This Week's News 7-11 June 2010

3

Momentum, mandates, and money: achieving health MDGs
The Lancet, UK

05/06/2010

Volume 375, Issue 9730, Pages 1946 – 1948

Ann Starrs a , Rotimi Sankore b

Recent years have seen an unprecedented surge of global attention to maternal, newborn, and child health (MNCH). However, despite repeated commitments and calls for action, no major, specific new funding has been directed at the MNCH continuum of care during the past 12—18 months. A UN event in September, 2009 resulted in strong rhetorical and—it seemed—financial commitments. But of the US$5•3 billion nominally pledged at that event, almost none was specifically for MNCH programmes; rather, it was promised broadly to commodities, health-system strengthening, and vaccines.1 These pledges, if fulfilled, will improve maternal and child health outcomes by strengthening overall health services, but will not necessarily generate new funds for essential MNCH interventions, including: family planning; skilled care during and after pregnancy and childbirth; safe abortion, when legal; immediate postnatal care for mother and newborn child; and improved child nutrition and management of childhood illnesses.
Will this situation change? Will key policy makers respond to calls for greater resources to realise the targets for the health Millennium Development Goals (MDGs) 4 (improve maternal health), 5 (reduce child mortality), and 6 (combat HIV/AIDS, malaria, and other diseases)? That remains to be seen. But an extraordinary combination of initiatives and opportunities in the coming months could prompt revolutionary funding changes and concrete actions by donors, countries, and other contributors.
The UN Secretary-General's Joint Action Plan for fulfilment of MDGs 4 and 5, announced in mid-April,2 aims to mobilise key champions and generate definite policy, programme, and funding commitments, including an additional $15 billion for 2011, to realise the vision set out in the Global Consensus for Maternal, Newborn and Child Health.3 The plan builds on widely accepted policies and programmes, and an accountability framework will track what pledges are made and met.

Canadian Prime Minister Stephen Harper intends to make maternal and child health (MCH) the top priority at the G8 Summit this June. Last year, G8 governments declared warm support for the global MNCH consensus;4 this year's support must become more concrete. A commitment to allocate at least 0•1% of gross national income to health assistance, as recommended by the Commission on Macroeconomics and Health,5 would constitute an excellent start.

A global funding mechanism whose mandate specifically includes reproductive, maternal, newborn, and child health (RMNCH) would be crucial to mobilise needed resources.6 The options are to add RMNCH to the mandate of an existing mechanism, or to establish a new one. One proposal is for the Global Fund to Fight AIDS, Tuberculosis and Malaria, the GAVI Alliance, and the World Bank to “coordinate, mobilize, streamline and channel the flow of existing and new international resources to support national health strategies”.7 However, it is unclear how this joint platform would function, especially in terms of its potential to generate and channel new funds, or in terms of its capacity to effectively address the full range of reproductive, maternal, newborn, and child health needs, including such issues as contraception, emergency obstetric care, and treatment of pneumonia and diarrhoea, which are not within the mandate of the Fund or the Alliance.
This situation might change. In April, the Global Fund's board explicitly recognised the link between the health-related MDGs, and encouraged countries and partners, as a matter of urgency, to scale up investments in MCH in the context of the Fund's mandate. It also noted that its present mandate does not address key areas of the continuum of care, and agreed to explore options for “enhancing the contributions of the Global Fund to MCH, recognizing the urgent need for additional and sufficient financing for MCH as well as for AIDS, tuberculosis and malaria”.8
To expect the Fund (or any other funding platform) to take on MNCH without a substantial increase in resources and a formal expansion of its existing mandate is neither reasonable nor realistic. Although funding for MNCH has been rising gradually (from $2•1 billion in 2003 to $4•1 billion in 2007), it is still far below what is needed. Generally, the funding gap is estimated at about $5 billion per year for direct programme costs in 49 aid-dependent countries, with health system needs likely to be three to four times higher.7 However, to increase funding for one health issue at the expense of another would be counterproductive. As implied by the Global Fund board's statement, “the success of one MDG depends on progress in all the others”, a more integrated approach to health will translate more money for health into more health for the money.9
Responsibility does not lie solely with donors, UN agencies, or the G8 countries—developing country governments must also allocate increased resources. In 2001 at Abuja, African Union governments pledged to allocate 15% of national budgets to health. Only six of 53 African Union member states have met the Abuja commitment thus far, and this July's African Union Summit in Kampala presents an opportunity to restate the 15% pledge and increase the health and related social investments that will bring measurable progress on MDGs 4, 5, and 6.10 If high-quality MNCH interventions reached every family in sub-Saharan Africa, nearly 4 million women, newborn infants, and children could be saved every year.11
Events in the coming months—including the Women Deliver and Countdown to 2015 joint conference, the G8 and G20 Summits, and the UN's MDG Summit in September—offer high-visibility opportunities for action. Equitable progress on RMNCH and AIDS, tuberculosis, and malaria needs overall increased funding, and a global funding mechanism that explicitly includes RMNCH and supports strengthened health systems. Leaders must take bold and concrete action to meet previous financial commitments, make new ones, and increase accountability for these commitments.

