladesh, Madagascar, and Senegal, significant reductions in nutrition rates were attributed to contracting initiatives (<a class="text-ref" href="/web/20080829125528/http://www.dcp2.org/pubs/DCP/9/Section/1000#1022">Marek and others 1999</a>). Only a few cases assess efficiency. Contracting with nonprofits works best when the contractors have well-functioning accountability arrangements and strong intrinsic motivation and when the government makes timely payments to the NGOs. The government needs to be capable of assessing, selecting, and managing the ongoing relationship with contractors. The methodological quality of evaluating contracting is often poor and needs to be improved. An exception is the Cambodian contracting trial that used a rigorous cluster randomized design, but the intervention groups had greater input of resources than the control communities, which may have been partly responsible for the difference in performance.</p> <p>Results on contracting with for-profit private service providers are also mixed. Experience from the hospital sector warns that weak government contracting capacity often allows the provider to capture efficiency gains or to expand volume鈥攏ot necessarily of cost-effective services鈥攖o generate more income. In Zimbabwe, the cost per service decreased, but the lack of volume control led to an increase in total cost (<a class="text-ref" href="/web/20080829125528/http://www.dcp2.org/pubs/DCP/9/Section/1000#1023">McPake and Hongoro 1995</a>). Other adverse outcomes are possible. In Brazil, contracting with for-profit hospitals led to increases in access, but also increases in fraud (false billing) and cream-skimming to avoid costly patients (<a class="text-ref" href="/web/20080829125528/http://www.dcp2.org/pubs/DCP/9/Section/1000#1041">Slack and Savedoff 2001</a>). These problems seem less pronounced in primary health care. In Peru and El Salvador, contracting with private primary health care providers increased access, choice, and consumer satisfaction (<a class="text-ref" href="/web/20080829125528/http://www.dcp2.org/pubs/DCP/9/Section/1000#1014">Fiedler 1996</a>). Contracting with for-profit providers seems to work best when the government invests in the development of capacity to manage the contracting process (<a class="text-ref" href="/web/20080829125528/http://www.dcp2.org/pubs/DCP/9/Section/1000#1027">Mills, Bennett, and Russell 2001</a>); when quality is at least as high in the private sector as in the public sector; and when the services involve primary care or other relatively observable services, such as diagnostic services.</p><a name="976">聽</a> <h3>Strengthening Core Public Health Functions</h3><br/> <p>Vulnerable populations need to be protected from risks and damages, informed, and educated. Public health regulations need to be established and enforced. Infrastructure needs to be in place to reduce the impact of emergencies and disasters on health. All this action needs to be implemented through a public health system that is transparent and accountable. Governments in developing countries generally recognize that these public health functions are important, but they often lack the capacity and financial resources to implement them. Indeed, few low-income countries invest in these public health functions.</p> <p>By employing public health professionals with core public health competencies, the government can develop and enforce standards; can monitor the health of communities and populations; and can emphasize health education, public information, health promotion, and disease prevention. Public action can help improve consumer knowledge and change attitudes so that private markets can operate effectively to meet the needs of the poor, for example, through social marketing of insecticide-treated bednets to reduce malaria transmission or of condoms for protection against HIV/AIDS.</p><a name="977">聽</a> <h3>Government-Led Monitoring and Evaluation</h3><br/> <p>Integrated disease surveillance, program assessment, and collection and analysis of demographic and vital registration data are essential if governments and donors are to ascertain whether policies and programs are positively affecting health goals. Governments can use a list of intermediate indicators and proxies for the goals that can help monitor progress, test the impact of policies, and adjust programs going forward (<a class="text-ref" href="/web/20080829125528/http://www.dcp2.org/pubs/DCP/9/Section/1000#1053">World Bank 2001</a>). Such indicators should be simple, easily measurable, representative, easy to understand, scientifically robust, and ethical. They need to be assessed regularly because the MDGs themselves are difficult to collect, thus entail delays, and are therefore not useful for regular monitoring of progress. Greater investments are needed in systems to monitor these intermediate indicators and to track expenditures on public health.