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USAID's MCH Portfolio_John Borrazzo_10.14.11
The document provides an overview of maternal and child health programs at USAID, including the alphabet soup of acronyms used, core interventions and approaches, and global initiatives like the Global Health Initiative. It discusses challenges in maternal and newborn health and progress made in reducing mortality. The document also outlines USAID's research-to-implementation pathway and strategies to scale up high-impact interventions.
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USAID's MCH Portfolio_John Borrazzo_10.14.11
- 1. GHI, BEST, SLB,DIV, NUVI, CSHGP, STI, PPP: MSotASfMCH@USAID CORE Group Conference October 14, 2011 1
- 2. Making Sense ofthe Alphabet Soup for Maternal and Child Health Programs at USAID CORE Group Conference October 14, 2011 2
- 3. There is aunique global opportunity to accelerate progress in maternal, newborn and child health
- 4. Despite working inchallenging environment… Poverty Infrastructure Status of Women Geography 4
- 5. Deaths Per 1000Live Births 50 0 100 150 200 250 300 Angola 1990-2009 Afghanistan 2000-2006 Mali 1995-2006 Liberia 1986-2009 DR Congo 2001-07 Malawi 1995-2010 Nigeria 2003-2008 Zambia 1996-2007 Rwanda 2000-2007 Mozambique 1995-2008 Benin 1996-2006 Ethiopia 2000-05 Madagascar 1997-2009 in BEST countries (1995-2010) Uganda 1995-2006 Senegal 1997-2009 Tanzania 1996-2010 India (UP) 1998-2005 Haiti 2000-2005 Nepal 1996-2006 Country, Two Survey Years Pakistan 1990-2006 Progress - Changes in under-five mortality Bangladesh 1996-2007 Kenya 1998-2008 (MICS); Sudan Household Survey 2006; Yemen: 2006 (MICS). Ghana 1998-2008 Earliest Yemen 1997-2006 Sudan 2000-2007 Guatemala 1995-2008 Latest Indonesia 1997-2007 Philippines 1998-2008 Source: Demographic and Health Surveys since 1995, except Angola, Pakistan and Liberia where and 2009); DR Congo: 2001 (MICS); Guatemala (RHS), Malawi: 2006 (MICS); Mozambique earlier datapoints are used. Exceptions are Afghanistan Health Survey; Angola (SOWC, 1990 5
- 6. Trends in Under-fiveDeaths, 1990-2009 With increasing birth cohort, >5 million more Millions of Deaths deaths/year if no U5MR reduction UNICEF – “Levels & Trends in Child Mortality – Report 2010” 6
- 7. Maternal mortality hasdeclined globally between 1990 & 2008; there has been considerable regional variation MMR: maternal deaths per 100,000 live births 26% 53% 34% 37% Source: Trends in Maternal Mortality: 1990 to 2008. UN Estimates, 2010 7
- 8. Despite progress, thelifetime 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: 260 1: 490 1: 31 Source: WHO, UNICEF, UNFPA, The World Bank. Trends in Maternal Mortality: 1990 to 2008 pub 2010 8
- 9. Greater effort isneeded in newborn survival to accelerate progress Changes in Neonatal and Post-Neonatal (1-11 months) Mortality Rate USAID MCH priority countries - 2000-2009 Neonatal mortality has lagged post- neonatal (and child) mortality Reflects limited newborn programs in most countries 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 9 (SOWC 2008 Report), and 2000 infant data are from www.childinfo.org.