We declare that we have no conflicts of interest.

References

1 International Health Partnership. Healthy women and healthy children: investing in our common future. Outcome document. http://www.internationalhealthpartnership.net/CMS_files/documents/un_general_assembly_meeting_outcome_document_EN.pdf. (accessed May 26, 2010).

2 Partnership for maternal, newborn & child health. Delivering maternal and child health: a call to action. Senior Strategy Meeting. http://www.who.int/pmnch/events/2010/actionplanframework.pdf. (accessed May 26, 2010).

3 Consensus for Maternal, Newborn and Child Health. http://www.who.int/pmnch/events/2009/20090922_consensus.pdf (accessed May 10, 2010).

4 G8 Leaders Declaration. Responsible leadership for a sustainable future. Para 122. http://www.g8italia2009.it/static/G8_Allegato/G8_Declaration_08_07_09_final,0.pdf. (accessed May 10, 2010).

5 Commission on Macroeconomics and Health. Macroeconomics and health: investing in health for economic development. Report of the Commission on Macroeconomics and Health. http://www.emro.who.int/cbi/pdf/CMHReportHQ.pdf. (accessed May 26, 2010).

6 Cometto G, Ooms G, Starrs A, Zeitz P. A global fund for the health MDGs?. Lancet 2009; 373: 1500-1502. Full Text | PDF(63KB) | CrossRef | PubMed

7 High Level Taskforce on Innovative International Financing for Health Systems. More money for health, and more health for the money. http://www.internationalhealthpartnership.net//CMS_files/documents/taskforce_report_EN.pdf. (accessed May 10, 2010).

8 Exploring options for optimizing synergies with maternal and child health: decision point GF/B21/DP20. http://www.theglobalfund.org/documents/board/21/GF-BM21-DecisionPoints_en.pdf. (accessed May 10, 2010).

9 WHO. Maximising positive synergies between health systems and global health initiatives. http://www.who.int/healthsystems/MaximizingPositiveSynergies.pdf. (accessed May 10, 2010).

10 Sankore R. A call for a massive paradigm shift from just health financing to integrated health, population and social development investment in Africa: the case for progressing from only 15% to 15% plus. Health Financing Paper for AU July 2010 Summit preparatory meeting, Addis Ababa. http://www.equinetafrica.org/bibl/docs/SANfin23052010.pdf. (accessed May 26, 2010).

11 ASADI. Science in action: saving the lives of Africa's mothers, newborns and children. http://www.who.int/pmnch/topics/continuum/2009_scienceinaction/en/index.html. (accessed May 10, 2010).

