New studies have uncovered the specific interventions and advances that have led to the success with these at-risk populations in the poorest countries.
New research across 142 countries finds that some 50 percent of the reduction in under-five child mortality in those countries is attributable to high impact health interventions such as early immunizations and skilled birth attendance.
The remaining 50 percent is due to factors outside the health sector, such as girls' education, women's participation in politics and the workforce, reduction of fertility rates, access to clean water and sanitation, economic development and political commitment, which underpin progress, according to a new series of studies, Success Factors For Women's and Children's Health.
The series' findings have been published in scientific journals including The Lancet Global Health and the Bulletin of the World Health Organization.
The series was coordinated by The Partnership for Maternal, Newborn & Child Health to answer the question of why some countries achieved faster reductions of maternal and child mortality compared to other low- and middle-income countries. Collaborators of the studies were the World Health Organization, the World Bank Group and the Alliance for Health Policy and Systems Research, Johns Hopkins Bloomberg School of Public Health and the London School of Hygiene & Tropical Medicine. The main collaborators worked closely with governments and development partners.
Countries charting their own destiny
According to the new research, ten low- and middle-income countries - Bangladesh, Cambodia, China, Egypt, Ethiopia, Lao PDR, Nepal, Peru, Rwanda and Viet Nam - have been highly successful in reducing maternal and child mortality, and in making good progress on sexual and reproductive health. The studies call these 10 nations "fast-track" countries. "Successful countries made rapid progress by deploying strategies tailored to their own contexts, strengths and challenges," says Carole Presern, a midwife and a PhD, Executive Director of the Partnership for Maternal, Newborn & Child Health (PMNCH).
"Our research uncovered that, surprisingly, it was not the countries with the highest GNP that progressed the fastest," says Shyama Kuruvilla, PhD, lead researcher for the success factors studies at PMNCH.
"Fast-track countries used a 'triple planning approach' -- to address immediate needs, work towards a long-term vision, and adapt quickly to change. They used robust evidence to make smart investments and mobilize national and international resources to achieve their objectives. These countries are charting their own destiny."
China, a fast-track country, has shown remarkable progress. Since 1990, China has reduced under-five child mortality by 74 percent from 54 per 1000 live births to 14 per 1000 live births in 2012. Maternal mortality has fallen by 67 percent from 97 deaths per 100,000 live births in 1991 to 32 deaths per 100,000 live births in 2013.
Other countries are making significant progress too, but not yet across the board. Some countries such as Niger have achieved high rates of reduction in child mortality. Eritrea has accelerated reduction of maternal mortality. India and Nigeria have seen excellent progress in some states, but more progress is required in other areas.
What surprised researchers was that around half the reduction in under-five child mortality is attributable to progress across different sectors in low- and middle-income countries since 1990.
Beyond high-impact health sector interventions such as immunizations and skilled birth attendance, other factors contributed less than 15 percent each. GDP growth contributed around 12 percent.
While economic development was a foundation for advancement, it was not sufficient without advancement across a core set of health and multi-sector factors. Good governance - including control of corruption - underpinned progress.
"Fast-track countries mobilized partnerships across the board, accelerating progress for women's and children's health," says Dr. Presern. "I worked in one of these countries, Nepal, for nine years. Considering where Nepal was in 1986, to now, it is nothing short of spectacular."
Political will and social commitment make a real difference, according to Tedros Adhanom Ghebreyesus, the Minister of Foreign Affairs of Ethiopia. "The old saying that 'where there is a will there is a way' holds true. Country leaders do not have to face their challenges alone, other countries have faced similar challenges. Sharing the best practices can support our collective global progress, so let's learn from each other," says Minister Ghebreyesus.
"These studies revealed that improving people's health and strengthening health systems required investing in health-enhancing sectors such as education, water and sanitation, social protection, and infrastructure development," explains Tim Evans, M.D., Senior Director of Health, Nutrition and Population at the World Bank Group. "Smart, focused, multi-sectoral interventions are critical to securing the essential foundations for the health of women and children."
