usaid's mch portfolio_john borrazzo_10.14.11
TRANSCRIPT
GHI, BEST, SLB, DIV, NUVI, CSHGP, STI, PPP:
MSotASfMCH@USAIDCORE Group Conference
October 14, 2011
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Making Sense of the Alphabet Soup for Maternal and Child Health Programs at USAID
CORE Group ConferenceOctober 14, 2011
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There is a unique global opportunity to accelerate progress in maternal, newborn and child health
InfrastructurePoverty
GeographyStatus of Women
Despite working in challenging environment…
4
0
50
100
150
200
250
300
Ang
ola
1990
-200
9
Afg
hani
stan
200
0-20
06
Mal
i 199
5-20
06
Libe
ria
1986
-200
9
DR
Con
go 2
001-
07
Mal
awi 1
995-
2010
Nig
eria
200
3-20
08
Zam
bia
1996
-200
7
Rwan
da 2
000-
2007
Moz
ambi
que
1995
-200
8
Beni
n 19
96-2
006
Ethi
opia
200
0-05
Mad
agas
car
1997
-200
9
Uga
nda
1995
-200
6
Sene
gal 1
997-
2009
Tanz
ania
199
6-20
10
Indi
a (U
P) 1
998-
2005
Hai
ti 20
00-2
005
Nep
al 1
996-
2006
Paki
stan
199
0-20
06
Bang
lade
sh 1
996-
2007
Keny
a 19
98-2
008
Gha
na 1
998-
2008
Yem
en 1
997-
2006
Suda
n 20
00-2
007
Gua
tem
ala
1995
-200
8
Indo
nesi
a 19
97-2
007
Phili
ppin
es 1
998-
2008
Dea
ths
Per
10
00
Liv
e B
irth
s
Country, Two Survey Years
Earliest Latest
Source: Demographic and Health Surveys since 1995, except Angola, Pakistan and Liberia where earlier datapoints are used. Exceptions are Afghanistan Health Survey; Angola (SOWC, 1990 and 2009); DR Congo: 2001 (MICS); Guatemala (RHS), Malawi: 2006 (MICS); Mozambique (MICS); Sudan Household Survey 2006; Yemen: 2006 (MICS).
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Progress - Changes in under-five mortality in BEST countries (1995-2010)
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Trends in Under-five Deaths, 1990-2009
UNICEF – “Levels & Trends in Child Mortality – Report 2010”
With increasing birth cohort, >5 million more deaths/year if no U5MR reduction
Mill
ion
s o
f D
ea
ths
Maternal mortality has declined globally between 1990 & 2008; there has been considerable regional variation
Source: Trends in Maternal Mortality: 1990 to 2008. UN Estimates, 2010
MM
R: m
ater
nal d
eath
s pe
r 100
,000
live
birt
hs
7
26%
53%
37%
34%
Despite progress, the lifetime chance of a woman dying as a result of pregnancy is substantial and far greater in developing than in developed regions
1: 4,300
1: 4901: 31
1: 260
Source: WHO, UNICEF, UNFPA, The World Bank. Trends in Maternal Mortality: 1990 to 2008 pub 2010 8
Source: 2009 data are from the State of the World’s Children (SOWC) 2011 Report. 2000 neonatal mortality data are from http://www.unicef.org/statistics (SOWC 2008 Report), and 2000 infant data are from www.childinfo.org.
