Draft - July 21, 2010

A Joint Plan of Action for Women's and Children's HealthSaving 16 Million Lives

UN Secretary-General Ban Ki-moon

Despite accelerating progress in tackling infectious diseases, the global death toll is still too high, especially for women, adolescents and newborns. From 1990 to 2008, over 200 million children under five, including almost 80 million newborns, have died needlessly from preventable causes[1]. Nearly 20 times that number – over 4 billion children – have survived, but did not reach their full potential[2]. Over the same period, over 8 million women and adolescent girls have died from preventable causes during pregnancy and childbirth[3]. And 30 times more – over 250 million women and adolescent girls – have suffered debilitating injury or infection[4]. The tragedy is that most of this death and disability could have been prevented with simple and cost-effective interventions. This cannot continue - we must do more for women and children to achieve the Millennium Development Goals (MDGs).

Progress is possible, even in resource poor settings. Many countries are prioritizing women’s and children’s health within national health agendas. Innovations in technology, treatment, and programs are making it easier to provide better and more effective care; existing and new financing mechanisms are making that care more accessible. By investing in these efforts, we will see major improvements. For example, we have already made dramatic progress in reducing child’s deaths. Globally, the total number of under-five deaths declined from over 12 million in 1990 to under 9 million in 2008. This means that, in 2008, 10,000 fewer children died each day than in 1990.[5]

Now is the time to come together to accelerate progress. We must scale up a priority package of high impact interventions, integrating our efforts across diseases and across sectors like health, education, gender equity, water and sanitation, poverty reduction, and nutrition. Women’s and children’s health is relevant for all the MDGs (See Annex 1). We must make better use of the money currently available. Over the next five years, we must raise between US$14 billion to US$22 billion per year for women’s and children’s health on top of existing funds. And we must hold ourselves accountable to deliver on our commitments.

With only five years left, UN Secretary-General Ban Ki-moon has initiated a global effort on women’s and children’s health, which encompasses newborns, infants, children, adolescents, and women at all phases of their reproductive lifecycle. This document is our Joint Plan of Action: ittells the world how we can coordinate our actions to save lives, to improve health, to achieve the MDGs, and to ensure our investments are fruitful. All partners must come together - including governments, policy-makers, civil society, community organizations, global and regional institutions, donors, philanthropic foundations, UN agencies, development banks, the private sector, the health workforce, professional associations and the academic and research community. Everyone has an important role to play.

SIDEBAR: Focusing on women and children across the continuum of care

Making progress on women’s and children’s health will require comprehensive, integrated and coordinated attention along the continuum of care for women and children. This includes newborns, infants, children under five, women of reproductive age, including adolescent girls, pregnant women and nursing mothers. This plan focuses especially on times in the continuum of care when women and children are most vulnerable. For women and newborns alike, the greatest risk of death comes during childbirth and in the first few hours and days afterwards.Adolescents are another vulnerable group – focused attention is needed to empower them with greater control over their life choices, including their fertility.

SIDEBAR: Saving 16 Million lives by 2015

If we are successful, the health and well-being gains would be tremendous. Between 2011 and 2015, we could help avert over 15.3 million deaths of children under five, including more than 3.4 million newborn deaths. We could help prevent 32.9 million unwanted pregnancies and 740,000 pregnant women from dying from complications related to pregnancy or childbirth, including unsafe abortion. Finally, an additional 87.8 million children under five years of age would be protected from stunting and an additional 120 million children would be protected from pneumonia.[6]

BOX 1: Building on our health and human rights commitments

The MDG Summit in September 2010 offers a unique chance for global leaders to make a decisive move to improve the health of women and children. But it also provides the opportunity to reaffirm commitments that have already been made. This global effort has received strong support recently from Member States during the G8, Pacific Health Summit, and African Union Summit. It also builds on commitments made at the ECOSOC Ministerial Review on Global Health; the UNGA Special Session, Healthy Women, Healthy Children: Investing in Our Common Future; the 54th session of the Commission on the Status of Women; the International Conference on Population and Development (ICPD) Programme of Action; and the Beijing Platform for Action. It builds on regional commitments and efforts, such as the Maputo Plan of Action and the Campaign on Accelerated Reduction of Maternal Mortality in Africa (CARMMA).

This Joint Plan of Action is also grounded in internationally recognized human rights treaties such as the International Covenant on Economic, Social and Cultural Rights (CESCR), the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW), and the Convention on the Rights of the Child (CRC). This was affirmed again through the recent resolution on maternal mortality adopted by the Human Rights Council.

Investing in the health of women and children makes good sense

Despite the central role that women and children play in development, progress has been slowest on the MDGs relating to their health, especially addressing maternal mortality. Deaths in pregnancy and childbirth result in economic and social catastrophe – depriving families of income and depriving surviving children of nurturing, nutrition, and education.

