Category Archives: health

Service Delivery Indicators Initiative: Monitoring Health and Education performances in Africa

This blog, written by Ousmane Aly Diallo, is part of the Wikiprogress focus on its Africa Network*.

After pilot tests in Tanzania and Senegal in 2010, the World Bank in partnership with the Kenya Institute for Public Policy Research andAnalysis (KIPPRA)launched the Kenyan Service Delivery Initiative (SDI) on 12 July  2013. The initiative aims to assess the performance of Kenya in the domains of education and health and more importantly to determine if what is spent on these domains is reflected in human development outcomes.

Better monitoring of policies with reliable data
For some time now, the lack of reliable data and statistical capacity has been a problem in accurately establishing the progress in well-being as well as the impact of government policies in many African countries (read more). It has also been a priority for international organizations (See the Paris21’s NSDS Initiative as an example of strenghtening statistical capacity in developing countries). The SDI is meant to help governments determine what is working in their national educationand health systems, where readjustments are needed and what has to be re-thought completely.
Basically, the SDI gives surveys to health and education providers in the host countries. Three main variables are present in theses questionnaires:
  • education and Health Provider’s Abilities (What do they know?);
  • their effort (What do they do?); and
  •  the Availability of Inputs (What do they have to work with?). 
In Kenya, around 5,000 health practitioners and the education staff in 600 facilities were surveyed for the first SDI (here). The results show that public and private school teachers have the same likelihood of working, but those in the public sector are 50% less likely to be in a classroom teaching students. This is mainly due to the public school system having 20 days of teaching fewer per term. Also, only 35% of teachers showed a mastery of their subjects. When campaigning for basic education and attaining the parity between girls/boys in primary school, the low level of teachers’ mastery is disappointing. Reinforcing the skills and mastery of teachers thus appears as important of an element as is children attending school.

In the health sector, over 29% of health providers were absent, and 80% of those absences were reported and sanctioned. Furthermore, only 58% of public health providers could diagnose 4 out of 5 common conditions such as diarrhea with dehydration or malaria with anemia. Additionally, the health providers used  less than half of the correct treatment actions to manage maternal and neonatal complications, and key drug availability for mothers remains a challenge (here). The latter result is particularly revelatory, since maternal health is one of the main health concerns in Africa. Therefore, knowing where the system fails is a step towards overcoming the barriers towards improvement.

Being able to have this level of data is one of the SDI’s main points since it gives a snapshot of what is not working and where the focus should be placed.

Assessing the synergy between well-being and expenditures.
“We cannot manage what we cannot measure. We count what we value”. The initial reason for the deployment of the SDI can be traced back to this phrase. Although a substantial part of their budget is spent on education and health, the expenditures have not kept pace with the population’s needs in most African countries. The World Bank estimates that developing country governments allocate, on average, a third of their budgets to education and health (read more). In a context of economic downturn and growing demand for transparency, assessing what teachers and help practitioners do in an average workday how well they are equipped and how they can be helped is a step towards higher societal well-being. Schools and health facilities are, more often than not, ill-equipped in terms of their infrastructure (particularly in rural areas) and competences. Additionally, in the fields of education and health “(…) if one considers the level of public funds invested in the process, then the glass becomes half-empty in the sense that a great deal of resources have been wasted in pushing reforms beyond what the existing capacity can command” (See here page 9).
The SDI is meant to help capture what is the cause of this discrepancy, determine how health practitioners and education providers are performing and establish corrective actions if need be.

Service Delivery Indicators and Open Data
One of the main contributions of the SDI is the provision of accurate data regarding the quality of education and health services to both decision-makers and citizens. Furthermore, since it is an Africa-wide initiative, it will help improve the quality of these services through comparisons and taking advantage of what has been done in high-delivery countries. The standardization of the indicators allows comparisons between states and sub-national entities. Sub-national regions with poor education and health infrastructure stand a better chance of seeing the quality of services being improved with the SDI Initiative.

Since the surveys are meant to be redone on a biennial basis, progress in this domain can be easily witnessed and monitored.

Transparency of public expenditures and accountability of governments to their citizens are likely to be two of the externalities of this initiative. The African Development Bank recently launched its Open Data Platform for Africa, which gives useful data on well-being and development issues for the 54 African countries, while giving flexibility and leverage to the user. These two initiatives give a better view of what needs to be done by  the policymakers and the citizens, as well as by the NGOs and international organizations. What matters to citizens and how to foster their well-being will be even more evident with this initiative.

Ousmane Aly Diallo

*Wikiprogress Africa Network aims, to provide a platform for knowledge sharing on measuring progress in an Africa context.

