Massive push to improve the health of women and children

In only one year, more than 100 countries, foundations, multilateral organizations, the UN, the private sector, and academic and professional associations have made unprecedented financial and political commitments to greatly improve the health of women and children.

Notably, 44 of the world's poorest countries — among them Bangladesh, Ethiopia, Nigeria, Burundi, and Nepal — have now joined the Every Woman, Every Child effort, which takes forward the Global Strategy for Women's and Children's Health, launched by UN Secretary-General Ban Ki-moon in September 2010.

These nations have committed almost $11 billion of their own limited resources to the global effort to reduce the annual death toll and improve the health of this group, according to a report released today, Analysing Commitments to Advance the Global Strategy for Women's and Children's Health, from The Partnership for Maternal, Newborn & Child Health (PMNCH).

Equally, these countries have made many important policy and service delivery commitments, many of which have not been monetized. These include:

• Bangladesh commits to double the percentage of births attended by a skilled health worker by 2015 and train 3,000 midwives;
• Ethiopia pledges to increase the proportion of births attended by a skilled professional from 18% to 60%;
• Nepal undertakes to train and deploy 10,000 additional skilled birth attendants and fund free maternal health services among hard-to-reach populations;
• Congo commits to reducing maternal mortality and morbidity by 20% by 2015 and will provide free obstetric care and free access to caesarian sections;
• Benin will increase access to life-saving drugs for HIV+ pregnant women, covering up to 90% of those in need.
• Indonesia will pay for at least 1.5 million deliveries by poor women in 2011.

Supporting these efforts, significant financial commitments were made by other stakeholders:

• High-income governments pledging $13.7 billion
• Middle-income governments committing $5.1 billion,
• Non-governmental organizations: $5.4 billion
• The United Nations and other multilateral organizations: $0.6 billion
• Global partnerships: $3.3 billion
• Foundations: $2.2 billion
• Private sector: $1.1 billion
• Health-care professional groups and academic institutions: $31 million

PMNCH calculated commitments amounting to $41.4 billion through May of 2011. Today, more than 100 new commitments, including major initiatives from the private sector, will be announced at a special event during the UN General Assembly to highlight progress in implementing the commitments.

"There is now unprecedented global collective action around women's and children's health," says Dr. Julio Frenk, Chair of PMNCH and Dean of the Harvard School of Public Health. "This type of joint action is critical to meeting the MDG targets and saving 16 million lives by 2015, as set out in the Global Strategy."

The Global Strategy was created to set out a clear plan of action to accelerate and coordinate efforts to meet Millennium Development Goal 4 to reduce the mortality rate of children under 5 and Millennium Development Goal 5 to improve maternal health.

According to the most recent data, 39 of the world's poorest 49 nations, most in south Asia and sub-Saharan Africa, were not on track to meet the child mortality goal and 47 were off-track in meeting the maternal mortality goal. According to the most recent UN estimates, approximately 358,000 women die due to complications related to pregnancy or childbirth each year, and 7.6 million newborns and children under the age of five die each year.

According to PMNCH's one-year assessment, commitments made by 127 different stakeholders during 2010 and through May 2011 amounted to $41.4 billion in financial aid.

Many other commitments, including those to improve policies and delivery of health services for women and children, were not monetized. Therefore, the $41.4 billion total significantly underestimates the total amount pledged in support of the Global Strategy.

For example, no dollar value was estimated in relation to Bangladesh's commitments to double the percentage of births attended by a skilled health worker by 2015 and train 3,000 midwives or Mongolia's promise to construct a new women and children's health center in Ulaanbaatar.

In May 2011, 16 low- and middle-income countries -- Burundi, Chad, the Central African Republic, Comoros, Guinea, Kyrgyzstan, the Lao People's Democratic Republic, Madagascar, Mongolia, Myanmar, Papua New Guinea, Sao Tome and Principe, Senegal, Tajikistan, Togo, and Viet Nam -- made policy and financial commitments to the UN's Global Strategy for Women's and Children's Health.

India, meanwhile, has made one of the biggest financial commitments of all, spending more than US$3.5 billion each year on health services, with specific efforts to focus on the 264 districts that account for nearly 70% of all infant and maternal deaths. Between now and 2015, India will provide technical assistance to other countries and share its experience, and will support the creation of a platform for global knowledge management to oversee the dissemination of best practices. UNFPA, on behalf of the "H4+" group of multilateral agencies (WHO, UNICEF, World Bank, and UNAIDS), has supported the development of country commitments to the Every Woman, Every Child effort. Says Dr. Frenk, "The leadership shown by the lowest-income countries in their commitments to improve women's and children's health has been outstanding."

Of the specific commitments, 70 percent focused on the 49 low-income countries that received Global Strategy priority.

Nearly 100 of the 127 stakeholders making commitments promised to strengthen health systems and improve the delivery of care. For example, CARE committed to expand its maternal health programs into at least 10 additional countries—a 50 percent increase—and by scaling-up programs in countries where it currently operates, CARE aims to assist more than 30 million women of reproductive age by the 2015 Millennium Development Goals deadline.

One hundred and six of the 127 committed to increasing coverage for essential components of reproductive, maternal and newborn and child health, such as improving the reach and quality of antenatal care, care at birth and immunization. For example, The Reproductive Health Supplies Coalition committed, through its launch of the HAND to HAND Campaign, to reach 100 million new modern contraceptive users by 2015 thereby fulfilling the family planning needs of 80 percent of women in low- and middle-income countries.

Other commitments focused on addressing the socio-cultural and legal barriers that impede progress in improving women's and children's health. For example, Bangladesh, Burkina Faso, Niger, and Laos pledged to increase the minimum age for marriage, prevent female genital mutilation, and/or reduce domestic violence. Yemen promised a safe motherhood law.