Changes in Neonatal and Post-Neonatal (1-11 months) Mortality Rate USAID MCH priority countries - 2000-2009
Greater effort is needed in newborn survival to accelerate progress
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Neonatal mortality has lagged post-neonatal (and
child) mortality
Reflects limited newborn
programs in most countries
Advantages: We know the causes of newborn, infant and child mortality in developing countries
Based on: Black RE et al. Global, regional, and national causes of child mortality in 2008: a systematic analysiswww.thelancet.com, May 12, 2010 (DOI10.1016/50140-6736(10)60549-1
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• Diarrheal disease and pneumonia still claim the most lives among older infants and children under age five
• Among newborns, preterm birth complications, birth asphyxia and infection pose the greatest dangers
• Undernutrition / low birth weight are major contributors to newborn, infant and child deaths
Undernutrition /Low birth weight
• Low birth weight is a significant contributor in 40–70% of neonatal deaths
• Neonatal death constitutes 41% of under 5 mortality
• Maternal nutrition is an important factor
• Tetanus toxoid • Clean Delivery• Cord Care• Early & Exclusive Breastfeeding• Hand washing• Antibiotics for
mother and baby• Warming • Resuscitation• Partograph
• Syphilis Control
• Folate Supplementation
• Malaria control• Antenatal Corticosteroid• Antibiotic for bacteriuria• Kangaroo Mother Care• Birth Spacing
There are proven interventions to address the leading causes of neonatal death
Source: Adapted from Black et al. for the CHERG of WHO and UNICEF, 2010, “Global, Regional, and National Causes of Child Mortality in 2008: A Systematic Analysis,” Lancet 2010
SepsisPneumoniaDiarrheaTetanus
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Hemorrhage
35%
Indirect and Other Direct
30%
Sepsis
8%
Abortion
9%
Preeclampsia
Eclampsia
18%
Source for Causes: Countdown to 2015
• Iron folate supplements• De-worming• Malaria intermittent treatment• Anti-retrovirals
• Tetanus toxoid• Clean delivery• Antibiotics
• Family planning• Post-abortion care
• Active management of the third stage of labor
• Uterotonics: oxytocin & misoprostol
• Blood transfusion
• Magnesium Sulfate• Aspirin• Anti-hypertensives• Cesarean section
There is a core set of proven interventions to address the leading causes of maternal death
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Underlying causes:• Unintended pregnancy • Under-nutrition
• Supporting development and implementation at scale of evidence-based high-impact interventions
• Developing and evaluating delivery approaches to reach underserved families
• Strengthening key elements of health systems to promote effectiveness & sustainability
The central strategic approaches of USAID’s MNCH Programs
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PRODUCT DEVELOPMENT
INTRODUCTIONFIELD
IMPLEMENTATIONPRIORITY SETTING
GLOBAL HEALTH MISSIONS
Catalytic activities to facilitate introduction
Multi-country program roll-out /diffusion into
regular use
Strategic planning, problem identification,
priority setting
Continued diarrhea deaths
Zinc tablets, improved ORS formula
Developing GMP & manufacturing capacity; policy development; pilot
testing in countries
Support for zinc introduction with ORT
in 14 countries
Applied research creates new interventions &
approaches
USAID’s MNCHprogram uses a research-to-implementation pathway approach
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• Oral Rehydration Therapy (ORT); improved ORS, zinc adjunctive treatment
• Vitamin A
• Early work on Hib, rotavirus, pneumococcal vaccines
• Community treatment of pneumonia
• Essential newborn care
Prior achievements Current activities• Community-based
treatment of severe pneumonia
• Simplified treatment for suspected newborn sepsis
Planned activities
E.g. Developing interventions, technologies & approaches to address critical needs in child health
(Examples)
Technologies
• Non-reusable syringes
• Vaccine Vial Monitors
• Safe birth kits
• Uniject (e.g. Tetanus
Toxoid)
• Antibiotics in Uniject for newborn treatment
• Chlorhexidine for newborn umbilical cord
• Simplified vitamin A blood level assay
• Anemia diagnostic tool
• Research on integrated community case management • Adaptation of
quality improvement for CHW performance• Behavioral interventions on indoor air pollution
• Research on family recognition of newborn illness, care-seeking, and health service response
• Evaluation of integrated services
Increasing
emphasis on
implementation
(vs.