- 10. Advantages: We knowthe causes of newborn, infant and child mortality in developing countries • Diarrheal disease and pneumonia still claim the most lives among older infants and children under age five • Among newborns, preterm Undernutrition /Low birth complications, birth birth weight asphyxia and infection pose the greatest dangers • Undernutrition / low birth weight are major contributors to newborn, infant and child deaths Based on: Black RE et al. Global, regional, and national causes of child mortality in 2008: a systematic analysis 10 www.thelancet.com, May 12, 2010 (DOI10.1016/50140-6736(10)60549-1
- 11. There are proveninterventions to address the leading causes of neonatal death •Syphilis Control •Folate •Malaria control Supplementation •Antenatal Corticosteroid •Tetanus toxoid •Antibiotic for bacteriuria •Clean Delivery •Kangaroo Mother Care •Cord Care •Birth Spacing •Early & Exclusive Breastfeeding •Hand washing •Antibiotics for •Warming mother and baby •Resuscitation •Partograph Sepsis Pneumonia • Low birth weight is a Diarrhea significant contributor in 40– Tetanus 70% of neonatal deaths • Neonatal death constitutes 41% of under 5 mortality • Maternal nutrition is an important factor 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 11 Analysis,” Lancet 2010
- 12. There is acore set of proven interventions to address the leading causes of maternal death • Magnesium Sulfate • Aspirin • Anti-hypertensives • Cesarean section • Active management of Preeclampsia the third stage of labor • Family planning • Post-abortion care Eclampsia • Uterotonics: oxytocin & misoprostol 18% Hemorrhage Abortion •Blood transfusion 9% 35% • Tetanus toxoid Sepsis • Clean delivery • Antibiotics 8% Indirect and Other Direct • Iron folate supplements 30% • De-worming Underlying causes: • Malaria intermittent treatment • Anti-retrovirals • Unintended pregnancy • Under-nutrition Source for Causes: Countdown to 2015 12
- 13. The central strategicapproaches of USAID’s MNCH Programs • 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 13
- 14. USAID’s MNCHprogram usesa research-to- implementation pathway approach PRIORITY SETTING PRODUCT FIELD INTRODUCTION DEVELOPMENT IMPLEMENTATION Strategic Applied research creates Catalytic activities to Multi-country program planning, problem new interventions & facilitate introduction roll-out /diffusion into identification, priority approaches regular use setting Developing GMP & Continued diarrhea Zinc tablets, improved manufacturing capacity; Support for zinc deaths ORS formula policy development; pilot introduction with ORT testing in countries in 14 countries GLOBAL HEALTH MISSIONS 14
- 15. E.g. Developing interventions,technologies & approaches to address critical needs in child health (Examples) Prior achievements Current activities Planned activities • Community-based • Oral Rehydration treatment of severe • Research on family Therapy (ORT); pneumonia recognition of improved ORS, zinc • Simplified treatment newborn for suspected illness, care- Increasing adjunctive treatment seeking, and health newborn sepsis emphasis on • Vitamin A service response • Research on • Early work on integrated community • Evaluation of implementation case management integrated services (vs. Hib, rotavirus, pneumoc occal vaccines • Adaptation of quality • Simplified vitamin A intervention) improvement for • Community treatment of CHW performance blood level assay research pneumonia • Anemia diagnostic • Behavioral • Essential newborn care interventions on tool indoor air pollution • Non-reusable syringes • Antibiotics in • Vaccine Vial Monitors Uniject for newborn • Safe birth kits treatment • Uniject (e.g. Tetanus • Chlorhexidine Toxoid) for newborn umbilical cord Technologies 15
- 16. Scale-up of highimpact interventions– PPH example National Strategic Program Implementation Sustainability / Global Actions Choices Institutionalization Introduction Early Mature Health system governance: Community Proactive financing of mobilization: maternal health services Awareness raising of PPH; Training programs: Birth preparedness Government budgeted training PPH Policy: National advocacy: Global advocacy programs on PPH; AMTSL/misoprostol use; Pilot programs: Expansion of and partnerships: PPH competencies Expanded job descriptions Phase 1 national program Global action to in pre-service and for skilled birth attendant implementation of and highlight work support work on in-service curricula cadres managing PPH; PPH misoprostol and/or of champions reduction of PPH AMTSL for all skilled service delivery guidelines birth attendant REDUCTION cadres Standardization: OF PPH AND Quality of care Clinical coverage: IMPROVED Service delivery capacity at approaches; High