How can health ministries present persuasive investment plans for women's, children's and adolescents' health?

Most low- and middle-income countries face financing pressures if they are to adequately address the recommendations of the Global Strategy for Women's, Children's and Adolescent's Health. Negotiations between government ministries of health and finance are a key determinant of the level and effectiveness of public expenditure in the health sector. Yet ministries of health in low- and middle-income countries do not always have a good record in obtaining additional resources from key decision-making institutions. This is despite the strong evidence about the affordability and cost-effectiveness of many public health interventions and of the economic returns of investing in health. This article sets out 10 attributes of effective budget requests that can address the analytical needs and perspectives of ministries of finance and other financial decision-makers. We developed the list based on accepted economic principles, a literature review and a workshop in June 2015 involving government officials and other key stakeholders from low- and middle-income countries. The aim is to support ministries of health to present a more strategic and compelling plan for investments in the health of women, children and adolescents.

La plupart des pays à revenu faible et intermédiaire font face à des contraintes de financement pour pouvoir suivre correctement les recommandations de la Stratégie mondiale pour la santé de la femme, de l'enfant et de l'adolescent. Les négociations entre le ministère de la Santé et celui des Finances sont un déterminant clé de l'importance et de l'efficacité des dépenses publiques en matière de santé. Or, dans les pays à revenu faible et intermédiaire, le ministère de la Santé ne parvient pas toujours à obtenir des ressources supplémentaires de la part des grandes institutions décisionnaires, en dépit d'éléments démontrant l'abordabilité et la rentabilité de nombreuses actions de santé publique et du rendement économique des investissements dans le domaine de la santé. Cet article présente 10 caractéristiques convaincantes de demandes de crédits permettant de tenir compte des besoins analytiques et des perspectives des ministères des Finances et d'autres décisionnaires financiers. Nous avons établi cette liste à partir des principes économiques courants, d'une analyse documentaire et d'un atelier organisé en juin 2015, auquel ont participé des représentants de gouvernements et d'autres acteurs clés de pays à revenu faible et intermédiaire. L'objectif est d'aider les ministères de la Santé à présenter un plan d'investissement plus stratégique et plus convaincant dans le domaine de la santé de la femme, de l'enfant et de l'adolescent.

La mayoría de los países con ingresos bajos y medios afrontan presiones de financiación para poder abordar de forma adecuada las recomendaciones de la Estrategia Mundial para la Salud de la Mujer, el Niño y el Adolescente. Las negociaciones entre los ministerios de sanidad y economía son un determinante fundamental del nivel y eficacia del gasto público en el sector sanitario. Aun así, los ministerios de salud de países con ingresos bajos y medios no siempre cuentan con una buena trayectoria a la hora de obtener recursos adicionales de instituciones fundamentales para la toma de decisiones. Esto se produce a pesar de la fuerte prueba acerca de la asequibilidad y rentabilidad de muchas intervenciones de salud pública y de los beneficios económicos de la inversión en sanidad. Este artículo presenta 10 características de solicitudes presupuestarias eficaces que pueden abordar las necesidades analíticas y las perspectivas de los ministerios de economía y otros responsables de la toma de decisiones financieras. La lista se desarrolló en base a los principios económicos aceptados, una revisión bibliográfica y un taller realizado en junio de 2015 en el que participaron funcionarios del gobierno y otras partes interesadas fundamentales de países con ingresos bajos y medios. El objetivo es dar apoyo a los ministerios de salud para que presenten un plan más estratégico y completo para invertir en la salud de mujeres, niños y adolescentes.

Advancing social and economic development by investing in women's and children's health: a new Global Investment Framework.

A new Global Investment Framework for Women's and Children's Health demonstrates how investment in women's and children's health will secure high health, social, and economic returns. We costed health systems strengthening and six investment packages for: maternal and newborn health, child health, immunisation, family planning, HIV/AIDS, and malaria. Nutrition is a cross-cutting theme. We then used simulation modelling to estimate the health and socioeconomic returns of these investments. Increasing health expenditure by just $5 per person per year up to 2035 in 74 high-burden countries could yield up to nine times that value in economic and social benefits. These returns include greater gross domestic product (GDP) growth through improved productivity, and prevention of the needless deaths of 147 million children, 32 million stillbirths, and 5 million women by 2035. These gains could be achieved by an additional investment of $30 billion per year, equivalent to a 2% increase above current spending.

Success factors for reducing maternal and child mortality.