intervention)
research
Scale-up of high impact interventions– PPH example
Global ActionsNational Strategic Choices
Program ImplementationSustainability /
InstitutionalizationIntroduction Early Mature
Global advocacy and partnerships: Global action to support work on reduction of PPH
Global clinical and program
approaches: Evidence-based
interventions for prevention and
management of PPH demonstrated
PPH Policy: AMTSL/misoprostol use;
Expanded job descriptions for skilled birth attendant
cadres managing PPH; PPH service delivery guidelines
Health system governance: Proactive financing of
maternal health services
Drugs & equipment Oxytocin/ misoprostol procurement, logistics,
distribution
Service delivery capacity at sites: Reliable infrastructure,
personnel, and systems to deliver services
Health workers training systems:
For PPH prevention and management
,
Community mobilization:
Awareness raising of PPH;
Birth preparedness
Pilot programs:Phase 1
implementation of misoprostol and/or AMTSL for all skilled
birth attendant cadres
Program initiatives in obstetric and postpartum
management: Quality of care; Clinical training;
Supervision
Pharmaceutical systems:
Uterotonics on Essential Drug List
and in Drug Registration; Supply chain management
National advocacy: Expansion of
national program and highlight work
of champions
Standardization: Quality of care approaches;
Government led training expansion
Programmatic growth:
Adding districts, partners, financing
Training programs: Government
budgeted training programs on PPH; PPH competencies in pre-service and
in-service curricula
Clinical coverage:High coverage use of a uterotonic; Public
and private implementation
Drug & equipment availability:
Drugs and supplies in government
routine procurement mechanisms
REDUCTION OF PPH AND IMPROVED MATERNAL
HEALTH STATUS
M&EReadiness
assessmentPilot project
dataSurvey data
Indicators in HMIS
Routine monitoring
Source: MCHIP, 2011. 16
Applying the financial “lever” is bringing more women into life saving services
Key Financing Approaches
• Health Insurance
• Conditional cash transfers
• Vouchers
• Free services
Rwanda
• There is a correlation between increased enrollment in health insurance and increased institutional deliveries
• National scale-up efforts have increased coverage from 7% in 2003 to 91% in 2010
• Institutional deliveries have increased from 31% in 2000 to 52.10% in 2008
• Recent research has shown a correlation between pay for performance (P4P) and an increase in institutional deliveries by 21.1%
Sources: Rajkotia and Charles/USAID; Soucat/WB17
REPRODUCTIVE• Post-abortion
care• STI case
management
CHILDBIRTH CARE• Emergency obstetric care
• Skilled obstetric care, immediate newborn care (hygiene, warmth, breastfeeding) & resuscitation
EMERGENCY NEWBORN AND CHILD CARE• Hospital care of newborn and childhood illness,
including HIV care•Extra care of preterm babies, including Kangaroo
Mother Care• Emergency care of sick newborns
REPRODUCTIVE HEALTH CARE
• Family planning• Prevention and management of
STIs and HIV• Peri-conceptual
folic acid
ANTENATAL CARE• 4-visit focused
package• IPTp and bednets
for malaria• PMTCT
POSTNATAL CARE• Promotion of healthy
behaviors• Early detection of and
referral for illness• Extra care of LBW
babies• PMTCT
CHILD HEALTH CARE• Immunizations & nutrition e.g.
Vitamin A supplementation & growth monitoring
•IPTp and bednets for malaria• Care of children with HIV,
including cotrimoxazole
FAMILY & COMMUNITY
• Adolescent & pre-pregnancy nutrition
• Education• Prevention of STIs
and HIV
• Counseling & preparation for newborn care, breastfeeding,
birth & emergency preparedness
• Where skilled care is not available, consider clean
delivery & immediate newborn care, including
hygiene, warmth, and early initiation of breastfeeding
HEALTHY HOME CARE, including:• Newborn care (hygiene, warmth)
• Nutrition, including exclusive breastfeeding & appropriate complementary feeding
• Seeking appropriate preventative careDanger sign recognition & care seeking for illness
• ORS & zinc for treatment of diarrhea• Where referral is not available, consider case management for
pneumonia, malaria, & neonatal sepsis
Improved living and working conditions– housing, water, sanitation & nutrition
Clin
ical
Out
reac
h/
Out
patie
nt
Fam
ily/
Com
mun
ity
Intersectoral
BIRTH
Strategic integration of FP, MNCH, nutrition, infectious diseases and water and sanitation interventions is essential
Pre-pregnancy Pregnancy Newborn/post-natal Childhood
18Adapted from K.J. Kerber, et al., Continuum of Care for Maternal, Newborn, and Child Health: From Slogan to Service Delivery, 370 Lancet 1358 (2007).