coverage use MATERNAL Program initiatives in sites: Reliable Government led of a uterotonic; HEALTH obstetric and Global clinical and infrastructure, personnel, an training expansion Public and private postpartum STATUS program d systems to deliver services implementation management: approaches: Quality of care; Evidence-based Clinical training; Drug & equipment interventions for Health workers training Programmatic Supervision growth: availability: prevention and systems: Adding districts, Drugs and supplies management of PPH For PPH prevention and partners, financing in government demonstrated management Pharmaceutical , routine systems: procurement Uterotonics on mechanisms Essential Drug List Drugs & equipment and in Drug Oxytocin/ misoprostol Registration; Supply procurement, logistics, distri chain management bution Readiness Pilot project Indicators in M&E Survey data Routine monitoring assessment data HMIS Source: MCHIP, 2011. 16
- 17. Applying the financial“lever” is bringing more women into life saving services Rwanda Key Financing Approaches • There is a correlation between increased enrollment in health insurance and increased institutional deliveries • Health Insurance • National scale-up efforts have increased coverage from 7% in 2003 to 91% in 2010 • Conditional cash • Institutional deliveries have transfers increased from 31% in 2000 to 52.10% in 2008 • Vouchers • Recent research has shown a correlation between pay for performance (P4P) • Free services and an increase in institutional deliveries by 21.1% Sources: Rajkotia and Charles/USAID; Soucat/WB 17
- 18. Strategic integration ofFP, MNCH, nutrition, infectious diseases and water and sanitation interventions is essential EMERGENCY NEWBORN AND CHILD CARE REPRODUCTIVE Clinical CHILDBIRTH CARE • Hospital care of newborn and childhood illness, • Post-abortion • Emergency obstetric care including HIV care care • Skilled obstetric care, immediate newborn care •Extra care of preterm babies, including Kangaroo • STI case (hygiene, warmth, breastfeeding) & resuscitation Mother Care management • Emergency care of sick newborns REPRODUCTIVE POSTNATAL CARE HEALTH CARE ANTENATAL CARE • Promotion of healthy CHILD HEALTH CARE Outpatient Outreach/ • Family planning • 4-visit focused • Immunizations & nutrition e.g. behaviors Vitamin A supplementation & • Prevention and package • Early detection of and growth monitoring management of • IPTp and bednets referral for illness •IPTp and bednets for malaria STIs and HIV for malaria • Extra care of LBW • Care of children with • Peri-conceptual • PMTCT babies HIV, including cotrimoxazole folic acid • PMTCT FAMILY & COMMUNITY HEALTHY HOME CARE, including: • Newborn care (hygiene, warmth) Community • Counseling & • Nutrition, including exclusive breastfeeding & appropriate • Adolescent & pre- preparation for • Where skilled care is not Family/ available, consider clean complementary feeding pregnancy nutrition newborn • Seeking appropriate preventative care delivery & immediate • Education care, breastfeeding Danger sign recognition & care seeking for illness newborn care, including • Prevention of STIs , birth & hygiene, warmth, and early • ORS & zinc for treatment of diarrhea and HIV emergency initiation of breastfeeding • Where referral is not available, consider case management for preparedness pneumonia, malaria, & neonatal sepsis Intersectoral Improved living and working conditions– housing, water, sanitation & nutrition Pre-pregnancy Pregnancy Newborn/post-natal Childhood BIRTH Adapted from K.J. Kerber, et al., Continuum of Care for Maternal, Newborn, and Child Health: From Slogan to Service Delivery, 370 Lancet 1358 (2007). 18
- 19. Program Progress: Bangladesh Maternaldeaths have declined by 40% in last 9 years More needs to be done: • Continue fertility reduction to replacement level • Increase women’s education • Improve referral systems 3,870 and referral level care • Focus on PPH and PE/E — still the biggest killers • Expand access to care at upazilla and union level 19
- 20. 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 20
- 21. MCH-relevant GHI Goals MaternalHealth • Reduce maternal mortality by 30 percent across assisted countries Child Health • Reduce under-5 mortality rates by 35 percent across assisted countries Nutrition • Reduce child under-nutrition by 30 percent across assisted food insecure countries in conjunction with the President’s Feed the Future Initiative Family Planning & Reproductive • Prevent 54 million unintended pregnancies Health 21
- 22. BEST: Best Practices atScale in the Home, Community and Facilities An Action Plan for Smart Integrated Programming in Family Planning, Maternal and Child Health, and Nutrition under the Global Health Initiative 22
