Assessing the health system and

policy environment for MNCH:

Countdown 2008 findings
Robert Scherpbier (WHO/CAH)
on behalf of
the Countdown Working Group on Health Policy and Health Systems
Presentation outline

• Rationale for assessing the

health system and policy
environment in the Countdown

• The conceptual framework

and methods used

• Selected findings

• Key messages
 Rationale

• Delivery of interventions depends on complex

organizations to:
– Generate information for effective decision-making
– Develop and manage the health work force
– Provide medicines and supplies
– Assure quality and efficiency
– Finance health services

• Increasing intervention coverage in an equitable way

requires investment in all these areas, using scarce
resources for maximum health outcomes
Countdown Working Group on
Health Policy and Health Systems
 Principles of intervention delivery

• Coverage: achieving high coverage of effective

interventions is the key to achieving MDG4
• Equity: delivery approaches must try to reach the most
vulnerable
• Quality: interventions should be delivered with quality,
"effective coverage
• Continuum of care (1): interventions should span across
pregnancy, birth, newborn period, infancy and childhood
• Continuum of care (2): relevant interventions must be
delivered at home, health facility and hospital
• Packaging and integration: packaging can create
synergies, integration with child at the centre increases
quality
Political commitment to child health and survival

• There is unprecedented consensus on the Millennium

Development Goals
• MDG4: reduce under-5 child mortality by two-thirds
between 1990 and 2015
• Convention on the Rights of the Child
• The right to life, survival and development (Article
6)
• Best interests of the child (Article 3)
• Non discrimination (Article 2)
Supportive policies and functioning health systems are
essential for maternal, newborn and child survival

Governance

New Policy Service Coverage Outcomes

Evidence and Environment Delivery
Information

Financing

Health Workforce

Adapted from Everybody's Business: Strengthening health

systems to improve health outcomes: WHO Framework for
action, 2007
 Methods used

• Thirteen policy and health

system indicators selected
through peer consultation
– Covering each of the health
system building blocks
– Covering the two dimensions
of the continuum of care

• Data collected from public

sources and from national
authorities

Source: Lancet 2008; 371:1284-93

 Selected findings

Evidence and information

Notification of maternal Information systematically 23 / 68 countries
deaths recorded and reported
Leadership and governance
International Code of Policy systematically 22 / 68 countries
Marketing of Breastmilk adopted/enacted
Substitutes and subsequent
relevant WHO resolutions
enacted
Maternity Protection Policy systematically 0 / 68 countries
Convention 183 ratified adopted/enacted
Costed national Plan developed and costed 31 / 68 countries
implementation plan (s) for
MNCH

Service delivery
Availability of emergency
obstetric care services
Midwives authorized to
deliver life-saving
interventions
IMCI guidelines adapted to
cover first week of life
Community health workers
authorized to identify and
treat pneumonia
Promotion of low osmolarity
ORS and zinc for
management of diarrhoea
Selected findings
Minimum of five emergency 11 / 27 countries:
obstetric care facilities per > 50%
500,000 population including 16 / 27 countries:
one for comprehensive care
14% - 48%
Policy systematically 27 / 68 countries
adopted/implemented
Policy systematically 39 / 68 countries
adopted/implemented
Policy systematically 18 / 68 countries
adopted/implemented
Policy systematically 34 / 68 countries
adopted/implemented
 Few countries adopted a complete
set of policies

Midwives authorized to
deliver life-saving interventions

Integrated Management All 4 3 1-2 No Data

of Childhood Illness adapted policies policies policies policy not
Policy to cover first week of life adopted adopted adopted adopted complete
indicators
for service
delivery Community health workers 3 14 31 2 18
authorized to identify and
manage pneumonia

Promotion of low
Osmolarity ORS and zinc for
management of
diarrhoea
 Progress has been made
but not evenly

Community health
45 workers authorized to
40 treat pneumonia, 2007
Community health
35 workers authorized to
30 treat pneumonia 2005
Promotion of new ORS
25
and zinc for diarrhoea,
20 2007
15 Promotion of new ORS
and zinc for diarrhoea,
10 2005
5
0
Yes Partial No No data

Countdown Working Group on

Health Policy and Health Systems
 Health financing

Three indicators tracked:

• Per head total expenditure on health (in international

dollars)