Program Progress: BangladeshMaternal deaths have declined by 40% in last 9 years
3,870
More needs to be done:
• Continue fertility reduction to replacement level
• Increase women’s education
• Improve referral systems and referral level care
• Focus on PPH and PE/E — still the biggest killers
• Expand access to care at upazilla and union level
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Global Health Initiative (GHI): Context and Rationale
Objectives• Achieve major improvements in health outcomes in 8
health areas, aligned with the health-related MDGs• Progress along 7 principles, including country ownership
and HSS
Approach• Multi-year initiative• Coordinates and integrates all U.S. global health efforts
through a whole of government approach• Do more of what works, including better alignment, smart
integration, and reform• Led by U.S. Ambassador and includes all U.S agencies in
health to promote and achieve sustainable health outcomes
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MCH-relevant GHI Goals
Maternal Health
Child Health
Nutrition
• Reduce maternal mortality by 30 percent across assisted countries
• Reduce under-5 mortality rates by 35 percent across assisted countries
• Reduce child under-nutrition by 30 percent across assisted food insecure countries in conjunction with the President’s Feed the Future Initiative
• Prevent 54 million unintended pregnancies
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Family Planning & Reproductive Health
An Action Plan for Smart Integrated Programming in Family Planning,
Maternal and Child Health,and Nutrition
under the Global Health Initiative
BEST:Best Practices at Scale in the Home, Community and Facilities
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Integrated programming in family planning, maternal and child health, and nutrition
28 countries are very high need
Asia/Middle East: Afghanistan, Bangladesh, India (UP), Indonesia, Nepal, Pakistan, Philippines, Yemen
Africa: Angola, Benin, DR Congo, Ethiopia, Ghana, Kenya, Liberia, Madagascar, Malawi, Mali, Mozambique, Nigeria, Rwanda, Senegal, (southern) Sudan, Tanzania, Uganda, Zambia
Latin America and the Caribbean: Guatemala, Haiti
Focus on vulnerable populations: urban as well as rural; poor; harder-to-reach and disadvantaged tribal, racial, ethnic and caste groups
Focus on countries and populations with greatest need…
BEST applies the GHI principles…
• Woman and girl-centered approach: with special attention to compassionate and dignified care; status and working conditions of midwives and nurses; female leadership in health policy; the role of men in improved health; and gender inequities.
• Strategic coordination and integration: across the 3 program areas and with other sectors to maximize benefits and increase impact.
• Partnerships: with multilaterals, other donors and private sector – in particular, drug merchants, private providers and social marketing programs.
• Country ownership: with government, communities and civil society to support national plans for family planning, maternal and child health, and nutrition.
• Sustainability through health systems strengthening: with special attention to human resources and removal of financial barriers to care.
• Metrics, monitoring and evaluation: with strong baseline measurement in place and support to monitor programs and measure impact.
• Research and innovation: with emphasis on feasible, community-based approaches; information technologies; and research to practice.
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New initiatives & partnerships
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To improve health outcomes of mothers and newborns and reduce mortality
Underway…• Helping Babies Breathe to expand access to and use of low-
cost resuscitation devices• Saving Lives at Birth – Grand Challenges for Development --
innovation • MAMA
…and others
Harnessing the power of innovation: “Saving Lives at Birth: A Grand Challenge for Development”
Goal: Dramatically and sustainably reduce stillbirth, newborn and maternal death
Challenge: To develop groundbreaking prevention and treatment approaches for pregnant women and newborns in rural, low-resource settings around the time of delivery
Partners:
Grants: $14M to support grants in the first round(1) Seed Grants ($250k) to demonstrate proof of concept(2) Transition Grants ($2 Million) to transition successful innovations
toward scale up
USAID, Government of Norway, the Bill & Melinda Gates Foundation, Grand Challenges Canada, and The World Bank
What We are Looking For:
Sustainable, scalable, and innovative technologies, service delivery models, and "demand side" innovations that empower women and their families to be aware of and access health care at the time of birth and adopt healthy behaviors.
• Content advisors• Expertise in
localization
• Link to UN programs
• Communications
• Strategic vision• Funding• In-kind
resources
• Global Knowledge Exchange
• Capacity building
• Strategic vision• Funding• Link to
governments• M&E Support
Founding Partners:
Supporting Partners:
Launched on May 3, 2011
MAMA: Mission
MAMA will harness the power of mobile technology to empower expectant and new mothers to make healthy decisions.
Target Audience: low income mothers and their household decision-makers with access to mobile phones
DRAFT
COORDINATIONTECHNOLOGY
CONTENT
MEDIA
MOBILE OPERATORS
CORPORATESPONSORS
OUTREACH -GOVERNMENT
OUTREACH - NGO
MAMA Bangladesh Partners as of July 2011
Implementing Partners Supporting Partners
RESEARCH
Lead Partners
ICDDR, B
GHCS MCH funding (including nutrition) – 2000-2011
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?
GHCS MCH Funding – 2000-2010
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356
451
495549
Constant 2000 dollars
USAID has focused funding on the field, principally on priority countries
Mil
lion
s of
Dol
lars
“BEST” Countries$276 million (58%)
Other MCH Countries$51 million (11%)
Central & Regional$69 million (15%)
GAVI$78 million (16%)
Total = $474 million
Allocation of MCH funds (excluding nutrition) (GHCS, FY 2010 Enacted)
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USAID’s MCH
program is highly
decentralized
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Health systems, governance & finance
Allocation of MCH funds is also focused on key technical / program areas
Derived from 2010 Operational Plan Reports – includes all MCH including nutrition
We will take a closer look at the main child health technical focus areas in the following slides
Thank You!35