Every minute a woman dies in pregnancy orchildbirth, over 500,000 every year. Andevery year over one million newborns diewithin their first 24 hours of life for lack

of quality care. Maternal mortality is the largesthealth inequity in the world, with 99 per cent ofdeaths occurring in developing countries–half ofthem in Africa. A woman in Niger faces a 1 in 7risk of dying during her lifetime from pregnancy-related causes, while a woman in Sweden has arisk of 1 in 17,400, a greater than one thousand-fold difference. No other health indicator illus-trates as starkly the global disparities in humandevelopment.

Though maternal mortality and morbidity con-tinue to be a major health problem in many parts ofthe world, notable progress has been achieved in over100 countries. Unfortunately, this progress has beenslow and unequal. During the 15-year period be-tween 1990 and 2005, Asia experienced a 20 percent reduction in maternal mortality ratio (MMR).During the same time period, MMR in sub-SaharanAfrica decreased a mere two per cent.

Fortunately, the vast majority of maternal andnewborn deaths can be prevented with proven in-terventions to ensure that every pregnancy is wantedand every birth is safe. Progress in many countrieshas led to a growing consensus in the maternal healthfield that reducing maternal and newborn mortalityand morbidity can be achieved by ensuring:

1) Access to family planning2) A skilled health professional present at ev-

ery delivery3) Access to emergency obstetric and newborn

care (EmONC), when needed

Mobilizing communities and governments tounderstand a woman’s right to these resources com-bined with efforts to eliminate financial, geographicand sociocultural barriers will allow universal ac-

cess to reproductive health and lead to a dramaticreduction in the number of maternal deaths.

On September 25th 2008, as world leadersgathered for the High-Level Event on the Millen-nium Development Goals (MDGs), the heads of theWorld Health Organization (WHO), the United Na-tions Population Fund (UNFPA),the United NationsChildren Fund (UNICEF) and the Vice-President ofHuman Development of the World Bank issued aJoint Statement on Maternal and Newborn Health –Accelerating Efforts to Save the Lives of Womenand Newborns (see Annex 2). The leaders jointlypledged to intensify their support to countries toachieve Millennium Development Goal 5, To ImproveMaternal Health, and the MDG showing the leastprogress:

During the next five years, we will enhancesupport to the countries with the highest mater-nal mortality. We will support countries instrengthening their health systems to achieve thetwo MDG 5 targets of reducing the maternal mor-tality ratio by 75 per cent and achieving univer-sal access to reproductive health by 2015. Ourjoint efforts will also contribute to achievingMDG 4 To Reduce Child Mortality.

We will work with governments and civil so-ciety to strengthen national capacity to:

Conduct needs assessments and ensure thathealth plans are MDG–driven and perfor-mance–basedCost national plans and rapidly mobilize re-quired resourcesScale-up quality health services to ensureuniversal access to reproductive health, es-pecially for family planning, skilled atten-dance at delivery and emergency obstetricand newborn care, ensuring linkages withHIV prevention and treatment

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Executive Summary

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Address the urgent need for skilled healthworkers, particularly midwivesAddress financial barriers to access, espe-cially for the poorestTackle the root causes of maternal mortalityand morbidity, including gender inequality,low access to education–especially for girls–child marriage and adolescent pregnancyStrengthen monitoring and evaluation systems

In the countdown to 2015, we call on Mem-ber States to accelerate efforts for achieving re-productive, maternal and newborn health. To-gether we can achieve Millennium DevelopmentGoals 4 and 5.

As part of this effort, UNFPA, through the Ma-ternal Health Thematic Fund (MHTF), aims to boostprogress towards reducing maternal mortality andmorbidity by supporting countries in working withcivil society, the United Nations and other key part-ners to implement and scale up effective maternaland newborn health interventions as part of perfor-mance-driven national health plans and systems.

UNFPA aims to raise $500 million over fouryears for the MHTF, which will help save women’slives and prevent maternal morbidity such as ob-stetric fistula, one of the most devastating compli-cations of childbirth. While this amount representsless than 2 per cent of the $7-8 billion needed an-nually to improve maternal and newborn health,it is a significant effort intended to be catalytic inleveraging resources for maternal and newbornhealth services.

One of the fundamental principles underpinningthe work will be country-owned and country-drivendevelopment and support to the one national healthplan. The specific outputs and activities supportedby the MHTF in each country will be identified bythe government through a consultative process withkey partners and stakeholders and in close coordi-nation with UNFPA’s Global Programme on Repro-ductive Health Commodity Security and the Cam-paign to End Fistula.

In collaboration with government and key part-ners the MHTF will support:

1. An enhanced political and social environmentfor Maternal and Newborn Health (MNH) andSexual and Reproductive Health (SRH)

2. Up-to-date needs assessments for the SRHpackage with a particular focus on family plan-ning, human resources for MNH, and EmONC

3. National health plans focus on SRH, especiallyfamily planning and EmONC with strong RH/HIV linkages to achieve the health MDGs

4. National responses to the human resource crisisin MNH, with a focus on planning and scaling upof midwifery and other mid-level providers

5. National equity-driven scale-up of family plan-ning and EmONC services and maternal andnewborn health commodity security

6. Monitoring and results-based management ofnational MNH efforts

7. Leveraging of additional resources for MDG5from government and donors

A detailed results framework is presented, an-chored to MDG5 targets and indicators and toUNFPA’s Strategic Plan 2008-2011. This includesthe key outputs of UNFPA’s Midwifery Programme,now a central component of the MHTF.

The MHTF Results Framework is linked to twoother key UNFPA programmes and their respectiveresults frameworks:

The Global Programme on Reproductive HealthCommodity Security, UNFPA, 2008The Campaign to End Fistula, GlobalProgramme Proposal; Making MotherhoodSafer by Addressing Obstetric Fistula 2006-2010, UNFPA, 2006

UNFPA is currently examining how best to in-tegrate the work of its three health thematic funds—Maternal Health, Fistula, and the Global Programmeon Reproductive Health Commodity Security. Theresults framework for the MHTF is closely linked tothose of the other two thematic funds. While main-taining the focus on specific results, it is envisagedthat the thematic funds will move towards a jointcountry application, annual work-planning and re-porting process in 2009.

Resources required for the MHTF are esti-mated at $25M, $72M, $138M and $269M each yearfrom 2008 to 2011 respectively, for a total of $504Mover the period. At the time of this writing in early2009, the MHTF was in the process of supporting11 countries, and had raised a total of $25M includ-

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ing the resources for the Midwifery Programme.A management structure and processes for the

MHTF are presented, based on UNFPA thematicfund guidelines and closely coordinated with the otherthematic funds, all housed within its Technical Divi-sion. A Maternal Health Inter-Divisional WorkingGroup ensures strong representation from regionaloffices and other key units and meets regularly viateleconferencing.

The country-specific UNFPA outputs, activitiesand indicators will be prepared with the ministries ofhealth (MoH) in close consultation with WHO,UNICEF, the World Bank and other key partners.

At the global level, the work of UNFPA, in-cluding the work supported by its thematic funds,will be closely coordinated with WHO, UNICEF andthe World Bank through the UN-MNH Joint Sup-port to Countries.

A consolidated annual report will be preparedwith overall and country-specific results. This willalso include financial reporting on income and onthe use of resources.

Based on a solid review of the scientific evi-dence and the results of programmes in countrieswhich have tackled maternal mortality, we believethat much progress can be accomplished betweennow and 2015, with a community outreach andhealth systems approach of scaling-up familyplanning, skilled attendance at delivery and emer-gency obstetric care, so that every pregnancy iswanted and every birth is safe. We could thenenvisage, in a not too distant future, a world wherematernal mortality has been eliminated as a pub-lic health problem and where the burden of suf-fering from maternal morbidity has been reducedconsiderably.

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List of Abbreviations and Acronyms

AMDD Averting Maternal Death and Disability Program – Columbia University

AWP Annual work plan

EmONC Emergency obstetric and newborn care

FP Family planning

GAVI Global Alliance for Vaccines and Immunization

IHP+ International Health Partnership

HMIS Health management information system

ICM International Confederation of Midwives

ICPD International Conference on Population and Development

IMMPACT Initiative for Maternal Mortality Programme Assessment – University of Aberdeen

M&E Monitoring and evaluation

MDG Millennium Development Goal

MHTF Maternal Health Thematic Fund

MMR Maternal mortality ratio

MNH Maternal and newborn health

MoH Ministry of Health

MVA Manual vacuum aspiration

ODA Official Development Assistance

OFWG Obstetric Fistula Working Group

PMNCH Partnership for Maternal Newborn and Child Health

PMTCT Prevention of mother-to-child transmission (for HIV)

RHCS Reproductive health commodity security

Sida Swedish international development agency

SRH Sexual and reproductive health

SWAp Sector-wide approach

UNFPA United Nations Population Fund

UNICEF United Nations Children Fund

VCT Voluntary counselling and testing (for HIV)

WHO World Health Organization

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Executive Summary .................................................................................................................................................................... 1

Background and Strategic Vision .............................................................................................................................................. 6

1. The Goal, Vision and Mandate ............................................................................................................................ 6

2. Challenges ............................................................................................................................................................ 7

3. Opportunities ....................................................................................................................................................... 12

4. Building on the Momentum ................................................................................................................................. 17

The Business Plan .................................................................................................................................................................... 19

1. Overall Goal .......................................................................................................................................................... 19

2. Guiding Principles ................................................................................................................................................ 19

3. The Maternal Health Thematic Fund embedded in UNFPA’s Strategic Plan and Joint UN work on Maternal and Newborn Health ........................................................... 21

4. Supporting National Capacity Building ............................................................................................................. 21

5. The Maternal Health Thematic Fund Results Framework ............................................................................... 21

6. Budget .................................................................................................................................................................... 34

7. Management and Governance .............................................................................................................................. 35

8. Monitoring and Evaluation and Reporting ......................................................................................................... 36

9. Conclusion ............................................................................................................................................................. 36

Annexes ..................................................................................................................................................................................... 37

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Table of Contents

1. THE GOAL, VISION AND MANDATE

Together as a global community, we havecommitted ourselves to achieve the fifthMillennium Development Goal (MDG)–ToImprove Maternal Health–and to reduce

the maternal mortality ratio (MMR) by three quar-ters by 2015 from a 1990 baseline. This goal wasfurther strengthened in 2007 by the addition of a newtarget: Achieve, by 2015, universal access to re-productive health, enshrining in the Millennium De-velopment Goal framework what had been agreedto by Member States at the International Confer-ence on Population and Development (Box 1).

Making rapid progress towards this goal overthe coming years will enable us to envision a worldwhere maternal mortality has been eliminated asa public health problem and where women willenjoy their reproductive rights. As seen with somany public health successes, rapid progress canonly be achieved when the global community unitesunder one common vision and strategy. Such a vi-sion was recently announced by the Secretary-General for the elimination of malaria mortality.The same can be done for maternal health. Thetime is now to muster all of the world’s creativeenergies to address maternal mortality, the great-est health inequity in the world.

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Background and Strategic Vision

“Too many women die duringpregnancy and childbirth because

their right to sexual andreproductive health is denied.”

– Ban Ki-Moon, United nations Secretary-General November 2007

We have an in-depth understanding of the prob-lem and its causes. Progress has been made in wellover 100 countries by strengthening national healthsystems to ensure near universal access to highlycost-effective maternal health interventions. Withstrong political commitment and improved manage-ment of health systems, similar progress can be madein even the world’s poorest countries.

There is now unprecedented international com-mitment to make maternal health a global priority.The recent Women Deliver and Countdown to 2015conferences reaffirmed this international mandate,as well as the need for rapid progress to reach theMDG5 targets. On 22 July 2008, the heads of WHO,UNICEF, UNFPA and the Vice President of Hu-man Development of the World Bank pledged toaccelerate joint support to all high maternal mortal-ity countries. On 25 September they followed up onthis pledge and issued a Joint Statement on Mater-

[1] United Nations. Report of the Secretary-General on thework of the Organization. General Assembly. OfficialRecords. Sixty-second Session. Suppl No. 1 (A/62/1).October 2007.

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BOX 1.MILLENNIUM DEVELOPMENT GOAL 5 [1]

Targets and Indicators

Reduce maternal mortality ratio by three quar-ters, between 1990 and 2015

• Maternal mortality ratio• Proportion of births attended by skilled

health personnel

New Target: Achieve, by 2015, universal accessto reproductive health

• Adolescent birth rate• Antenatal care coverage (at least one visit

and at least four visits)• Unmet need for family planning• Contraceptive prevalence rate

nal and Newborn Health during a high level MDGevent (see Annex 2). This United Nations jointprogramme will provide enhanced support to 25countries before the end of 2009 and all 60 highmaternal mortality countries within five years.

WHY A THEMATIC FUND

FOR MATERNAL HEALTH?

MDG5 may well be the most challenging MillenniumDevelopment Goal to achieve. The link betweenprogress towards MDG5, newborn survival and childhealth (MDG4), and poverty reduction (MDG1) isinextricable. Improving maternal health is an ur-gent mandate that requires focused attention andsupport to save the lives of women, newborns andchildren.

In line with the UNFPA mission (Box 2) andStrategic Plan (2008-2011), the Executive Directorannounced the creation of a Maternal Health The-matic Fund (MHTF) at the Executive Board in Sep-tember 2007 as part of a much needed global move-ment. The MHTF, focusing on 60 high maternalmortality countries, will complement UNFPA’s coreresources which are used to cover 140 programmecountries and its entire mandate (population and de-velopment, gender and the whole of reproductivehealth).

Designed as a pro-poor, performance-based and MDG-driven mechanism, the MHTFwill provide more focused capacity develop-ment, technical assistance, financial resourcesand life-saving equipment, supplies and drugsto those countries in greatest need, and thusfurther contribute to achieving national results.

Such funding, in support of national health plansand integrated within UNFPA’s country programmesrather than as a separate funding mechanism, maycircumvent the need for a multitude of parallelprojects, and therefore reduce transaction costs forall concerned: donors, UNFPA, and most importantly,countries.

UNFPA foresees raising $500 million over thefour-year period from 2008 to 2011 for the MHTF.While this is not an insignificant sum, it representsonly two per cent of the funding required to achieveMDG5. WHO estimates that at least $6 billion a yearwill be needed to improve maternal health with anadded $1.5 billion annually to meet the unmet needfor family planning. Therefore, the MHTF is in-tended to be catalytic in leveraging major MDG5

resources by strengthening the capacity of nationalhealth systems to achieve results towards reducingmaternal mortality and morbidity. MDG5 will onlybe achieved with both a major effort by high mater-nal mortality countries, including the allocation of 15per cent of their national budget to health, and a sig-nificant increase in donor funding for maternal andnewborn health and health system strengthening. Asmaternal health is a litmus test for the functioning ofa health system, maternal health programmes shouldbe a priority entry point for health system strength-ening in the context of primary health care for ev-ery district and every community.

2. CHALLENGES

MATERNAL MORTALITY:THE GREATEST HEALTH INEQUALITY IN THE WORLD

Maternal mortality represents the greatest healthinequity in the world. No other health indicator asstarkly illustrates global disparities in human devel-opment. Each year more than 500,000 women dieduring pregnancy or childbirth–one every minute.Nearly all of these deaths occur in developing coun-tries with a greater than one thousand-fold differ-ence in lifetime risk between parts of Africa andmore industrialized countries. A woman in Nigerhas a 1 in 7 risk of dying from maternal causes ascompared to a 1 in 17,400 risk for a woman in Swe-den. Half of the maternal deaths that occur eachyear are in Africa–a continent which represents 11per cent of the world’s population.[2] It is no won-der that maternal and newborn mortality have re-mained so high when the time around delivery is such

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BOX 2. UNFPA’S MISSION

UNFPA, the United Nations Population Fund, is aninternational development agency that promotes theright of every woman, man and child to enjoy a life ofhealth and equal opportunity. UNFPA supports coun-tr ies in using populat ion data for pol icies andprogrammes to reduce poverty and to ensure thatevery pregnancy is wanted, every birth is safe, everyyoung person is free of HIV/AIDS, and every girl andwoman is treated with dignity and respect.

