POLICY BRIEF The Global Family Health Action Plan: U.S. Leadership for a Healthier, Safer World The United States has the opportunity to contribute to the dramatic success in global health by reducing the 9.2 million deaths among young children (including 3.7 million newborns) and 536,000 maternal deaths from pregnancy and childbirth, as well as the approximately 76 million unintended pregnancies that occur every year.1 Investing in the health of women and children is an effective and popular form of U.S. assistance to developing nations. Launching a Global Family Health Action Plan (GFHAP) will deploy proven methods and entail relatively modest increases in cost to save the lives of millions of women and children each year. In addition, GFHAP will reaffirm the role of the United States as the global leader in the fight for better health, be a highly visible statement of U.S. moral leadership, and project the values of the American people. This brief will highlight the components of GFHAP and make recommendations for launching the Plan.
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Success stories in global family health, which encompasses maternal, newborn, child and reproductive health, are legion: eliminating polio in all but a handful of countries, saving mothers’ lives in Sri Lanka, preventing diarrheal deaths in Egypt, reducing birth rates in Bangladesh, and eliminating measles in southern Africa, to name but a few.2 In the past 35 years, child mortality has fallen from more than 16 million in 1970 to just over 9 million in 2005.3 During the same period, the birth rate in developing countries has dropped from 5.7 to 3.3 births per woman. The challenge to achieve further reductions in maternal, newborn and child mortality remains. About 99 percent of maternal and child deaths occur in lowand middle-income countries – 50 percent occur in sub-Saharan Africa and 30 percent in South Asia.1, 4, 5 Over the past 19 years, the child mortality rate has either increased or remained constant in 26 countries.4 Ten countries have under-5 mortality rates greater than or equal to 180 per 1,000 live births.1
Developed in 2000, the Millennium Development Goals (MDGs) provide a framework for progress on some of the most serious problems facing the developing world.6 Achieving the maternal and child health targets would drop the number of child deaths to less than 4.2 million and the number of maternal deaths to less than 147,000. Providing access to reproductive health care would allow for healthier pregnancies and deliveries, and would enable families to space births. In addition, a commitment to MDGs 4 and 5 would stimulate economic growth and contribute to progress on achieving the other MDGs. Historically, the United States has been a leader in global family health by contributing both technical and financial assistance. However, between 1998 and 2008, U.S. appropriations for global family health in developing nations stagnated and, in real terms, actually declined. This trend is baffling in light of historic successes and the availability of proven strategies for fostering family health.7
Millennium Development Goals 4 and 56 MDG 4: To reduce the 1990 child mortality rate, defined as the number of deaths among children under age 5 years per 1,000 live births, by two-thirds by 2015. Key indicators are: » » »
Child mortality rate Infant mortality rate Proportion of infants immunized against measles
MDG 5: To reduce the 1990 maternal mortality ratio – the number of maternal deaths per 100,000 live births – by three-quarters and ensure universal access to reproductive health care. Key indicators are: » » » » » »
Maternal mortality ratio Proportion of births attended by skilled health personnel Contraceptive prevalence rate Adolescent birth rate Antenatal care coverage Unmet need for family planning
Mother and Child Continuum of Care1,8
Adolescence and pre-pregnacy
Pregnancy
Birth
Global Family Health The elements of global family health are interdependent and need to be mutually supportive. Family health can be addressed using a continuum of care, which meets health needs by focusing on stage-appropriate interventions.8 Success at each stage increases the likelihood of survival by implementing proven, cost-effective services; undermining any stage in the process is like breaking the links in a chain. Adolescence and pre-pregnancy. Providing reproductive health services and counseling about gender-based violence (GBV) and delaying pregnancy are key interventions. Adolescents under age 15 are five times more likely to die during birth than women over 20; mothers under age 18 have a 60 percent greater chance of losing their infant in the first year of life than those over 19.9, 10 GBV is often exacerbated by pregnancy or may result in pregnancy. It is estimated that one-third of women are subjected to one or more acts of physical, sexual or emotional violence.11 Family planning and reproductive health care are essential to delay or appropriately space births and to treat conditions that could increase the risk of pregnancy complications. Providing modern contraceptives to meet the unmet family planning needs could avert 52 million unintended pregnancies, 142,000 maternal deaths and 22 million induced abortions.12
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Pregnancy, labor and delivery. Women who have intended pregnancies and experience a healthy pregnancy and childbirth are more likely to have healthy babies than those whose pregnancies are unintended or unsupported by good care.1, 13, 14 Nutrition during pregnancy is critical, as malnutrition can lead to low birth weight; an estimated 20 percent of newborns in developing countries have low birth weight.1, 15 Most maternal deaths stem from emergencies that do not receive the required rapid, skilled interventions – skilled care during delivery and emergency obstetrical care are essential. More than half of births in Africa and South-Central Asia take place without a skilled attendant present.16