"For the first time we can affirm with certainty that greater improvements in women's and children's health are the result of investments not only in the health sector, but across other sectors too," says Flavia Bustreo, M.D., Assistant Director General at the World Health Organization.
"The findings of the Success Factors studies are an important addition to the findings and recommendations of the Global Investment Framework for Women's and Children's Health launched in November last year, which reported that with the right investments towards women's and children's health, benefits of up to nine times the value can be generated in social and economic terms."
Barriers to investment and collaboration across sectors are formidable as most governments, donor agencies and international organizations are organized by sector.
"It is like having a wheel with the central government at the hub and line ministries or departments as the spokes, but with no rim connecting them," says Julian Schweitzer, PhD, Principal at Results for Development.
"Government departments and development partners need to transform how they collaborate so that they can accelerate progress together. This does not mean that everyone has to work together all the time. Rather, there are opportunities for strategic planning and coordination that could enhance the resources and results across sectors."
"Multisectoral progress in countries can be coincidental or coordinated. I have seen first-hand the importance of a strategic, coordinated approach across sectors in India's polio eradication efforts," says Anuradha Gupta, Deputy Chief Executive Officer of the GAVI Alliance.
"India was declared polio-free in March 2014. One of the last barriers we had to cross was in underserved areas where children were administered several doses of polio vaccine and yet polio outbreaks continued. Data showed that frequent diarrheal diseases were preventing children from retaining the polio vaccine in their gut. The health department then worked closely with the water and sanitation departments, and together with other development partners and communities we were able to cross this barrier to polio eradication."
Progress across a set of core factors and sectors
The detailed evidence shows there is "no standard formula" for improved results, but progress across a set of core factors and sectors made the most difference. Conversely, countries that failed to make sufficient overall progress, while often making progress on a few factors, generally did not keep pace on the full set.
"There are powerful synergies across different sectors to improve the health of women, children and their families," explains Minister Tedros Adhanom Ghebreyesus. "The best health facility is only as good as the road that leads to it. The best method of family planning is girls' education. The best way to improve a family's nutrition is to invest in agriculture. Government budgets for different sectors should not be seen as a competition, but as a joint contribution to people improving their quality of life."
Most fast-track countries improved health outcomes, despite low GDP per capita, relatively low levels of investment, and significant political and economic challenges.
These countries have achieved more than 90 percent immunization coverage for children under 5.
In Cambodia, multi-stakeholder partnerships were used to promote maternal and child health through mass-media campaigns, using TV, radio, and a TV "soap opera" to promote exclusive breastfeeding. The result: national exclusive breastfeeding rates increased from 11 percent in 2000 to 74 percent in 2010.
"In Nepal, strong community partnerships with our amazing workforce of female community health volunteers are at the heart of our successes in improving women's and children's health," says Praveen Mishra, Secretary of Health. "Since 1995, these dedicated women have visited every home in every community twice a year to give doses of Vitamin A to breastfeeding women and children up to age five."
"They have branched out to provide immunizations, family planning materials, and information on sanitation, nutrition and infant care. We now have 49,000 volunteers in our program and we reach 94 percent of all children six months to five years old. At least 12,000 lives have been saved."
In Peru, 86 percent of newborns are born in hospitals or birthing clinics. Under the Casa Materna, pregnant women in remote areas await birth in dedicated maternity centers. These rural women are also offered more culturally sensitive birthing options. This context-specific strategy contributed to the 50 percent reduction in maternal mortality in rural areas.
Health services are being strengthened. In China, some 30,000 grass-roots health workers have been trained as general physicians.
China, Bangladesh, Cambodia and Viet Nam, all fast-track countries, have developed industries that employ large numbers of women, many of whom migrate from rural areas. With increased income, these female workers can improve their own and their children's health.