Climate Change and Health Beyond 2015: The Sustainable Development Agenda

This blog is part of the Wikiprogress Environment Series
Global Health Institute, University of Wisconsin-Madison
The Outcome Document from the recent Rio+20 Summit, “The Future We Want”, recognises that health is both a precondition for, and an outcome of, sustainable development. Climate change affects health through a myriad of exposure pathways, each presenting simultaneously both challenges and opportunities for sustainable health and development.
Interventions targeting either adaptation or mitigation of climate change, therefore, can have multiple health and societal benefits – the key is to find root points of leverage where a single policy might have numerous beneficiaries.
The relationship between health and all three original (1992) Rio Conventions – on Climate Change, Biological Diversity, and Desertification was recently documented in “Our Planet, Our Health, Our Future”, a collaborative effort between the World Health Organization (WHO) and all three Rio Conventions. In particular, the report revealed both risks and interdependencies. Climate change will directly lead to net negative health impacts, including through extreme weather events, spread of vector-borne disease, diarrhoeal disease, food security and malnutrition. Natural capital, such as biodiversity, underpins ecosystem services – upon which health and societal wellbeing depend – but are threatened by climate and land use change. Just a few measurable benefits that ecosystems provide mankind include flood protection, disease regulation, and water purification. Desertification leaves populations vulnerable to water quality degradation, water scarcity and droughts, decreases agro-ecosystem productivity and increases food scarcity/malnutrition.
If human society could advance from a carbon-intensive economy to a green economy, human health opportunities would abound. For example, reducing fossil fuel combustion might not only reduce the extent of climate change, but more immediately such intervention would improve air quality, and if done in the transportation sector, could potentially increase ‘active’ transport that subsequently would lower the risk of obesity and associated chronic diseases. This is just one policy example of how addressing climate change can both enhance sustainable development and save lives.
Sustainable development remains the central context of the post-2015 development agenda. Yet, at this juncture it is critical to acknowledge how health is inextricably linked to ecosystems and our earth’s climate; this awareness is especially salient in the UNFCCC process toward developing a set of post-2015 Sustainable Development Goals (SDGs). With the centrality of health as both an input and outcome, and climate change as a cross-cutting issue, a new level of inter-sector awareness and collaboration is warranted, especially as revised targets and indicators are being drafted for the SDGs.
Furthermore, establishment of appropriate indicators will help ensure that interventions in any sector will lessen, rather than add to, the disease burden. WHO, in fact, is now strongly advocating a holistic “Health in All Policies” approach which accepts that population-wide health is determined by many sectors beyond solely health. The role of weather variability and health is obvious for thematic areas such as water and sanitation, food security and nutrition, and disaster management, as well as climate change specifically. Outcome indicators might include: annual mortality rates from climate-sensitive diseases (i.e. the sum of all vector-borne disease, diarrhoeal disease, malnutrition, and weather-related disasters etc.); household dietary diversity scores as an output indicator for food security; and percentage population with access to weather/climate-resilient infrastructure (such as water sources and hygienic sanitation facilities for example).
Health should also be a key consideration for other areas. Representative outcome indicators in the area of energy, for example, might include the percentage of households using only modern, low-emissions heating, cooking and lighting technologies that meet emission and safety standards; or measuring the burden of disease attributable to household air pollution could be another outcome indicator. Indicators for the reliability of energy supply to health facilities are also important. In jobs, healthy workforces are a precondition for sustainable development, and indicators such as the proportion of workplaces that comply with national occupational health and safety standards (an output indicator), or measuring occupational disease and injury rates (an outcome indicator) merit consideration.
Clearly the health of our human population depends on the healthy conditions across all societal sectors and natural systems. Climate change, now solidly tied to our  carbon-intensive economy, challenges all communities working on core elements of sustainable development. Human health has been relatively sidelined in the UN Framework Conventions, but now needs to be better interwoven into the process of defining the next set of global development goals.
Professor Jonathan Patz
This article first appeared on Outreach Magazine 


Highlights of the week: Governance and more!

Welcome to another Week in Review! This week’s post includes a ‘Resource Governance Index’, a ‘World Health Statistics’ report and World Telecommunication & Information Society Day.

State of Civil Society Report 2013 by CIVICUS calls for an enabling environment for civil society, it includes nearly 50 contributions from experts and civil society leaders from around the world.  These experts highlighted good practices and challenges on the horizon for citizens and civil society globally. 
“57% of the world’s population live in countries where basic civil liberties and political freedoms are curtailed” State of Civil Society Report 2013

The 2013 Resource Governance Index Report measures the quality of governance in the oil, gas and mining sector of 58 countries. The RGI scores and ranks the countries, relying on a detailed questionnaire completed by researchers with expertise in the extractive industries. According to this year’s study there is a major governance deficit in natural resources around the world, and the deficit is largest in the most resource- dependent countries, where nearly half a billion people live in poverty despite that resource wealth.

Wikigender Special Focus: Women and Elections – As part of our focus on Governance, Wikigender is currently spotlighting the critical role that women have to play in elections to have their voice heard, both as voters and elected representatives. This ‘Special Focus’ looks at the role of women in elections, drawing on articles from various situations around the world.
World Health Statistics 2013 – this report contains WHO’s annual compilation of health-related data for its 194 Member States, and includes a summary of the progress made towards achieving the health-related Millennium Development Goals (MDGs) and associated targets.  

World Telecommunication and Information Society Day  (WTISD) is on 17 May – The purpose of  WTISD is to help raise awareness of the possibilities that the use of the Internet and other information and communication technologies (ICT) can bring to societies and economies, as well as of ways to bridge the digital divide. Make sure you follow the #WTISD for updates!

