GHI, BEST, SLB, DIV, NUVI, CSHGP, STI, PPP:

MSotASfMCH@USAIDCORE Group Conference

October 14, 2011

1

Making Sense of the Alphabet Soup for Maternal and Child Health Programs at USAID

CORE Group ConferenceOctober 14, 2011

2

There is a unique global opportunity to accelerate progress in maternal, newborn and child health

InfrastructurePoverty

GeographyStatus of Women

Despite working in challenging environment…

4

0

50

100

150

200

250

300

Ang

ola

1990

-200

9

Afg

hani

stan

200

0-20

06

Mal

i 199

5-20

06

Libe

ria

1986

-200

9

DR

Con

go 2

001-

07

Mal

awi 1

995-

2010

Nig

eria

200

3-20

08

Zam

bia

1996

-200

7

Rwan

da 2

000-

2007

Moz

ambi

que

1995

-200

8

Beni

n 19

96-2

006

Ethi

opia

200

0-05

Mad

agas

car

1997

-200

9

Uga

nda

1995

-200

6

Sene

gal 1

997-

2009

Tanz

ania

199

6-20

10

Indi

a (U

P) 1

998-

2005

Hai

ti 20

00-2

005

Nep

al 1

996-

2006

Paki

stan

199

0-20

06

Bang

lade

sh 1

996-

2007

Keny

a 19

98-2

008

Gha

na 1

998-

2008

Yem

en 1

997-

2006

Suda

n 20

00-2

007

Gua

tem

ala

1995

-200

8

Indo

nesi

a 19

97-2

007

Phili

ppin

es 1

998-

2008

Dea

ths

Per

10

00

Liv

e B

irth

s

Country, Two Survey Years

Earliest Latest

Source: Demographic and Health Surveys since 1995, except Angola, Pakistan and Liberia where earlier datapoints are used. Exceptions are Afghanistan Health Survey; Angola (SOWC, 1990 and 2009); DR Congo: 2001 (MICS); Guatemala (RHS), Malawi: 2006 (MICS); Mozambique (MICS); Sudan Household Survey 2006; Yemen: 2006 (MICS).

5

Progress - Changes in under-five mortality in BEST countries (1995-2010)

6

Trends in Under-five Deaths, 1990-2009

UNICEF – “Levels & Trends in Child Mortality – Report 2010”

With increasing birth cohort, >5 million more deaths/year if no U5MR reduction

Mill

ion

s o

f D

ea

ths

Maternal mortality has declined globally between 1990 & 2008; there has been considerable regional variation

Source: Trends in Maternal Mortality: 1990 to 2008. UN Estimates, 2010

MM

R: m

ater

nal d

eath

s pe

r 100

,000

live

birt

hs

7

26%

53%

37%

34%

Despite progress, the lifetime chance of a woman dying as a result of pregnancy is substantial and far greater in developing than in developed regions

1: 4,300

1: 4901: 31

1: 260

Source: WHO, UNICEF, UNFPA, The World Bank. Trends in Maternal Mortality: 1990 to 2008 pub 2010 8

Source: 2009 data are from the State of the World’s Children (SOWC) 2011 Report. 2000 neonatal mortality data are from http://www.unicef.org/statistics (SOWC 2008 Report), and 2000 infant data are from www.childinfo.org.

Changes in Neonatal and Post-Neonatal (1-11 months) Mortality Rate USAID MCH priority countries - 2000-2009

Greater effort is needed in newborn survival to accelerate progress

9

Neonatal mortality has lagged post-neonatal (and

child) mortality

Reflects limited newborn

programs in most countries

Advantages: We know the causes of newborn, infant and child mortality in developing countries

Based on: Black RE et al. Global, regional, and national causes of child mortality in 2008: a systematic analysiswww.thelancet.com, May 12, 2010 (DOI10.1016/50140-6736(10)60549-1

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• Diarrheal disease and pneumonia still claim the most lives among older infants and children under age five

• Among newborns, preterm birth complications, birth asphyxia and infection pose the greatest dangers

• Undernutrition / low birth weight are major contributors to newborn, infant and child deaths

Undernutrition /Low birth weight

• Low birth weight is a significant contributor in 40–70% of neonatal deaths

• Neonatal death constitutes 41% of under 5 mortality

• Maternal nutrition is an important factor

• Tetanus toxoid • Clean Delivery• Cord Care• Early & Exclusive Breastfeeding• Hand washing• Antibiotics for

mother and baby• Warming • Resuscitation• Partograph

• Syphilis Control

• Folate Supplementation

• Malaria control• Antenatal Corticosteroid• Antibiotic for bacteriuria• Kangaroo Mother Care• Birth Spacing