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Postpartum and newborn period. In sub-Saharan Africa, 50 percent of maternal deaths and 30-50 percent of newborn deaths take place within one day of childbirth.17 In addition, about one-quarter of the 3 million stillbirths occur during childbirth.1 Newborn deaths can be averted by having trained personnel available during and following birth, and through simple practices, including breastfeeding and keeping the baby warm.18 Family planning services can be provided in the postpartum period – birth intervals of three years reduced infant mortality by 29 percent and child mortality by 36 percent in India, and reduced newborn mortality by 14 percent in Latin America.19, 20 Infancy and childhood. Child deaths are preventable with simple, “low-tech,” proven, low-cost interventions.21 Illness, malnutrition and injuries have short- and long-term conse-
Postpartum and Newborn
Infancy
Childhood
quences, including physical disabilities and fewer opportunities.22 Undernutrition contributes to 35 percent of child deaths by weakening their ability to fight off infection.15 Children who lose their mothers are three to ten times more likely to die than those with living mothers.1, 23 Chronic maternal ill-health affects the health and quality of life of surviving children, who depend on her for support.24 Countries with the highest child mortality rates also have among the highest birth rates, maternal mortality ratios, lifetime risk of maternal death, and population growth rates.9
Economic, Social and Political Benefits Improved maternal and child health is the first step toward enabling families to break out of a cycle of ill-health and poverty that may otherwise continue for generations.25 The economic impact of maternal disability is high, as productivity is diminished.26 USAID estimates the annual lost productivity cost of maternal and newborn mortality to be $15 billion.27 Appropriately spaced births and smaller family size allow families and governments to invest more in each child’s education and health, which raises productivity and economic growth. Many families facing illness or death incur medical expenditures they can ill afford. Physical stunting, intellectual impairment, and blindness have long-term impact – children with these conditions are more likely to perform poorly in school and to be less economically productive in later life compared with their peers.22 Simple interventions to prevent stunting have long-term benefits on schooling and intelligence tests in adulthood and return up to $3 in additional wages for every $1 invested in improving child nutrition.28, 29
GFHAP Strategy, Principles and Activities The strategy for improving global family health includes delivering an intervention “package” that is cost-effective.8 GFHAP ensures that the full range of core maternal, newborn and child health services are available to every family. Under GFHAP, the U.S. government will expand on the Maternal and Child Health Plan developed by the Agency for International Development (USAID) in 2008, which targets 30 countries with a limited set of interventions that would move them toward MDG achievement. GFHAP calls for either an expansion of target countries, and/or more substantial efforts in the currently selected countries. GFHAP also supports a comprehensive, integrated program of maternal, child and reproductive health interventions that is adapted to the needs of each recipient country, and strengthens the underlying capacity of national health systems to design, deliver, monitor and evaluate essential health services. The design, implementation, scaling up and assessment of GFHAP reflects well-tested, internationally agreed upon principles of collaboration and coordination to support health and development:
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Support national governments in undertaking their responsibility to lead realistic, inclusive, resultsbased strategies for improving global family health;
» Link global family health to other development sectors;
Have clear targets and benchmarks for progress towards MDGs 4 and 5;
» Encourage operations research and research on critical
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Direct resources to the countries most affected by high maternal and child mortality and morbidity;
» Respect and protect fundamental human rights; and,
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Stabilize health assistance to countries over time;
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Use the maternal, newborn and child health continuum of care as the framework for program planning, implementation, monitoring and evaluation;
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» Sustain services in conflict and post-conflict situations; barriers to family health;
» Monitor and evaluate progress using valid methods and
» Optimize integration of maternal, newborn, child and reproductive health services, and integrating global family health with other health services;
» Allow maximum flexibility to design programs responsive to country needs;
» Strengthen and sustain health systems and financing; » Support evidence-based health policies and practices; » Ensure appropriate involvement of all concerned sectors in program design, implementation and evaluation;
indicators.