[2] Maternal Mortality in 2005: Estimates developed by WHO,UNICEF, UNFPA and The World Bank. October 2007.Geneva. WHO.

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[1] Maternal Mortality in 2005: Estimates developed by WHO, UNICEF, UNFPA and the World Bank. October 2007. Geneva.WHO.

[2] Round II Country Reports on Health, Nutrition, and Population Conditions Among the Poor and the Better-Off in 56Countries. 2004. Washington, D.C. the World Bank.

[5] Measuring Maternal Mortality. Challenges, Solutions, and Next Steps. Impact. Population Reference Bureau. February 2007.http://www.prb.org/pdf07/MeasuringMaternalMortality.pdf. Accessed 4 June 2008.

[6] Murray C and Lopez A (1998). Health Dimensions of Sex and Reproduction. Geneva. WHO.[7] State of the World’s Children 2008: Child Survival. December 2007. UNICEF.

BOX 3. RISK OF MORTALITY AND COVERAGE

The graph shows estimates of carecoverage for the 51 most indebtedcountries along a continuum frompregnancy through to birth and thecare of the child through newborncare, breastfeeding and immunisation.Superimposed is an illustrative dia-gram of the risk of mortality formothers and children loosely basedon Demographic and Health surveysand selected studies. The diagramshows that health care is accessedleast where the risks are highest forwomen and their babies–at the timeof birth.

a risky period for both mother and newborn and whencoverage of health interventions has remained so low(Box 3).

Though maternal mortality and morbidity con-tinue to be a major health problem in many parts ofthe world, notable progress has been achieved in over100 countries. Unfortunately, this progress has beenslow and unequal. During the 15-year period be-tween 1990 and 2005, Asia experienced a 20 percent reduction in MMR. During the same time pe-riod MMR in sub-Saharan Africa decreased a meretwo per cent.[3]

Poor women often lack access to the life sav-ing interventions provided by skilled health person-nel (emergency obstetric and newborn care). Fig-ure 1 shows the tremendous difference in the pro-portion of births attended by skilled personnel amongthe poorest and richest wealth quintiles in six devel-oping countries. In countries such as Ethiopia,

Bangladesh and Mauritania the proportion of womengiving birth with a skilled attendant in the highestwealth quintiles is between 7 and 25 times greatercompared to those in the poorest wealth quintiles.[4]

As can be seen in Figure 2, women in the poor-est quintile may have more than double the risk ofmaternal death when compared to the wealthiestquintile.[5]

For each woman who dies during pregnancyor delivery, there are many more who suffer com-plications resulting in disability. An estimated twomillion women and girls around the world are livingwith obstetric fistula, a devastating, and potentiallylifelong injury, caused by prolonged, obstructedlabour.[6] When mothers die or face serious illness,their children suffer; over one million newborns andchildren die each year because of poor maternal andneonatal health services.[7]

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FIGURE 1. BIRTHS ATTENDED BY SKILLED PERSONNEL* AMONG THE POOREST AND RICHEST WOMEN

FIGURE 2. MATERNAL DEATHS BY

SELECTED WEALTH QUINTILES

* Defined to include a doctor, nurse or trained midwife.Source: World Bank, 2004, Round II Country Reports on Health, Nutrition, and Population Conditions Amongthe Poor and the Better-Off in 56 Countries.

FEW CAUSES ACCOUNT FOR THE MAJORITY OF

MATERNAL MORTALITY

Figure 3 shows that a small number of direct causesaccount for around 80 percent of maternaldeaths.[8] Fortunately, we have cost-effectiveand proven interventions for each of these causes.

Other contributing causes of maternal mor-tality include malnutrition, HIV, malaria and vio-lence against women. All of these factors arelinked to larger health determinants including gen-der inequality, poverty and low education level,and when combined can have catastrophic re-sults. Cultural norms and religious beliefs mayalso interact with socio-economic status and gen-der to restrict a woman’s access and right to thefull continuum of reproductive and sexual healthservices including maternal health services, as dis-cussed below.

[8] The World Health Report 2005: Make every mother andchild count. 2005. Geneva. World Health Organization.

MATERNAL MORBIDITY: OFTEN SEVERE,LONG-LASTING WITH HIGH BURDEN OF SUFFERING

Maternal morbidity affects millions of women eachyear often with severe and long-lasting physical andmental suffering. In 2003, UNFPA and partnerslaunched a global Campaign to End Fistula with thegoal of making obstetric fistula as rare in developingcountries as it is in the industrialized world. Thereader is referred to the website of this highly suc-cessful campaign.[9]

Complications of unsafe abortion leavewomen with long-lasting problems such as infer-tility. Perinatal depression is another severe, andoften neglected, pregnancy related condition re-sponsible for high numbers of suicides and dis-ability in many countries.[10]

GENDER AND SOCIO-CULTURAL

NORMS AND PRACTICES

Maternal mortality and morbidity are, at their core,a consequence of gender inequality and health ineq-uity. Data from national surveys reveal that accessto maternal health services is highly inequitable, with

[9] www.endfistula.org[ 1 0 ] UNFPA Emerging Issues: Mental, Sexual and Reproduc-

tive Health. 2008. UNFPA.

FIGURE 3. DIRECT CAUSES OF MATERNAL MORTALITYthe lowest socio-economic quintiles andrural populations having the least ac-cess. Other marginalized groups, suchas adolescents, minorities and indig-enous groups, face similar barriers toaccess. Gender inequality further con-tributes to poor maternal health on vari-ous levels from the prioritization ofwomen’s health by governments intheir health plans and budgets to gen-der norms within villages and commu-nities. Women, and particularly poorwomen, are often unable to access carebecause they lack the decision-makingpower, the financial resources, and theempowerment to obtain a full range ofreproductive health services and infor-mation, including family planning,skilled attendance at birth and emer-gency obstetric care.

Cultural norms and practices mayseverely restrict or enhance maternalhealth. The perceptions of health and

risks during pregnancy, birth and the postpartum/newborn period strongly influence both health-seek-ing behaviour and appreciation of the quality of theavailable services. For adolescents in particular, highlevels of maternal mortality and morbidity stem fromgender norms that force them into child marriageand to drop out of school, and deprive them of basicknowledge and decision-making about reproductivehealth, as discussed further below. Meeting the chal-lenge of MDG5 will rely heavily on efforts to re-duce health and gender disparities and improve ac-cess to primary and secondary education for girls.

ADOLESCENTS

Pregnancy and childbirth-related deaths are the num-ber one killers of 15-19 year old girls worldwide.Each year, nearly 70,000 die. At least two millionmore are left with chronic illness or disabilities thatmay bring them life-long suffering, shame and aban-donment. Pregnancy rates among adolescents arehigh in many countries, particularly among the poor(see Figure 4). In 2004 in Niger, for example, 72per cent of adolescents in the poorest quintile hadgiven birth by age 18, compared to 39 per cent inthe richest quintile. High fertility rates among ado-lescents are associated with higher maternal mor-tality due to complications from pregnancy and de-

*Total is more than 100% due to roundingSource: The World Health Report 2005, WHO

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FIGURE 4. CHILDBEARING AMONG THE POOREST AND RICHEST ADOLESCENTS

livery as well as from unsafe abortions. Adolescentgirls are twice as likely to die during pregnancy orchildbirth as women in their 20s. For those under15, the risks are five times higher.

In many countries girls are married at a youngage, often against their will, and are expected to havechildren soon after to prove their fertility. Globally,the overwhelming majority of adolescents who be-come pregnant are married. Married adolescent girlsoften lack awareness of their rights and have lim-ited access to family planning. Unmarried adoles-cent girls face a different set of challenges. Theyare more likely than married girls to suffer unplanned,financially unsupported and socially unsanctionedpregnancies. An unmarried adolescent mother mayface the social stigma of single motherhood and lackthe financial means to take care of herself and herchild. Adolescent girls confronted with unplannedpregnancy are more likely to resort to unsafe abor-tions than older women.

Both married and unmarried pregnant adoles-cents are likely to face poverty, ill health and abuse,and to have frequent pregnancies, engage in unpro-tected sex carrying HIV risk, lack education and havefew positive life options. Their children are more

likely than those of older mothers to be malnour-ished and have developmental problems. One mil-lion babies born to adolescent mothers will not makeit to their first birthday. Several hundred thousandmore will be dead by age five.[11]

HIV/AIDS

Around 2.2 million HIV positive women give birthevery year.[12] In areas of high prevalence, HIV isthe cause of a significant number of maternal deaths.In a scientifically robust cohort study in rural RakaiDistrict, Uganda, the MMR was 5.4 times greaterin HIV-positive women as compared to HIV-nega-tive women.[13]

The HIV/AIDS epidemic is increasingly moreprominent among women; over 60 per cent of peopleliving with HIV in sub-Saharan Africa are women.HIV and AIDS have also had a devastating effecton health systems in many high prevalence coun-tries by depleting the health workforce. In theseareas, women are less likely to be accompanied bya skilled attendant at the time of delivery leading toan increased risk of maternal death or disability.

Source: Rani, M. and E. Lule, 2004, “Exploring the Socioeconomic Dimension of Adolescent Repro-ductive Health: A Multicountry Analysis” International Family Planning Perspectives 30 (3): 112.

[11 ] Giving Girls Today and Tomorrow: Breaking the Cycle of Adolescent Pregnancy. UNFPA. 2007[ 1 2 ] WHO, World Health Report, 2005[ 1 3 ] Sewankambo NK et al. Mortality associated with HIV infection in rural Rakai District, Uganda. AIDS, 2000, 14:2391-2400.

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FIGURE 5. NUMBER OF YEARS TO HALVE MATERNAL MORTALITY, SELECTED COUNTRIES

3. OPPORTUNITIES

PROVEN INTERVENTIONS

Fortunately, the vast majority of maternal and new-born deaths can be prevented with proven, highlycost-effective interventions to ensure that every preg-nancy is wanted and that every birth is safe. First,we must tackle the root causes of maternal mortal-ity, including gender inequality, low access to edu-cation—especially for girls—child marriage and ado-lescent pregnancy. Many countries with limited re-sources have been able to reduce maternal mortal-ity by half in less than 10 years (see Figure 5).Progress in these countries has led to a growingconsensus in the global health community on threesets of interventions most effective in reducing ma-ternal mortality and morbidity:

1) universal access to family planning2) a skilled health professional present at ev-

ery delivery3) access to emergency obstetric and newborn

care, when needed

Working towards the elimination of financial, geo-graphic and sociocultural barriers will allow universalaccess to these interventions. Community mobilizationand communication for social change will empowerindividuals to demand services and enhance politicalsupport. In successful countries, this increased demandtogether with universal access has resulted in high uti-lization and thus rapid declines in maternal mortality.

Source: The World Health Report 2005, WHO

Family planning

World leaders reaffirmed their commitment to achiev-ing universal access to reproductive health at the WorldSummit in 2005. Despite these renewed pledges, anestimated 137 million women around the world still hadan unmet need for contraception in 2008.[14] In sub-Saharan Africa, the proportion of married women us-ing modern family planning–the contraceptive preva-lence rate–remains under 20 per cent while unmet needstands at 27 per cent.[15] Despite declines in globalfertility, lack of access to resources and informationabout family planning, particularly among adolescents,has contributed to total fertility rates of more than 5children per woman in over 30 countries is sub-Sa-haran Africa. In Gambia, 1 in 5 adolescent girls (aged15-19) becomes pregnant compared to 1 in 140 ado-lescent girls in Sweden.[16] Meeting the need for fam-ily planning could reduce maternal mortality by at least33 per cent.[17]

The recent adoption of a new MDG5 target—to achieve universal access to reproductive health—recognizes the importance of family planning in improv-ing maternal health as part of the greater sexual andreproductive health continuum. Empowering womenwith the resources they need to exercise their right toplan the number of children they have will signifi-cantly reduce the number of unintended pregnan-cies and unsafe abortions. Meeting the unmet needfor family planning will thus have a profound impacton a woman’s risk of dying from pregnancy-relatedcomplications over the course of her lifetime.

[ 1 4 ] Guttmacher Institute, UNFPA. Contraception: An Investment in Lives, Health and Development. November 2008.[ 1 5 ] UNFPA – UN Population Division 2008.[ 1 6 ] Maternal Mortality in 2005: Estimates developed by WHO, UNICEF, UNFPA and The World Bank. October 2007. Geneva. WHO.[ 1 7 ] UNFPA 2007.

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It will be important to insure a judicious mix offamily planning policies, advocacy and communica-tion, client education and quality service delivery toensure optimal impact with available resources.

To help meet the unmet need for family plan-ning, particularly in isolated rural areas, many coun-tries have enlisted community health workers to pro-vide basic primary care including family planningeducation and services at the community level. Forexample, the Government of Ethiopia has decidedto accelerate its successful community health workerprogram to cover the entire country by 2009. TheHealth Extension Program is working towards uni-versal access to primary care through the trainingand deployment of over 30,000 health extensionworkers to deliver services at the community level.For the first time in Ethiopia’s history, every com-munity should have access to family planning infor-mation, education and services.

A skilled health professional present at everydelivery: towards quality facility-based deliveries

Prevention of death and disability during labour anddelivery is greatly increased by the presence of askilled health professional. Life threatening compli-cations occur in around 15 per cent of deliveries andcannot be predicted. In regions with high maternalmortality and morbidity, such as sub-Saharan Africaand Asia, the proportion of births attended to by a skilledprofessional are as low as 47 and 61 per cent, respec-tively. In the least developed nations in Eastern Af-rica, only 34 per cent of women give birth with the helpof a skilled attendant.[18] These proportions fall signifi-cantly short of the ICPD+5 target of 85 per cent by2010, and are thought to be overestimates due tomethodological problems in determining the skill levelof birth attendants as well as their lack of suppliesand/or an enabling environment.[19]

Countries face serious challenges in ensuringskilled attendance at birth due to major global short-ages in the health workforce and in particular, mid-wives. Midwives have an essential role in providingnormal pregnancy, delivery and post-partum care;in managing complications and providing basic emer-gency obstetric and newborn care; and in referringwomen, when needed, for comprehensive emergencyobstetric newborn care (EmONC).

These human resource challenges are com-pounded by poor training, unequal geographic distri-bution and decreasing retention of health profession-als. The Global Health Workforce Alliance estimates

the deficit of trained health providers to be over fourmillion in 57 countries.[20] In Afghanistan, a countrywith one of the highest MMR, there were less than500 midwives in the entire country in 2002.[21] In manycountries shortages are increasing due to “brain drain”caused by skilled health-care providers leaving theircountries to seek more advantageous opportunitieselsewhere. Health workforce shortages have also beenexacerbated by the death and illness of many pro-fessionals due to AIDS.

In 2007, WHO developed global recommenda-tions for task-shifting to create more effective healthsystems through the redistribution of tasks amonghealth-workers. By allocating tasks to health pro-fessionals with less training and fewer qualificationsthrough standardized protocols, facilities can moreoptimally use existing human resources to improveservice delivery.[22] If health providers work in teamsand are effectively supervised, task-shifting can helpto relieve overburdened health systems and rapidlyimprove coverage. To this end, great emphasis has beenplaced on the need to scale up the training and deploy-ment of non-physician providers, such as midwives andsurgical technicians. Several countries have developednational human resource strategies to increase the num-ber of mid-level providers and improve their retention,particularly in more isolated, rural areas. These pro-viders are essential to increasing coverage of familyplanning services and EmONC, through direct pro-vision or through referral systems, as is the casewith comprehensive EmONC.[23], [24], [25]

Given the importance of the issue of skilled healthprofessionals for maternal health and in particular mid-wives, UNFPA has developed the Midwives Pro-gramme (See Box on Midwives Programme next page).