Finally, don’t miss World Day for Cultural Diversity for Dialogue and Development – The day provides us with an opportunity to deepen our understanding of the values of cultural diversity and raise awareness about the importance of intercultural dialogue, diversity and inclusion.

We look forward to checking in next week to bring you more highlights from the world of well-being and progress.

Robbie Lawrence
The Wikiprogress Team
WikiprogressWikgender and Wikichild

What’s driving the quiet revolution in basic healthcare?

This article by Romina Rodriguez Pose, ODI, is part of the Wikiprogress #health series.

Rarely a day goes by when the news is not filled with both warnings about possible epidemics and more encouraging tales of medical breakthroughs. And yet, while these often extreme perspectives occupy the limelight, more nuanced and in-depth understandings of how and why things are working in certain countries and not in others remains relatively unheard.
Health is a key component of ODI’s Development Progress project, which for the past three years has been documenting national-level case studies (on what is working in development and why), enabling us to reflect on how far we have come in addressing basic health issues around the world and uncover hidden stories of progress.
The project’s first-round health case studies explored progress in Bangladesh, Eritrea and Rwanda and were carried out between 2009 and 2011. The second round, currently underway, has two focus areas: maternal health (with case studies in Nepal and Mozambique) and neglected tropical diseases (NTDs) (Sierra Leone and Cambodia).
Maternal health is intrinsically important because people’s prospects in life depend on it to a large extent. It is also a proxy for the capacity and strength of health systems and government’s ability to deliver core services. NTDs are of particular interest as they disproportionally affect the world’s poorest and are dependent on and can accelerate progress in a range of other development areas (poverty, nutrition, water and sanitation, women’s empowerment, education).
Although these countries represent very different local contexts, we can identify clear and consistent factors driving progress across them all:
  • Strong leadership and sustained political commitment have been key to pushing through reforms and engaging populations in development processes. Progress is not possible without the prioritisation of health within governments’ agendas.
  • Bottom-up approaches invoking social mobilisation and community participation were the cornerstone for progress in all three case studies in the first round, and preliminary findings from Nepal and Sierra Leone support this trend. Community participation and involvement in health service delivery have not only helped alleviate staff shortages, but also proved extremely effective in accessing hard-to-reach populations, bringing services closer to the community while at the same time allowing for behavioural change. They have also transformed community members from being passive recipients to being active participants in their own development and wellbeing. Among other things, the empowerment of women and their increased decision-making power in health matters has been key in both Bangladesh and Nepal.
  • The role of donors has been instrumental, not only financially but also through the provision of evidence of successful schemes in similar countries. All the countries studied are heavily dependent on external funding, but all have mechanisms to ensure funding is aligned with national planning (e.g.implementation of health sector-wide approaches has helped governments shape health policy, strengthen delivery and make health financing more predictable and flexible). Balancing government ownership of a development agenda with outside help can be challenging but is essential to ensure commitment and sustainability. Ownership varies across the countries studied, with some governments acting more strongly than others in responding to priorities on the development agenda.
  • Both demand- and supply-side interventions have been put in place and contribute towards progress in health in these countries. Community health insurance schemes (e.g. mutuelles de santé in Rwanda) and removal of users fees (e.g. free health care for pregnant and breastfeeding women and children under five in Sierra Leone) have boosted demand for health services by removing financial barriers for underserved populations. From a supply point of view, rewarding health service providers for their performance incentivises them and enhances their commitment to working to higher standards in the delivery of services, although strong controls and quality checks need to be in place.
Despite the high levels of progress these strategies have attained, challenges remain. For instance, the provision of health services has relied widely on community involvement and voluntarism. Despite volunteers being rewarded in terms of respect shown by members of their communities and by the few incentives in place (e.g. provision of mobile phones, T-shirts etc.), keeping them motivated is becoming increasingly challenging. In the same vein, progress has been possible as a result of the financial flows provided by donor countries, which puts sustainability in question, as aid budgets in the developed world are under threat. As such, there is still a need for countries to mobilise internal resources in order to reduce their dependence on aid.
The bigger picture, however, should put a spring in our step. We can state, without doubt, that progress in health care is happening and reaching the most underserved populations in the poorest countries in the world. The increasing body of evidence documenting how progress has been achieved in some settings provides a great opportunity for policymakers from countries facing similar challenges to get inspired by successful strategies and best practices that have worked elsewhere.