There are proven interventions to address the leading causes of neonatal death

Source: Adapted from Black et al. for the CHERG of WHO and UNICEF, 2010, “Global, Regional, and National Causes of Child Mortality in 2008: A Systematic Analysis,” Lancet 2010

SepsisPneumoniaDiarrheaTetanus

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Hemorrhage

35%

Indirect and Other Direct

30%

Sepsis

8%

Abortion

9%

Preeclampsia

Eclampsia

18%

Source for Causes: Countdown to 2015

• Iron folate supplements• De-worming• Malaria intermittent treatment• Anti-retrovirals

• Tetanus toxoid• Clean delivery• Antibiotics

• Family planning• Post-abortion care

• Active management of the third stage of labor

• Uterotonics: oxytocin & misoprostol

• Blood transfusion

• Magnesium Sulfate• Aspirin• Anti-hypertensives• Cesarean section

There is a core set of proven interventions to address the leading causes of maternal death

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Underlying causes:• Unintended pregnancy • Under-nutrition

• Supporting development and implementation at scale of evidence-based high-impact interventions

• Developing and evaluating delivery approaches to reach underserved families

• Strengthening key elements of health systems to promote effectiveness & sustainability

The central strategic approaches of USAID’s MNCH Programs

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PRODUCT DEVELOPMENT

INTRODUCTIONFIELD

IMPLEMENTATIONPRIORITY SETTING

GLOBAL HEALTH MISSIONS

Catalytic activities to facilitate introduction

Multi-country program roll-out /diffusion into

regular use

Strategic planning, problem identification,

priority setting

Continued diarrhea deaths

Zinc tablets, improved ORS formula

Developing GMP & manufacturing capacity; policy development; pilot

testing in countries

Support for zinc introduction with ORT

in 14 countries

Applied research creates new interventions &

approaches

USAID’s MNCHprogram uses a research-to-implementation pathway approach

14

15

• Oral Rehydration Therapy (ORT); improved ORS, zinc adjunctive treatment

• Vitamin A

• Early work on Hib, rotavirus, pneumococcal vaccines

• Community treatment of pneumonia

• Essential newborn care

Prior achievements Current activities• Community-based

treatment of severe pneumonia

• Simplified treatment for suspected newborn sepsis

Planned activities

E.g. Developing interventions, technologies & approaches to address critical needs in child health

(Examples)

Technologies

• Non-reusable syringes

• Vaccine Vial Monitors

• Safe birth kits

• Uniject (e.g. Tetanus

Toxoid)

• Antibiotics in Uniject for newborn treatment

• Chlorhexidine for newborn umbilical cord

• Simplified vitamin A blood level assay

• Anemia diagnostic tool

• Research on integrated community case management • Adaptation of

quality improvement for CHW performance• Behavioral interventions on indoor air pollution

• Research on family recognition of newborn illness, care-seeking, and health service response

• Evaluation of integrated services

Increasing

emphasis on

implementation

(vs.

intervention)

research

Scale-up of high impact interventions– PPH example

Global ActionsNational Strategic Choices

Program ImplementationSustainability /

InstitutionalizationIntroduction Early Mature

Global advocacy and partnerships: Global action to support work on reduction of PPH

Global clinical and program

approaches: Evidence-based

interventions for prevention and

management of PPH demonstrated

PPH Policy: AMTSL/misoprostol use;

Expanded job descriptions for skilled birth attendant

cadres managing PPH; PPH service delivery guidelines

Health system governance: Proactive financing of

maternal health services

Drugs & equipment Oxytocin/ misoprostol procurement, logistics,

distribution

Service delivery capacity at sites: Reliable infrastructure,

personnel, and systems to deliver services

Health workers training systems:

For PPH prevention and management

,

Community mobilization:

Awareness raising of PPH;

Birth preparedness

Pilot programs:Phase 1

implementation of misoprostol and/or AMTSL for all skilled

birth attendant cadres

Program initiatives in obstetric and postpartum

management: Quality of care; Clinical training;

Supervision

Pharmaceutical systems:

Uterotonics on Essential Drug List

and in Drug Registration; Supply chain management

National advocacy: Expansion of

national program and highlight work

of champions

Standardization: Quality of care approaches;

Government led training expansion

Programmatic growth:

Adding districts, partners, financing

Training programs: Government

budgeted training programs on PPH; PPH competencies in pre-service and

in-service curricula

Clinical coverage:High coverage use of a uterotonic; Public

and private implementation

Drug & equipment availability:

Drugs and supplies in government

routine procurement mechanisms

REDUCTION OF PPH AND IMPROVED MATERNAL

HEALTH STATUS

M&EReadiness

assessmentPilot project

dataSurvey data

Indicators in HMIS

Routine monitoring

Source: MCHIP, 2011. 16

Applying the financial “lever” is bringing more women into life saving services

Key Financing Approaches

• Health Insurance

• Conditional cash transfers

• Vouchers

• Free services

Rwanda

• There is a correlation between increased enrollment in health insurance and increased institutional deliveries

• National scale-up efforts have increased coverage from 7% in 2003 to 91% in 2010

• Institutional deliveries have increased from 31% in 2000 to 52.10% in 2008

• Recent research has shown a correlation between pay for performance (P4P) and an increase in institutional deliveries by 21.1%

Sources: Rajkotia and Charles/USAID; Soucat/WB17

REPRODUCTIVE• Post-abortion

care• STI case

management

CHILDBIRTH CARE• Emergency obstetric care

• Skilled obstetric care, immediate newborn care (hygiene, warmth, breastfeeding) & resuscitation

EMERGENCY NEWBORN AND CHILD CARE• Hospital care of newborn and childhood illness,

including HIV care•Extra care of preterm babies, including Kangaroo

Mother Care• Emergency care of sick newborns

REPRODUCTIVE HEALTH CARE

• Family planning• Prevention and management of

STIs and HIV• Peri-conceptual

folic acid

ANTENATAL CARE• 4-visit focused

package• IPTp and bednets

for malaria• PMTCT

POSTNATAL CARE• Promotion of healthy

behaviors• Early detection of and

referral for illness• Extra care of LBW

babies• PMTCT

CHILD HEALTH CARE• Immunizations & nutrition e.g.

Vitamin A supplementation & growth monitoring

•IPTp and bednets for malaria• Care of children with HIV,

including cotrimoxazole

FAMILY & COMMUNITY

• Adolescent & pre-pregnancy nutrition

• Education• Prevention of STIs

and HIV

• Counseling & preparation for newborn care, breastfeeding,

birth & emergency preparedness

• Where skilled care is not available, consider clean

delivery & immediate newborn care, including

hygiene, warmth, and early initiation of breastfeeding

HEALTHY HOME CARE, including:• Newborn care (hygiene, warmth)

• Nutrition, including exclusive breastfeeding & appropriate complementary feeding

• Seeking appropriate preventative careDanger sign recognition & care seeking for illness

• ORS & zinc for treatment of diarrhea• Where referral is not available, consider case management for

pneumonia, malaria, & neonatal sepsis

Improved living and working conditions– housing, water, sanitation & nutrition

Clin

ical

Out

reac

h/

Out

patie

nt

Fam

ily/

Com

mun

ity

Intersectoral

BIRTH

Strategic integration of FP, MNCH, nutrition, infectious diseases and water and sanitation interventions is essential

Pre-pregnancy Pregnancy Newborn/post-natal Childhood

18Adapted from K.J. Kerber, et al., Continuum of Care for Maternal, Newborn, and Child Health: From Slogan to Service Delivery, 370 Lancet 1358 (2007).

Program Progress: BangladeshMaternal deaths have declined by 40% in last 9 years

3,870

More needs to be done:

• Continue fertility reduction to replacement level

• Increase women’s education

• Improve referral systems and referral level care

• Focus on PPH and PE/E — still the biggest killers

• Expand access to care at upazilla and union level

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Global Health Initiative (GHI): Context and Rationale

Objectives• Achieve major improvements in health outcomes in 8

health areas, aligned with the health-related MDGs• Progress along 7 principles, including country ownership

and HSS

Approach• Multi-year initiative• Coordinates and integrates all U.S. global health efforts

through a whole of government approach• Do more of what works, including better alignment, smart

integration, and reform• Led by U.S. Ambassador and includes all U.S agencies in

health to promote and achieve sustainable health outcomes

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MCH-relevant GHI Goals

Maternal Health

Child Health

Nutrition

• Reduce maternal mortality by 30 percent across assisted countries

• Reduce under-5 mortality rates by 35 percent across assisted countries

• Reduce child under-nutrition by 30 percent across assisted food insecure countries in conjunction with the President’s Feed the Future Initiative

• Prevent 54 million unintended pregnancies

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Family Planning & Reproductive Health