• General government expenditure on health

• Out-of pocket expenditure on health as a proportion

of total expenditure on health

Countdown Working Group on

Health Policy and Health Systems
 Health financing

Per-head expenditure of less than

US$ 45 is likely too low to provide
basic services 6 out of 68 countries met Abuja target
of 15% GGE on health as proportion of
Per capita total expenditure on health (at international dollar rate)
total government expenditure
D.R. Congo
Burundi
Afghanistan
Ethiopia
Liberia General government expenditure on health as % of total government expenditure
Niger
Eritrea
Guinea Bissau
Tanzania Myanmar
Madagascar Pakistan
Congo Burundi
Sierra Leone Afghanistan
Myanmar India
Angola Iraq
Benin Azerbaijan
Mozambique Guinea
Nigeria
Chad Eritrea
Mauritania Congo
D.P.R. Korea Angola
Pakistan Guinea
Nigeria Tajikistan
Tajikistan Côte d'Ivoire
Sudan Laos P.D.R.
Indonesia
Mali Mauritania
Central African Rep. Morocco
Malaw i Yemen
Zambia Bangladesh
Togo Gambia
Côte d'Ivoire D.P.R. Korea
Bangladesh Philippines
Nepal Togo
Equatorial
Senegal Sudan
Laos P.D.R. D.R. Congo
Burkina Faso Sierra Leone
Yemen Egypt
Haiti Nepal
Cameroon Kenya
Kenya Ghana
Djibouti Tanzania
Madagascar
Gambia Zimbabw e
India Peru
Ghana Mozambique
Guinea Ethiopia
Indonesia Chad
Rw anda Benin
Uganda Senegal
Uganda
Iraq Papua New
Azerbaijan China
Zimbabw e Niger
Lesotho Cameroon
Cambodia Botsw ana
Papua New Guinea South Africa
Bolivia Central
Philippines Sw aziland
Cambodia
Equatorial Guinea Djibouti
Morocco Mali
Peru Zambia
Turkmenistan Bolivia
Guatemala Mexico
Egypt Lesotho
Gabon Gabon
Brazil
China Turkmenistan
Sw aziland Burkina Faso
Botsw ana Rw anda
Mexico Guatemala
South Africa Liberia
Brazil Haiti
Malaw i
0 100 200 300 400 500 600 700 800 900 1000 1100 1200 1300 1400 1500 1600
0 5 10 15 20 25 30
 Health financing

Out-of-pocket expenditures as % of total expenditure on health

Lesotho
Papua New
Malaw i
South Africa
Botsw ana
Mozambique
D.P.R. Korea
• Where out-of pocket (OOP)
payments are less than 15%,
Sw aziland
Rw anda
Equatorial
Angola
Madagascar

very few households tend to

Iraq
Zimbabw e
Brazil
Djibouti
Mauritania
Turkmenista
Gabon
Zambia
Bolivia
Uganda
Liberia
be affected by catastrophic
Ethiopia
Niger
Sierra Leone
Peru
Haiti
health spending
Burkina Faso
Ghana
Philippines
Tanzania
Kenya
Benin
Indonesia

• 60 out of 67 Countdown
Gambia
Morocco
Mali
Mexico
Congo
Guatemala
China
Senegal
Egypt
Yemen
Central
countries had OOP of more
Chad
Eritrea
Nigeria
Sudan
Cambodia
than 15%
Bangladesh
Nepal
Guinea
Togo
Côte d'Ivoire
Cameroon
Azerbaijan
Laos P.D.R.
D.R. Congo
Burundi
Tajikistan
India
Pakistan
Afghanistan
Guinea
Myanmar
0 15 30 45 60 75 90
 Human resources

54 countries have fewer than 2.5 health

care professionals per 1000 population:
Too few to make a difference!

Source: Countdown Working Group on Policy and Health Systems. Assessment of the health system and policy environment as a
critical complement to tracking intervention coverage for maternal, newborn and child health. Lancet 2008; 371:1284-93
 Key messages

• The adoption of clear policies on interventions and delivery

mechanisms is a key building block of well functioning health
systems

• Few Countdown countries have a comprehensive set of policy

measures in place that would facilitate increase in access to and
utilization of MNCH interventions

• Coupled with formidable challenges in health financing and

human resources, lack of policy measures poses a serious
threat to rapid scaling-up of effective MNCH interventions

• The implementation of a systematic framework to assess policy

and health system indicators at country and global levels is
critical to facilitating accelerated action for MNCH
Countdown Working Group on
Health Policy and Health Systems