- 23. Focus on countriesand populations with greatest need… 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, Ye men Africa: Angola, Benin, DR Congo, Ethiopia, Ghana, Kenya, Liberia, Madagas car, 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 23
- 24. BEST applies theGHI 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. 24
- 25. New initiatives &partnerships 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 25
- 26. Harnessing the powerof 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: USAID, Government of Norway, the Bill & Melinda Gates Foundation, Grand Challenges Canada, and The World Bank What We are Sustainable, scalable, and innovative technologies, service delivery Looking For: 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. 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
- 27. Founding Partners: • Strategic vision • Funding • Strategic vision • Link to • Funding governments • In-kind resources • M&E Support Supporting Partners: • Content advisors • Global Knowledge • Link to UN Exchange programs • Expertise in localization • Capacity building • Communications
- 28. Launched on May3, 2011
- 29. MAMA: Mission DRAFT 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
- 30. MAMA Bangladesh Partnersas of July 2011 Lead Partners Implementing Partners Supporting Partners TECHNOLOGY COORDINATION CORPORATE SPONSORS OUTREACH - NGO CONTENT MOBILE OPERATORS OUTREACH - GOVERNMENT ICDDR, B MEDIA RESEARCH
- 31. GHCS MCH funding(including nutrition) – 2000-2011 ? 31
- 32. GHCS MCH Funding– 2000-2010 549 495 451 356 Constant 2000 dollars 32
- 33. USAID has focusedfunding on the field, principally on priority countries Allocation of MCH funds (excluding nutrition) (GHCS, FY 2010 Enacted) Total = $474 million “BEST” Countries Millions of Dollars $276 million (58%) USAID’s MCH program is highly Other MCH Countries decentralized $51 million (11%) Central & Regional $69 million (15%) GAVI $78 million (16%) 33
- 34. Allocation of MCHfunds is also focused on key technical / program areas Health systems, governan ce & finance We will take a closer look at the main child health technical focus areas in the following slides Derived from 2010 Operational Plan Reports – includes all MCH including nutrition 34
- 35. Thank You! 35
Editor's Notes
- #5 I could have put this slide at the end—to signify some of the challenges.However, I chose to state up front some aspects of the environment in which we work:Poverty—both rural and urbanPoor infrastructure—include lack of the basics –water, sanitation and electricity—sometimes even in places where they need to do surgeryGeography—some women are literally days away from emergency care in transport by boat, donkey or bullock cartAnd the status of women--where in some places they are valued less highly than animals
- #8 Nevertheless, for the first time, in 2010, with estimates from UN agencies, we can point to a global reduction of maternal mortality of 34% in MMR since 1990We also see wide regional variation:It is encouraging to see the 53% reduction of MMR -- which has such a large population.The decline in LAC is 41% -- but masks wide variation within the regionOf most concern is sub-Saharan Africa where overall decline is 26% -- we must remember the effect of HIV epidemic which may have masked improvements in obstetric care as lives were lost to AIDS
- #9 Despite the progress, we still confront a situation where there is a staggering differential between the developed and developing world.The chance of a woman dying over a lifetime as a result of pregnancy in sub-Saharan Africa is 138 x the same lifetime chance of death of a woman in North America or western Europe
- #12 Likewise, USAID is addressing the major newborn killersWe tare tackling newborn mortality through focused antenatal care using all relevant high impact interventions including improving maternal nutritional status and preventing and treating infectionWe are also promoting essential newborn care for all and resuscitation, when necessaryOf course, we are programming this in integrated packages with maternal health – taking care of the mother and the perinate simultaneously
- #13 USAID is addressing the major maternal killersWhile they vary by country, almost invariably, postpartum hemorrhage followed by preeclampsia/eclampsia are the major killersTo the extent possible, we are focusing on prevention and therefore are promoting AMTSLThen we pay attention to early detection and immediate treatment of complications: postpartum hemorrhage and preeclampsia/eclampsia, postabortion complications, and sepsis.We also are programming for emergency care.The interventions shown here is not an exhaustive list, and some interventions are useful for more than one complicationOf course, family planning to meet unmet need is essential