Conclusion After a decade of stagnant funding, the past two years have seen increased U.S. funding for family health. However, funding is far from the levels that would best serve national interests. A diverse group of organizations has developed the Global Family Health Action Plan, which would restore U.S. leadership, save lives, reduce suffering, strengthen economies and increase political stability. The stability of governments can be enhanced as they are able to offer families essential health care. GFHAP responds directly to President Obama’s call for renewed U.S. leadership. No single action would do more to better demonstrate the U.S. commitment to a safer, healthier, more just world than saving millions of women and children. Visibility in promoting global family health can contribute to greater development assistance and elevate U.S. credibility, legitimacy and moral standing.
The Global Health Council Supports the Following Measures » U.S. Government global family health programs should be country-focused and implemented in partnership with the government under which the programs or actions take place. They should be relevant to country circumstances, and build on existing mechanisms and health plans in countries, as appropriate. Programs should be held accountable for results, so that the money spent is linked to the results achieved.
» Led by USAID, an inter-agency Task Force on Global Family Health should be established to craft the global family health strategy, ensure coordination among the concerned departments and agencies (USAID, State, Health and Human Services and Defense, among others) and asses progress in implementing the strategy. This would include coordinated reporting, information gathering and record keeping.
» Currently, the U.S. devotes about $1 billion/year to family health through the maternal and child health and family planning accounts and should provide an additional $3 billion a year to support implementation of the global family health strategy. An additional $10 billion a year is necessary to achieve the maternal, child and reproductive health MDGs.31 This increase should be ramped up over a five year period.
» Disease-specific and health systems approaches should be mutually reinforcing and contribute to achieving the MDGs. Effective partnerships between donors, governments, the private sector, implementing organizations and other civil society organizations need to be developed and sustained, with a long-term commitment to support holistic and integrated country strategies and programs.
» The United States should continue to support its international partners in child, maternal, and reproductive health, including UNICEF and UNFPA.
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» The U.S. Government should develop a five-year “family health strategy” using the Global Family Health Action Plan as a guide. It should focus on improving maternal, newborn, and child health and reproductive health among poor and marginalized populations. It should be integrated with programs aimed at major causes of death and diseases, efforts to strengthen health systems and the health workforce, and building local capacity.