Reducing maternal and child mortality is a priority in the Millennium Development Goals (MDGs), and will likely remain so after 2015. Evidence exists on the investments, interventions and enabling policies required. Less is understood about why some countries achieve faster progress than other comparable countries. The Success Factors for Women's and Children's Health studies sought to address this knowledge gap using statistical and econometric analyses of data from 144 low- and middle-income countries (LMICs) over 20 years; Boolean, qualitative comparative analysis; a literature review; and country-specific reviews in 10 fast-track countries for MDGs 4 and 5a. There is no standard formula--fast-track countries deploy tailored strategies and adapt quickly to change. However, fast-track countries share some effective approaches in addressing three main areas to reduce maternal and child mortality. First, these countries engage multiple sectors to address crucial health determinants. Around half the reduction in child mortality in LMICs since 1990 is the result of health sector investments, the other half is attributed to investments made in sectors outside health. Second, these countries use strategies to mobilize partners across society, using timely, robust evidence for decision-making and accountability and a triple planning approach to consider immediate needs, long-term vision and adaptation to change. Third, the countries establish guiding principles that orient progress, align stakeholder action and achieve results over time. This evidence synthesis contributes to global learning on accelerating improvements in women's and children's health towards 2015 and beyond.

La réduction de la mortalité maternelle et infantile est une priorité des objectifs du Millénaire pour le développement (OMD) et le restera probablement après l'échéance de 2015. Il existe des données sur les investissements, les interventions et les politiques habilitantes nécessaires. On comprend mal pourquoi certains pays ont réalisé des progrès plus rapidement que d'autres pays comparables. Les Facteurs de réussite des études sur la santé des femmes et des enfants ont cherché à combler ce manque de connaissances en utilisant les analyses statistiques et économétriques des données provenant de 144 pays à faible revenu et à revenu intermédiaire et recueillies depuis 20 ans: une analyse comparative qualitative booléenne; une étude bibliographique et des études spécifiques à chaque pays pour les 10 pays à progression rapide pour les points 4 et 5a des OMD. Il n'existe pas de formule standard ­ les pays à progression rapide ont déployé des stratégies personnalisées et se sont adaptés rapidement aux changements. Cependant, ces pays ont en commun des approches efficaces visant 3 grands axes afin de réduire la mortalité maternelle et infantile. Premièrement, ils impliquent de nombreux secteurs pour traiter les facteurs déterminants et cruciaux pour la santé. Près de la moitié de la réduction de la mortalité infantile dans les pays à faible revenu et à revenu intermédiaire depuis 1990 résulte des investissements dans le secteur de la santé, l'autre moitié étant attribuée aux investissements réalisés dans les secteurs extérieurs à la santé. Deuxièmement, ces pays utilisent des stratégies pour mobiliser les partenaires dans la société, en utilisant des données solides et opportunes pour la prise de décisions et la responsabilisation, ainsi qu'une approche de planification triple pour prendre en considération les besoins immédiats, la vision à long terme et l'adaptation aux changements. Troisièmement, ces pays établissent des principes directeurs qui orientent les progrès, harmonisent les actions des parties prenantes et génèrent des résultats dans le temps. Cette synthèse de données contribue à l'ensemble des connaissances requises pour accélérer les améliorations sur la santé des femmes et des enfants en vue de l'échéance de 2015 et au-delà.

La reducción de la mortalidad materna e infantil es una prioridad en los Objetivos de Desarrollo del Milenio (ODM), y probablemente lo seguirá siendo después de 2015. Existen evidencias sobre las inversiones, las intervenciones y las políticas necesarias, pero se sabe menos acerca de por qué algunos países logran un progreso más rápido que otros países comparables. Los estudios relativos a los Factores de Éxito en la Salud de las Mujeres y los Niños han tratado de abordar esta brecha de conocimiento por medio de análisis estadísticos y econométricos de datos de 144 países de ingresos bajos y medianos (PIBM) a lo largo de más de 20 años, análisis comparativos cualitativos booleanos, revisión de la literatura y revisiones específicas de cada país en 10 países bien encarrilados para los ODM 4 y 5a. No existe una fórmula estándar, estos países despliegan estrategias a medida y se adaptan rápidamente a los cambios. Sin embargo, comparten ciertos enfoques eficaces a la hora de abordar tres áreas principales para reducir la mortalidad materna e infantil. En primer lugar, involucran a numerosos sectores para hacer frente a los factores sanitarios decisivos. Alrededor de la mitad de la reducción de la mortalidad infantil en los PIBM desde 1990 es el resultado de inversiones en el sector de la salud, y la otra mitad se atribuye a las inversiones realizadas en sectores fuera del ámbito sanitario. En segundo lugar, estos países utilizan estrategias para movilizar a socios a través de la sociedad, utilizando evidencias oportunas y sólidas para la toma de decisiones y la rendición de cuentas, así como un enfoque de planificación triple para considerar las necesidades inmediatas, la visión a largo plazo y la adaptación al cambio. En tercer lugar, los países establecen principios rectores que orientan el progreso, armonizan las acciones de las partes interesadas y logran resultados en el tiempo. Este compendio de evidencias contribuye al aprendizaje global sobre cómo acelerar las mejoras en la salud de mujeres y niños hacia el 2015 y más adelante.