Many commitments targeted specific needs identified by the Global Strategy. For example, 33 pledged to increase skilled attendance at birth, 31 to expanding family planning services, 66 to expand and/or strengthen the health care workforce, and 23 to reduce or eliminate financial barriers, such as high costs and user fees, to reproductive, maternal and child health care.

However, the report also revealed certain gaps. Relatively few commitments referenced key needs such as postnatal care for mothers, insecticide-treated bednets for children, and nutrition. Under-nutrition is an underlying cause of stillbirths as well as one-third of child deaths, while maternal nutritional status is increasingly recognized as an underlying determinant of not just newborn health but subsequent adult health as well.

Going forward, other challenges include strengthening the engagement of players from outside the traditional health sector, such as those engaged in education, nutrition, water and sanitation, trade, agriculture and infrastructure. Only 5% of the current set of commitments were made by those from outside the health arena.

There were also relatively few commitments from middle-income countries (4%) and the business community (11%), although these are expected to increase significantly this year. Notable exceptions included commitments from Merck, which committed $840 million over five years to HIV prevention and treatment, childhood asthma programs, and donation of HPV vaccine to prevent cervical cancer. Johnson & Johnson pledged $200 million over 5 years for a package of commitments that included providing more than 15 million expectant and new mothers with free mobile phone messages about prenatal health.

"The Global Strategy underlines the need for greater innovation to catalyze progress," says Carole Presern, Ph.D, a midwife and the Director of PMNCH. "New ways of working, such as the use of information and communications technology, is critical in accelerating implementation and improving efficiency."

Many low-income countries are making commitments based on their own internal needs analysis.

For example, beside Bangladesh's commitment to add 3,000 midwives, it will staff its district health centers to provide round-the-clock midwifery services, including emergency obstetric care. It also promises to reduce the unmet need for family planning by half.

To prevent mother-to-child transmission of HIV/AIDS, Burundi pledges to increase coverage from 25 to 85 percent; Chad plans to increase coverage from 7 to 80 percent; Myanmar to reach 80 percent, and Vietnam from 20 to 50 percent.

• Afghanistan pledges to increase the use of contraception from 15 to 60 percent.

• Congo, Madagascar, Papua New Guinea and Zimbabwe will introduce maternal death audits.

• Burundi, Lao, and Papua New Guinea plan to increase skilled birth attendance. Papua New Guinea also promises to add 23 more obstetricians as well.

Many commitments involve some type of financial reform. For instance, 23 countries committed to abolishing user fees or providing new income protection for the poorest and most vulnerable groups, especially women and children.

• Kyrgyzstan promises free medical care to pregnant women and children under 5;
• Malawi will partner with private institutions to provide free care;
• Nepal will provide free maternal health services for hard to reach populations, encourage public-private partnerships to increase use of family planning services, and provide cash incentives to pregnant and lactating women to improve maternal nutrition;
• Chad will provide free emergency care for women and children and provide free HIV testing and anti-retroviral drugs.
• Yemen pledges to enforce a ministerial decree to provide free deliveries and free contraceptives to all women of reproductive age.

Some commitments aimed to improve health facilities and drug supplies. For example, Rwanda pledges to provide water and electric services to all health facilities.

China will provide free breast and cervical cancer screening, subsidies for hospital deliveries, free folic acid supplements and hepatitis B vaccines for children under 15, and will reimburse 90 percent of medical expenses for rural children with leukemia or congenital heart disease.

The assessment also looked at countries that received commitments for specific help. India, which accounts for 20 percent of all maternal and young child deaths, received the most specific commitments for support, even though India is not one of the world's poorest countries.

Other countries that received specific commitments were Nigeria, Kenya, Ethiopia, Bangladesh, Tanzania, Uganda, Pakistan, Zambia, Mali, South Africa, Afghanistan, Burkina Faso, Democratic Republic of Congo, Congo, Haiti, Malawi, and Nepal.

The reports authors suggest some special assistance may be needed in the following areas:

• Several of the world's poorest nations-- Democratic People's Republic of North Korea, Sao Tome and Principe, the Solomon Islands, and Yemen-- received no special pledges
• French-speaking African countries—Burundi, Djibouti, Equatorial Guinea, Central African Republic, Gabon, Madagascar, and Togo—received little specific support;
• Indonesia, the world's fourth most populous country, and the Philippines received very little pledged support.

The one-year assessment identifies a shortage of financing as a significant obstacle faced by low-income countries in implementing Global Strategy commitments. Also, the PMNCH team that conducted the assessment through a series of questionnaires and interviews found it difficult to assign a monetary value to some commitments, such as those for improved service delivery or changes in laws and policies, and indeed is not necessarily important to do so.

The assessment shows it is too soon after commitments were made to report on concrete steps to honour them. A majority of those who responded asked for a regular reporting process to keep track of progress and a system for measuring results and assessing their impact, according to the report.

The PMNCH report is intended to support the recommendations of the Commission for Information and Accountability, which was tasked by UN Secretary-General Ban Ki-moon to develop an accountability framework to track resources and results related to women's and children's health worldwide. A multi-stakeholder independent Expert Review Group will help take forward the Commission's recommendations. Members of this group will be announced at the September 20th event.

"We must not forget that women and children, their families and communities are at the heart of the Global Strategy, and we are ultimately accountable to them," says Dr Carole Presern of PMNCH. "The success of the Global Strategy will be determined by whether the action it mobilized was able to save 16 million lives in the world's poorest countries by 2015. PMNCH will continue to act as a platform for joint action and accountability to support this goal."