Investments will target the inequities that prevent the most vulnerable people in society from accessing the quality health care they require, for example, by removing financial barriers and providing social health protection. Increasing investment in women’s and children’s health is not only critical for stable, peaceful and productive societies; it helps them attain their basic human rights:

  • Investing in women’s and children’s healthhelps them realize their fundamental human rights. Women and children are entitled to the highest attainable standard of health. This is a fundamental principle of development work and human rights, affirmed by many countries in various international and regional human rights treaties. If women and children view health and development as their right, they could demand quality, essential services, and accountability for commitments.
  • Investing in health is cost-effective. Providing essential health care to women and children prevents illness and disabilities, saving billions of dollars that would otherwise have been spent on medical treatment. In many countries, every dollar spent on family planning saves at least four dollars that would have been spent treating complications arising from unplanned pregnancies[7]. For as little as $1 to $5, childhood immunization can give a child a year of life free from disability and suffering.[8]
  • Investing in the health of women and children reduces poverty. Reducing out-of-pocket payments for women’s and children’s health services will encourage access to health care while protecting poor families from financial hardship. This will allow them to provide for immediate needs such as food and education, and invest more in their future – for example, in housing, education, and income generating activities. Healthy women work more productively, and stand to earn more. Addressing under-nutrition in pregnant women and children can lead to an increase of up to 10% in an individual’s lifetime earnings.[9] Poor sanitation leads to diarrhoea and parasitic diseases, which reduce productivity and keep children out of school.
  • Investing in health stimulates the economy.Maternal and newborn mortality alone causes global productivity losses of US$15 billion annually[10] and hampers economic growth.[11] Investing in children’s health has high economic returns, creating the foundation for a more productive future workforce. By not addressing under-nutrition, a country’s GDP may be lowered by as much as 2%.[12] For example, 30-50% of Asia’s economic growth between 1965 and 1990 has been attributed to reductions in infant and child mortality, reduced fertility rates, and improvements in reproductive health.[13]

Working together to accelerate progress

We know what works. Women and children need an essential and integrated package of interventions and services delivered in a well-functioning health system. Many countries are making progress. Tanzania, for instance, has reduced deaths of children under five by 15% to 20% by providing vitamin A supplementation twice a year during campaigns. By ensuring that 99% of its women receive 4 prenatal visits and give birth in a health facility, Sri Lanka has reduced maternal mortality rate by 87% in the past 40 years.

In line with the Paris Declaration, the Accra Agenda for Action, and the Monterrey Consensus partners need to commit to working together in the following areas:

Package of essential interventions and services. Women and children should have access to a universal package of guaranteed benefits. For women, adolescents and newborns, this package should includefamily planning information and services, antenatal, newborn and postnatal care, emergency obstetric newborn care, quality skilled care during childbirth at appropriatefacilities, and safe abortion services (whennot against the law). For children, exclusive breastfeeding for children under 6 months, immunizations, oral rehydration therapy, case management of pneumonia, nutritional supplements (Vitamin A and Zinc) and access to appropriate supplementary processed foods to prevent malnutrition should be provided. For both women and children, integrated care is needed for the prevention and treatment of the main communicable diseases (e.g., diarrhoea, malaria, HIV/AIDS, pneumonia, and TB), and health promotion.

Integrated delivery of health care.Partners need tosupport integration of programs and approaches, focusing their efforts on joint goals that span the health-related MDGs and other social determinants of health. Partners should promote integration of health-care services (such as HIV testing and family planning) and build on existing systems with proven delivery mechanisms, so that women and children can receive efficient services in one location and at one time. In particular, they must build stronger links with HIV/AIDS, malaria and TB programs and services such as Expanded Programme on Immunization, sexual reproductive health, adolescent reproductive health and the integrated management of childhood illness, to jointly serve women and children affected by those diseases.

Health systems strengthening. Partners need to support efforts to strengthen health systems in order to deliver integrated high-quality services for women and children at all stages of life, utilize existing health service platforms efficiently to extend the reach of services especially to the community level, and manage scarce resources more effectively. In particular, the number of health facilities need to increase significantly to adequatelyserve the populations most in need with the health workforce, drugs and supplies that they need.

Health workforce capacity building.Partners need to work together with countries to resolve critical shortages of health workers. Coordinated and coherent support should be provided to help countries develop national health plans that include strategies to adequately train, retain and deploy its health workforce so that they are in the right place, at the right time with the right skills and resources.

Country-led health plans. Partners need to build on existing costed national health plans – in the areas of human resource development, financing, delivery and monitoring of an integrated package of priority health interventions – to improve access to services centered around women, newborns, children and adolescents.