From the Bottom to the Top: One Step to Improving Global Sanitation

This article by Robbie Lawrence, Wikichild Coordinator, considers how global sanitation can be improved in the context of the International Federation of Red Cross’s ‘Getting the Balance Right’ report. This is part of the Wikiprogress #Health Series. 
“Communities in rural areas and urban settlements must be empowered to increase their resilience through access to safe water, improved sanitation and effective hygiene promotion.” Getting the Balance Right, International Federation of Red Cross, 2013

This post follows on from Wednesday’s blog on the dangers of diarrhoea by focusing on the disease’s chief causation: poor sanitation. Currently 3.4 million people die each year from water, sanitation and hygiene-related causes ( An estimated 2.5 billion do not have access to basic sanitation and 1.1 billion of those people practice open defecation. This is not only degrading but a severe health risk as fecal matter-oral transmitted diseases cause at least 1.5 million deaths per year in children under the age of five (Getting the Balance Right). As Gary White and Matt Damon so bluntly put it, by the time you’ve read this paragraph, another child will have died from something that is eminently preventable.  
In the same way that inequality has reared its head in the post-2015 discussions, forcing global leaders to consider how poverty reduction might be carried out more equitably in the future, it is evident that we need to address water and sanitation issues. The “Progress on Drinking Water and Sanitation 2012” report by the WHO and UNICEF highlights that, although the MDG target of halving the number of people globally without access to improved water source will be fulfilled by the MDG 2015 deadline, the target for sanitation is unlikley to be met.  
More often than not aid donors and development agencies have aimed at providing clean and safe water supplies rather than making sanitation a priority. As it stands, sanitation only receives 12 percent of global aid put towards combatting water and sanitation related issues. In the short term this trajectory make sense, since water is usually in more immediate demand, however, if diarrhoea and other hygiene related illnesses are to be dealt with, access to sanitation facilities must be increased. The ‘Getting the balance right’ report emphasizes that ‘neither water nor sanitations is more important: both elements are required to maintain and improve health and dignity.’ argues that the inability of philanthropic efforts to efficiently deal with the problem of poor sanitation has been a problem in the past. Even the money that has gone towards solving the issue has largely missed the goal of providing relief for those most in need. The organization recognized that if local communities were to make progress, independent of donors, then they must be viewed and view themselves as the owners of the project. Community ownership is the linchpin of’s philosophy. Without an active engagement from communities from the start of a project to its completion there is a strong likelihood that previously entrenched social norms such as public defecation will continue.
The ‘Getting the Balance Right’ report delivers a similar message, and uses a number of examples of community-based initiatives that have succeeded in improving sanitation. In Eritrea, a country where only three percent of its rural population has access to sanitation, the IFRC and the EU implemented a program focused on mobilizing and educating women in hygiene knowledge that reached a total of 145,000 people in 120 villages. By empowering these local women and providing them with  information, the program motivated them to become promoters of sanitation within their own communities. The website also lists various bottom to the top initiatives that have shown remarkable success rates. An Emory University review of a community based ventures in Lempira, Honduras reported that 100 per cent of the project sites were still operational after 10 years with 98 per cent of respondents satisfied with the system.
Since poor sanitation is now firmly in the crosshairs of policy makers and aid groups, it seems that the and IRFC have laid out a fairly effective framework for combating the problem. Changing intrinsic social norms from the routes of a community appears a far more effective means of catalyzing change than large, trickle down cash injections. The flow of international water aid must of course be rebalanced towards sanitation, but organizations, governments and NGOs need to go further and ensure that it reaches the right groups and individuals. The stark reality of IRCF’s report brings to light the vital role that sanitation plays in human health and dignity:  
“Let us speak clearly; the single largest cause of human illness globally is faecal matter. A society – regardless of how many clinics or water supply points it has – can never be healthy is human waste is not safely disposed of.” Getting the Balance Right

Robbie Lawrence

Childhood Pneumonia and Diarrhoea KILLS!

This article, by Ousmane Aly Diallo, Wikiprogress Africa Advisor, is part of the Wikiprogress Health Series. Wikiprogress Africa aims to  provide a platform for knowledge sharing on measuring progress and well-being in an Africa context. 

We know what works against pneumonia and diarrhoea – the two illnesses that hit the poorest hardest. Scaling up simple interventions could overcome two of the biggest obstacles to increasing child survival, help give every child a fair chance to grow and thrive, Anthony Lake, UNICEF Executive Director.

The Lancet recently published a series of papers on Childhood Pneumonia and Diarrhoea in collaboration with the Aga Khan University of Pakistan, in April 2013.  The series demonstrates that it is possible to eradicate the prevalence of these two diseases among children through a comprehensive strategy involving all the stakeholders and highlights the barriers that have enabled children’s death from it.

Pneumonia and diarrhoea are low in incidence in the developed world but remain serious health concerns in the developing world. Childhood Pneumonia and Diarrhoea are particularly lethal in the developing world; nearly 90% of the children who died from these diseases are from Sub-Saharan Africa and South Asia, according to a recent World Health Organization report.

Assessing  the global burden of childhood pneumonia and diarrhoea in the world,  Walker and Alii’s paper show that these two diseases remain the leading infectious causes of death in children younger than 5 years, and caused an estimated 700 000 and 1·3 million deaths, respectively, in 2011. 

According to the study, more than half of the burden (56% of severe episodes of diarrhoea and 64% of severe episodes of pneumonia) is upon 15 countries and among this category, 10 of them are Sub-Saharan Africa’s ones: Angola, Burkina Faso, Democratic Republic of the Congo, Ethiopia, Kenya, Mali, Niger, Nigeria, Tanzania, and Uganda. Most of these deaths could have been prevented through vaccines and other means of prevention according to this study. Besides, undernourishment constitutes another obstacle to these children’s survival. Any program to tackle childhood pneumonia and diarrhoea should include a facet on improving child nutrition.