[ 1 8 ] Proportion of births attended by a skilled attendant- 2008updates. WHO Factsheet. Department of ReproductiveHealth and Research.

[ 1 9 ] Ibid.[ 2 0 ] The World Health Report 2006- Working together for

health. 2006. Geneva, World Health Organization.[ 2 1 ] Ronsman C, Graham WJ. Maternal mortality: who, when,

where, and why. Lancet 2007;368:1189-200.[ 2 2 ] Task Shifting: Global Recommendations and Guidelines.

World Health Organization 2007.[ 2 3 ] Freedman et al. Practical lessons from global safe moth-

erhood initiatives: time for a new focus on implementa-tion. Lancet 2007; 370: 1383-1391.

[ 2 4 ] Global Health Workforce Alliance Forum, Kampala, 2008.www.ghwa.org.

[ 2 5 ] Global Health Workforce Alliance and Health Systems forEquity Project. Report of a meeting. London 10 November2008 (forthcoming).

13

THE MIDWIVES PROGRAMME

Jointly implemented by UNFPA and the International Confederation of Midwives (ICM), the MidwivesProgramme was officially launched in April 2008 with the slogan “The world needs midwives now more thanever to save the lives of mothers and babies”. It was conceived as UNFPA’s response to the growing need forhuman resources for health in many countries. UNFPA chose to focus on midwives as they are a keycomponent to reducing maternal and newborn deaths and are in critical demand in most high maternalmortality countries.

The Midwives Programme calls for a global effort to promote the work and role of midwives and others withmidwifery skills in order to accelerate progress towards MDG5. The Programme is aligned with the ICPDagenda and the international call for investing in sexual and reproductive health and rights. The aim is todevelop national capacity in high maternal mortality countries, ensuring skilled attendance at all births.Increasing the number and capacity of midwives will also contribute to the other health MDGs: reducingneonatal mortality (MDG4), promoting gender equality and empowering women (MDG3) and combating HIV/AIDS, malaria and other diseases (MDG6).

With initial funding received from Sida in 2008, support was provided to an initial group of 11 high prioritycountries through the posting of national midwife advisors in each country who are supervised by regionalmidwife advisers. An international UNFPA Programme Coordinator and an international ICM Midwife Adviserwere also brought on board to coordinate the global efforts of the two partners—UNFPA and ICM. Thecountries involved in this first wave are in Francophone Africa (Benin, Burkina Faso, Burundi, Côte d’Ivoire,Madagascar), in Anglophone Africa (Ethiopia, Ghana, Uganda, Zambia) and in the Arab region (Djibouti andSudan). UNFPA country offices in Haiti and Cambodia have also initiated midwifery activities.

The Midwives Programme aims at building a critical mass of midwife advisers in all regions who will leadcountry level efforts in capacity building on four focus areas: strengthening regulatory mechanisms; devel-oping/strengthening education and accreditation mechanisms; promoting the development of midwiferyassociations and promotion of midwives as a key health workforce for the achievement of MDGs 4 and 5.These advisers will also have the necessary capacity to participate in policy level discussions and deci-sions concerning maternal and reproductive health. Working in full coordination with the ministries of healthand national training institutions, the advisers will receive technical support from international and regionalmidwifery schools or universities, as well as from international training programmes.

The Programme is initially planned for three years and aims at addressing at least 20-25 priority countriesthat will also be supported under the Maternal Health Thematic Fund. The two programmes will thus harmo-nize with aligned financial flows, monitoring frameworks and reporting procedures. This will create syner-gies with the three key pillars of safe motherhood (family planning, skilled attendance at birth and emer-gency obstetric care) and ensure a concerted response in addressing maternal mortality and morbidity andneonatal survival.

Emergency Obstetric and Newborn Care(EmONC)

Basic and comprehensive EmONC represent a setof interventions that address each of the directcauses of maternal death. The term has been broad-ened recently to include life-saving newborn caresuch as newborn resuscitation (Figure 6).

Access to basic and comprehensive EmONCgreatly increases a woman’s chance of survival dur-ing childbirth. Lack of access to simple interven-tions such as oxytocics to prevent or treathaemorrhage or antibiotics to treat infection often

leads to death or severe disability. Many countrieslack the health infrastructure to provide emergencycare to women, particularly poorer women andwomen living in isolated, rural areas.

Even in areas where adequate basic and com-prehensive EmONC facilities exist, significant bar-riers prevent women from reaching facilities or re-ceiving care upon arrival. The three major delays inobtaining EmONC are a delay in 1) deciding to seekcare 2) identifying and reaching a medical facilityand 3) receiving adequate and appropriate treatment.Many factors influence the delays at each stage ina woman’s path to obtaining EmONC (Figure 7).

14

In Primary Health Care Facility

Basic EmONC

• Antibiotics IV• Oxytocics IV• Anticonvulsivant• Manual removal of placenta• Post abortion care (MVA)• Assisted vaginal delivery (vacuum extraction)• Newborn care

In District Hospital

Comprehensive EmONC

All Basic EmONC +

• Surgery (caesarean section)• Blood transfustion• Care to sick and low birth weight

newborns

FIGURE 6. EMERGENCY OBSTETRIC AND NEWBORN CARE

Women often fail to recognize labour complications;they may not have the means for timely transporta-tion to facilities or the money to afford quality careonce they have arrived; and the cost of EmONCcan be catastrophic for households.[26] Preventingdelays in obtaining EmONC can only occur whensolid health infrastructure is combined with outreachand education as part of a functioning national healthsystem.

There is now universal agreement that coun-tries should move as rapidly as possible to ensurethat every woman has access to a quality, facility-based delivery:

“The advantages of facility-based deliver-ies–both from a technical perspective andfrom systematic analysis of mothers’ expe-riences–are many. They enable teamwork,so that midwives can attend far more birthsthan if would be possible in home deliver-ies. They also enable non-professionals, suchas assistants and auxiliaries, to help, mak-ing care more cost-effective. This allows asingle midwife to attend up to 220 deliveriesper year, compared with less than 100 for asingle-handed midwife visiting mothers athome. In addition, the mixture of profession-als in a facility means that life-saving emer-gency care can be given quickly. Skilled care

[ 2 6 ] Renaudin P, Prual A, Vangeenderhuysen C et al. Ensuring financial access to emergency obstetric care: Three years ofexperience with Obstetric Risk Insurance in Nouakchott, Mauritania. Int J of Gynecol and Obstet (2007), doi: 10.1016/j.ijgo.2007.07.006.

[ 2 7 ] The Global Campaign for the Health Millennium Development Goals. First year report 2008. Published by the Office of thePrime Minister of Norway, Oslo, September 2008.

at facilities also ensures safety, cleanlinessand the availability of supplies. Other workcan be performed, and referrals are easier,as is emergency transport.”

— Margaret Chan, Director General, WHO[27]

UNFPA’s Campaign to End Fistula is intendedto address the devastating childbearing injury causedby prolonged obstructed labour (See box on the Cam-paign to End Fistula next page).

FIGURE 7. THE “THREE DELAYS” FRAMEWORK

Source: UNFPA Website: http://www.unfpa.org/ mothers/obstetric.htm

15

THE CAMPAIGN TO END FISTULA

Obstetric fistula is a devastating childbearing injury caused by prolonged, obstructed labour that is unre-lieved by medical intervention. Women with fistula constantly leak urine and/or faeces and suffer life shatter-ing consequences—the baby usually dies and the smell associated with fistula combined with misperceptionsabout the condition often causes women to be stigmatized within their communities and abandoned by theirhusbands. Left untreated, fistula can lead to medical problems such as bladder infections, painful genitalulcerations, kidney failure and infertility. This physical and emotional suffering is frequently accompanied bya loss of financial support and inability to work.

It is estimated that at least two million women are currently living with obstetric fistula and 50,000 to 100,000more are affected each year—almost all in sub-Saharan Africa and parts of Asia and the Arab World.1, 2 Thechronic incidence of obstetric fistula in low-resource settings highlights the enormous disparities in mater-nal health care between the developed and the developing world. The women affected are among the mostmarginalized—young, poor, illiterate and rural—and as a result, they have remained invisible and the issuehas been largely neglected.

Fortunately, the means to prevent and treat fistula are well understood. Prevention is the ultimate goal,through universal access to high quality and accessible maternal health care services, including familyplanning, skilled birth attendance and emergency obstetric care, particularly caesarean section. Recon-structive surgery can mend the injury, and with comprehensive care to address the social consequences,most women can resume full and productive lives.

As part of its commitment to universal access to reproductive health, UNFPA launched a global Campaign toEnd Fistula with partners in 2003 aiming to prevent and treat fistula and to rehabilitate and empower womenafter treatment. The Campaign has grown from 12 countries to over 45 countries in Africa, Asia and the ArabStates. The Campaign has helped to spotlight the need to reduce morbidity as well as mortality in order toimprove maternal health. In addition, a focus on fistula has contributed to promoting equitable access tomaternal health care that responds to women’s needs. The target for achieving fistula elimination is 2015, in linewith ICPD and MDG targets.

Significant progress is being made toward this goal, as shown by some of the following results to date:• Thirty-six countries have now assessed the national need to address fistula• At least 16 countries have integrated fistula in relevant national health policies and plans• More than 7,800 women have received fistula treatment 3

The Campaign to End Fistula emphasizes coordination and partnership building. Global efforts to eliminatefistula are coordinated among partners via the international Obstetric Fistula Working Group (OFWG), forwhich UNFPA serves as the Secretariat. Established in 2003, the group is comprised of approximately 25institutional members including international and regional NGOs, universities, health facilities and UnitedNations agencies. While UNFPA and partners provide support, the Campaign emphasizes locally-drivensolutions and South-South collaboration, addressing communities' awareness of fistula and women's ac-cess to care and building on existing capacities.

The voices of women who have lived with fistula are joining the global call to urgently make maternal healthcare accessible and affordable for all. In recognition of the unique perspective fistula survivors lend to thematernal health dialogue, UNFPA sponsored the first-ever fistula advocate delegation to attend the WomenDeliver Conference in 2007. Following the conference, countries engaged in the Campaign have also begunefforts to create platforms for women to engage in dialogue at community and national levels for the reduc-tion of maternal mortality and morbidity.

The Campaign has made remarkable progress, but the needs are great. Ending fistula worldwide will demandpolitical will, resources and strengthened collaboration between governments, civil society and health professionals.Support for governments’ efforts to improve maternal health, including the Campaign to End Fistula, can helpbring the world closer to the day when safe and healthy childbirth is a reality for all women, not just the lucky few.

[1] Wall, L. 2006. “Obstetric Vesicovaginal fistula as an international public-health problem.” The Lancet 368 (9542):1201-1209.

[2] Abou Zahr, C (2003). “Global Burden of Maternal Death and Disability,” British Medical Bulletin 67 (1).[3] Treatment services supported by UNFPA may have also received support from governments and other partners.

16

Scaling-up coverage of effective interventionsthrough MDG-driven, performance-basedhealth systems strengthening

Maternal mortality is increasingly accepted as a lit-mus test of a functioning health system. Strong na-tional health systems are necessary for makingprogress towards MDG5 and the other health MDGs.To achieve universal access to the interventionsneeded to prevent maternal death, national healthsystems must be strengthened to improve overallfunctioning, coverage and quality. Investments inmaternal health must be fully integrated into, and inline with national strategies, plans and budgets asthey relate to health systems and services. Initia-tives must support country-led processes that bringtogether important stakeholders to develop, cost andimplement national plans and strategies for improv-ing maternal health services within a larger healthsystems framework.

WHO has identified six building blocks of thehealth system: service delivery; health workforce;information; medical products, vaccines and tech-nologies; financing; and leadership and governance(stewardship).[28] Identifying the problems andbottlenecks within each building block will help coun-tries identify and prioritize areas within the healthsystem that need support to improve maternal sur-vival. Improving the national health system to de-liver quality care to all will allow women more regu-lar access to medical services. More regular in-teractions with the health system—including pre-and postnatal visits—will also allow women con-sistent support for family planning, preventing un-wanted pregnancies and diminishing the unmet needfor contraception.

Investments in maternal health will also con-tribute to the building of health systems better ableto respond to all medical needs and emergencies,not just those faced in pregnancy and childbirth. Thestrengthening of health systems at the national, dis-trict and community levels to expand coverage willcontribute to sustainable improvements in health atthe population level. For example, the sound func-

tioning of a primary health centre will contribute tothe reduction of child mortality from severe disease(pneumonia, diarrhoea, malaria). The availability ofsurgery, anesthesia and a blood bank made avail-able for maternal health in the district hospital willcontribute to much improved survival rates fromsevere injuries or other urgent surgical conditions.

Costs and financial resources required

In developing countries, it costs approximately $50to ensure a safe pregnancy and delivery, protectingthe life of the mother and newborn child. This cor-responds to about $3 to $4 per capita annually.[29] Arecent review of estimates has calculated that in 51aid-dependent countries, these services will costaround $2.4 billion in 2009, increasing to $7 billionby 2015 plus an estimated $1 to $1.5 billion annuallyfor family planning services.[30]

With an increase in the share of governmentexpenditures for health by developing countries to-wards the 15 per cent target and increased develop-ment assistance by OECD countries towards 0.7 percent of GNI by 2015, this financial target can bereached.

4. BUILDING ON THE MOMENTUM

A positive momentum is building around MDG5 asinternational organizations are joining forces. ThePartnership for Maternal Newborn and Child Health(PMNCH) has helped to ensure that maternal healthreceives a far greater priority in the global healthagenda.

Several major international conferences havetaken place in the last year, bringing together gov-ernment leaders, ministry of health officials, NGOsand civil society. The landmark Women Deliver Con-ference in London in October 2007 convened over1,800 participants from 109 countries to mark the20th anniversary of the Safe Motherhood Initiative.The Statement from the Ministers’ Forum and the

[ 2 8 ] Everybody's Business: Strengthening health systems to improve health outcomes: WHO's framework for action. WorldHealth Organization. 2007.

[ 2 9 ] Graham WJ, Cairns J, Bhattacharya S, Bullough CHW, Quayyum ZQ, Rogo K. Maternal and Perinatal Conditions. Chapter26 in Disease Control Priorities in Developing Countries. Second Edition. Oxford University Press and The World Bank2007.

[ 3 0 ] The Global Campaign for the Health Millennium Development Goals. First year report 2008. Published by the Office of thePrime Minister of Norway, Oslo, September 2008.

17

call from the participants put forth a renewed com-mitment to improving maternal health.[31] Sixmonths later the Countdown to 2015 Conferencebrought together important members of the globalhealth community to track progress on the maternaland child health MDGs and to commit to a call forfuture action.[32]

Following these conferences, United NationsSecretary General Ban Ki-moon declared in May2008 that the world’s maternal death rates are “un-acceptable” and that strengthening national healthsystems is key to improving them. The G8, at their2008 summit in Japan, committed to greater effortsin support of reproductive, maternal and child health.

The Global Campaign for the Health MDGs,which started in 2007, has already received signifi-cant commitments, including Norway’s pledge of $1billion for maternal, newborn and child health overthe next 10 years and Canada’s contribution to theUNICEF Catalytic Initiative to save a million lives.The United Kingdom is also playing a prominent role.In September 2007, Prime Minister Gordon Brownconvened leaders in London to create an Interna-tional Health Partnership to support developing coun-tries in strengthening their national health systemsto achieve the health MDGs. The Prime Minister’s

wife, Sarah Brown, is working closely with the WhiteRibbon Alliance on a maternal mortality campaigncalling for $10 billion annually for maternal new-born and child health, as well as increases in thenumber of trained health workers. Recently theBill & Melinda Gates Foundation convened a ma-ternal health task force, with support fromEngenderHealth.