Coordinated research and innovation. Partners need to expand research for women’s and children’s health to develop new interventions (such as vaccines, medicines and diagnostic devices) and find innovative ways of increasing access to effectivehigh-quality care, as well as increasing update of services. They must develop and implement a prioritized and coordinated global research agenda for women’s and children’s health.

The Global Consensus for Maternal, Newborn and Child Health, developed and adopted by a wide range of stakeholders, lays out an approach to accelerate progress. It highlights the need to align actions in politics, finance, and delivery around a cohesive set of policies and priority interventions, and offers a framework on which stakeholders can align and take action. (See Figure 1.)

Figure 1. The Global Consensus on Maternal, Newborn and Child Health

More health for the money

We must demand more from the money that we invest - increasing efficiency and effectiveness is critical to achieving the MDGs. Experiences from countries show that how efficiently money is spent can have a major impact on outcomes, with Benin, MalawiandBurkina Faso[14] experiencing impressive results with the funds they had available. Greater efficiency can be achieved by integrating efforts across diseases and across social determinates, increasing innovation of cost-effective, evidence-based tools and approaches and improving the effectiveness of financing flowing into countries.

Increasing efficiency through integration

The conditions under which women and children are born, grow, live, work, and age will have a major impact on their health. Efforts to improve the health of women and children must be closely linked to efforts to improve these social determinants – decreasing poverty and malnutrition, increasing access to education, improving equity and the empowerment of women, decreasing incidence of major diseases, improving access to safe drinking water and adequate sanitation. Through integrating the care of women and children with other important services, we can provide care in the most cost-effective and efficient way possible. For example, US$1.5 billion can be saved while achieving the same outcomes by investing in both family planning and maternal and newborn services over just investing in maternal and newborn services alone[15]. Countries have demonstrated this as well. Zimbabwe, for example, has successfully integrated HIV/AIDS care with family planning efforts in 16 health districts, resulting in improved utilization of family planning, expanded condom distribution, greater HIV/AIDS awareness and increases in referrals to Voluntary Counseling and TestingCenters[16].La Paz, Bolivia has reduced maternal mortality by 75% in two indigenous communities by integrating efforts to educate women and educating men about gender equality and reproductive health with training community health workers[17].

Increasing efficiency through innovation

We know that progress is possible. Some of the poorest countries are now making significant reductions in maternal and neonatal mortality and improving women’s and children’s health. Country-led innovations can achieve further reductions, enabling health services to produce better outcomes at the same cost. These range from financial incentives to promote performance and results, to innovative use of communication tools.

BOX 2: Innovation and mobile phones

Mobile phones are an example of how innovation creates unprecedented potential for scale-up. Two out of three mobile users live in the developing world. The UN estimates that half of all residents in remote areas of the world will have mobile phones by 2012. More than 100 countries are now exploring the use of mobile phones for health purposes. In Ghana, for instance, nurse midwives used mobile phones to consult with their peers and supervisors on complex cases. In India, a program sends text messages with information on various health topics not commonly discussed. Finally, Rwanda has a Rapid SMS “alert system” that offers community health workers a way to alert health centers by mobile phone of emergency obstetric and infant cases. Health centers then provide advice or call for an ambulance if needed.

In several countries, dynamic national leadership at the cabinet level, exercised through parliament, is holding local governments accountable for providing reliable information and improving the performance of local health systems. This bold leadership has resulted in rapid development of health systems, often through innovative programs to train and retain new health workers. In addition, public-private partnerships tap the enormous potential of the private sector to increase innovation and risk-taking, improve the quality of services, and to accelerate access to advanced technologies. Innovation also applies to leadership.

Increasing efficiency in our funding channels

A number of international and regional taskforces[18] have recommended that financing should be long-term, predictable, and harmonized. Yet both for countries and for organizations, funding often remains unpredictable. Commitments and disbursements often fail to reach countries. When funding does reach countries, it is often excessively earmarked for specific uses. Donors may be funding similar initiatives in country that could be coordinated in a way that is complementary and achieves greater efficiency. Countries without a unified national health plan may not have clearly articulated health priorities that can guide the use of funds and may not be disbursing all the money they have budgeted.

Countries and donors have agreed on a set of principles to address these challenges. In short, emphasis must be on country-level plans, and should encourage donors to align their aid to countries' health plans where they exist, and to work with countries to develop national health plans where they do not. Countries, with the support of their development partners, should harmonize their health and development budgets and provide clear and separate health budget lines, with all public spending and donor financing on-budget. The International Health Partnership (IHP+) is an example of one initiative that outlines a set of principles to address these challenges for countries and donors.