a Family Care International, New York, NY 10012, USA

b Africa Public Health Alliance and 15%+ Campaign, Lagos, Nigeria

4

Don't get ill
The Economist, UK

03/06/2010

ON TAKING over as minister of health a year ago, Aaron Motsoaledi declared himself “shocked” by the state of the public health-care system. Media horror stories about dirty and overcrowded hospitals, long waiting times, lack of medicines and a shortage of medical staff were largely true, he admitted: “I don’t think it will be an exaggeration to say that some of our hospitals are death traps.”
Money is not the main reason. The government is pumping over 100 billion rand into the system this year, which amounts to 12% of its budget and 3.7% of GDP—not massive, but more than most provincial governments (who are responsible for health care) know how to spend. The main problem is once again an acute shortage of qualified staff. Many thousands of public-sector doctors, nurses and other medical practitioners have left the country, fed up with the poor pay and appalling conditions. Others have gone into the rapidly expanding private sector. A study in 2007 found that one-third of public medical posts were unfilled. In some hospitals the vacancy rate for nurses is as high as 60%. The public sector now has just one doctor for every 4,570 inhabitants, against one for every 600 in private medicine. For specialists the disparity is even greater.
Under apartheid, public health-care for whites, like education, was generally so good that there was little need for private medicine. Even health services for blacks were often a lot better than they are now. The service has deteriorated so much that more than 8m South Africans (17% of the population) have taken out private medical insurance. Half of them are black. The flat-rate basic premium, set by the government, is 800 rand per month for an individual and 2,000 rand for a family, regardless of age or state of health. A further 20% of South Africans use the private sector occasionally and pay as they go. In all, South Africa spends some 8.6% of its GDP on health, close to the international average. But the public sector accounts for only 41% of that total, compared with 82% in Britain, 79% in France and 46% even in America.
In an attempt to bridge the gulf between public and private health care, the government has proposed introducing a national health-insurance scheme. This has sent private health-care users into a tizzy, especially when a purported draft proposal seemed to suggest that 85% of their health-insurance premiums would be incorporated in the new scheme, and that any service provided by the public sector would no longer be covered by private health schemes. If true, that would be a sure way to cause a massive further brain-drain. However, as the scheme would cost anything between 165 billion and 244 billion rand, it seems unlikely to be introduced in the near future.
The silent killer

South Africa’s HIV/AIDS epidemic, exacerbated by a decade of AIDS “denialism” under Mr Mbeki, who claimed the disease was not caused by HIV, is putting a huge extra strain on the public health system. The number infected is now put at around 6m, or one in eight South Africans. An estimated 3m people have already died from the disease and over 350,000 more are succumbing every year. New infections run at about 1,350 a day, though the rate may have started to come down. Some 1m sufferers, under two-thirds of those in need, are now receiving antiretroviral treatment. The consequences of the epidemic have been devastating. Countless families have lost their breadwinner; hundreds of thousands of children have been orphaned; desperately needed skilled workers are being cut down in their prime.

It is often said that HIV/AIDS knows no barriers, striking indiscriminately at rich and poor, young and old, men and women. But in South Africa there is a huge racial disparity: 14% of the black population is infected, against 1.7% of coloureds and only 0.3% of whites and Indians. Poverty is a factor, but cultural differences also play a role. Research shows that black males in South Africa tend to be more promiscuous and have more sex and more concurrent sexual partners than other racial groups.
In March the government announced a campaign to get 15m people—one in three of the population—tested for HIV/AIDS by June next year. Mr Zuma, not always the most careful in his own personal relations, agreed to spearhead the campaign. Condom use has already been boosted by government advertising campaigns. The government is also planning a large-scale male-circumcision programme because studies have shown that circumcised men halve their chance of infection. A Johannesburg medical centre has begun offering lunch-break “quickies” at 400 rand a snip.
One in three black South African males already undergoes ritual circumcision, but such operations are usually done by unqualified people and cause hundreds of deaths a year. Zulus have traditionally shunned the practice because it would keep them away from the battlefield that called the warrior tribe. However, last year their king, Goodwill Zwelithini, told them to forget the battlefield. Mr Zuma, himself a Zulu, announced last month that he had been circumcised some time ago.
The HIV/AIDS epidemic has caused the average life expectancy in South Africa to fall from over 60 years to below 50 in the past two decades. Here again there are huge racial differences. Whereas a white South African can still expect to live for 72 years, his black compatriot can look forward to only 47. South Africa also performs badly on infant and maternal mortality and tuberculosis, for which it has one of the world’s highest infection rates.
Alcohol abuse is another big health problem. Although 60% of South Africans (mainly women) claim not to drink at all, those who do tend to go over the top. Directly or indirectly, alcohol is responsible for 30% of all hospital admissions. Two-thirds of domestic violence is alcohol-related, as are three-quarters of knife murders and at least half of all road deaths. South Africans are also among the world’s highest users of various illegal drugs. Consumption of dagga (cannabis), cocaine and tik (methamphetamine or speed) is two to three times the world average, says the country’s Central Drug Authority.
Drug and alcohol abuse are partly responsible for the carnage on South Africa’s roads, where the death rate is 33 per 100,000 inhabitants—almost double the world average. For the size of its population the country has relatively few vehicles, fewer than 9m, yet last year some 16,000 people were killed on its roads—victims of speeding, huge pot-holes and road rage, as well as the easy availability of a driving licence for a small bribe.