The study found that when women held high political office, mothers, newborns and children received improved care. In Lao PDR, the proportion of women members in the national legislature tripled between 1990 and 2003. Now the Lao PDR Government explicitly recognizes the importance of gender parity and the rights of women, via the Law on the Development and Protection for Women. One result of this is the decrease in the total fertility rate from 6 in 1990 to 3 in 2012.
In Rwanda, another fast-track country, 64 percent of the parliamentarians are women, the highest percentage in the world.
Several factors outside the health sector support the fast-track countries' progress, with different political philosophies and models of economic and social development being developed and tested.
"We are now in the midst of a worldwide experiment with different political approaches and models of development being tested by different countries," says Professor Nicholas Mays from the London School of Hygiene & Tropical Medicine who advised on the methods for the research.
"Continuing to learn which approaches work in what circumstances and why will help support our global endeavor to facilitate people living healthy and fulfilled lives in whichever country they are."
Another way to analyze why the 10 fast-track countries have accelerated progress is to compare the list of interventions to 65 other low- and middle-income countries, including the 49 lowest-income countries. Together these 75 countries account for 95 percent of maternal and child deaths worldwide, according to the Countdown to 2015 initiative.
The comparative data from the success factors studies is from 1990 to 2010.
|Progress Indicator||Fast-Track Countries||Other Low- And Middle-Income Countries|
|Skilled birth attendance||22 percentage points increase||10 percentage points increase|
|Measles immunization||24 percentage points increase||16 percentage points increase|
|Prenatal care||24 percentage points increase||11 percentage points increase|
|Health expenditure per capita||9 percentage points increase||7 percentage points increase|
|Girls' education||2.3 years increase in schooling||1.8 years increase in schooling|
|Access to sanitation||27 percentage points increase||9 percentage points increase|
|Access to clean water||21 percentage point increase||13 percentage points increase|
|Contraceptive prevalence||18 percentage point increase||10 percentage points increase|
|Total fertility rate||2.1 births decrease per woman||1.3 births decrease per woman|
|Women in parliament||18 percentage point increase||9 percentage points increase|
|Roads paved||7 percentage points increase||4 percentage points increase|
As part of the success factors study series, a paper by Johns Hopkins researchers, Country Progress towards Millennium Development Goals: Adjusting for socioeconomic factors reveals greater progress and new challenges, shows that many of the poorest low- and middle-income countries are not on track to reduce under-five child mortality (U5MR) by 66 percent and maternal mortality (MMR) by 75 percent between 1990 and 2015, according to the targets set by the United Nations in its Millennium Development Goals (MDGs).
By using a minimum performance target that adjusts for time and national gross domestic product, the Johns Hopkins study calculated that 74 percent and 59 percent of low- and middle-income countries are on track for reducing U5MR and MMR respectively.
That compares with 69 percent for U5MR and 22 percent for MMR using the global MDGs alone, a major difference.
The Johns Hopkins researchers considered a third target for adoption of the best attainable performance in a region across a multisector set of policies. They called this the fast-track target. Only 20 percent and 7 percent of low- and middle-income countries are on track for the child and maternal mortality fast-track targets.
Using these three targets, the study sought to measure which low- and middle-income countries were truly underperforming while also flagging superior performers for analysis and emulation.
The minimum performance standard showed that 27 sub-Saharan African countries are not on track for improvements in child mortality. Given the GDP growth and accounting for their prior burden of disease (including HIV), they should be doing better.
Politicians and civil society in those countries should be concerned that opportunities to use the GDP growth to make life better are being missed. What should they do? The high performance target offers a clue. Four African countries that exceeded the fast-track performance target: Botswana, Liberia, Niger and Rwanda.
"If citizens could have a valid set of expectations for progress in their countries, they could hold their own leaders accountable," says Professor David Bishai, MD, PhD, Director of Health Economics at Johns Hopkins Bloomberg School of Public Health, the lead researcher on this analysis. "Right now a leader can say that global goals are wild aspirations and not relevant."