Lack of national leadership in the fight against these diseases and a lack of financial resources are important bottlenecks. This, coupled with the inadequate training of health workers, and a lack of health indicators, are key obstacles that need to be addressed to lower the morbidity rate of pneumonia and diarrhoea among children and to improve their survival rates, for these authors.

The second paper on “Interventions to address deaths from childhood pneumonia and diarrhoea…” shows that scaled interventions could save 95% of diarrhoea and 67% of pneumonia deaths in younger children (under 5 years) by 2025. But to reach that goal, the emphasis must be put on community-level healthcare as it is the best way to reach the most exposed populations. 

This series show that childhood pneumonia and diarrhoea are serious health concerns in many developing countries, particularly in Sub-Saharan Africa, but that they could be eradicated through prevention (immunisation campaigns) and effective intervention. In its subject and objectives, this series echoes the recent publication by the World Health Organization and UNICEF, the Integrated Global Action Plan for the Prevention and Control of Pneumonia and Diarrhoea. This plan aims to reduce by 75% (with 2010 levels as reference) the incidence of severe pneumonia and diarrhoea, as well as the death from both these diseases among children under-five. It also aims for a 40% reduction in the global number of children under five who are stunted since undernutrition is one of the key risk factor for children suffering from pneumonia and diarrhoea. There’s a global commitment to ending child death from preventable diseases and these two Lancet publications show that this objective is reachable if all means are galvanised.

Childhood diarrhoea and pneumonia are deadlier in low-income countries of Sub-Saharan Africa and South Asia than in the developed world. Closing the gap is one of the ultimate aims of the Lancet series as shown through different models, it is an objective that is within our reach.

To find out more about Wikiprogress Africa, click here

Ousmane Aly DIALLO
(Wikiprogress Africa Advisor)

Nutrition and Obesity Week in Review

This Week in Review blog is part of the Wikiprogress Health focus. See the full range of health articles on Wikiprogress

The theme of this Week in Review is nutrition and obesity as part of wider focus on health during April. Highlights from this review include: IDS UK’s new Hunger and Nutrition Commitment Index, a collaborative report from PBS News Hour and the OECD on obesity in America, a joint paper on global malnutrition from UNICEF, WHO and the World Bank and more.
*The Institute of Development Studies’ new Hunger and nutrition commitment index is a measurement of political commitment to tackling hunger and malnutrition in 45 developing countries. The index was created to provide greater transparency and public accountability by measuring what governments achieve, and where they fail, in addressing hunger and undernutrition.
*PBS News Hour has released its first commentary in a collaborative series with the OECD, which explores how health care and health policy in the latter’s member countries compare with the US. New data reveals relatively promising figures with obesity rates slowing in the America, England, France and Korea. However, these encouraging trends show that obesity has become one of the biggest threats in developed countries and increasingly so in emerging economies, as today’s article from the Guardianrelating to the growing problem of obesity, diabetes and heart disease in Africa shows.  The article references the OECD’s “Better Life Index” tool, which allows members of the public to firstly rank what they value in life and then see how their own country measures up on the topics they value most.
*For the first time UNICEF, WHOand the World Bankreport joint estimates of child malnutrition for 2011 and trends since 1990. The aim of the initiative is to alleviate the double burden of malnutrition in children, starting from the earliest ages of development. To find out more, visit our Wikichild page.
*While it was released last year, the EFA Global Monitoring Report has been an important touch point for preceding publications related to malnutrition, particularly in relation to its effects on children. Despite a decline in the global number of deaths of children under five from 12 million in 1990 to 9.6 million in 2000 and 7.6 million in 2010 (EFA 2012), this drop is not sufficient if the fourth Millennium Development Goal of reducing child mortality by two-thirds by 2015 is to be met. 

In 2005the WHO reported that more than half of all deaths among children are caused by malnutrition. It is therefore arguable that if governments seek to provide adequate quantities of higher quality food with more micronutrients, child mortality levels may drop to the targeted percentage. Malnutrition, through lack of both macronutrients and certain micronutrients has long-term negative impacts on brain and nerve development and function, including on mental skills and activity, and the acquisition of skills needed to interact well socially.
*A new report by UNICEF to be published next week reveals the high prevalence of stunting in children under five years old, but also outlines the tremendous opportunities that exist to make it a problem of the past. In response to nutrition crisis in Chad and the Sahel Belt region, UNICEF, the Government of Chad and partners such as ECHO have scaled up services and facilities to treat the growing number of children affected by malnutrition. Check out the video below to find out more about the initiative. 

Look forward to more health related articles, blogs, tweets, spotlights and videos over the next few weeks. 