5

Gender equity is the key to maternal and child health (Editorial)
The Lancet, UK

05/06/2010

Volume 375, Issue 9730, Page 1939
This week's issue of The Lancet covers a range of global issues on maternal, newborn, and child health. On June 7—9, Washington, DC, USA, will host the Women Deliver and Countdown to 2015 joint conference, which will build on the current momentum behind achieving Millennium Development Goals (MDGs) 4 and 5 (improving child, maternal, and sexual and reproductive health). Although the links between the health-related MDGs (which include MDG 6, to combat HIV/AIDS, malaria, and other diseases) is increasingly being realised, one glaring omission from the conversation on how the targets will be met in 2015 is the essential contribution of MDG 3—to promote gender equity and empower women.
Solving the predicaments facing women is a crucial development objective. But it is also a neglected instrument for health. Women and girls make up 60% of the world's poorest people and two-thirds of the world's illiterate people. Yet, with education and empowerment, they can lead healthy lives, lift themselves and their families out of poverty and disease, usually marry later, and have fewer and healthier children who are more likely to attend school themselves. The MDG 3 target was to eliminate gender disparity in primary and secondary education, preferably by 2005, and in all levels of education no later than 2015. The indicators for MDG 3 are: ratios of girls to boys in primary, secondary, and tertiary education; share of women in wage employment in the non-agricultural sector; and proportion of seats held by women in national parliament.
To date, the MDG 3 target for 2005 has not been achieved and progress since then has been slow and insufficient. Of the 113 countries that failed to achieve gender parity in both primary and secondary education by the target date of 2005, only 18 are likely to achieve the goal by 2015. The widest gaps are in sub-Saharan Africa, Oceania, and western Asia. In terms of employment, women occupy almost 40% of all paid jobs outside agriculture in 2008, compared with 35% in 1990. But almost two-thirds of women in the developing world work in vulnerable jobs as self-employed or unpaid family workers. As for political representation, since 2000, the proportion of seats for women in parliaments only increased from 13•5% to 17•9%. There are notable exceptions, such as Rwanda, where impressively, women occupy 56% of parliamentary seats.
Tackling gender equity is difficult because it involves challenging cultural norms and stereotypes. Providing education to girls is not enough to make a substantial difference to health and development. A challenge is to understand and support more culturally sensitive and rights-based approaches to gender equity so that the discriminatory social structures, and systems that keep gender equity from being realised can be eliminated. For example, improving child labour laws and getting tougher on the legal age of marriage.
A medicalised and technological approach to MDGs 4, 5, and 6 has meant that the political discussion around them has excluded gender equity. Yet this approach marginalises the analysis of gender equity as a root cause and contributing variable to maternal and child health, and is reflected in the absence of a gender focus in public health policies and programmes. Technological fixes, such as access to services, drugs, and vaccines will not by themselves achieve long lasting change for future generations. They will not percolate through all layers of society. Huge inequities in maternal and child health both within and between countries will be perpetuated.

Gender-responsive governments and policies need to be put in place to protect and favour women and girls—for example, allowing young mothers to return to school. If the right to health and education is not accepted as an argument for action, then an economic case should be used. For example, in India, if the ratio of female to male workers was increased by just 10%, the gross domestic product would rise by 8%. With the world's largest generation of young people now entering their sexual and reproductive lives, there is an urgent need to mobilise a culture of men and women to support gender equality as a solution to some of these persistent development problems.

