$20 billion for women's and children's health

The Global Strategy for Women's and Children's Health has received about $20 billion in new money, according to a new report from The Partnership for Maternal, Newborn & Child Health (PMNCH).

The report, "The PMNCH 2012 Report: Analyzing Progress on Commitments to The Global Strategy for Women's and Children's Health," shows that of this $20 billion, about $10 billion has already been spent.

Commitments to the Global Strategy come from 220 partners; 98 of these are expressed in financial terms, including 27 from low- and middle-income countries.

The Global Strategy, launched by UN Secretary-General Ban Ki-moon two years ago, aims to save the lives of 16 million women and young children in the world's 49 poorest countries by 2015.

Progress is urgently needed. Although the numbers of deaths of women and children are falling steadily at the global level, progress is lacking in many individual countries and regions. Recent reports indicate:

• There are now an estimated 287,000 maternal deaths per year, according to UN partners – a decline of nearly one-half since 1990. However, 1 in 8 births in low-income settings occurs among adolescent girls, and sub-Saharan Africa continues to lag in progress overall;

• On a global level, the UN and partners estimate that child mortality has declined by 41 percent since 1990, from 12 million deaths per year to 6.9 million in 2011. However, many countries, especially in sub-Saharan Africa, are still far off-target in reducing child deaths.

"Most of the gains have come in low-income countries where more than 95 percent of maternal and child deaths occur," says Carole Presern, PhD, Director of PMNCH and a midwife. "Country leadership and evidence-led policy has been key to these gains. However, there is still much to do, and we can't shy away from the remaining challenges. Everyone has a part to play, and everyone needs to think creatively about how we can really demonstrate results."

At this writing, financial commitments of nearly $58 billion in pledges to The Global Strategy for Women's and Children's Health does not include the value of related policy and service delivery commitments, many of which are difficult to monetize.

Progress is occurring, but it remains fragile and uneven, concurs Mickey Chopra, M.D., Chief of Health for UNICEF and co-chair of the Countdown to 2015 movement, which tracks progress towards achieving the Millennium Development health goals for women and children. "National governments and donors must maintain their efforts and investments in maternal and child health. We are excited that even the poorest countries are making big steps forward in terms of money, services and care for reproductive, maternal, newborn and child health," Dr. Chopra says.

The UN attributes the recent gains in mortality reduction to such factors as greater access to skilled delivery care, use of contraception, and increases in female literacy, as well as the spread of new and more effective vaccines, treatment to prevent mother-to-child HIV transmission, increases in use of insecticide-treated bed nets to prevent malaria in children, and improved nutrition, including vitamin A supplementation.

The current emphasis on women and children's health dates to the Millennium Development Goals (MDGs) adopted by the UN General Assembly in 2000. MDG 4 calls for a two-thirds reduction in the deaths of children under five by 2015 compared to 1990. MDG 5 calls for three-quarters reduction in maternal deaths and universal access to family planning by 2015, compared to 1990.

In its recent report, Countdown to 2015, which focuses on progress in the 75 highest-burden countries where 95 percent of maternal and young child deaths occur, found that:

• On reducing maternal deaths: Annual maternal deaths are down by 47 percent over the past two decades. Nine Countdown countries are on track to meet their 2015 MDG 5 goal by reducing the maternal mortality rate by 75 percent. But more than a third of the 75 Countdown countries have made little, if any, progress.

• On reducing deaths of children under age 5: Twenty-three Countdown countries are expected to achieve MDG 4. But 13 countries have made no progress in reducing child deaths.

The Global Strategy for Women's and Children's Health was created in 2010, along with the Every Woman Every Child movement, to accelerate action where progress is lagging.

The Global Strategy identified a funding gap of $88 billion between 2011-2015 to save the lives of 16 million women and children by 2015. The new and additional funding of $20 billion would go some way towards narrowing this gap. In total, PMNCH estimates that approximately $10 billion of the initial $58 billion has been spent.

Additionally, recent commitments to preterm birth, child survival, commodities, and family planning, such as the $2.6 billion pledged in July at the London Family Planning Summit, have not yet been tallied as part of the overall pledge total.