The heads of the eight global agencies work-ing in health meet regularly to discuss how to fur-ther strengthen their contribution to progress in glo-bal health and how to better support countries. Thisgroup, known as the H8, comprises WHO, UNICEF,UNFPA, the World Bank, UNAIDS, The GlobalFund, the GAVI Alliance and the Bill & MelindaGates Foundation. As part of this effort towardsalignment and harmonization, WHO, UNICEF,UNFPA and the World Bank are increasingly pro-viding joint support to countries as they work towardsimproving maternal and newborn health (Annex 2).

Based on the principles of the Paris Declara-tion and of national ownership, this work must leadto coordinated country support to the one MDG-driven, results-based national health plan, withpredictable, progressively increasing and sustainedfinancing.

[ 3 1 ] http://2007.womendeliver.org/closing/pdf/WD_Ministers_Statement_English_FINAL.pdf[ 3 2 ] http://www.countdown2015mnch.org/

18

○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○

The Business Plan

1. OVERALL GOAL

The MHTF aims to boost support to high maternalmortality countries to reduce maternal mortality andmorbidity.

2. GUIDING PRINCIPLES

#1. Maternal and reproductive health as ahuman right and as key to addressing genderequality

The World Health Organization states in itsconstitution, “the enjoyment of the highest attainablestandard of health is one of the fundamental rightsof every human being...” and that every country inthe world recognizes at least one treaty that includeshuman rights related to health.[33]

The rights-based approach to public health anddevelopment work is increasingly promoted by in-ternational health organizations, translating thesefundamental rights into quantitative measures ofaccess, coverage and ultimately impact: survival andreduction of morbidity. The right to reproductiveand maternal health underlies the ICPD Programmeof Action and Millennium Development Goal 5, asexpressed in the target universal access to repro-ductive health.

Working to ensure that every pregnancy iswanted and that every birth is safe promotes genderequality, as maternal mortality is the greatest healthinequity in the world.

The work of UNFPA’s MHTF is driven by thefundamental right to safe pregnancy and childbirthfor every woman, regardless of socio-economic sta-tus, geographic location, cultural or religious beliefs.Support to countries will assist in expanding the cov-erage of family planning and maternal health ser-vices to increase access for vulnerable andmarginalized populations such as adolescent girls,women living in rural areas, persons with disabilities

and members of ethnic minorities. By focusing onthe countries with the highest maternal mortality andby combining national capacity building, the provisionof reproductive health and maternal health commodi-ties as well as catalytic funding, the MHTF is able tocontribute to maternal survival where it is needed most.

The strategies and outputs of the MHTF aredrawn from–and align with–UNFPA’s Strategic Plan2008-2011 and UNFPA’s Sexual and ReproductiveHealth Framework as part of the support for theprovision of a basic package of SRH services, in-cluding family planning, pregnancy-related services,skilled attendance at delivery and emergency ob-stetric care.[34]

The MHTF will address high adolescent fertil-ity, and therefore will contribute to UNFPA’s focuson young people. Meeting the unmet need for fam-ily planning will also address high and unwanted fer-tility which is the root of inter-generational trans-mission of poverty. Meeting this need will improvequality of life and contribute to sustainable humandevelopment.

The work of the MHTF is also guided by therecognition that improvements in maternal health areheavily dependent on the information, knowledgeand opportunities individuals and couples have toexercise their rights. When empowered, communi-ties are not just recipients; they can play an activerole in reducing maternal mortality and morbidity byadvocating for their right to quality health care andsupporting women’s access to services. The MHTFwill support efforts to raise awareness and commu-nity mobilization around the importance of maternalhealth and family planning as part of the nationalagenda and the need for strong national governanceand leadership to make women’s health a priority inevery country.

#2. Country-owned and country-driven devel-opment

The work of the MHTF will promote nationalownership and capacity building in line with the prin-ciples of the Paris Declaration on Aid Effectiveness.The improvement of maternal health is viewed withinthe broader spectrum of sexual and reproductivehealth and as part of the one national health plan

[ 3 3 ] http://www.who.int/hhr/en/[ 3 4 ] Making Reproductive Rights and Sexual and Reproductive Health a Reality for All. Reproductive Rights and Sexual and

Reproductive Health Framework. United Nations Population Fund. May 2008.

19

and health systems strengthening. The MHTF willwork with governments and key partners tostrengthen MDG-driven national health systems toensure universal access to the three recognized pil-lars for improving maternal health:

• Family planning• Skilled care in pregnancy and childbirth, includ-

ing quality facility deliveries• Emergency Obstetric and Newborn Care

The MHTF will provide strategic capacity build-ing and resources to address priorities identified atthe country level by ministries of health in collabo-ration with key partners. This work will be guidedby the WHO Health System Framework and its sixbuilding blocks (Figure 8).[35]

In response to requests from countries for morestreamlined funding processes and reporting, UNFPAis working to closely coordinate the activities of thethree health thematic funds - Maternal Health, Fis-tula, and Reproductive Health Commodity Security.The results framework for the MHTF is closelylinked to the other Thematic Funds, as well as to theUNFPA’s Midwives Programme. While maintain-ing the focus on specific results, it is envisaged thatthe thematic funds will move towards a joint coun-try application and reporting process in 2009.

[ 3 5 ] Everybody`s Business: Strengthening health systems to improve health outcomes: WHO`s framework for action. WorldHealth Organization. 2007.

FIGURE 8. THE WHO HEALTH SYSTEM FRAMEWORK

Source: WHO Health System Strengthening Strategy 2007

Similarly, enhanced maternal and newbornhealth support from agencies within the United Na-tions will be better streamlined to avoid duplicate ef-forts and further burden countries. As noted in theJoint Statement (Annex 2), UNFPA, UNICEF, WHOand the World Bank are committed to working to-gether at the global, regional and country levels.

#3 A focus on results and strong support tonational monitoring and evaluation: MDG-driven and performance-based national healthsystem strengthening

Much attention will be given to measuring re-sults and strengthening national capacity to do so.

As will be seen in the Results Framework andin the Monitoring and Evaluation Sections of this docu-ment, we now have a solid set of internationally-agreed upon impact, outcome and coverage indica-tors. The challenge is to strengthen, with part-ners, the capacity of the one national health man-agement information system (HMIS) and to se-cure periodic facility and district reporting on aminimum number of robust indicators of progressin all countries supported by the MHTF. This,together with periodic population-based surveys,

20

should enable UNFPA to better report to finan-cial contributors and its Executive Board.

Lessons learned on effective performance-based financing for health, including those from thecurrent efforts supported by the World Bank, willbe shared with countries so as to ensure inclusionas deemed appropriate.

3. THE MATERNAL HEALTH THEMATIC

FUND EMBEDDED IN UNFPA’S STRATEGIC

PLAN AND JOINT UN WORK ON

MATERNAL AND NEWBORN HEALTH

The work of the MHTF stems from UNFPA’s Stra-tegic Plan 2008-2011 Outcome 2.2- Access and uti-lization of quality maternal health services in-creased in order to reduce maternal mortality andmorbidity. The work of the MHTF will also con-tribute to Outcomes: 2.1 Universal access to Sexualand Reproductive Health, 2.3 Access to and uti-lization of Family Planning and 2.4 Demand,access and utilization of quality HIV preventionservices.

As part of the WHO-UNICEF-UNFPA-WorldBank joint support to countries to accelerate progresstowards MDG5, the MHTF will support an increas-ing number of countries through a series of waves,reaching around 25 countries before the end of 2009and reaching all 60 high maternal mortality countriesno later than 2012, subject to funding. In each country,the level of effort should increase progressively. Thus,it will be critical to rapidly expand the resource basefor the MHTF. Through solid reporting on results, it ishoped the MHTF will foster a virtuous cycle similar tothat at the Global Fund under the theme: “raise it, spendit, prove it”, to use the words of Richard Feachem, theGlobal Fund’s former head.

4. SUPPORTING NATIONAL CAPACITY

BUILDING

Strengthening UNFPA’s Country Offices to bet-ter contribute to national capacity buildingIn order to optimally support national capacity build-

ing and health system strengthening, and to managethe additional resources provided through the MHTF,UNFPA is strengthening its country office capacity,in numbers and skills mix, through the provision oftools and job aids, and timely access to internationalexperts. This effort aligns with UNFPA’s re-orga-nization towards a greater field focus.

Network of regional institutions and roster ofexperts

UNFPA and partners are in the process of estab-lishing a network of regional institutions and a ros-ter of international experts. Long-term arrangementsare being explored and will include institutions fromAfrica and Asia to foster South-South collaboration.The roster will include national experts who will beavailable for short periods to support countries intheir region, sharing lessons learned and best prac-tices. This roster will be developed in close collabo-ration with WHO, UNICEF, the World Bank and keyacademic partners, in particular the Columbia Uni-versity Averting Maternal Death and Disability Pro-gram. This is described at length in the MOU signedbetween UNFPA, UNICEF and Columbia Univer-sity on strengthening national capacity forEmONC.[36]

5. MATERNAL HEALTH THEMATIC FUND

RESULTS FRAMEWORK

The Maternal Health Thematic Fund Results Frame-work is anchored to MDG5 and to the UNFPA Stra-tegic Plan 2008-2011.

The MHTF Results Framework is linked tothree other key UNFPA programmes and their re-spective results frameworks:

• The Global Programme on ReproductiveHealth Commodity Security

• The Campaign to End Fistula, GlobalProgramme Proposal; Making Mother-hood Safer by Addressing Obstetric Fis-tula 2006-2010

• The UNFPA- ICM Midwives Programme

[ 3 6 ] Contributing to Millennium Development Goal 5 to Improve Maternal Health. Delivering Emergency Obstetric and New-born Care at Scale: A UNFPA, UNICEF and Mailman School of Public Health / AMDD Alliance to develop technical supportcapacity in the countries and regions. UNFPA, UNICEF, Columbia University, 17 July 2008.

21

OUTPUTS

One of the fundamental principles underpinning thework supported by the MHTF will be country-ownedand country-driven development and support to theone national health plan. Therefore the specific out-puts and activities supported by the MHTF in eachcountry will be determined by the country through aconsultative process with key stakeholders.

There will be, however, a set of seven essen-tial outputs which the MHTF will support in everycountry (unless otherwise fully supported). In col-laboration with government and key partners theMHTF will support:

1. An enhanced political and social environmentfor Maternal and Newborn Health (MNH) andSexual and Reproductive Health (SRH)

2. Up-to-date needs assessments for the SRHpackage with a particular focus on family plan-ning, human resources for MNH, and EmONC

3. National health plans focus on SRH, especiallyfamily planning and EmONC with strong RH/HIV linkages to achieve the health MDGs

4. National responses to the human resource cri-sis in MNH, with a focus on planning and scal-ing up of midwifery and other mid-level pro-viders

5. National equity-driven scale-up of family plan-ning and EmONC services and maternal andnewborn health commodity security

6. Monitoring and results-based management ofnational MNH efforts

7. Leveraging of additional resources for MDG5from government and donors

1. AN ENHANCED POLITICAL AND SOCIAL

ENVIRONMENT FOR MATERNAL AND NEWBORN

HEALTH (MNH) AND SEXUAL AND

REPRODUCTIVE HEALTH (SRH)

As stated in UNFPA’s Sexual and ReproductiveHealth Framework, [37] a main strategy for improv-ing maternal health will be advocacy and policy dia-logue. The MHTF will contribute to an evidencebase for advocacy and resource mobilization at thecountry, regional and global levels. This will con-

tribute to universal access to a basic package of SRHservices as described in the framework.

The MHTF will act as a leveraging mechanism,generating awareness and support for maternalhealth. Increased visibility and understanding amonggovernments, civil society, the general public andprivate sector on the issues related to maternal healthwill build greater awareness and support for action.This is true at the national, regional and global lev-els. It will thus be important to increase recognitionof the issues surrounding maternal health and re-productive health among the media, donors, policymakers, communities and the general public throughadvocacy, media, communication for social changeand community mobilization.

MHTF resources will be used to support theministries of health, convene partners and bring to-gether district health management teams for plan-ning, problem-solving during scale-up, emulation be-tween districts and monitoring of progress.

The MHTF will also focus on partnership-build-ing in order to provide more harmonized support tocountries, as well as to raise awareness about ma-ternal and reproductive health. The MHTF will buildon UNFPA’s existing partnerships with key stake-holders at national, regional and global level. Thepositioning of the MHTF within the joint UN-MNHaccelerated support to countries represents a har-monized effort by United Nations agencies in accel-erating progress towards MDG5.

As part of this effort, UNFPA and UNICEFhave signed a memorandum of understanding withColumbia University (Averting Maternal Deathand Disability Program) to provide joint technicalsupport to countries, focusing on the area ofEmONC.

UNFPA is a member of the Partnership for Ma-ternal, Newborn and Child Health (PMNCH) andsits on the advisory board of the Women DeliverInitiative—a global advocacy and outreach effortfocused on promoting and advancing maternal andwomen’s health. As a member of these and othercommunication and advocacy initiatives, UNFPAis well positioned in the global framework of ma-ternal health initiatives and will carry out a sup-portive role based on its comparative advantagein advocacy, media, communication, technical as-sistance and programming to raise awareness andresources for MDG5.

[ 3 7 ] Making Reproductive Rights and Sexual and Reproductive Health a Reality for All. Reproductive Rights and Sexual andReproductive Health Framework. United Nations Population Fund. May 2008.

22

2. UP-TO-DATE NEEDS ASSESSMENTS FOR THE

SRH PACKAGE WITH A PARTICULAR FOCUS ON

FAMILY PLANNING, HUMAN RESOURCES FOR

MNH, AND EMONC

The MHTF will prioritize supporting national as-sessments in the areas of family planning/RHCS(with the Global Programme on RH Commodity Se-curity), human resources for MNH and EmONC.These assessments will provide valuable quantita-tive and descriptive information for advocacy andpolicy dialogue. For countries lacking up-to-dateassessments, this process will provide baselinesagainst which progress can be measured. Most im-portantly, information collected through these assess-ments will contribute to solid national and districtplanning, allowing for a more targeted, results-fo-cused approach in each country.

3. NATIONAL HEALTH PLANS FOCUS ON SRH,ESPECIALLY FAMILY PLANNING AND EMONCWITH STRONG RH/HIV LINKAGES TO ACHIEVE

THE HEALTH MDGS

The MHTF will support ongoing national planningprocesses including the enhancement of existingnational and district health plans, including ser-vice delivery plans, to ensure that they include com-munity mobilization, family planning education andservices, quality facility deliveries, and RH/HIV in-tegration.

a) Community mobilizationNational efforts in community mobilizationaround SRH, including demand creation forfamily planning and birth planning, should besupported as part of UNFPA’s general sup-port and in close collaboration with the GlobalProgramme on RH Commodity Security.

b) Family planning education and servicesFamily planning education and services shouldbe offered in every community and in everyprimary health facility (public and private).Meeting the unmet need for family planningwill require that every health facility provides

quality family planning services as an integralpart of SRH and primary health care. Repro-ductive health commodity security (RHCS) willneed to be ensured at every level (national,district and facility).

c) Quality facility deliveriesIn order to reduce maternal mortality, coun-tries will need to ensure that all women, espe-cially those from marginalized areas and popu-lations, have access to a quality facility deliv-ery in a primary health centre (public and pri-vate) with a skilled health professional capableof providing basic EmONC. Referral to a dis-trict hospital for comprehensive EmONC, in-cluding caesarean section and/or blood trans-fusion, should also be readily available.[38] Inorder to achieve this level of access, servicedelivery plans must include:

• For every 500,000 population and everysub-national area / district, a minimum of fivebasic EmONC primary health facilities

• For every 500,000 population and everysub-national area / district, at least one of thesefacilities provides comprehensive EmONC.[39]

d) RH/HIV Integration and prevention ofmother-to-child transmissionReducing maternal mortality in countries withhigh HIV prevalence will involve support toHIV prevention initiatives and their integra-tion within reproductive health. In line withUnited Nations Resolution 60/262 PoliticalDeclaration on HIV/AIDS, the MHTF willsupport the United Nations commitment to:

...ensuring that pregnant women have ac-cess to an tenata l care , in format ion ,counseling and other HIV services andto increasing the availability of and ac-cess to effective treatment to women liv-ing with HIV and infants in order to re-duce mother-to-child transmission of HIV,as well as to ensuring effective interven-tions for women living with HIV, includ-ing voluntary and confidential counsel-

[ 3 8 ] The Global Campaign for the Health Millennium Development Goals. First year report 2008. Published by the Office of thePrime Minister of Norway, Oslo, September 2008.