Equity in maternal, newborn, and child health interventions in Countdown to 2015: a retrospective review of survey data from 54 countries.

BACKGROUND: Countdown to 2015 tracks progress towards achievement of Millennium Development Goals (MDGs) 4 and 5, with particular emphasis on within-country inequalities. We assessed how inequalities in maternal, newborn, and child health interventions vary by intervention and country. METHODS: We reanalysed data for 12 maternal, newborn, and child health interventions from national surveys done in 54 Countdown countries between Jan 1, 2000, and Dec 31, 2008. We calculated coverage indicators for interventions according to standard definitions, and stratified them by wealth quintiles on the basis of asset indices. We assessed inequalities with two summary indices for absolute inequality and two for relative inequality. FINDINGS: Skilled birth attendant coverage was the least equitable intervention, according to all four summary indices, followed by four or more antenatal care visits. The most equitable intervention was early initation of breastfeeding. Chad, Nigeria, Somalia, Ethiopia, Laos, and Niger were the most inequitable countries for the interventions examined, followed by Madagascar, Pakistan, and India. The most equitable countries were Uzbekistan and Kyrgyzstan. Community-based interventions were more equally distributed than those delivered in health facilities. For all interventions, variability in coverage between countries was larger for the poorest than for the richest individuals. INTERPRETATION: We noted substantial variations in coverage levels between interventions and countries. The most inequitable interventions should receive attention to ensure that all social groups are reached. Interventions delivered in health facilities need specific strategies to enable the countries' poorest individuals to be reached. The most inequitable countries need additional efforts to reduce the gap between the poorest individuals and those who are more affluent. FUNDING: Bill & Melinda Gates Foundation, Norad, The World Bank.

How changes in coverage affect equity in maternal and child health interventions in 35 Countdown to 2015 countries: an analysis of national surveys.

BACKGROUND: Achievement of global health goals will require assessment of progress not only nationally but also for population subgroups. We aimed to assess how the magnitude of socioeconomic inequalities in health changes in relation to different rates of national progress in coverage of interventions for the health of mothers and children. METHODS: We assessed coverage in low-income and middle-income countries for which two Demographic Health Surveys or Multiple Indicator Cluster Surveys were available. We calculated changes in overall coverage of skilled birth attendants, measles vaccination, and a composite coverage index, and examined coverage of a newly introduced intervention, use of insecticide-treated bednets by children. We stratified coverage data according to asset-based wealth quintiles, and calculated relative and absolute indices of inequality. We adjusted correlation analyses for time between surveys and baseline coverage levels. FINDINGS: We included 35 countries with surveys done an average of 9·1 years apart. Pro-rich inequalities were very prevalent. We noted increased coverage of skilled birth attendants, measles vaccination, and the composite index in most countries from the first to the second survey, while inequalities were reduced. Rapid changes in overall coverage were associated with improved equity. These findings were not due to a capping effect associated with limited scope for improvement in rich households. For use of insecticide-treated bednets, coverage was high for the richest households, but countries making rapid progress did almost as well in reaching the poorest groups. National increases in coverage were primarily driven by how rapidly coverage increased in the poorest quintiles. INTERPRETATION: Equity should be accounted for when planning the scaling up of interventions and assessing national progress. FUNDING: Bill & Melinda Gates Foundation; World Bank; Governments of Australia, Brazil, Canada, Norway, Sweden, and UK.

Inequalities in reproductive, maternal, newborn and child health in Vietnam: a retrospective study of survey data for 1997-2006.