The Global Strategy push comes at a critical moment. An assessment of development aid targeted to women's and children's health from 2003-2010 published in a special issue of the Lancet medical journal (forthcoming Sept 28) shows that aid from donor governments and multilateral agencies more than doubled in this period, but that the rate of increase has been slowing since 2008, and declined slightly for the first time between 2009-2010, by $32 million, to $6.48 billion.

"The recent leveling off in aid to maternal, newborn and child health is likely due to the economic crisis," says Justine Hsu, a health economist at the London School of Tropical Medicine and lead author of the Lancet paper and a member of the finance working group of Countdown to 2015. "What is worrisome is that if the leveling off continues, it will have an impact on the provision of child and maternal health services."

Authors of all the reports call for better and more precise targeting of funds to areas of greatest need.

The PMNCH analysis showed that donors tend to focus on countries with the largest numbers of maternal and child deaths, like India and Ethiopia, which also receive the most development aid. Other countries are largely ignored. For example, five countries -- Azerbaijan, Congo, Gabon, Sao Tome and Principe, and Turkmenistan -- that are not expected to meet either of the MDG maternal and child goals, received fewer than three commitments each.

Likewise, while interventions that previously received little attention, such as family planning, pre-natal care and skilled birth attendants, are now getting more attention, there is still inadequate investment and policy attention to newborn survival – despite the fact that newborns account for 40 percent of the total burden of child mortality – as well as a surprising lack of attention to life-saving interventions related to child pneumonia and diarrhea, which count among the leading causes of child deaths.

The importance of targeting funds and efforts to areas of greatest need is reinforced by a second study from the Countdown to 2015 group in the September 28th issue of The Lancet, which suggests that targeting health and nutrition resources to the neediest and most vulnerable may be both more effective and efficient than mainstreaming these programs. "There are concerns that the current focus on overall progress in coverage and health status may contribute to increasing health inequalities," says Cesar Victora, M.D., of the University of Pelotas in Brazil, lead author of the study. "Our study confirms the importance of taking equity into account."

Countdown to 2015 papers included in The Lancet special issue also show far greater reductions in child mortality in Niger than in its neighboring West African countries. Because Niger is one of the world's poorest countries, beset by malnutrition, lack of education and hostile geography, Countdown wanted to find out why.

The Niger case study, led by a team of researchers including Agbessi Amouzou, PhD, of The Johns Hopkins University in the US, shows that under-5 mortality rates dropped from 226 per 1,000 births in 1995 to 128 in 2009. Wasting declined by about half, mostly in children under two.

During the same period, coverage for most child survival interventions increased. In 2009, an estimated 56,000 children under five were saved, 25 percent attributable to the introduction of bed nets treated with insecticides against mosquitoes which carry malaria; 22 percent to the correct care and treatment of diarrhea, malaria and pneumonia; 19 percent to better nutrition; 9 percent to vitamin A supplementation; and 12 percent to vaccination.

Government policies supporting free care for children and pregnant women, and decentralized nutrition programs have also been key to Niger's success.

The study provides invaluable evidence for other low-income countries as to how child health can be improved in a comparatively short space of time, at relatively low cost. According to author Agbessi Amouzou: "This study codifies, for the first time, policies, programmatic strategies, and what was actually done on the ground in Niger to achieve the dramatic reductions in child mortality and wasting that we've seen there in the last 10 years."

Writing in a linked Comment in The Lancet, Niger's Minister of Health, Soumana Sanda, says: "These results are a source of enormous pride on the part of the Government of Niger, and especially the Ministry of Health, for having moved Niger from its position in 1990, when the country had the highest child mortality rate in the world, to where we are today. Our success provides evidence that it is possible to reduce child mortality substantially in an incredibly hard socioeconomic context."

"Niger shows what can be achieved," says Dr. Chopra, who also contributed to two UNICEF-led studies on equity and child survival in this special issue of The Lancet. "Just getting simple things to poor people can save a lot of lives. Niger shows how global activism and national leadership can actually make a difference."