"In contrast, I think that the leaders of the countries that failed to meet minimum performance targets should be asked why GDP growth did not lead to the expected improvements in the lives of mothers and children. An ongoing dialogue between a people who know what to expect and leaders who get support in how to deliver it is the engine of progress in public health. Better indicators of progress are fuel for this engine."
Worldwide, 29 low- and middle-income countries passed all three targets (MDGs, a minimum performance target, fast-track target) for U5MR: China, Maldives, Mongolia, Albania, Belarus, Bulgaria, Czech Republic, Estonia, Hungary, Latvia, Lithuania, Macedonia, Romania, Russian Federation, Serbia, Ukraine, Brazil, Mexico, Peru, El Salvador, Egypt, Lebanon, Oman, Turkey, Vanuatu, Botswana, Liberia, Rwanda and Niger.
Countries that passed all three targets for MMR are: Maldives, Egypt and Turkey.
Here are highlights of the 10 "fast-track" countries:
Maternal and child mortality reduction in 10 fast-track countries
|Under-five mortality rate per 1000 live births - U5MR||Maternal mortality ratio per 100,000 live births - MMR|
|Countries||1990||2012||percent decline||1990||2013||percent decline|
Source: PMNCH analysis of data from the UN Inter-Agency Groups on maternal and child mortality trends
Note: New 2013 under-five child mortality estimates will be released on 16 September 2014 .
Bangladesh, despite socioeconomic hindrances, has taken enormous strides towards the improvement of women and children's health. Bangladesh has successfully achieved a 72 percent reduction in the under-five child mortality rate from 144 to 41 per 1000 live births between 1990 and 2012. The maternal mortality ratio has also decreased dramatically, from 550 to 170 per 100,000 live births between 1990 and 2013, showing a decline of 69 percent.
These major reductions stem from integral governmental initiatives such as immunization, oral rehydration therapy and family planning. The Bangladeshi Government has worked hard to guarantee these health initiatives are widely, easily and inexpensively available to the populace. In order to ensure the accessibility, Bangladesh has aligned its health strategy with policies that constantly advance better service delivery and ally with NGOs as well as the private sector.
In 2010, the United Nations recognized Bangladesh for its exceptional progress towards MDGs 4 and 5 to reduce child and maternal mortality in the face of many socioeconomic challenges. Success has been achieved through targeted and well-designed programs, and a government willing to experiment with service delivery and to work collaboratively with partners such as NGOs and the private sector. Other contributing factors have included: women's education, empowerment and gender equity, improvements in road networks and information and communication technology.
Under-five birth registration increased from 10 percent in 2006 to more than 50 percent in 2009 through the use of information and communication technologies.
Between 1991 and 2011 the proportion of literate females aged 15-24 years old increased from 38 percent to 80 percent.
Although Cambodia is a developing country that has emerged from years of conflict, it has shown significant advancements in women and children's health. Cambodia has decreased its under-five child mortality rate by 66 percent between 1990 and 2012 from 116 to 40 per 1000 live births. The country also achieved a reduction of 86 percent in the maternal mortality ratio from 1200 to 170 per 100, 000 live births between 1990 and 2013.
Cambodia tailors its governmental RMNCH policies and programs towards three areas: laws, standards and guidelines; essential health systems; and improved delivery strategies. On health financing, Cambodia uses three health-care financing schemes: performance-based financing, health equity funds and vouchers. The government has also instituted policies to increase the number of health workers, particularly midwives.
Improvements in education, nutrition and access to improved water and sanitation have been central to mortality declines and better health. Policy and program inputs in these areas have included: increased resource allocation and partnerships with development partners, NGOs and civil society. These programs have formed links between different sectors.
GDP per capita grew by 54.5 percent between 2004 and 2011.
The People's Republic of China has the second largest GNP after the U.S. and is the most populous nation with 1.37 billion inhabitants.
Inequality in wealth and access to education persists within the country. Aside from this inequality, China has reduced the under-five child mortality rate by 74 percent from 54 to 14 per 1000 births between 1990 and 2012 and the maternal mortality by 67 percent from 97 to 32 per 100,000 live births between 1990 and 2013.