</p> <p>Although some good practices in surveillance are being developed鈥攆or example, in Brazil, China, and India鈥攆ew low-income developing countries can afford to invest in the infrastructure required for strong surveillance systems. Most rely on alternative short- to medium-term solutions for data gathering, such as intermittent household surveys, health facility surveys, and simplified facility-based routine reporting. A few countries have made special efforts to improve the surveillance of a specific intervention, such as AIDS and tuberculosis treatment or childhood immunization, whereas others have attempted to monitor progress toward a specific MDG. INDEPTH (International Network of Field Sites with Continuous Demographic Evaluation of Populations and Their Health in Developing Countries), which is supported by the Rockefeller Foundation with help from other donors, coordinates a range of surveillance sites, many of them in Africa, and the Health Metrics network aims at improving the quality of surveillance data. Some governments are explicitly developing or modifying their monitoring and evaluation framework to focus on the MDGs.</p><a name="978">聽</a> <h3>Intersectoral Actions鈥擥oing Beyond the Ministry of Health</h3><br/> <p>A review of the evidence base for the key determinants of the health and nutrition MDGs identifies significant potential for intersectoral synergies (<a class="text-ref" href="/web/20080829125528/http://www.dcp2.org/pubs/DCP/9/Section/1000#1048">Wagstaff and Claeson 2004</a>).</p> <h2>Transportation</h2> <p>Although roads and transport are vital for health services, especially for reducing maternal mortality, it is not just the physical infrastructure that matters. Also important are the availability of transportation and the affordability of its use, as shown in a study in Nigeria (<a class="text-ref" href="/web/20080829125528/http://www.dcp2.org/pubs/DCP/9/Section/1000#1011">Eissen, Efenne, and Sabitu 1997</a>). Transportation and roads complement health services. A 10-year study in Rajasthan, India, found that better roads and transportation helped women reach referral facilities, but many women still died because no corresponding improvements took place at household and facility levels. Working with the transportation sector is also important for reducing HIV transmission in many settings and making progress on the HIV/AIDS-related MDG.</p> <h2>Hygiene</h2> <p>Improved hygiene (use of hand washing) and sanitation (use of latrines and safe disposal of children's stools) are at least as important as drinking water quality in shaping health outcomes, specifically in reducing diarrhea and associated child mortality (<a class="text-ref" href="/web/20080829125528/http://www.dcp2.org/pubs/DCP/9/Section/1000#1012">Esrey and others 1991</a>). Constructing water supply and sanitation facilities is not enough to improve health outcomes; sustained human behavior change must accompany the infrastructure investment. By collaborating with other sectors, the health sector can develop public health promotion and education strategies and implement them in partnership with agencies that plan, develop, and manage water resources. The health sector can also work with the private sector to manufacture, distribute, and promote affordable in-home water purification solutions and safe storage vessels鈥攁nd advocate for water, sanitation, and hygiene interventions in strategies to reduce poverty.</p> <h2>Indoor Air Quality</h2> <p>Indoor air pollution is caused by use of low-cost, traditional energy sources, such as coal and biomass for cooking and heating, the main source of energy for 3.5 billion people. Indoor air pollution is a major risk factor for pneumonia and associated deaths in children and for lung cancer in women who risk exposure during cooking (see chapter 42). Studies in China, Guatemala, and India are under way to improve access to efficient and affordable energy sources through local design, manufacturing, and dissemination of low-cost technologies, modern fuel alternatives, and renewable energy solutions. The community-based project in China was initiated by the Ministry of Health, which was troubled by the leveling off of child mortality reductions among the rural poor and was seeking ways to influence major environmental determinants of child mortality. The program combines appropriately improved stoves and ventilation with behavior-change modification; it is in an early stage of implementation, and results on outcomes are not yet available. Agricultural policies and practices influence food prices, farm incomes, diet diversity and quality, and household food security. Policies that focus on women's access to land, training, and agricultural inputs; on their roles in production; and on their income from agriculture are more likely to have a positive effect on nutrition than interventions without a focus on women, particularly if combined with other strategies, such as women's education and behavior change (<a class="text-ref" href="/web/20080829125528/http://www.dcp2.org/pubs/DCP/9/Section/1000#1018">Johnson-Welch 1999</a>; <a class="text-ref" href="/web/20080829125528/http://www.dcp2.org/pubs/DCP/9/Section/1000#1035">Quisumbing 1995</a>). The MDG agenda highlights the need not only to prioritize within health to achieve better health outcomes, but also to better inform priority setting in resource allocations between sectors, identifying intersectoral synergies and finding ways to maximize benefits for health.