[ 3 9 ] The Indicators for Monitoring the Availability and Use of Obstetric Services: A Handbook. WHO, UNFPA, UNICEF,Columbia University, Draft 9 September 2008. Publication expected first quarter 2009.

23

ing and testing, with informed consent,access to treatment, especially life-longantiretroviral therapy and, where appropri-ate, breast-milk substitutes and the provi-sion of a continuum of care.[40]

Support from the MHTF will align with thefour elements of comprehensive prevention ofmother-to-child transmission (PMTCT):

• Prevent primary HIV infection among girlsand women

• Prevent unintended pregnancies amongwomen living with HIV

• Reduce mother-to-child transmission throughanti-retroviral drug treatment or prophylaxis,safer deliveries and infant feeding counseling

• Provide care, treatment and support towomen living with HIV and their families[41]

4. NATIONAL RESPONSE TO THE HUMAN

RESOURCE CRISIS IN MNH, WITH A FOCUS ON

PLANNING AND SCALING-UP OF MIDWIFERY AND

OTHER MID-LEVEL PROVIDERS

A national MNH service delivery plan will require awell deployed, competent and motivated healthworkforce, a key building block of the health sys-tem. A major thrust of the MHTF will be to supportcountries to increase skilled attendance at deliverywith a focus on midwives. This will involve supportto national assessments and planning of human re-sources for maternal health as part of broader na-tional health human resource planning.

The joint UNFPA-International Confedera-tion of Midwives (ICM) Midwives Programme,described in detail elsewhere, is a priority compo-nent of the MHTF.[42]

The following issues will be addressed:

• Numbers and deployment of midwives andothers with midwifery skills (MOMS)

• Regulatory environment to enable midwives

[ 4 0 ] Resolution Adopted by the General Assembly. 20/262 Political Declaration on HIV/AIDS. United Nations General Assembly60th Session. 15 June 2006.

[ 4 1 ] A Framework for Priority Linkages. WHO, UNFPA, IPPF, UNAIDS, 2005.[ 4 2 ] UNFPA investing in Midwives and others with midwifery skills to accelerate progress towards MDG5. A proposal for 3

years. 14 March 2008.

to perform the seven signal functions of basicEmONC

• Scale-up of production to achieve the re-quired numbers for the service delivery plan(midwifery schools, skills-based curricula, clini-cal training sites, etc.)

• Team work within primary health centresand district hospitals including task shiftingwith standardized protocols and adequate su-pervision to increase the number of deliveriesthan can be safely overseen by midwives

• Strengthening of national midwifery asso-ciations and councils

Countries participating in the MHTF will re-ceive midwifery support, particularly in the form ofnational and/or international midwifery advisers.

5. NATIONAL EQUITY-DRIVEN SCALE-UP OF

FAMILY PLANNING AND EMONC SERVICES AND

MATERNAL AND NEWBORN HEALTH COMMODITY

SECURITY

A dual approach: addressing systemic issues andresolving bottlenecks to scale-up

Teaming up with key development partners, thein-country approach to health system strengtheningwill use a combination of addressing systemic is-sues (such as building up the midwifery cadre), whilesupporting the resolution of bottlenecks. Coveragerates often progress slowly because of bottleneckswhich may be relatively straightforward to solve.

For example, in a meeting with a minister ofhealth from West Africa and his team in early 2008,it was revealed that family planning was being of-fered in only one out of five primary health carefacilities. A cursory assessment indicated that thisshould be relatively simple and low cost to addressthrough MoH decisions and management, sometraining, logistics capacity strengthening, contracep-tive supplies and modest additional financing. Simi-larly, ensuring that midwives are authorized to carryout the seven signal functions of basic EmONC

24

through national regulation and ensuring the requiredin-service training, could increase the provision ofbasic EmONC at a relatively low marginal cost andeffort. This could have a rapid and significant im-pact on reducing maternal mortality from causessuch as haemorrhage or eclampsia.

This approach to resolving bottlenecks is oneof the components behind some highly successfulchild survival programmes. Figure 9 represents theapproach, which aims to achieve the highest in-crease in coverage of an effective intervention inthe least amount of time and with the least amountof resources. Such an approach addresses the morelong-term systemic issues, such as scaling up theproduction of midwives.

Family planningMHTF support to family planning is closely

coordinated with the Global Programme on RH Com-modity Security, which will provide key resources.There are many factors that affect access to anduse of family planning services. A variety of ap-proaches will be considered and areas of supportwithin family planning carefully selected by eachcountry. For some countries advocacy and commu-nication campaigns are needed to address lack ofinformation or misinformation—and to enhance po-

100%

FIGURE 9. SCALING-UP COVERAGE FOR IMPACT: THE BEST USE OF RESOURCES TO

SCALE-UP RAPIDLY... MAKING THE MONEY WORK TO ACHIEVE RESULTS RAPIDLY

litical support. In other countries, quality of familyplanning services needs to be improved throughskills building amongst health care providers, moreuser-friendly health services, or community-baseddistribution of contraceptives and other RH ser-vices, including for HIV prevention. Outreachactivities should be implemented to galvanize com-munity participation and target those at risk for so-cial exclusion from such services. Family planningservices may need to be strengthened in some re-gions / districts through improvement in HMIS, link-ages of family planning services with post-partumand post-abortion services, or supply managementand distribution.

The most conservative estimates indicate thatunsafe abortions are responsible for about 13 percent of maternal deaths. Therefore, it is importantto prevent unsafe abortions by increasing access tofamily planning, emergency contraception and accessto post-abortion care. Post-abortion care also providesa very important entry point for provision of family plan-ning services to women who need it most at a timewhen they are most open to receive it.

Most women want to use family planning afterchildbirth and are thus open to information andmethod provision immediately after their delivery,while still in contact with the health system. Provi-

25

sion of voluntary family planning to post-partumwomen will prevent short intervals between deliver-ies, and will positively affect both maternal and childhealth.[43],[44]

EmONC services including upgrading of prior-ity EmONC facilities

Much has been learned about supporting ma-ternal health in resource-poor settings. One of theprograms that has achieved high impact is the Co-lumbia University-UNFPA-UNICEF Averting Ma-ternal Death and Disability (AMDD) Programfunded by the Bill & Melinda Gates Foundation(1999-2005). Peer-reviewed publications, its exter-nal evaluation and extensive documentation haveclearly demonstrated the impact of this programmeand have provided many practical lessons for pro-gramming in resource-poor settings.[45], [46] Over aperiod of five years, this programme has succeededin doubling the number of women served and reduc-ing by half the obstetric case fatality rate (the pro-portion of women dying from obstetric complica-tions). The reader is referred to one of the moreuseful publications for revitalizing and scaling-upEmONC services, Practical Lessons from GlobalSafe Motherhood Initiatives: Time for a New Focuson Implementation.[47]

UNFPA will work with governments in collabo-ration with Columbia University, UNICEF and WHOto carry forward this successful approach. Basedon the needs assessments in each country, a sys-tematic approach to strengthening national healthplans will be undertaken in the area of EmONC ser-vice delivery, including the costing of these plans.

More and more is known about the potentialimpact of reviewing maternal deaths and near-missesat facility level in terms of reducing the third delayand improving the quality of care and reporting.Based on national strategies, the MHTF will sup-port efforts to institutionalize such practices. [48]

The MHTF will also provide resources for therevitalization of priority maternal health services, to

bring them up to basic or comprehensive EmONCstandards as required. This will be done through in-service training, MNH commodities (see below),upgrading of facilities and strengthening of HMIS.Basic and comprehensive EmONC facilities thathave important clinical training responsibilities willreceive particular attention in order to contribute tothe scale-up in production of quality skilled healthprofessionals and midwives in particular.

Essential maternal and newborn health commod-ity security improved

UNFPA, UNICEF and WHO are in the pro-cess of updating their lists of MNH equipment andsupplies, and are planning to further strengthen pro-curement services to address quality, price, and main-tenance, including strategic spare parts, and otherimportant issues. This work, to be completed in 2009,will facilitate the capacity building work in countriesas they move towards self-sufficiency in nationalprocurement, supply chain management and main-tenance of equipment. The MHTF and the GlobalProgramme on Reproductive Health CommoditySecurity (GPRHCS) will support the strengtheningof this key health system building block. Access toquality essential equipment, supplies and drugs willthus be strengthened with national, MHTF, GPRHCSand other resources.

6. MONITORING AND RESULTS-BASED

MANAGEMENT OF NATIONAL MNH EFFORTS

Support will be provided to countries to strengthentheir capacity to monitor progress. Ensuring thatevery country supported by the MHTF has up-to-date assessments in family planning/RHCS, humanresources for MNH and for EmONC will enablecountries to determine baselines for measuringprogress towards MDG5. Support will also be pro-vided to national HMIS to ensure the adoption and

[ 4 3 ] Jones G, Steketee RW, Black RE, Bhutta ZA, Morris SS, and the Bellagio Child Survival Study Group. How many child deathscan we prevent this year? Lancet 2003; 362: 65–71.

[ 4 4 ] Report of a WHO Technical Consultation on Birth Spacing, Geneva, Switzerland, 13-15 June, 2005. www.who.int.[ 4 5 ] Caro DA, Murray SF, Putney P. Evaluation of the Averting Maternal Death and Disability Program. A Grant from the Bill and

Melinda Gates Foundation to the Columbia University Mailman School of Public Health. 26 July 2004.[ 4 6 ] www.amddprogram.org.[ 4 7 ] Freedman LP, Graham WJ, Brazier E, et al. Practical lessons from global safe motherhood initiatives: time for a new focus

on implementation. Lancet 2007; 370:13831390.[ 4 8 ] Beyond the numbers. Reviewing maternal deaths and complications to make pregnancy safer. WHO, Department of Repro-

ductive Health and Research, 2004.

26

regular use of the internationally-agreed MNH indi-cators within the HMIS in each country. Technicalassistance will be provided to improve HMIS at fa-cility, district and national levels, use for programmemanagement at each level and regular bi-directionalinformation flows between levels. This should fos-ter friendly emulation between districts, a highly suc-cessful strategy for scale-up. The organization anddelivery of monitoring and evaluation (M&E)courses for maternal and newborn healthprogrammes by universities in developing countriesis part of the MHTF-funded partnership withIMMPACT – University of Aberdeen.

7. LEVERAGING OF ADDITIONAL RESOURCES FOR

MDG5 FROM GOVERNMENT AND DONORS

The work supported by the MHTF will contribute toinvesting current resources more effectively and ef-ficiently, and with a greater focus on SRH andMNH. It will also support government and partnersin leveraging additional resources for maternal andnewborn health. This will be done through policydialogue; the availability of detailed quantitative in-formation on the national situation provided by theneeds assessments; the quality and results focus ofthe national health plans to reduce maternal mortal-ity; the costing of these plans; the improved report-ing on results through strengthened monitoring; andthe momentum created through the national partner-ship building.

OTHER OUTPUTS AS DETERMINED BY EACH

COUNTRY

While the above seven outputs are essential, unlessthey have already been fully supported through othermeans, countries are encouraged to prioritize their

requests for support for other important areas ofmaternal health such as improving financial, socio-cultural and geographic access to sexual and repro-ductive health services.

Many women in high maternal mortality coun-tries experience significant barriers to accessing thefull range of sexual and reproductive health ser-vices. Countries may request support from theMHTF for a number of activities related to re-ducing gaps in health equity such as mapping ex-ercises to determine coverage rates amongmarginalized groups, community-based initiativesto extend coverage to isolated communities, andpartnership with and contribution to national per-formance-based funding.

In line with UNFPA’s Sexual and Reproduc-tive Health Framework, the MHTF will encour-age and support countries in their efforts to em-power communities to demand access to qualitymaternal health services, including family plan-ning. Demand-creation and community mobili-zation activities, supported by the MHTF, couldinclude communication or social marketing cam-paigns around family planning and MNH, maleinvolvement initiatives, training of community rep-resentatives on health issues and verbal autop-sies. Efforts may also be supported to increasecommunity participation in order to create culture-and gender-sensitive maternal and reproductivehealth initiatives.

UNFPA recognizes that special efforts mustbe made to reach out to adolescents, both mar-ried and unmarried, with reproductive health in-formation, including HIV prevention. Dependingon the expressed needs of each country, theMHTF will support advocacy for the rights ofyoung people to education and to access reproduc-tive health services and the campaign for changesin policies and laws, particularly around access tocare and child marriage.[49]

[49] PATH and United Nations Population Fund. Meeting the Need: Strenthening Family Planning Programs. Seattle: PATH/UNFPA; 2006.

27

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28

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ely

tech

ni-

cal

assi

stan

ce /

cap

acity

bui

ld-

ing

from

nat

iona

l ex

pert

s an

dre

gion

al i

nstit

utio

ns

3.