Robbie Lawrence
Wikichild Coordinator  
The Wikiprogress Team

Post-2015: Aim here

You’d be pretty foolish to propose a complete post-2015 development framework right now, wouldn’t you? What with the High Level Panel still to have their second substantive meeting (in Monrovia, following London last November and with the Indonesian fixture to follow), and the global consultations still running… You’d pretty much be putting up a target and inviting attack, wouldn’t you? Still, hard hats on, here goes!
Save the Children today publishes the modestly titled Ending Poverty in our Generation, which sets out a vision of how the successor to the Millennium Development Goals could look. Rather than try to summarise it here, I’ll suggest reading it instead – but you can get the gist of it from the contents page, which is reproduced at the bottom of this post. And Mark Tran at the Guardian has a very good (and kind!) piece up already.
The central points, to my mind at least, are these:
  • to continue the MDG structure of a limited number of goals with specific targets and indicators;
  • to address inequalities in various dimensions across every thematic area;
  • to prioritise the achievement of universal (or ‘zero’) goals, from e.g. universal healthcare to the eradication of hunger and absolute income poverty;
  • to ensure sustainability of development progress is given much greater priority; and
  • to radically improve accountability, including through prioritisation of domestic taxation as the source of finance, and with substantial investment in the availability of data
You could summarise this as ‘MDGs+ with our priorities rather than yours’, but I hope you won’t. The intention is not to make the case for this specific proposed framework, and we won’t be lobbying for this as a complete set against any other alternative.
Instead, we’re publishing this because we hope it can be useful, in two particular ways.
The first reflects that we’ve been a little worried about the need to bring the conversation on post-2015 around to specifics. For example, there is in the technical discussions, and increasingly in the political ones also, what feels like an overwhelming consensus on inequality. However, it’s much easier to have a consensus on the importance of an abstract concept than on the actual policy implications thereof. Does that consensus translate, for example, into support for a global goal on income inequality? Or for targets on the ratio of progress between the most and least favoured groups (say by gender, or ethnolinguistic group) in each and every goal? While we recognise there is a long way to go, and that many voices are still to be heard, we hope that putting up a specific proposal may help crystallise some views – even if it’s in fierce opposition to our suggestions!
The second way in which we hope this might be useful is from our own learning. Save The Children is a large and complex organisation, and the process of engaging all the internal stakeholders to reach agreement has been an eye-opening one.  We had (repeatedly!) the kinds of discussions you might expect about how progressive or conservative a position to take in particular areas, and about how much we should be setting a utopian goal, or a politically feasible one. We also had surprisingly creative and good-tempered discussions about the importance of different thematic areas, and how some could be combined rather than excluded, and on where draconian decisions were really needed in order to maintain the clarity and simplicity of the MDG structure.
Of course, that last point  is one that took a good deal of discussion: just how much should we see the MDGs’ simplicity and clarity as an ideal, or at least as necessary to their political traction? You might well take a different view, which could lead to a quiet different structure (or indeed to the absence of one; I confess I’m still attracted to the idea of much broader, and non-exclusive menus of targets and indicators from which nationally-representative processes could prioritise…).
There’s a long way to go. As the UN consultations begin to report back (you can comment on the inequalities draft report here – please do!), and the High Level Panel will start to crystallise some of their thinking, there is still prolonged technical and then political discussion to be had – not least bringing together more completely the thinking and the talking on post-2015 and Sustainable Development Goals.
With a bit of luck, Ending Poverty in our Generation can be of some use in moving these discussions along. Even if it’s just as a target for criticism. Please do share your responses with us, whether in comments below or directly etc. In the end it’s only useful if we learn more publishing it about where post-2015 is going.
Building on the strengths of the MDGs
Finishing the job
Addressing the MDGs’ limitations
Responding to changes and new challenges
1) Finishing the job: better outcomes, faster progress
1 Reducing inequalities
2 Increasing transparency and accountability
3 Synergies and systems
4 Ensuring access is not at the expense of outcomes
5 Environmental sustainability
2) Putting in place the foundations of human development
Goal 1: By 2030 we will eradicate extreme poverty and reduce relative poverty through inclusive growth and decent work
Goal 2: By 2030 we will eradicate hunger, halve stunting, and ensure universal access to sustainable food, water and sanitation
Goal 3: By 2030 we will end preventable child and maternal mortality and provide healthcare for all
Goal 4: By 2030 we will ensure all children receive a good-quality education and have good learning outcomes
Goal 5: By 2030 we will ensure all children live a life free from all forms of violence, are protected in conflict and thrive in a safe family environment
Goal 6: By 2030 governance will be more open, accountable and inclusive
3) Creating supportive and sustainable environments
Goal 7: By 2030 we will have robust global partnerships for more and effective use of financial resources
Goal 8: By 2030 we will build disaster-resilient societies
Goal 9: By 2030 we will have a sustainable, healthy and resilient environment for all
Goal 10: By 2030 we will deliver sustainable energy to all
4) Institutional support and enabling mechanisms
Financing and policy coherence for development
Data availability
5) Save the Children’s proposal for a post-2015 framework

 Alex Cobham, Uncounted Blog
This blog is about inequality and development and those who are uncounted. It is written and maintained by Alex Cobham, Save the Children’s Head of Research. Uncounted aims to stimulate debate but is not a reflection of official Save the Children policy

Ending Poverty in Our Generation is Wikichild‘s most recent Spotlight.