- #15 Collaboration with WHO & UNICEF: zinc on Essential Medicines List guidelines for treatment of diarrhea with LOORS and zincworked with Ministries of Health to update policiesSupporting US Pharmacopoeia: developed zinc pharmaceutical standards & GMP to allow UNICEF and USAID purchasesupported manufacturers in 6 countries in meeting standardsDeveloping production and marketing capacity:over 30 pharmaceutical companies in Bangladesh, India, Indonesia, Nepal, Pakistan, and TanzaniaCountry Assessment Guide for zinc treatment introductionSupporting 14 countries in introducing zinc with ORT in public and/or private sectors
- #17 We use a framework for identifying all the components of scaling up a high impact intervention—this one has been developed for PPH.It is designed to be used by multiple partners so work can be divided and it is set up to identify gaps..This framework designates what needs to be done and by whom in order to get to the mature phase of program implementation whenTraining programs are included in govt budgetsClinical coverage is regularly is high and measured in routine HMIS, andDrugs and equipment are in routine logistics system
- #18 New financing approaches are starting to have an important impact on bringing women in contact with potentially life-saving services: skilled care, facility care, and Cesarean section, to name a few.These include: health insurance cash transfers, voucher and free care policies.The work in Rwanda is a work in progress. In the 8 years up to 2008 , there was an increase in facility delivery. Up from 31% to 52%. There are multiple health reform efforts occurring in Rwanda that would help explain the increase in facility deliveries. These include community-based health insurance with coverage now reaching more than 90% of Rwandans as well as P4P incentives. But, no one intervention can fully explain trends for increased facility delivery. Additionally, we are expecting within 4-5 months the results of both the NHA [WHAT IS THIS – WRITE OUT OR AT LEAST EXPLAIN] and DHS from Rwanda. These data sources will tell us much more about the results of Rwanda’s health coverage and outcomes.Beyond the at-first-glance positive results of financial incentives, we need to be alert and document “rigging the system” and unintended results—such as husbands forcing wives to bad services to get the cash paymentsoverwhelming facilities without sufficient staff, drugs or commodities to provide life saving care
- #19 We adhere to the principle of “smart integration”—where it makes sense technically and programmatically.This detailed list of interventions shows variation in application in family and community, outreach and outpatient, and clinical facility settings.MCH, FP, nutrition, nutrition, water, sanitation and hygiene, HIV and malaria are all included.
- #20 There is much to learn from Bangladesh. We are continuing to support analysis of this data and anotehr study is ongoing at ICCDRB (you might want to discuss with Maureen Norton as she gave us lots of info/ details on a call yesterday) to give us a more in-depth understanding.A number of factors have come together here with the data showing higher levels of education for women (compared to 2001) and fewer women > 40 yrs. and with high parity that are getting pregnant-- those at a much higher risk of death from pregnancy related causes.
- #21 A way to pull together all of USG efforts in health in allcountries with health investments in partnership withpartner governments and other donor partners.Use common goals and objectivesA way to pull together all of USG efforts in health in all countries with health investments in partnership with partner governments and other donor partners. Announced in May 2009 as a 6-year, $63 billion initiative - largely delivered through existing programsWhole-of-government approach supporting common goals and objectives Designed to connect and close the gaps among existing programs to achieve dual objectives:Improving health outcomes (focus on women, children)Strengthening health systems (long-term sustainability)
- #27 Additionally we have committed to stand up a center of excellence to accelerate the deployment of good ideas into practice at scale
- #33 We have seen a gradual increase in MCH funding over the past decade – more modest in constant US dollars. When we developed the goal of 30% reduction across assisted countries we had anticipated the possibility of a significant increase in FH 11 to allow for the sufficient time to strengthen systems, and trained skilled providers to accomplish the task AND IMPLEMENT INNOVATIVE ACTIVAITIES AND PROGRAMS.