MDG 3 is not just a goal in itself but a driver for all the MDGs, and is intimately linked and causally connected to MDGs 4, 5, and 6. Now is the time to invest in understanding these linkages and form strong alliances between constituencies in health and gender equity. The Women Deliver gathering provides such a platform and an immense opportunity to take maternal and child health issues out of their currently narrow health contexts.
For more on The Millennium Development Goals Report 2009 see http://www.un.org/millenniumgoals/pdf/MDG%20Report%202009%20ENG.pdf
For more on Keeping the promise: a forward-looking review to promote an agreed action agenda to achieve the Millennium Development Goals by 2015 see http://www.un.org/ga/search/view_doc.asp?symbol=A/64/665
For more on the Development Assistance Committee guiding principles for aid effectiveness, gender equality and women's empowerment see http://www.oecd.org/dataoecd/14/27/42310124.pdf

6

Melinda Gates tells the world that women matter
The Guardian, UK

07/06/2010

Sarah Boseley
Melinda Gates today urged the world on to greater efforts to save the lives of women in childbirth and their babies, with a stirring speech at the Women Deliver conference in Washington and a pledge of $1.5 billion for programmes to help. This is what she said:
Every year, millions of newborns die within a matter of days or weeks, and hundreds of thousands of women die in childbirth. The death toll is so huge, and has persisted for so long, it's easy to think we're powerless to do much about it. The truth is, we can prevent most of these deaths – and at a stunningly low cost – if we take action now.
Gates has moved a long way from the early philanthropic years, when she and Bill backed promising scientific breakthroughs with cash but the words were few. Today, Melinda Gates was openly political in a cause that her travels in the developing world have made dear to her. This is what she told the conference, a mass gathering of activists in the cause of women and babies:
It is not that the world doesn't know how to save the 350,000 mothers and 3 million newborns who die every year. It is that we haven't tried hard enough. Policymakers in both rich and poor countries have treated women and children as if they matter less than men. They have squandered opportunities to improve their health. The world hasn't come together to do what's necessary to save women's and children's lives.
Until now. Now, the world is changing. You are changing it. In this room, there are health experts who worked tirelessly for women and children, even when it was lonely work. There are advocates who kept up the drumbeat, even when others were silent. There are government officials who listened, and acted, even when others were deaf and dormant.
Death in childbirth is not inevitable, she said. Fatalism must not be tolerated. And interestingly, she urged a different approach that she said the Gates Foundation was espousing - integration not only of maternal and newborn health, which has become an accepted rallying cry, but of all the health needs of women and their families. That means not only childbirth but also proper nutrition, not only immunisation but contraception. The new money from the Bill and Melinda Gates Foundation will support "family planning, maternal and child health, and nutrition programs" in developing countries, she said.
Gates said the next few months will offer unprecedented opportunities to lower the death toll, which the (Gates-funded) Institute of Health Metrics and Evaluation in Seattle recently set at 343,000 women a year - down from the 500,000 that had been used as a ballpark figure since 1980. Canada will put forward a major maternal and child health initiative at the G8 summit it is hosting later this month ahead of the UN summit on progress towards the Millennium Development Goals in September (maternal mortality is well off target).
A significant proportion of the new Gates money will go to Ethiopia ($60 million) and India ($94 million) and other countries with high maternal mortality rates.
For more from the conference, click here for the live webcast and replay.
Meanwhile Oxford University is using a new approach to try to find out from the doctors, nurses and midwives in hard-pressed countries what would help them to cut the death toll. They will use crowd-sourcing, a technique at one time employed by this newspaper to investigate MPs' expenses claims. The Oxford team will ask 10,000 healthcare professionals across Africa, Asia, Latin America and the Middle East ("the crowd") to complete an online survey to establish where the gaps lie. Global Voices for Maternal Health claims to be the first international project to make use of crowd-sourcing technology in the public health sector on such a scale. The project has the support of the International Federation of Gynecology and Obstetrics (FIGO), and the International Confederation of Midwives (ICM).