Governmental health expenditure per capita grew annually by more than 13 percent from US$ 53 in 1995 to US$ 480 in 2012. China has also taken steps towards increasing the number of the health care workers, improving the quality of personnel training, collecting quantitative data, administering oversight and providing health insurance to ensure its RMNCH initiatives' success. The fruits of China's RMNCH efforts are a multi-level medical and health care system that stretches from the provinces down through the townships and into the villages. This multi-tiered network allows for expansive health care access for women and children in even the most remote of places.
Multiple non-health sectors have contributed to improvements in women and children's health in China over the last two decades. These achievements are a result of widespread poverty reduction, increased wealth and socioeconomic improvements. The State Council issued several programs, which integrated women's health care, including reproductive health into the overall strategic plans for socioeconomic development.
The government has initiated more than 200,000 projects to supply safe drinking water to 220 million rural residents. In rural areas, access to improved water sources increased from 86.7 percent in 1995 to 94.2 percent in 2011. Access to improved sanitation facilities improved from 40.3 percent in 2000 to 69.2 percent in 2011.
China is on track to achieve 100 percent literacy among 15 to 24 year-olds. The government formulated the Outline for the Development of Food and Nutrition in China (2001-2010). This contributed to strong progress in reducing the percentage of underweight children under-five from 13 percent in 1990 to 4 percent in 2010.
Egypt has seen dramatic improvement in women and children's health, despite a tumultuous political situation and a stalled economy. Egypt has been able to achieve a 76 percent decrease in the under-five child mortality rate between 1990 and 2012 from 86 to 21 per 1000 live births. Egypt has also curtailed the maternal mortality ratio by 63 percent between 1990 and 2013 from 120 to 45 per 100,000 live births.
The government's allocation of funds to health care has been constant over the past decade. The Egyptian Government has implemented several forward-looking policies. The Ministry of Health and Population, supported by UNICEF, UNFPA and WHO, has worked on the Egypt National MCH acceleration plan (2013-2015) which focuses on improving areas of RMNCH such as the capacity of obstetric and emergency care, availability of family planning services, and the quality of training for midwives and nurses.
Egypt has made educational reform a priority since the early 1990s, instituting targeted initiatives to improve access to education for underserved populations and girls. Egypt is on track to meet most of its MDG targets including MDG 1c (to halve the proportion people suffering from hunger). Additionally, the country has prioritized innovation and research through its National Academy of Science and Technology and by building linkages between health research programs and policy formulation by decision-makers.
The youth literacy rate increased from 73 percent in 1996 to 86 percent in 2007, alongside a primary education completion rate of 98 percent in 2011.
Access to improved water sources increased from 93 percent in 1990 to 99 percent in 2011 and access to improved sanitation facilities from 72 percent to 95 percent.
Ethiopia is the fifteenth poorest country in the world. Ethiopia, however, has reduced both its under-five child mortality rate by 67 percent between 1990 and 2012 from 204 to 68 per 1000 live births and its maternal mortality ratio by 70 percent from 1400 to 420 per 100,000 live births between 1990 and 2013. Ethiopia's success in the fields of women's and children's health care follows on the heels of the adoption of the Health Sector Developmental Plan (HSDP) which was launched in 1997/98 and catapulted RMNCH to the forefront of the country's agenda.
The HSDP seeks to constantly enhance the quality and availability of health services through improvements in immunization, nutrition and most importantly community- and facility-based services.
The Health Extension Program (HEP), introduced in 2004, established community-based primary care and is carried out by health extension workers (HEWs). These HEWs are salaried health care personnel, mainly female workers, and are chosen by their respective communities. HEWs provide greater access to health care through their dissemination of various health interventions covering maternal, child and newborn health; disease prevention and control; personal and environmental hygiene and sanitation; and health education. The HEP now employs 38,700 HEWs who, along with the construction of 16,000 health outposts, provide wide-reaching service to the country's most rural communities.