Nat

iona

l hea

lth p

lans

focu

s on

SRH

, esp

ecia

lly fa

mily

pla

nnin

g an

dEm

ON

C w

ith s

tron

g R

H/H

IV li

nkag

esto

ach

ieve

the

heal

th M

DG

s

•U

p-to

-dat

e co

sted

nat

iona

l pla

nsfo

r FP

/RH

CS

and

Em

ON

C

•P

ropo

rtio

n of

ser

vice

del

iver

ypo

ints

whe

re w

omen

at

tend

ing

an-

tena

tal c

are

rece

ive

VC

T an

d P

MTC

T

•S

uppo

rt n

atio

nal

and

dist

rict

heal

th p

lans

incl

udin

g th

eir

serv

ice

deliv

ery

plan

s to

ens

ure

that

they

incl

ude

com

mun

ity m

obili

zatio

n, fa

mily

plan

ning

edu

catio

n an

d se

rvic

es,

qual

ity f

acili

tyde

liver

ies,

and

RH

/HIV

inte

grat

ion:

natio

nal

effo

rts

in c

omm

unity

mob

iliza

tion

arou

nd S

RH

, inc

ludi

ng d

eman

d cr

eatio

n fo

rfa

mily

pla

nnin

g an

d bi

rth

plan

ning

fam

ily p

lann

ing

educ

atio

n an

d se

rvic

es t

obe

offe

red

in e

very

com

mun

ity a

nd in

eve

rypr

imar

y he

alth

faci

lity

(pub

lic a

nd p

rivat

e)re

prod

uctiv

e he

alth

com

mod

ity s

ecur

ity(R

HC

S)

be e

nsur

ed a

t eve

ry le

vel (

natio

nal,

dist

rict a

nd fa

cilit

y)al

l w

omen

hav

e ac

cess

to

a qu

ality

fac

ility

deliv

ery

in a

prim

ary

heal

th c

entr

e (p

ublic

and

priv

ate)

with

a s

kille

d he

alth

pro

fes-

sion

al c

apab

le o

f pr

ovid

ing

basi

c E

mO

NC

.re

ferr

al to

a d

istr

ict h

ospi

tal f

or c

ompr

ehen

-si

ve E

mO

NC

•S

uppo

rt R

H-H

IV in

tegr

atio

n, jo

int F

P/H

IV p

re-

vent

ion,

ant

enat

al V

CT

and

PM

TCT

•S

uppo

rt n

atio

nal

plan

ning

pro

cess

es f

orco

stin

g an

d fin

anci

ng o

f MN

H c

ompo

nent

s w

ithin

the

natio

nal h

ealth

pla

ns in

clud

ing

wor

k on

sec

tor

•M

oH fu

lly o

wns

nat

iona

l as-

sess

men

ts a

nd M

DG

-dri

ven

plan

ning

pro

cess

es

•A

vaila

bilit

y of

tim

ely

tech

ni-

cal

assi

stan

ce /

cap

acity

bui

ld-

ing

from

nat

iona

l ex

pert

s an

dre

gion

al i

nstit

utio

ns

•N

atio

nal H

IV /A

IDS

con

stitu

-en

cy fu

lly c

omm

itted

to R

H /

HIV

inte

grat

ion

29

MTE

Fs, p

redi

ctab

ility

and

sus

tain

abili

ty o

f fun

d-in

g, a

nd fi

scal

spa

ce; s

uppo

rt th

e av

aila

bilit

y of

cost

ing

pack

ages

;

•S

uppo

rt p

lann

ing

to i

mpr

ove

finan

cial

ac-

cess

(e.

g. w

ork

with

Wor

ld B

ank

on p

erfo

r-m

ance

-bas

e fin

anci

ng)

4. S

uppo

rt t

he n

atio

nal

resp

onse

to t

he h

uman

res

ourc

e cr

isis

in

MN

H, w

ith a

focu

s on

pla

nnin

g an

dsc

alin

g up

of m

idw

ifery

and

oth

erm

id-le

vel

prov

ider

s (a

s pe

r M

id-

wiv

es P

rogr

amm

e D

ocum

ent)

4.1

Nat

ion

al h

ealt

h h

um

an r

e-so

urce

pla

ns f

or M

NH

incl

ude

in-

tern

atio

nally

-agr

eed

upon

requ

ire-

men

ts fo

r fa

mily

pla

nnin

g, n

orm

alde

liver

y an

d ba

sic

and

com

preh

en-

sive

Em

ON

C d

istr

ict-b

ased

ser

vice

deliv

ery

4.2

Upg

rade

d m

idw

ifery

edu

catio

nan

d tr

aini

ng p

rogr

ams

with

cur

-ri

cula

bas

ed o

n th

e IC

M e

ssen

tial

com

pete

ncie

s fo

r bas

ic m

idw

ifery

prac

tice

4.3

Incr

ease

d nu

mbe

r of m

idw

ifery

asso

ciat

ions

with

cap

acity

to

ad-

voca

te fo

r and

impl

emen

t the

sca

l-in

g up

of m

idw

ifery

ser

vice

s in

the

coun

try

4.4

Nat

iona

l re

gula

tory

pro

fes-

sion

al s

tand

ards

and

mon

itori

ngsy

stem

s in

p

lace

to

en

sure

sust

aina

bilit

y of

hig

h qu

ality

mid

-w

ifery

ser

vice

s an

d ca

re

•N

atio

nal

MN

H h

uman

res

ourc

ene

eds

asse

ssm

ents

up-

to-d

ate

•N

atio

nal

MN

H h

uman

res

ourc

epl

an d

evel

oped

•N

umbe

r an

d P

ropo

rtio

n of

mid

-w

ifery

tra

inin

g in

stitu

tions

, in

all

par-

ticip

atin

g co

untr

ies,

with

rev

ised

and

cult

ural

ly a

ppro

pria

te c

urri

cula

-ba

sed

on I

CM

ess

entia

l co

mpe

ten-

cies

ado

pted

and

im

plem

ente

d

•A

nnua

l nu

mbe

r of

mid

wif

ery

grad

uate

s fr

om n

atio

nal

mid

wife

rytr

aini

ng i

nstit

utio

ns i

n al

l pa

rtic

ipat

-in

g co

untr

ies

bein

g de

ploy

ed a

t ba

-si

c an

d co

mpr

ehen

sive

Em

ON

C f

a-ci

litie

s

•N

umbe

r an

d pr

opor

tion

of m

id-

wiv

es,

in a

ll th

e pa

rtic

ipat

ing

coun

-tr

ies,

who

are

aut

horiz

ed a

nd e

mpo

w-

ered

to a

dmin

iste

r the

cor

e se

t of l

ife-

savi

ng i

nter

vent

ions

(th

e 7

Bas

icE

mO

NC

fun

ctio

ns)

•P

ropo

rtio

n of

mid

wiv

es,

in t

hepa

rtic

ipat

ing

coun

trie

s, w

ho b

enef

itfr

om s

yste

ms

for c

ompu

lsor

y su

ppor

t-iv

e su

perv

isio

n an

d co

ntin

ued

edu

-ca

tion

for

mid

wiv

es

•P

ropo

rtio

n of

par

ticip

atin

g co

un-

trie

s w

ith a

nat

iona

l m

idw

ifery

cou

n-ci

l/boa

rd, w

ith in

tern

atio

nal s

tand

ards

See

join

t UN

FPA

-Inte

rnat

iona

l Con

fede

ratio

nof

Mid

wiv

es (I

CM

) Mid

wiv

es P

rogr

amm

e do

cu-

men

t fo

r de

taile

d de

scri

ptio

n of

UN

FPA

sup

-po

rt fo

r thi

s ou

tput

.

This

out

put

can

incl

ude:

•S

uppo

rt t

o na

tiona

l po

licie

s, p

lann

ing

and

prog

ram

mes

for

HR

for

MN

H w

ith a

foc

us o

nm

idw

ifery

: p

rodu

ctio

n, d

eplo

ymen

t, re

tent

ion

incl

udin

g ta

sk s

hifti

ng a

nd t

eam

wor

k (n

atio

nal

regu

latio

ns b

ased

on

inte

rnat

iona

l st

anda

rds,

prof

essi

onal

ass

ocia

tions

, st

anda

rdiz

ed p

roto

-co

ls a

nd s

uper

visi

on, j

ob a

ids,

etc

.) a

nd n

atio

nal

scal

e-up

of

trai

ning

ins

titut

ions

•S

uppo

rt to

the

expa

nsio

n/up

datin

g of

exi

st-

ing

mid

wife

ry s

choo

ls–a

nd t

he d

evel

opm

ent

ofne

w s

choo

ls–b

ased

on

inte

rnat

iona

l st

anda

rds

•S

uppo

rt t

he d

evel

opm

ent

of n

atio

nal

bur-

sary

pro

gram

mes

for

mid

wife

ry s

tude

nts

from

rura

l ar

eas–

refu

ndab

le t

hrou

gh p

rovi

sion

of

serv

ice

in u

nder

serv

ed a

reas

for

equ

ival

ent

num

ber

of y

ears

•C

apac

ity b

uild

ing

with

the

natio

nal m

idw

ifery

asso

ciat

ion

•S

uppo

rt t

he d

evel

opm

ent

of r

oste

r of

mid

-w

ifery

sch

ools

(in

tern

atio

nal

and

regi

onal

) ca

-pa

ble

of s

uppo

rtin

g de

velo

pmen

t of n

ew s

choo

lsin

MH

TF c

ount

ries

•A

gree

men

t an

d st

rong

sup

-po

rt b

y M

oH

•E

xist

ing

buy-

in a

nd w

illin

g-ne

ss o

f th

e in

stitu

tions

to

en-

hanc

e sc

alin

g-up

and

tra

inin

g(R

isks

: m

idw

ifery

tra

inin

g in

sti-

tutio

ns a

nd p

rogr

amm

es d

o no

tha

ve s

uffic

ient

res

ourc

es a

ndsu

stai

ned

supp

ort)

•S

uffic

ient

nat

iona

l fin

anci

alre

sour

ces

•IC

M t

rain

ing

prog

ram

mes

in

advo

cacy

and

cap

acity

bui

ldin

g fo

rm

idw

ifery

ass

ocia

tions

are

cul

tur-

ally

app

ropr

iate

and

effe

ctiv

e

•St

rong

sup

port

from

MoH

and

legi

slat

ors

for

cont

inue

d pr

ofes

-si

onal

mid

wife

ry t

rain

ing,

sup

er-

visi

on a

nd m

idw

ives

’ pr

otec

tion

30

5. N

atio

nal e

quity

-dri

ven

scal

e-up

of fa

mily

pla

nnin

g an

d Em

ON

C s

er-

vice

s, m

ater

nal

an

d n

ewb

orn

heal

th c

omm

odit

y se

curi

ty (

incl

ose

coor

dina

tion

with

UN

FPA

’sG

loba

l P

rogr

amm

e on

RH

CS

and

with

join

t fin

anci

al s

uppo

rt)

5.1

Acc

ess

to fa

mily

pla

nnin

g im

-pr

oved

5.2

Acc

ess

to q

ualit

y E

mO

NC

im-

prov

ed

5.3

Ess

entia

l mat

erna

l and

new

born

heal

th c

omm

odity

sec

urity

impr

oved

(in c

lose

coo

rdin

atio

n w

ith U

NFP

A’s

Glo

bal P

rogr

amm

e on

RH

CS

and

with

join

t fin

anci

al s

uppo

rt)

•P

ropo

rtio

n of

ser

vice

del

iver

ypo

ints

offe

ring

at l

east

thr

ee m

oder

nm

etho

ds o

f co

ntra

cept

ion

Uni

ted

Nat

ions

Em

ON

C In

dica

tors

•C

ase

fata

lity

rate

for d

irect

obs

tet-

ric c

ause

s in

fac

ilitie

s

•A

vaila

bilit

y of

em

erge

ncy

obst

et-

ric a

nd n

ewbo

rn c

are:

bas

ic a

nd c

om-

preh

ensi

ve E

mO

NC

fac

ilitie

s

•P

ropo

rtio

n of

all

birt

hs in

Em

ON

Cfa

cilit

ies

•M

et n

eed

for

Em

ON

C

•P

ropo

rtio

n of

cou

ntry

com

mod

ityre

ques

ts s

atis

fied

•S

uppo

rt t

he s

calin

g-up

of

fam

ily p

lann

ing

serv

ices

to

ever

y he

alth

fac

ility

and

res

olvi

ng o

fbo

ttlen

ecks

in r

eal t

ime

•S

uppo

rt t

rain

ing

of s

taff

for

fam

ily p

lann

ing

•S

uppo

rt p

ost-

part

um f

amily

pla

nnin

g

•A

dvoc

acy

and

supp

ort

for

fam

ily p

lann

ing

serv

ices

to

be in

tegr

ated

into

pos

t-pa

rtum

car

e•

Sup

port

the

scal

ing-

up

of m

ater

nal

heal

thse

rvic

es–

and

res

olvi

ng o

f bo

ttlen

ecks

-, i

nclu

d-in

g su

ppor

ting

stre

ngth

enin

g se

rvic

e de

liver

y in

–an

d up

grad

ing–

prio

rity

basi

c an

d co

mpr

ehen

sive

Em

ON

C f

acili

ties

•S

uppo

rt a

ppro

ache

s w

ith o

ther

sec

tors

to

redu

ce th

e th

ree

dela

ys (

com

mun

icat

ion,

tran

s-po

rt, e

.g. t

axi a

ssoc

iatio

n vo

uche

r sy

stem

s et

c.)

•C

apac

ity b

uild

ing

for

qual

ity o

f ca

re (

e.g.

,ac

cred

itatio

n of

faci

litie

s, w

ork

with

pro

fess

iona

las

soci

atio

ns,

natio

nal

regu

latio

ns,

mat

erna

lde

ath

audi

ts,

etc.

)•

Sup

port

the

pro

visi

on o

f co

ntra

cept

ives

•S

uppo

rt t

he p

rovi

sion

of

esse

ntia

l M

NH

drug

s, s

uppl

ies

and

equi

pmen

t•

Stre

ngth

enin

g of

nat

iona

l cap

acity

dev

elop

-m

ent

in h

ealth

sup

plie

s lo

gist

ics

syst

ems

•S

usta

ined

and

suf

ficie

nt n

a-tio

nal

and

dono

r fin

anci

al c

om-

mitm

ents

•C

omm

itte

d di

stri

ct h

ealt

hm

anag

emen

t te

ams

•M

otiv

ated

hea

lth w

orke

rs

6.

Mon

itori

ng a

nd r

esul

ts-b

ased

man

agem

ent

of n

atio

nal

MN

H e

f-fo

rts

supp

orte

d

•In

tern

atio

nally

-agr

eed

MN

H i

ndi-

cato

rs in

tegr

ated

in n

atio

nal H

MIS

•M

anda

tory

not

ifica

tion

of m

ater

-na

l de

aths

•A

nnua

l num

ber o

f mat

erna

l dea

thau

dits

•P

ropo

rtio

n of

dis

tric

ts r

epor

ting

year

ly o

n na

tiona

lly-a

gree

d M

NH

in-

dica

tors

•S

uppo

rt to

nat

iona

l HM

IS: r

evie

w a

nd a

dop-

tion

of i

nter

natio

nal

MN

H i

ndic

ator

s w

ithin

na-

tiona

l HM

IS

•N

atio

nal c

apac

ity b

uild

ing

for

HM

IS, i

nclu

d-in

g te

chni

cal

assi

stan

ce a

nd p

artic

ipat

ion

intr

aini

ng c

ours

es (e

.g.,

IMM

PAC

T –

IPA

CT)

•S

uppo

rt to

HM

IS s

tren

gthe

ning

incl

udin

g in

-se

rvic

e tr

aini

ng w

ith d

istr

ict

team

s an

d he

alth

faci

litie

s te

ams

•S

uppo

rt t

o pe

riod

ic n

atio

nal

cens

us a

ndsu

rvey

s (D

HS

, M

ICS

, ot

hers

) to

mea

sure

ma-

tern

al m

orta

lity

and

rela

ted

popu

latio

n-ba

sed

MN

H/F

P in

dica

tors

•In

tegr

atio

n of

inte

rnat

iona

lly-

agre

ed in

dica

tors

for

RH

/MN

H in

heal

th s

yste

m s

tren

gthe

ning

ef-

fort

s su

ch a

s IH

P+,

etc

.