India’s Health-Issues and Challenges

Public health is squarely a state responsibility and particularly so in a developing country. It has to go hand-in-hand with sanitation, drinking water, health education and disease prevention.

The challenges facing India’s health sector are mammoth. They will only multiply in the years ahead. Surprisingly many of the challenges are neither a result of the paucity of resources nor of technical capacity. These hurdles exist because of a perception that the possible solutions may find disfavour with voters or influential power groups.
The first malady has been the utter neglect of population stabilisation in states where it matters the most.
The second is the monopoly that an elitist medical hierarchy has exercised for over 60 years on health manpower planning. The result has given a system where high-tech speciality services are valued and remunerated far higher than the delivery of public health services. The latter ironically touches the lives of millions.
Related to this is the third big challenge — how to make sure that doctors serve the growing needs of the public sector when the working conditions are rotten, plagued by overcrowding, meagre infrastructure and a virtual absence of rewards and punishments.

Divergent Attitudes to Birth Control.

In the aftermath of the 1975 Emergency and the odium of forced sterilisations, the emphasis on population control shrivelled in most of North India. While countries like Korea and Iran which then had fertility rates far higher than ours, embraced the joys of planned parenthood, India dodged the subject. In 1994 the country adopted a target free policy and the states were encouraged to implement a “cafeteria approach” while supplying contraceptives.
However the southern states of Kerala and Tamil Nadu unlike the rest of the country went full force to make family planning their top-most priority. No matter which party came to power, political support was there in abundance. In the mid- eighties the programme was spearheaded by no less than the state Chief Secretary of Tamil Nadu, Mr.T V Anthony, (nick-named Tubectomy-Vasectomy Anthony) which speaks for itself. With enthusiastic politicians, civil servants and doctors joining hands, Kerala and Tamil Nadu reduced fertility rates to equalise European levels. That was more than 20 years ago. Meanwhile, North India (where most of the emergency driven sterilizations had taken place) recoiled from the very mention of family planning- a mind-set that persists even to this day.

The Challenge of Reducing Maternal and Infant Mortality

There is a clear correlation between the health of the mother and maternal and infant mortality. In the northern states more than 60% of the girls and boys (respectively) are married well before the legal ages of 18 and 21. The repercussions of early pregnancy and child birth have not even dawned on the pair when they wed. The first child arrives within the year when most adolescent girls are malnourished, anaemic and poorly educated. With no planned spacing between the births, another child is born before the young mother has rebuilt her strength or given sufficient nutrition and mothercare to the first born. These are among the main causes of high deaths of young women and infants. The chart and tables below clearly show the regional difference in maternal, infant and child mortality. Narrowing the gaps poses one of the biggest health challenges.

Regional Variations: Maternal Mortality Ratio* (MMR)

Extract from – Special Bulletin (June, 2011) on Maternal Mortality in India 2007-09 (Sample Registration System) Office of Registrar General, India
*MMR: Maternal deaths per 1,00,000 live births
The regional variations in the deaths of mothers in the states of Uttar Pradesh, Bihar, Jharkhand, Madhya Pradesh, Chattisgarh, Odisha, Rajasthan and Assam show that the percentage of maternal deaths is 6 times higher than in the Southern states.
Source: Special Bulletin on Maternal Mortality in India 2007-09 (SRS, 2011) Office of Registrar General, India and Unicef SOWC, 2011
Taken together the EAG States and Assam account for 62% of the maternal deaths. Schemes for nutrition, supplementary feeding, literacy, the right to education and health care remain hollow expressions without any meaning as long as women (and chiefly adolescents) have no control over pregnancy. Unlike other South and South East Asian countries the use of IUD and injectibles has not taken off in India -nor are these the thrust areas for family planning anywhere in the country. Although long term, reversible methods of preventing pregnancy are available, young mothers and children continue to suffer or die. The challenge lies in bringing the issue to centre –stage and not wait for incremental improvements to take place in the fullness of time. The charts below show the colossal difference that has been achieved by the southern states that invested heavily in family planning (albeit through the adoption of terminal methods like sterilisation which can be avoided today.)
Source: Registrar General of India, Ministry of Home   Affairs (SRS, 2011)
Source: Registrar General of India, Ministry of Home   Affairs (SRS, 2011)

Health Management and Manpower Planning

The second challenge relates to a obsession for exclusivity that has consumed the medical sector for too long. The Councils that regulate education and register the practitioners (Medical Council of India (MCI), Dental Council, Pharmacy Council, Nursing Council) were established with laudable goals- to elect a cross section of doctors and other health professionals democratically and to entrust to them the responsibility for designing and executing professional corses. It was expected that the country’s needs for professional health manpower would be met both qualitatively and quantitatively. But because the Councils were constituted through a political process of elections, the baggage of money, patronage and quid pro quos became a predictable accessory. Today, gaining entry to professional colleges has become highly commercialised-ultimately reflecting in the aspirations of the health fraternity to reap back benefits from huge investments incurred. As the quest to produce specialists and super specialists grows, the production of qualified technical manpower has declined severely creating a mis-match which cannot be corrected by people who work in silos and lack the understanding and vision to think of the country’s health needs in totality.