</p></div> </div> <div class="contentblock"> <a href="/web/20080829125528/http://www.dcp2.org/pubs/DCP/9/Section/952" id="prevSection"> < Previous Section </a>  |  <a href="/web/20080829125528/http://www.dcp2.org/pubs/DCP/9/Section/982" id="nextSection"> Next Section > </a> </div> </div>  </div> </div> <div class="rightcol"> <div class="rightblock nextprev"> <div class="contentblock"> <a href="/web/20080829125528/http://www.dcp2.org/pubs/DCP/8/FullText" id="previous_chapter">< Previous Chapter</a>  |  <a href="/web/20080829125528/http://www.dcp2.org/pubs/DCP/10/FullText" id="next_chapter">Next Chapter ></a> </div> </div> <div class="rightblock detail"> <div class="contentblock normal"> <h3>Chapter Sections</h3> <ul id="outlines" class="normal"> <li class=""><a href="/web/20080829125528/http://www.dcp2.org/pubs/DCP/9/Section/934" id="link_chapter_section_35314"> Intro </a> </li> <li class=""><a href="/web/20080829125528/http://www.dcp2.org/pubs/DCP/9/Section/940" id="link_chapter_section_34670"> The Millennium Development Goals for Health: Progress and Prospects </a> </li> <li class=""><a href="/web/20080829125528/http://www.dcp2.org/pubs/DCP/9/Section/952" id="link_chapter_section_34671"> Scaling Up: Defining Interventions and Removing Constraints </a> </li> <li class="on"><a href="/web/20080829125528/http://www.dcp2.org/pubs/DCP/9/Section/957" id="link_chapter_section_34672"> What Do Countries Need To Do? </a> </li> <li class=""><a href="/web/20080829125528/http://www.dcp2.org/pubs/DCP/9/Section/982" id="link_chapter_section_34673"> Costing and Financing Additional Spending for the MDGs </a> </li> <li class=""><a href="/web/20080829125528/http://www.dcp2.org/pubs/DCP/9/Section/1000" id="link_chapter_section_34674"> References </a> </li> </ul> <div id="chapterparts"> <h3> Boxes </h3> <ul id="boxes" class="normal"> <li> 9.1 <a href="/web/20080829125528/http://www.dcp2.org/pubs/DCP/9/Box/9.1" id="link_chapterPart_117738"> The Health-related Millennium Development Goals </a> </li><li> 9.2 <a href="/web/20080829125528/http://www.dcp2.org/pubs/DCP/9/Box/9.2" id="link_chapterPart_117856"> Estimating the Cost of Scaling Up to Achieve the MDGs </a> </li> </ul> <h3> Tables </h3> <ul id="tables" class="normal"> <li> 9.1 <a href="/web/20080829125528/http://www.dcp2.org/pubs/DCP/9/Table/9.1" id="link_chapterPart_117414"> Effective Interventions to Reduce Illness, Deaths, and Malnutrition </a> </li><li> 9.2 <a href="/web/20080829125528/http://www.dcp2.org/pubs/DCP/9/Table/9.2" id="link_chapterPart_117787"> Alternative Cost Estimates Using Millennium Project and Marginal Budgeting for Bottlenecks Models </a> </li> </ul> </div> </div> </div> </div> </div> <div class="copyright"> <div class="content"> <ul> <li><a href="/web/20080829125528/http://www.dcp2.org/page/main/About.html" id="nav_about-dcpp">About</a>  | </li> <li><a href="/web/20080829125528/http://www.dcp2.org/page/main/ContactUs.html" id="nav_contactus">Contact Us</a>  | </li> <li><a href="/web/20080829125528/http://www.dcp2.org/page/main/Sitemap.html" id="nav_sitemap">Site Map</a>  | </li> <li><a href="/web/20080829125528/http://www.dcp2.org/page/main/Privacy.html" id="nav_privacy">Privacy Policy</a>  | </li> <li><a href="/web/20080829125528/http://www.dcp2.org/page/main/Terms.html" id="nav_terms">Terms Of Use</a>  | </li> <li><a href="/web/20080829125528/http://www.dcp2.org/page/main/Feedback.html" id="nav_feedback">Feedback</a></li> </ul> <span class="rights"> © 2006 The World Bank Group, All Rights Reserved. </span> </div> </div> <div class="footer"> <div class="logos"><img src="/web/20080829125528im_/http://www.dcp2.org/images/logos_bottom.jpg" usemap="#logosMap" alt=""/></div> <map name="logosMap" id="logosMap"> <area shape="rect" target="_blank" coords="10,12,91,65" href="https://web.archive.org/web/20080829125528/http://www.worldbank.org/" alt="The World Bank" title="The World Bank"/> <area shape="rect" target="_blank" coords="102,12,220,65" href="https://web.archive.org/web/20080829125528/http://www.who.int/en" alt="World Health Organization" title="World Health Organization"/> <area shape="rect" target="_blank" coords="228,12,361,65" href="https://web.archive.org/web/20080829125528/http://www.fic.nih.gov/" alt="John E. 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