BACKGROUND: Vietnam has achieved considerable success in economic development, poverty reduction, and health over a relatively short period of time. However, there is concern that inequalities in health outcomes and intervention coverage are widening. This study explores if inequalities in reproductive, maternal, newborn and child health and nutrition changed over time in Vietnam in 1997-2006, and if inequalities were different depending on the type of stratifying variable used to measure inequalities and on the type of outcome studied. METHODS: Using data from four nationally representative household surveys conducted in 1997-2006, we study inequalities in reproductive, maternal, newborn and child health and nutrition outcomes and intervention coverage by computing concentration indices by living standards, maternal education, ethnicity, region, urban/rural residence, and sex of child. RESULTS: Inequalities in maternal, newborn and child health persisted in 1997-2006. Inequalities were largest by living standards, but not trivial by the other stratifying variables. Inequalities in health outcomes generally increased over time, while inequalities in intervention coverage generally declined. The most equitably distributed interventions were family planning, exclusive breastfeeding, and immunizations. The most inequitably distributed interventions were those requiring multiple service contacts, such as four or more antenatal care visits, and those requiring significant support from the health system, such as skilled birth attendance. CONCLUSIONS: Three main policy implications emerge. First, persistent inequalities suggest the need to address financial and other access barriers, for example by subsidizing health care for the poor and ethnic minorities and by support from other sectors, for example in strengthening transportation networks. This should be complemented by careful monitoring and evaluation of current program design and implementation to ensure effective and efficient use of resources. Second, greater inequalities for interventions that require multiple service contacts imply that inequalities could be reduced by strengthening information and service provision by community and village health workers to promote and sustain timely care-seeking. Finally, larger inequalities for interventions that require a fully functioning health system suggest that investments in health facilities and human resources, particularly in areas that are disproportionately inhabited by the poor and ethnic minorities, may contribute to reducing inequalities.

Countdown to 2015 decade report (2000-10): taking stock of maternal, newborn, and child survival.

The Countdown to 2015 for Maternal, Newborn, and Child Survival monitors coverage of priority interventions to achieve the Millennium Development Goals (MDGs) for child mortality and maternal health. We reviewed progress between 1990 and 2010 in coverage of 26 key interventions in 68 Countdown priority countries accounting for more than 90% of maternal and child deaths worldwide. 19 countries studied were on track to meet MDG 4, in 47 we noted acceleration in the yearly rate of reduction in mortality of children younger than 5 years, and in 12 countries progress had decelerated since 2000. Progress towards reduction of neonatal deaths has been slow, and maternal mortality remains high in most Countdown countries, with little evidence of progress. Wide and persistent disparities exist in the coverage of interventions between and within countries, but some regions have successfully reduced longstanding inequities. Coverage of interventions delivered directly in the community on scheduled occasions was higher than for interventions relying on functional health systems. Although overseas development assistance for maternal, newborn, and child health has increased, funding for this sector accounted for only 31% of all development assistance for health in 2007. We provide evidence from several countries showing that rapid progress is possible and that focused and targeted interventions can reduce inequities related to socioeconomic status and sex. However, much more can and should be done to address maternal and newborn health and improve coverage of interventions related to family planning, care around childbirth, and case management of childhood illnesses.

Mind the gap: equity and trends in coverage of maternal, newborn, and child health services in 54 Countdown countries.

BACKGROUND: Increasing the coverage of key maternal, newborn, and child health interventions is essential if Millennium Development Goals (MDG) 4 and 5 are to be reached. We have assessed equity and trends in coverage rates of a key set of interventions through a summary index, to provide overall insight into past performance and progress perspectives. METHODS: Data from household surveys from 54 countries in the Countdown to 2015 for Maternal, Newborn and Child Survival initiative during 1990-2006 were used to compute an aggregate coverage index based on four intervention areas: family planning, maternal and newborn care, immunisation, and treatment of sick children. The four areas were given equal weight in the computation of the index. Standard measures were applied to assess current levels and trends in the coverage gap measure by wealth quintile. FINDINGS: The overall size of the coverage gap ranged from less than 20% in Tajikistan and Peru to over 70% in Ethiopia and Chad, with a mean of 43% for the most recent surveys in the 54 countries. Large intracountry differences were noted, with a country mean coverage gap of 54% for the poorest quintiles of the population and 29% for the wealthiest. Differences between the poorest and the wealthiest were largest for the maternal and newborn health intervention area and smallest for immunisation. In 40 countries with more than one survey, the coverage gap had decreased by an average of 0.9 percentage points per year since the early 1990s. Declines greater than 2 percentage points per year were seen in only three countries after 1995: Cambodia, Mozambique, and Nepal. Country inequity patterns were remarkably persistant over time, with only gradual changes from top inequity (disproportionately smaller gap for the wealthiest) in countries with coverage gaps exceeding 40%, to linear patterns and bottom inequity (disproportionately greater gap for the poorest) in surveys with gaps below 40%. INTERPRETATION: Despite most Countdown countries having made gradual progress since 1990, coverage gaps for key interventions remain wide and, in most such countries, the pace of decline needs to be more than doubled to reach levels of coverage of these and other interventions needed in the context of MDG 4 and 5. In general, in-country patterns of inequality are consistant and change only gradually if at all, which has implications for the targeting of interventions.