An Action Plan for Smart Integrated Programming in Family Planning,

Maternal and Child Health,and Nutrition

under the Global Health Initiative

BEST:Best Practices at Scale in the Home, Community and Facilities

22

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Integrated programming in family planning, maternal and child health, and nutrition

28 countries are very high need

Asia/Middle East: Afghanistan, Bangladesh, India (UP), Indonesia, Nepal, Pakistan, Philippines, Yemen

Africa: Angola, Benin, DR Congo, Ethiopia, Ghana, Kenya, Liberia, Madagascar, Malawi, Mali, Mozambique, Nigeria, Rwanda, Senegal, (southern) Sudan, Tanzania, Uganda, Zambia

Latin America and the Caribbean: Guatemala, Haiti

Focus on vulnerable populations: urban as well as rural; poor; harder-to-reach and disadvantaged tribal, racial, ethnic and caste groups

Focus on countries and populations with greatest need…

BEST applies the GHI principles…

• Woman and girl-centered approach: with special attention to compassionate and dignified care; status and working conditions of midwives and nurses; female leadership in health policy; the role of men in improved health; and gender inequities.

• Strategic coordination and integration: across the 3 program areas and with other sectors to maximize benefits and increase impact.

• Partnerships: with multilaterals, other donors and private sector – in particular, drug merchants, private providers and social marketing programs.

• Country ownership: with government, communities and civil society to support national plans for family planning, maternal and child health, and nutrition.

• Sustainability through health systems strengthening: with special attention to human resources and removal of financial barriers to care.

• Metrics, monitoring and evaluation: with strong baseline measurement in place and support to monitor programs and measure impact.

• Research and innovation: with emphasis on feasible, community-based approaches; information technologies; and research to practice.

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New initiatives & partnerships

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To improve health outcomes of mothers and newborns and reduce mortality

Underway…• Helping Babies Breathe to expand access to and use of low-

cost resuscitation devices• Saving Lives at Birth – Grand Challenges for Development --

innovation • MAMA

…and others

Harnessing the power of innovation: “Saving Lives at Birth: A Grand Challenge for Development”

Goal: Dramatically and sustainably reduce stillbirth, newborn and maternal death

Challenge: To develop groundbreaking prevention and treatment approaches for pregnant women and newborns in rural, low-resource settings around the time of delivery

Partners:

Grants: $14M to support grants in the first round(1) Seed Grants ($250k) to demonstrate proof of concept(2) Transition Grants ($2 Million) to transition successful innovations

toward scale up

USAID, Government of Norway, the Bill & Melinda Gates Foundation, Grand Challenges Canada, and The World Bank

What We are Looking For:

Sustainable, scalable, and innovative technologies, service delivery models, and "demand side" innovations that empower women and their families to be aware of and access health care at the time of birth and adopt healthy behaviors.

• Content advisors• Expertise in

localization

• Link to UN programs

• Communications

• Strategic vision• Funding• In-kind

resources

• Global Knowledge Exchange

• Capacity building

• Strategic vision• Funding• Link to

governments• M&E Support

Founding Partners:

Supporting Partners:

Launched on May 3, 2011

MAMA: Mission

MAMA will harness the power of mobile technology to empower expectant and new mothers to make healthy decisions.

Target Audience: low income mothers and their household decision-makers with access to mobile phones

DRAFT

COORDINATIONTECHNOLOGY

CONTENT

MEDIA

MOBILE OPERATORS

CORPORATESPONSORS

OUTREACH -GOVERNMENT

OUTREACH - NGO

MAMA Bangladesh Partners as of July 2011

Implementing Partners Supporting Partners

RESEARCH

Lead Partners

ICDDR, B

GHCS MCH funding (including nutrition) – 2000-2011

31

?

GHCS MCH Funding – 2000-2010

32

356

451

495549

Constant 2000 dollars

USAID has focused funding on the field, principally on priority countries

Mil

lion

s of

Dol

lars

“BEST” Countries$276 million (58%)

Other MCH Countries$51 million (11%)

Central & Regional$69 million (15%)

GAVI$78 million (16%)

Total = $474 million

Allocation of MCH funds (excluding nutrition) (GHCS, FY 2010 Enacted)

33

USAID’s MCH

program is highly

decentralized

34

Health systems, governance & finance

Allocation of MCH funds is also focused on key technical / program areas

Derived from 2010 Operational Plan Reports – includes all MCH including nutrition

We will take a closer look at the main child health technical focus areas in the following slides

Thank You!35