The Challenge of Establishing NCHRH.

The neglect of public health is one of the fallouts of the elitism that has pervaded medical education. Whereas cities and towns at least have alternatives available- at a price- epidemics and acute illnesses that occur in rural areas often leave people in the hands of fate. The erstwhile elected MCI had relegated public health to the lowest rung of the health hierarchy and the doctors that once decimated dreaded diseases like malaria and smallpox are not to be found. The complement of technical staff, nurses, pharmacists, dentists, lab technicians and operation theatre staff are all in short supply outside the urban areas as the bodies that register them do not work in tandem. More importantly no Council has a stake in health care of any particular state- leave alone the country.
The proposal to set up a National Council for Human Resources in Health (NCHRH), far from being a bureaucratic response was a well thought out strategy having its roots in the recommendations of independent think tanks and expert committees. The rationale for setting up such an umbrella body was to see that the goals of health manpower planning, the prescription of standards, the establishment of accreditation mechanisms and preservation of ethical standards were served in a co-ordinated way, on the lines of structures that operate successfully in other countries.
The Indian Medical Association in particular and doctors in general have been arguing against the need for such a body because they perceive it as a threat to their autonomy and a camouflage for political and bureaucratic meddling. The fact that health manpower planning was simply ignored, that there was a complete lack of coordination between the councils and most important of all the fact that public health had become a low priority have been overlooked in the fire and fury of opposing the NCHRH concept tooth and nail. The challenge today is how to ensure that the health sector produces adequate professionals as required for the primary, secondary and tertiary sectors, both for the public as well as the private sector health facilities. If the NCHRH Bill before the Standing Committee of Parliament does not see light of day, the resurrection of the superseded scam-ridden MCI is a foregone conclusion.
The Challenge of Allopathy and AYUSH.

Public health cannot be run on contract basis and much less be farmed out to private insurance companies and HMOs (Health Management Organisations) as a recent report on Universal Health Coverage seems to suggest. Public health is squarely a state responsibility and particularly so in a developing country. It has to go hand-in-hand with sanitation, drinking water, health education and disease prevention. The National Rural Health Mission (NRHM) which is a public-sector programme has registered an encouraging impact in even the most intractable regions of the country. A UNFPA study has shown that nearly three quarters of all births in Madhya Pradesh and Odisha had been conducted in a regular health facility. The percentage of institutional deliveries in Rajasthan, Bihar in Uttar Pradesh was lower but even so, accounted for almost half the deliveries conducted in those states. Indeed these achievements are immense.

Having said this, institutional deliveries alone cannot be the answer to all the problems that beset the rural health sector. A visit to any interior block or taluka in the Hindi belt states shows that most primary health centres beyond urban limits are bereft of doctors, except sporadically. Some state governments have taken to posting contractual AYUSH*  doctors engaged under NRHM to man the primary health centres. These doctors dispense allopathic drugs, prescribe and administer IV fluids, injections and life-saving drugs, assisted by AYUSH pharmacists and nursing orderlies. This reality must be confronted. If an AYUSH is doctor has been entrusted with the responsibility of running a primary health centre, and found in shape to handle the national programmes, the controversy over what AYUSH doctors can and cannot do must be settled. The trend of AYUSH doctors working in as registrars and second level physicians in private sector hospitals, clinics, and nursing homes is wide-spread in states like Uttar Pradesh, Maharashtra, and Punjab; so also in Delhi and Mumbai. The challenge lies in understanding what can be changed and what cannot be changed, without getting intimidated by protests from Medical Associations that will always protect their turf to retain primacy.

The Challenge of Retaining Doctors.

The most important concern by far is to decide what kind of medical and public health cover is necessary and feasible to be given to people living beyond the bigger towns and cities. If all general duty doctors are making a beeline for post graduation- failing which opting for management, administration and even banking jobs (because cities are better places to live in,) the facts must be faced. Pursuing post-graduation, migrating abroad and prospecting for jobs outside the medical sector cannot be stopped by any Government. But fixed term requirements to stay bonded to the public sector can certainly be insisted upon for state sponsored medical graduates. But equally the working conditions, facilities and remuneration of such doctors should be respectable. In the state of Jammu and Kashmir the compensation given for working in more difficult areas has been graded. Such practical solutions can greatly bolster doctor retention.
At the end of the day, the challenges of the health sector can only be met if doctors, essential drugs and supporting staff are available in the health facilities. The biggest transformation will come if wriggling out of postings and manipulating things through political patrons stops. The doctors will fall in line only if postings are notified through a transparent and fair process and no exceptions whatsoever are allowed. Only the state Chief Ministers and Health Ministers can make this happen. But will they?

*AYUSH refers to Ayurveda, Siddha, Unami and Homeopathy medical systems supported by Yoga . The status of Indian Medicine & Folk Healing can be seen in a publication by the author at ;

Shailaja Chandra will be speaking on Day Two of the 4th OECD World Forum on “Statistics, Knowledge and Policy”