Improvements in water and sanitation and access to safe drinking water are factors in the reduction of under-five mortality, and there is overlap with the community-education work of health extension workers on safe sanitation practices.
Access to primary and secondary education has improved significantly and the road network has been expanded. Ethiopia also achieved near parity in school attendance by 2008/09: at 90.7 percent for girls and 96.7 percent for boys from 20.4 percent and 31.7 percent respectively in 1994/1995.
Lao PDR is a predominantly rural country, lacking formal infrastructure such as paved roads. It is one of the most ethnically diverse societies in the entire world, with 49 official ethnic groups. Lao PDR also ranked 138 out of 186 countries on the Human Development Index, but has still managed to shrink its under-five child and maternal mortality rates. Lao PDR reduced its under-five child mortality rate by 56 percent between 1990 and 2012 from 163 to 72 per 1000 live births and also curtailed its maternal mortality ratio by 80 percent between 1990 and 2013, from 1100 to 220 per 100,000 live births.
Lao PDR has created policies and implemented programs that affect major areas: laws, standards and guidelines; essential health systems; and improved delivery strategies. Lao PDR has sought to augment the quantity, quality and distribution of personnel, namely midwives, through advancements in training, pathways of accreditation and incentives for formerly undesirable placement. The Government of Lao PDR also conducted a study about user fees which led to the provision of free health care for pregnant women and children under five (Prime-Ministerial decree 178/M 2010).
Improvements in education, access to improved water and sanitation, and a 40 percent reduction in poverty over the last 20 years have been central to mortality declines and better health.
The Government of Lao PDR has put in place policies and programs designed to improve women's rights and participation at all levels of society. Over the last 15 years, women's gender parity has improved in primary and secondary education and female literacy. The share of women in wage employment in non-agricultural sectors has increased from about 20 percent in 1990 to 34 percent in 2010 - a key marker of women's improved ability to get higher-paid work. In addition, significantly more women are participating in the national parliament of Lao PDR.
Lao PDR also achieved close to universal primary education for girls from 54 percent in 1992 to 95 percent in 2012. Increased access to clean water to all population groups from 40 percent in 1994 to 70 percent in 2011.
Nepal is a low-income, politically unstable country with a geographically and ethnically diverse population. Nepal has widely disparate access to education, wealth and health. All of these factors, however, do not detract from the improvements the country has made in RMNCH. Nepal diminished the under-five child mortality rate by 70 percent from 142 to 42 per 1000 live births and the maternal mortality ratio by 76 percent from 790 to 190 per 100,000 live births between 1990 and 2013.
The improvement of women and children's health care in Nepal has advanced significantly since the institution of the National Health Policy in 1991. The Nepalese Government's strategy for advancing and fortifying RMNCH revolves around creative, context-specific approaches backed by data. The health care initiative is a multi-level strategy that employs various programs at different tiers of the health system.
These programs optimize maternal and newborn outcomes and include the community-based Integrated Management of Childhood Illness Programme, the National Immunization Programme and the National Newborn Care Package. The Nepalese Government, as a result of research findings, abolished user fees and instituted a free delivery plan for mothers in 2009 while also incentivizing antenatal care (ANC) visits with benefits. The removal of user fees and introduction of incentives for ANC visits led to a 36 percent increase in the rate of skilled birth attendance.
Improvements in women's educational status has been linked with reductions in maternal and neonatal mortality in Nepal. In recent years, girls' enrollment in schools has increased, driven partly by targeted free education policies. In addition, women's and children's health has benefited from improvements in transport infrastructure, communications, water quality and sanitation, and from a multisectoral approach to nutrition.
The constitutional reform of 2007 guarantees the right to free basic health care services and establishes health as a fundamental right of every person.