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References 1. UNICEF. State of the World’s Children; 2009. 2. Levine R, Kinder M. Millions saved: proven successes in global health. Washington, DC: Center for Global Development; 2004. 3. Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat. World Population Prospects: The 2008 Revision Population Database. [cited 2009 May 1, 2009]; Available from: http://esa.un.org/unpp 4. Countdown Coverage Writing Group. Countdown to 2015 for maternal, newborn, and child survival: the 2008 report on tracking coverage of interventions. Lancet. 2008;371:1247-58. 5. UNICEF. Progress for children: a report card on maternal mortality; 2008. 6. United Nations. Millennium Development Goals report; 2008. 7. Institute of Medicine. U.S. committment to global health: recommendations for the new administration; 2008. 8. Kerber KJ, de Graft-Johnson JE, Bhutta ZA, Okong P, Starrs A, Lawn JE. Continuum of care for maternal, newborn, and child health: from slogan to service delivery. Lancet. 2007;370:1358-69. 9. UNICEF. The state of the world’s children 2007. 10. UNFPA. Facts about safe motherhood. [cited 2009 April 7, 2009]; Available from: http://www.unfpa.org/mothers/facts.htm 11. UN Millennium Project. Public choices, private decisions: sexual and reproductive health and the Millennium Development Goals. New York: U.N. Millennium Project; 2006. 12. Singh S, Darroch JE, Vlassoff M, Nadeau J. Adding it up: the benefits of investing in sexual and reproductive health care. New York: The Alan Guttmacher Institute, UNFPA; 2003. 13. Rudan I, El Arifeen S, Black RE, Campbell H. Childhood pneumonia and diarrhoea: setting our priorities right. Lancet Infec Dis. 2007;7:56-61. 14. Kinder M. Preventing diarrheal deaths in Egypt. In: Levine R, editor. Case studies in global health: millions saved. Sudbury, MA: Jones & Bartlett Publishers; 2007. 15. Black RE, Allen LH, Bhutta ZA, Caulfield LE, de Onis M, Ezzati M, et al. Maternal and child undernutrition: global and regional exposures and health consequences. Lancet. 2008;371:243-60. 16. World Health Organization, Department of Reproductive Health and Research. Proportion of births attended by a skilled health worker: 2008 update; 2008. 17. Lawn J, Kerber K, editors. Opportunities for Africa’s Newborns: Practical data, policy and programmatic support for
newborn care in Africa. Cape Town: The Partnership for Maternal, Newborn and Child Health 2006. 18. Lawn J, Khan A, Teshome S, Kerber K. Newborn survival and health - delivering the future. European Paediatrics. 2008:16-9. 19. Norton M, Griffin J. Birth spacing: a call to action. Birth intervals of 3 years or longer for infant and child health.: USAID. 20. Brockman S, Stout I, Marsh K. The public health impact of optimal birth spacing: new research from Latin America and the Caribbean. Washington, DC: CATALYST Consortium; 2003. 21. Lawn JE. A price tag for newborn and child survival: Countdown to 2015 Child Survival Partnership. 22. Grantham-McGregor S, Cheung YB, Cueto S, Glewwe P, Richter L, Strupp B, et al. Developmental potential in the first 5 years for children in developing countries. Lancet. 2007;369:60-70. 23. World Health Organization. World health report 2005: make every mother and child count. Geneva: WHO; 2005. 24. United Nations Population Division. Surviving childbirth, but enduring chronic ill-health. [cited August 16, 2007]; Available from: http://www.endfistula.org/q_a.htm 25. Islam MK, Gerdtham U. The costs of maternal-newborn illness and mortality. Geneva: WHO; 2006. 26. United Nations Population Division. Mental, sexual and reproductive health; 2006. 27. Gill R, Malhotra A. Women deliver for development. Women Deliver Conference; 2007. 28. Engle PL, Black MM, Behrman JR, de Mello MC, Gertler PJ, Kapiriri L, et al. Strategies to avoid the loss of developmental potential in more than 200 million children in the developing world. Lancet 2007;369:229-42. 29. Belli PC, Bustreo F, Preker A. Investing in children’s health: what are the economic benefits? Bulletin of the World Health Organization. 2005;83(10):777-84. 30. UNICEF. Countdown to 2015: Tracking progress in maternal, newborn and child survival: the 2008 report. 2008 [cited; Available from: http://www.countdown2015mnch.org/documents/2008report/200 8Countdown2015FullReport_2ndEdition_1x1.pdf 31. PMNCH. Global call to leaders. 2008 [cited April 9, 2009]; Available from: http://www.who.int/pmnch/activities/calltoactionstatement/en/index.html
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