Health financing for the poor produces promising short-term effects on utilization and out-of-pocket expenditure: evidence from Vietnam.

BACKGROUND: Vietnam introduced the Health Care Fund for the Poor in 2002 to increase access to health care and reduce the financial burden of health expenditure faced by the poor and ethnic minorities. It is often argued that effects of financing reforms take a long time to materialize. This study evaluates the short-term impact of the program to determine if pro-poor financing programs can achieve immediate effects on health care utilization and out-of-pocket expenditure. METHOD: Considering that the program is a non-random policy initiative rolled out nationally, we apply propensity score matching with both single differences and double differences to data from the Vietnam Household Living Standards Surveys 2002 (pre-program data) and 2004 (first post-program data). RESULTS: We find a small, positive impact on overall health care utilization. We find evidence of two substitution effects: from private to public providers and from primary to secondary and tertiary level care. Finally, we find a strong negative impact on out-of-pocket health expenditure. CONCLUSION: The results indicate that the Health Care Fund for the Poor is meeting its objectives of increasing utilization and reducing out-of-pocket expenditure for the program's target population, despite numerous administrative problems resulting in delayed and only partial implementation in most provinces. The main lessons for low and middle-income countries from Vietnam's early experiences with the Health Care Fund for the Poor are that it managed to achieve positive outcomes in a short time-period, the need to ensure adequate and sustained funding for targeted programs, including marginal administrative costs, develop effective targeting mechanisms and systems for informing beneficiaries and providers about the program, respond to the increased demand for health care generated by the program, address indirect costs of health care utilization, and establish and maintain routine and systematic monitoring and evaluation mechanisms.

The other crisis: the economics and financing of maternal, newborn and child health in Asia.

The Global Financial Crisis (GFC) of 2008/2009 was the largest economic slowdown since the Great Depression. It undermined the growth and development prospects of developing countries. Several recent studies estimate the impact of economic shocks on the poor and vulnerable, especially women and children. Infant and child mortality rates are still likely to continue to decline, but at lower rates than would have been the case in the absence of the GFC. Asia faces special challenges. Despite having been the fastest growing region in the world for decades, and even before the current crisis, this region accounted for nearly 34% of global deaths of children under 5, more than 40% of maternal deaths and 60% of newborn deaths. Global development goals cannot be achieved without much faster and deeper progress in Asia. Current health financing systems in much of Asia are not well placed to respond to the needs of women and their children, or the recent global financial and economic slowdown. Public expenditure is often already too low, and high levels of out-of-pocket health expenditure are an independent cause of inequity and impoverishment for women and their children. The GFC highlights the need for reforms that will improve health outcomes for the poor, protect the vulnerable from financial distress, improve public expenditure patterns and resource allocation decisions, and so strengthen health systems. This paper aims to highlight the most recent assessments of how economic shocks, including the GFC, affect the poor in developing countries, especially vulnerable women and children in Asia. It concludes that conditional cash transfers, increasing taxation on tobacco and increasing the level, and quality, of public expenditure through well-designed investment programmes are particularly relevant in the context of an economic shock. That is because these initiatives simultaneously improve health outcomes for the poor and vulnerable, protect them from further financial distress, improve public financing and/or provide a much-needed counter-cyclical stimulus at times of economic slowdown.

Health insurance reform in Vietnam: a review of recent developments and future challenges.

Vietnam is undertaking health financing reform with a view to achieve universal coverage of health insurance within the coming years. To date, around half of the population is covered with some type of health insurance or prepayment. This review applies a conceptual framework of health financing to provide a coherent assessment of the reforms to date with respect to a set of key policy objectives of health financing, including financial sustainability, efficiency in service provision, and equity in health financing. Based on the assessment, the review discusses the main implications of the reforms focusing on achievements and remaining challenges, the nature of the Vietnamese reforms in an international perspective, and the role of the government. The main lessons from the Vietnamese experiences, from which other reforming countries may draw, are the need for sustained resource mobilization, comprehensive reform involving all functions of the health financing system, and to adopt a long-term view of health insurance reform. Future analysis should include continued evaluation of the reforms in terms of impacts on key outcomes and the political dimensions of health reform.