Peru is a South American country that, within the past decade and a half, has experienced a politically stable landscape, continuous economic growth and social advancement. Despite some problems, Peru has effectively reduced its under-five child and maternal mortality rates. Between 1990 and 2012 Peru reduced its under-five mortality rate by over 77 percent from 79 to 18 per 1000 live births and curtailed its maternal mortality ratio by 64 percent from 250 to 89 per 100,000 live births between 1990 and 2013.
Peru increased public and private health expense per capita from US$ 194 in 1995 to US$ 496 in 2011. Besides the increase in spending, the enormous success in improving the amount and caliber of institutional deliveries achieved by Peru largely emanates from the Comprehensive Health Insurance and the Support Programme for Health Reform (PARSalud), along with various other programs and investments.
The Comprehensive Health Insurance is directed to severely impoverished mothers and their children, and provides the foundation for Universal Health Insurance in Peru. Peru has also created accommodations for expecting rural women at birthing centers up to a few weeks before they deliver.
Non-health sectors and stakeholders have contributed significantly to improving women and children's health in Peru over the past two decades.
The Peruvian Government has created a number of national programs on nutrition, health, water and sanitation, literacy and extreme poverty which have had a big impact on maternal, newborn and child health. For example, malnutrition in children under five declined from 27 percent to 17 percent between 2007 and 2013.
In recovering from the genocide in 1994, Rwanda has experienced positive economic growth with an increase in the GDP per capita from US$ 707 to US$ 1,167 between 1990 and 2012. Along with this positive economic upswing has come a reduction in the Rwandan maternal and under-five mortality rates. Rwanda has been able to reduce the under-five mortality by 64 percent from 151 to 55 per 1000 live births between 1990 and 2012 and maternal mortality by 77 percent from 1400 to 320 per 100,000 live births between 1990 and 2013 respectively.
Following the 1994 genocide, the Rwandan Government chose to focus on RMNCH, due to very high rates of maternal and child mortality. Inhibiting factors that the government had to overcome included a lack of health care personnel and minimal health infrastructure. The Government of Rwanda instituted Mutuelles de santé, a community-based health insurance arrangement to provide universal health care. Mutuelles de santé insures those enrolled against huge out-of-pocket fees and permits channels for health care through 30 district-based mutuelles, local facilities and national hospitals.
The Government of Rwanda has prioritized multisector approaches in areas such as education, nutrition and water and sanitation. A strong focus on eliminating gender disparity in education has resulted in 90 percent of girls of primary school age being enrolled in school. Rwanda has led in the use of mobile technology, which links community health workers to pregnant women.
In 2013, women constituted 64 percent of parliamentarians, the highest percentage in the world.
Viet Nam is now a lower-middle-income country since its per capita income rose from US$ 972 in 1990 to US$ 4,998 in 2012. Viet Nam has drastically cut its under-five mortality rate by 55 percent from 51 to 23 per 1000 live births between 1990 and 2012. It has done even better with the reduction of its maternal mortality rate by 65 percent from 140 to 49 per 100,000 live births from 1990 to 2013.
Since 1990, Viet Nam has quintupled its per capita government expenditures on health. The result of this quintupling is an increase in health care facilities and the number of health workers, especially midwives. This proactive strategy of aggressive government investment and job creation has increased the percentage of births attended by a trained health care professional from 77 percent in 1997 to 97.9 percent in 2012. Complementary strategies meant to exacerbate the advancement of RMNCH include programs tailored to immunizations, the construction of inter-communal polyclinics, promotion of family planning and midwife initiatives.
Access to clean drinking water increased from 58 percent of the population in 1990 to 96 percent in 2011. In the same period, access to sanitation facilities increased from 37 percent of the population to 75 percent. Between 1990 and 2009, total primary school net enrollment increased from 87 percent to 97 percent, while secondary school enrollment more than doubled between 1993 and 1998, from 30 percent to 62 percent, and to 79 percent by 2006.
The government has introduced a number of laws and policies to tackle nutrition issues. Thus, the stunting prevalence dropped from close to 40 percent in 1999 to 25.9 percent in 2013.