•M

oH

com

mit

ted

to

sus-

tain

ed r

esul

ts-b

ased

app

roac

han

d to

reg

ular

faci

lity

and

dist

rict

repo

rtin

g th

roug

h st

rong

HM

IS

31

•S

uppo

rt p

erio

dic

MN

H/R

H r

evie

ws/

eval

ua-

tions

as

part

of

heal

th s

ecto

r re

view

s

7. S

uppo

rt to

cou

ntri

es in

leve

rag-

ing

addi

tiona

l res

ourc

es fo

r M

DG

5fr

om g

over

nmen

t and

don

ors

•S

hare

of g

over

nmen

t exp

endi

ture

for

heal

th (a

s pe

r ann

ual g

over

nmen

tfig

ures

)

•N

atio

nal

budg

et f

or M

NH

ove

rall

and

per

capi

ta (

incl

udin

g al

l flo

ws:

dom

estic

and

ext

erna

l), a

s m

easu

red

thro

ugh

nati

onal

hea

lth

acco

unts

whe

re th

ey e

xist

•S

uppo

rt g

over

nmen

t to

mob

ilize

and

lev

er-

age

reso

urce

s fo

r m

ater

nal

and

repr

oduc

tive

heal

th f

rom

dom

estic

and

ext

erna

l so

urce

s

•S

usta

ined

nat

iona

l an

d do

-no

r fin

anci

al c

omm

itmen

ts

Oth

er o

utpu

ts a

s de

term

ined

by

each

cou

ntry

Ple

ase

refe

r to

cou

ntry

-spe

cific

pro

posa

ls to

the

MH

TF fo

r ea

ch M

HTF

sup

port

ed c

ount

ry

REG

ION

AL

LEV

EL -

AS

PA

RT O

F U

NFP

A’S

REG

ION

AL P

RO

GR

AM

MES

: T

O S

TR

ENG

TH

EN R

EGIO

NA

L ST

EWA

RD

SHIP

AR

OU

ND

MN

H -

PO

LIC

Y

DIA

LOG

UE

AN

D C

OO

RD

INA

TIO

N

1. In

crea

sed

regi

onal

reco

gniti

on o

fM

NH

by

polic

y m

aker

s

2. E

nhan

ced

regi

onal

coo

rdin

atio

nar

ound

MN

H

3. In

crea

sed

Sou

th-S

outh

sup

port

to n

atio

nal c

apac

ity b

uild

ing

4. I

ncre

ased

sup

port

at

regi

onal

leve

l for

mid

wife

ry a

s a

key

heal

thw

orkf

orce

for

the

ach

ieve

men

t of

MD

G5

5. I

ncre

ased

sha

ring

of

less

ons

lear

ned

and

prod

uctio

n of

evi

denc

e

•N

umbe

r of

reg

iona

l m

eetin

gs o

nM

NH

•A

nnua

l nu

mbe

r of

Sou

th-S

outh

MN

H c

apac

ity b

uild

ing

mis

sion

s /

exch

ange

s w

ith

MH

TF

-sup

port

edco

untr

ies

•P

rese

nce

of re

gion

al e

fforts

to s

tan-

dard

ize

mid

wife

ry c

urric

ula

with

in r

e-gi

ons

base

d on

inte

rnat

iona

l sta

ndar

ds

•N

umbe

r of M

HTF

-sup

porte

d co

un-

trie

s in

eac

h re

gion

with

a fu

nctio

ning

natio

nal M

idw

ifery

Cou

ncil

/ B

oard

•S

uppo

rtin

g U

NFP

A R

egio

nal

Pro

gram

mes

with

add

ition

al t

echn

ical

cap

acity

•S

uppo

rt r

egio

nal a

dvoc

acy

and

com

mitm

ent

for M

NH

(e.g

., M

aput

o P

lan

of A

ctio

n, p

arlia

men

-ta

ry a

ssoc

iatio

ns,

high

-leve

l m

eetin

gs,

etc.

)

•W

ork

with

WH

O t

o en

sure

MN

H h

igh

onag

enda

of r

egio

nal h

ealth

mee

tings

and

with

the

Wor

ld B

ank

for

regi

onal

fin

ance

mee

tings

•S

uppo

rt r

egio

nal

capa

city

bui

ldin

g th

roug

hth

e te

chni

cal

assi

stan

ce n

etw

ork

of r

egio

nal

in-

stitu

tions

and

indi

vidu

als,

wor

king

with

UN

ICE

Fan

d C

olum

bia

Uni

vers

ity (

see

UN

FPA

-UN

ICE

F-C

olum

bia

Uni

vers

ity A

MD

D M

OU

)

•S

uppo

rt r

egio

nal

inte

r-ag

ency

coo

rdin

atio

non

MN

H (

WH

O,

UN

ICE

F, U

NFP

A,

Wor

ld B

ank,

Reg

iona

l Dev

elop

men

t B

anks

(e.

g.,

Har

mon

iza-

tion

for

Hea

lth in

Afr

ica,

reg

iona

l dire

ctor

s m

eet-

ings

, et

c.)

•S

uppo

rt

stan

dard

izat

ion

of c

urric

ula

and

exch

ange

of

expe

rienc

es a

s re

late

d to

hum

anre

sour

ces

for

MN

H

•R

egio

nal

com

mit

men

t to

SR

H (

such

as

Map

uto

Pla

n of

Act

ion

in A

fric

a)

•E

ffect

ive

Uni

ted

Nat

ions

re-

gion

al c

oord

inat

ion

(e.g

. H

arm

o-ni

zatio

n fo

r Hea

lth in

Afri

ca, r

egu-

lar m

eetin

gs o

f reg

iona

l dire

ctor

s)

•E

ffect

ive

and

cultu

rally

ap-

prop

riate

adv

ocac

y fo

r mid

wife

ryis

fea

sibl

e

32

GLO

BA

L LE

VEL

- A

S P

AR

T O

F U

NFP

A’S

GLO

BA

L P

RO

GR

AM

ME:

TO

ST

REN

GT

HEN

GLO

BA

L ST

EWA

RD

SHIP

AN

D C

OO

RD

INA

TIO

N A

RO

UN

D M

NH

1. G

loba

l ste

war

dshi

p an

d le

ader

-sh

ip fo

r MN

H e

nhan

ced

2. J

oint

UN

-MN

H s

uppo

rt to

cou

n-tr

ies

3. T

echn

ical

ass

ista

nce

netw

ork

esta

blis

hed

and

func

tioni

ng

4. In

crea

sed

supp

ort a

t glo

bal l

evel

for

mid

wif

ery

as a

key

hea

lth

wor

kfor

ce f

or t

he a

chie

vem

ent

ofM

DG

5

5. A

dvoc

acy

for m

ater

nal h

ealth

•Le

vel o

f fin

anci

ng fo

r MN

H fo

r hig

hm

ater

nal

mor

talit

y co

untr

ies

•N

umbe

r of

cou

ntri

es r

ecei

ving

join

t U

N-M

NH

sup

port

•N

umbe

r of

ins

titut

ions

act

ivel

ypa

rtic

ipat

ing

in t

he t

echn

ical

ass

is-

tanc

e ne

twor

k

•S

uppo

rt g

loba

l ad

voca

cy a

nd r

esou

rce

mo-

biliz

atio

n / l

ever

agin

g fo

r M

NH

•S

uppo

rt jo

int U

N-M

NH

wor

k an

d co

ordi

nate

dac

tion

to p

rovi

de e

nhan

ced

supp

ort t

o 25

prio

rity

coun

trie

s by

end

of

2009

and

to

the

60 p

riorit

yco

untr

ies

by e

nd o

f 20

12

•C

ontr

ibut

e to

the

dev

elop

men

t of

a g

loba

lpr

ogra

mm

e of

wor

k w

ith k

ey s

take

hold

ers

to a

c-ce

lera

te p

rogr

ess

tow

ards

MD

G5

(par

ticip

ate

info

llow

-up

to t

he c

ampa

ign

for

the

heal

th M

DG

san

d ef

forts

of N

orw

ay, U

K, S

wed

en a

nd th

e B

ill &

Mel

inda

Gat

es F

ound

atio

n)

•S

uppo

rt t

he P

artn

ersh

ip f

or M

ater

nal,

New

-bo

rn a

nd C

hild

Hea

lth

•S

uppo

rt g

loba

l com

mun

icat

ion

and

advo

cacy

initi

ativ

es f

ocus

ing

on M

NH

•D

evel

opin

g pr

int

and

audi

o-vi

sual

adv

ocac

yan

d m

edia

mat

eria

ls i

n se

vera

l la

ngua

ges

•P

itchi

ng s

torie

s to

the

med

ia,

issu

ing

pres

sre

leas

es a

nd h

oldi

ng p

ress

eve

nts

to i

ncre

ase

med

ia c

over

age

of t

he i

ssue

•W

orki

ng w

ith h

igh

net

wor

th i

ndiv

idua

l do

-no

rs a

nd p

hila

nthr

opic

gro

ups

that

rai

se f

unds

and

awar

enes

s ab

out

mat

erna

l he

alth

•G

loba

l com

mitm

ent t

o M

NH

sust

aine

d

•E

ffec

tive

follo

w-u

p of

the

WH

O-U

NF

PA

-UN

ICE

F-W

orld

Ban

k Jo

int

Stat

emen

t on

Mat

er-

nal

and

New

born

Hea

lth

•D

onor

gov

ernm

ents

and

foun

datio

ns p

rovi

de s

uffic

ient

mul

tilat

eral

fund

ing

for

MN

H, i

n-cl

udin

g to

the

MH

TF

Ris

ks:

•D

onor

fatig

ue /

insu

ffic

ient

dono

r sup

port

•G

loba

l fin

anci

al c

risi

s

•C

ompe

titio

n fo

r ot

her

de-

velo

pmen

t pri

oriti

es

33

Country Level Outputs

1. Enhanced political and social environment for MNH

2. Needs assessments

3. National Health Plans strengthened for FP and EmONC

4. National response to human resource crisis-midwifery

5. Support to national scale-up of FP an EmONC*

6. Monitoring and results-based management

7. Leveraging of additonal resources for MDG5

Country Level Total

Regional Level

Global Level

Total less indirect costs**

Total

6. BUDGET

The proposed MHTF budget is based on a progres-sively increasing income scenario for 2008-2011,totaling around $500 million. Under such incomeprojections, significant progress can be made in 25countries mostly of middle size, but with some largerones (such as Bangladesh and Ethiopia); and workcould begin towards the end of the 2008-11 cycle inapproximately 48 countries. We would thus be onthe way to providing support to the 60 high maternalmortality countries by no later than 2012.

It is worth remembering that the MHTF fundingis meant to be catalytic; $500 million over four yearsrepresents less than two per cent of the $6 billion to $7billion annually estimated by WHO, plus the $1.5 bil-lion annually for family planning. It is assumed thatpriority countries will receive the bulk of their healthODA through other mechanisms, ideally through pooledsector funding of an MDG-driven national health planthrough a Sector Wide Approach (SWAp).

Financial requirements for the MHTF increaserapidly over the next four years, based on both theincreasing number of countries (12 countries peryear) and the rapidly increasing level of yearly ef-fort in each country supported as scale-upprogresses.

Ideally, pledges from donors should be multi-year (for the period 2008-2011) and progressivelyincreasing, commensurate with the growing finan-cial requirements of the MHTF.

These resources should provide an importantcontribution to the WHO-UNICEF-UNFPA-WorldBank joint support to countries to accelerate progresstowards MDG5.

Impact of different levels of funding on theMHTF-supported programme of work

Scenario One: $70 million to $75million a year:initial work in 25 countriesA total of around $72 million will be required for

2008 2009 2010 2011 2008-2011

% ofTotal

Number of countries added each year

Total number of MHTF-supported countries12

12

$M

12

24

$M

12

36

$M

12

48

$M

48

$M

1.02

2.04

2.04

6.12

6.12

2.04

1.02

20.40

0.70

2.18

23.28

24.90

3.06

6.12

6.12

18.36

18.36

6.12

3.06

61.20

1.40

4.35

66.95

71.64

6.12

12.24

12.24

36.72

36.72

12.24

6.12

122.40

1.40

5.35

129.15

138.19

12.24

24.48

24.48

73.44

73.44

24.48

12.24

244.80

1.40

5.35

251.55

269.16

22.44

44.88

44.88

134.64

134.64

44.88

22.44

448.80

4.90

17.23

470.93

503.89

95.3

1.0

3.7

100

Notes: * In close collaboration with Global Programme on Reporductive Health Commodity Security ** Indirect costs = 7%

34

MATERNAL HEALTH THEMATIC FUND BUDGET–$500 MILLION OVER FOUR YEARS

operations in 2009. Since the four United Nationsagencies have committed to accelerated support in25 countries by the end of 2009, the minimum sce-nario to begin work in the 25 countries would befunding of the order of $25 million in 2008 and $70million to $75 million per year thereafter. However,such a funding level would not allow much supportto scale up in those 25 countries, and would pre-clude expanding to the other 35 or so high maternalmortality countries.

Scenario Two: Continued expansion to $140 mil-lion in 2010 and $270 million in 2011: impor-tant contribution in 48 of the 60 high maternalmortality countriesAdding 12 countries in each of 2010 and 2011 andscaling up coverage within each country would re-quire around $140 million in 2010 and $270 million in2011. This, coupled with the resources of UNICEF,the World Bank and the continued technical supportof WHO, could go a long way in ensuring that thenational health system can improve maternal andnewborn survival, achieving better results—andvalue for money—with its overall sector resources.

7. MANAGEMENT AND GOVERNANCE

The management and governance of the MHTF willrespect the usual UNFPA accountability lines, as wellas the approved thematic fund guidelines. Specifi-cally, accountability for country activities rests withthe representative who is supervised by her/his re-gional director. Regional activities are the responsi-bility of the respective regions supervised by theirregional director. All global activities will be super-vised under the Director of the Technical Division(TD) or the Information and External Relations Di-vision (IERD), as relevant. The overall programstewardship rests with the Deputy Executive Direc-tor of Programs and with the Executive Director.

A small team at UNFPA headquarters, withinthe Sexual and Reproductive Health Branch of theTechnical Division, will manage and coordinate theMHTF. The team will include a coordinator, an M&Especialist and a finance associate, as well as admin-istrative and consultative support where needed.Most importantly, the coordination team will workto ensure that the MHTF effort represents aUNFPA-wide approach by including input from alldivisions as we work towards a common goal. In

order to operationalize this integrated strategy, oneconsolidated annual workplan including all relevantdivisions is being developed.

The Maternal Health Inter-Divisional WorkingGroup (MH-IDWG) has been created as a mecha-nism for communication and coordination. The MH-IDWG operates on both a policy and working levelto assure coherence in planning, funding allocations,reporting and other functions for country, regionaland global programs. At the working-group level,focal points have been identified within each divi-sion to participate in the MH-IDWG and liaise be-tween divisions and the MHTF team to ensure thatevery relevant unit is effectively involved. The MH-IDWG meets monthly at the working level and an-nually at the policy level.

All countries considered for support from theMHTF have high maternal mortality, defined as anMMR greater than 300 maternal deaths for every100,000 live births. The country selection process ishighly interactive, involving consultations with coun-tries, regions and other United Nations agencies.Beyond high MMR, countries selected for supportmust be identified as having the potential for rapidsuccess based on the criteria listed below or be fac-ing significant maternal health needs due to humani-tarian crisis.

Criteria for the selection of countries for MHTFsupport:

1. Participation in recent global initiatives, andin particular the International Health Part-nership (IHP+)

2. Strong national commitment

3. Strong country office commitment and lead-ership

Countries will be selected to join in successivewaves as funding becomes available, until eventu-ally all 60 high maternal mortality countries are sup-ported.

Application ProcessCountries are asked to submit a simple proposal

outlining the maternal and reproductive health out-comes they would like to achieve and the associ-ated activities for which they need support. Coun-tries will be allocated funding on an annual basisthrough an annual workplan based on the amountrequested in the proposal and the availability ofMHTF resources. This funding will support the

35

country programme as part of “other resources” inthe country programme document approved by theExecutive Board. The MHTF is not intended to bea parallel funding entity, but an integrated compo-nent of each country’s programme to ensure opti-mal in-country results.

Contributions received by the MHTF from do-nors will be pooled. Donors will receive one con-solidated annual report that will include both genericand country-specific results. The funding mecha-nism is intended to be simple and flexible to allowcountries to adapt to changing situations and needs.Pooling resources under one thematic area, ratherthan many separate projects, will also reduce trans-actional costs at every level and allow for a moreharmonized development effort in countries. To fur-ther streamline support to countries, and increasecontinuity, UNFPA is considering the integration ofthe Fistula Programme into the MHTF. As men-tioned earlier, the Midwives Programme, which isstill in part funded as a separate project, has beenrecently integrated within the MHTF. There will beclose coordination of country support with the glo-bal programme for RHCS so as to decrease trans-action costs with ministries of health and streamlineworkflows and business processes with country of-fices, regions and headquarters.

The work of the MHTF will be guided by thisbusiness plan as well as a set of tools and publica-tions. Most of these tools for MNH needs assess-ment, planning, implementation, scale-up and moni-toring already exist. Work is on-going to make themeasily available to countries. Some will requiredevelopment / adaptation, particularly those relatedto human resources planning for MNH.

8. MONITORING AND EVALUATION

AND REPORTING

Strengthening national capacity for monitoring MNHis a prominent feature of MNH support. Supportfrom the MHTF will aim to strengthen the na-tional HMIS to ensure that a minimal set of inter-nationally agreed MNH indicators are includedand reported on annually. In this regard, work

led by WHO is on-going, including in particular sup-port through the International Health PartnershipM&E framework.[51]

It will be critical to capture these indicators atfacility, district and national levels. StrengtheningM&E capacity at district-level will thus be impor-tant. This will be supplemented with periodic popu-lation-based surveys, to measure such indicators asunmet need for family planning and contraceptiveprevalence.

Preliminary discussions have begun with aca-demic institutions to explore the feasibility and costsof measuring maternal mortality every three yearsin all priority countries (60 of them) so as to providea few time points between now and 2015 (for ex-ample 2009, 2012, 2015).

The coverage, outcome and impact indicatorsare imbedded in the MHTF Results Framework.Please see Annex 1 (the MHTF Results FrameworkIndicator Table), for means of verification, frequencyof reporting and other relevant information on eachindicator.

The country-specific UNFPA outputs and ac-tivity indicators will be prepared by UNFPA countryoffices in close consultation with MoH and partners.

Annual reportA consolidated annual report will be prepared

with both overall and country-specific results. Thiswill also include reporting financially on income andon the use of resources.

9. CONCLUSION

Based on a solid review of the scientific evidenceand the results of programmes in countries whichhave tackled maternal mortality, we believe thatmuch progress can be accomplished between nowand 2015, with a health systems approach of scalingup family planning, skilled attendance at delivery andemergency obstetric care, so that every pregnancyis wanted and every birth is safe.

We could then envisage, in a not too distantfuture, a world where maternal mortality has beeneliminated.

[ 5 1 ] A common framework for monitoring performance and evaluation of the scale up for better health. Monitoring & EvaluationWorking Group, International Health Partnership+. February 2008.

36

Indi

cato

rsN

atio

nal B

asel

ines

(to

be c

ompl

eted

by e

ach

coun

try

Nat

iona

l Tar

gets

(to

be c

ompl

eted

by e

ach

coun

try

Mea

ns o

f Ver

ifica

tion

Freq

uenc

y

AN

NEX

1.

MH

TF

RES

ULT

S FR

AM

EWO

RK I

ND

ICA

TO

R T

AB

LE

MD

G5

•M

ater

nal m

orta

lity

ratio

•P

ropo

rtio

n of

birt

hs a

ttend

ed b

y sk

illed

hea

lthpe

rson

nel

•C

ontr

acep

tive

prev

alen

ce r

ate

•A

dole

scen

t bi

rth

rate

•A

nten

atal

car

e co

vera

ge (

at le

ast o

ne v

isit

and

atle

ast

four

vis

its)

•U

nmet

nee

d fo

r fa

mily

pla

nnin

g

UN

FPA

Str

ateg

ic P

lan

(with

all

of th

e ab

ove)

•P

ropo

rtion

of

coun

tries

with

nat

iona

l dev

elop

men

tpl

ans

that

allo

cate

dom

estic

res

ourc

es f

or a

nes

sent

ial s

exua

l and

rep

rodu

ctiv

e he

alth

pac

kage

•P

ropo

rtio

n of

cou

ntrie

s w

here

Cae

sare

anse

ctio

n as

a p

ropo

rtio

n of

all

birt

hs f

alls

in t

hera

nge

of 5

-15%

(na

tiona

l, ru

ral a

nd u

rban

)

•P

ropo

rtio

n of

ser

vice

del

iver

y po

ints

offe

ring

atle

ast

thre

e m

oder

n m

etho

ds o

f co

ntra

cept

ion

Nat

iona

l out

put i

ndic

ator

s

•N

atio

nal c

omm

unic

atio

n an

d ad

voca

cy s

trat

egy

deve

lope

d

•C

oord

inat

ion

team

in p

lace

, led

by

MoH

, with

UN

FPA

, WH

O, U

NIC

EF,

the

Wor

ld B

ank,

Re-

gion

al D

evel

opm

ent

Ban

k, k

ey b

ilate

rals

, ci

vil

soci

ety

and

othe

r pa

rtne

rs

•C

ensu

s, D

HS,

MIC

S, o

ther

MM

pop

ulat

ion-

base

d st

udie

s

•H

MIS

, DH

S, M

ICS

•D

HS

, MIC

S

•D

HS

, C

ensu

s

•H

MIS

•D

HS

, MIC

S

•M

OH

bud

gets

and

fin

anci

alre

port

s

•H

MIS

, DH

S, M

ICS

•H

MIS

•E

xist

ence

of

docu

men

t

•M

inut

es o

f m

eetin

gs o

fco

ordi

natio

n te

am

Eve

ry 3

- 10

yea

rs

Eve

ry 1

- 5

yea

rs i

n-cr

easi

ng to

yea

rly

Eve

ry 3

- 5

year

s

Eve

ry 5

yea

rs

Eve

ry y

ear

Eve

ry 3

- 5

year

s

Year

ly

Eve

ry 1

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40

ANNEX 2.

A. JOINT STATEMENT ON MATERNAL AND NEWBORN HEALTH

B. WHO-UNFPA-UNICEF-WORLD BANK JOINT COUNTRY SUPPORT FOR

ACCELERATED IMPLEMENTATION OF MATERNAL AND NEWBORN CONTINUUM OF

CARE

C. PROPOSED LIST OF PRIORITY COUNTRIES FOR UN MNH JOINT WORK

41

Today, 25 September 2008, as world leaders gather for the High-Level Event on the Millennium Development Goals (MDGs), we jointly pledge to intensify our support to countries to achieve Millennium Development Goal 5 To Improve Maternal Health — the MDG showing the least progress.

During the next five years, we will enhance support to the countries with the highest maternal mortality. We will support countries in strengthening their health systems to achieve the two MDG 5 targets of reducing the maternal mortality ratio by 75 per cent and achieving universal access to reproductive health by 2015. Our joint efforts will also contribute to achieving MDG 4 To Reduce Child Mortality.

Every minute a woman dies in pregnancy or childbirth, over 500,000 every year. And every year over one million newborns die within their first 24 hours of life for lack of quality care. Maternal mortality is the largest health inequity in the world; 99 per cent of maternal deaths occur in developing countries — half of them in Africa. A woman in Niger faces a 1 in 7 chance during her lifetime of dying of pregnancy–related causes, while a woman in Sweden has 1 chance in 17,400.

Fortunately, the vast majority of maternal and newborn deaths can be prevented with proven interventions to ensure that every pregnancy is wanted and every birth is safe.

We will work with governments and civil society to strengthen national capacity to:

• Conduct needs assessments and ensure that health plans are MDG–driven and performance–based;

• Cost national plans and rapidly mobilize required resources;

• Scale-up quality health services to ensure universal access to reproductive health, especially for family planning, skilled attendance at delivery and emergency obstetric and newborn care, ensuring linkages with HIV prevention and treatment;

• Address the urgent need for skilled health workers, particularly midwives;

• Address financial barriers to access, especially for the poorest;

• Tackle the root causes of maternal mortality and morbidity, including gender inequality, low access to education — especially for girls — child marriage and adolescent pregnancy;

• Strengthen monitoring and evaluation systems.

In the countdown to 2015, we call on Member States to accelerate efforts for achieving reproductive, maternal and newborn health. Together we can achieve Millennium Development Goals 4 and 5.

JOINT STATEMENT ON MATERNAL AND NEWBORN HEALTH

Margaret Chan Director General, WHO

Ann M. Veneman Executive Director, UNICEF

Joy Phumaphi Vice President Human Development, World Bank

Thoraya Ahmed Obaid Executive Director, UNFPA

Accelerating Efforts to Save the Lives of Women and Newborns

WHO-UNFPA-UNICEF-World Bank Joint Country Support for Accelerated

Implementation of Maternal and Newborn Continuum of Care 22 July 2008

Objective To harmonize approaches by UN agencies towards improving maternal and newborn health (MNH) at country level and jointly raise the necessary resources. Background The year 2007 represented the mid-point for the Millennium Development Goals (MDGs). While there has been some progress in the health-related MDGs, MDG 5 is the one with the least progress.1,2 It represents the greatest inequality in health and one that affects women, with a life-time risk of maternal death of one thousand times greater in parts of sub-Saharan Africa and Asia (as high as 1 in 7) than in some industrialized countries. Complications of pregnancy and childbirth leave 10-20 million women with physical and mental disabilities every year. Maternal mortality has root causes in gender inequality, low access to education, especially for girls, early marriage, adolescent pregnancy, low access to sexual and reproductive health, including for adolescents, and other social determinants. Maternal mortality can be effectively reduced by addressing the above determinants and by ensuring universal access to a) family planning, b) skilled attendance at birth and c) basic and comprehensive emergency obstetric care. Maternal and newborn health is also intrinsically related to health programmes such as HIV and AIDS, in particular primary prevention and prevention of mother-to-child transmission, malaria prevention and treatment, nutrition and immunization. Taking into consideration the comparative advantage, core expertise/experience, and collective strengths in MNH, WHO, UNFPA, UNICEF and The World Bank undertake to accelerate our joint support to countries to improve maternal and newborn survival by strengthening the continuum of care. The agencies will coordinate their support at country level guided by the national health plan and according to each agency’s respective country-specific strengths and capacities. Support to these activities will be embedded within the strengthening of national health systems. The agencies will jointly contribute to national capacity strengthening, building of sustainable national health systems and costing and financing of MNH national plans whilst ensuring national and global advocacy. 1 Maternal Mortality in 2005: Estimates developed by WHO, UNICEF, UNFPA and The World Bank. October 2007. Geneva. WHO.

Africa and the Millennium Development Goals. United Nations. 2007 Update. http://www.un.org/millenniumgoals/docs/MDGafrica07.pdf

2 The Millennium Development Goals Report. United Nations. 2007. http://millenniumindicators.un.org/unsd/mdg/Resources/Static/Products/Progress2007/UNSD_MDG_Report_2007e.pdf

2

Core functions of the UN agencies based on their comparative advantage:

• WHO: policy, normative, research, monitoring & evaluation • UNFPA: reproductive health commodity security, support to implementation, human resources for sexual and reproductive health including MNH, technical assistance on building M&E capacity • UNICEF: financing, support to implementation, logistics & supplies, monitoring &

evaluation • The World Bank: health financing, inclusion of MNCH in national development frameworks, strategic planning, investment in inputs for health systems, including fid- ciary systems and governance, taking successful programmes to scale

Focal agencies Focal agencies – (or shared focal agencies) – have been identified for each component of the MNH continuum of care and related functions to ensure and facilitate coordinated, optimal support to countries and clear accountability (Table 1). While these provide global guidance, the work of each agency at country level will be determined by existing situations in countries where agency strengths and experience differ as well as by arrangements such as sector-wide approaches (SWAps), or other sector plans, within the context of support to the national health plan/compacts. Being a focal agency would imply accountability at global and national level for facilitating and ensuring coordinated optimal support to countries for scale-up of the agreed programme components including:

ensuring knowledge of the situation, inventory (mapping) of existing activities and resources, including human resources;

ensuring support for the inclusion of MNH continuum of care concept in the development of detailed national plans/compacts and district plans;

ensuring availability of technical support (tools and people); identifying relevant partners and supporting government coordination; supporting resource mobilization; and ensuring that a strong monitoring and evaluation system and the required skills are in place

and used.

Being a focal agency does not mean that other agencies are not involved; on the contrary, the focal agency should help coordinate a strong UN response in support of the national health plan and national leadership, and foster the involvement of other key partners. The government should always lead and coordinate the process. Table 1 Proposed focal agency per building blocks, i.e. core areas within the continuum of care

Area Focal agency Partners Family Planning UNFPA, WHO UNICEF, WB Antenatal Care UNICEF, WHO UNFPA, WB Skilled Attendance at Birth WHO, UNFPA UNICEF, WB B-EmONC3 UNFPA, UNICEF WHO, WB C-EmONC4 WHO, UNFPA UNICEF, WB Post-partum WHO, UNFPA UNICEF, WB Newborn care WHO, UNICEF UNFPA, WB Maternal and Neonatal Nutrition UNICEF, WHO,WB ( for

maternal nutrition) UNFPA

3 B-EmONC Basic Emergency Obstetric and Newborn Care 4 C-EmONC Comprehensive Emergency Obstetric and Newborn Care

3

Table 2 lists additional issues and functions to be considered for maternal and newborn health programming. Table 2: Focal and partner UN agencies in additional areas of MNH work

Area Focal Agency Partners Girls education UNICEF UNFPA, WB Gender/culture/male involvement UNFPA, UNICEF WHO, WB Gender-based violence UNFPA, UNICEF WHO Adolescent sexual reproductive health - young people

UNFPA, UNICEF, WHO WB

Communication for development UNFPA, UNICEF WHO, WB Obstetric fistula UNFPA WHO Prevention of unsafe abortion/ post-abortion care

WHO UNFPA

Female genital mutilation UNFPA, UNICEF, WHO WB MNH in humanitarian situations UNFPA, UNICEF, WHO WB Sexually transmitted infections WHO UNFPA, UNICEF HIV/AIDS and integration with family planning

As per UNAIDS Technical Support Division of Labour

Pre- and in-service training of human resources for MNH

WHO, UNFPA UNICEF, WB

Regulation/legislation for human resources for health

WHO UNFPA, UNICEF, WB

Essential drug list WHO UNFPA, UNICEF Road maps' development and implementation

WHO, UNFPA, WB UNICEF

Proposed list of Priority Countries for UN MNH Joint Work

Country MMR

Lifetime risk of maternal death. 1 in IHP Catalytic EU Gates Norway

CIDA-PMTCT

UNFPA-MHTF

WB-Norway SPP*

GF-MNH Joint UN-MNH

Afghanistan 1800 8 1 1 1 1Angola 1400 12 1 1Bangladesh 570 51 1Benin 840 20 1 1 1 1 1Burkina Faso 700 22 1 1 1 1 1 1 1Burundi 1100 16 1 1 1Cambodia 540 48 1 1 1 1Cote d'Ivoire 810 27 1Djibouti 650 35 1DRC 1100 13 1 1Eritrea 450 44 1Ethiopia 720 27 1 1 1 1 1 1Ghana 560 45 1 1 1 1Guyana 470 90 1 1Haiti 670 44 1 1 1India (very high MMR states) 450 70 1 1 1Kenya 560 39 1 1 1Lesotho 960 45 1Liberia 1200 12 1 1Madagascar 510 38 1 1 1Malawi 1100 18 1 1 1 1 1 1Mali 970 15 1 1 1Mozambique 520 45 1 1 1 1 1Nepal 830 31 1 1Niger 1800 7 1 1 1 1Nigeria 1100 18 1 1 1Pakistan 320 74 1 1 1 1Rwanda 1300 16 1 1Senegal 980 21Sierra Leone 2100 8 1Sudan 450 53 1Swaziland 390 120 1 1Tanzania 950 24 1 1 1 1 1 1Uganda 550 25 1Vietnam 150 280 1 1Zambia 830 27 1 1 1 1Zimbabwe 1 1 1

Total 11 14 8 3 4 4 11 9 14 4 25Selection criteria

Sub-set of 68 Countdown countries

Very high MMR > 550

Committed Country Teams (governement and partners)

Potential for scale-up including availability of financial resources