· web viewsingh s, darroch j, ashford l, vlassoff m. adding it up: the costs and benefits of...

Draft - July 21, 2010

A Joint Plan of Action for Women's and Children's Health Saving 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 causes1. Nearly 20 times that number – over 4 billion children – have survived, but did not reach their full potential2. Over the same period, over 8 million women and adolescent girls have died from preventable causes during pregnancy and childbirth3. And 30 times more – over 250 million women and adolescent girls – have suffered debilitating injury or infection4. 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.

1 WHO. World Health Statistics 2010. Geneva, WHO, forthcoming in May 2010. WHO Mortality database [online database]. Geneva, World Health Organization, 2010. (http://www.who.int/whosis/mort/download/en/index.html). Unicef. State of the world's children 2010. New York, Unicef, 2009. Black et al for the for the Child Health Epidemiology Reference Group. Global, regional, and national causes of child mortality in 2008: a systematic analysis. The Lancet, Volume 375, Issue 9730, Pages 1969 - 1987, 5 June 2010. 2 Lancet series on Early Childhood development.3 WHO, UNICEF, UNFPA, The World Bank maternal mortality database - preliminary data.4 Ashford L. Hidden suffering: disabilities from pregnancy and childbirth in less developed countries. http://www.prb.org/pdf/HiddenSufferingEng.pdf.5 The Millennium Development Goals Report 2010. Department of Economic and Social Affairs of the United Nations Secretariat. 2010.

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http://www.prb.org/pdf/HiddenSufferingEng.pdf

http://www.who.int/whosis/mort/download/en/index.html


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: it tells 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 2015If 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

6 Based on analysis by the Joint Plan of Action Finance working group. Derived from the High Level Task Force estimates taking an average of the WHO Normative approach developed by WHO in collaboration with UNAIDS and UNFPA, and the Marginal Budgeting for Bottlenecks (MBB) approach developed by the World Bank and UNICEF in collaboration with the UNFPA and the PMNCH.

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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 senseDespite 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 health helps 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 pregnancies7. For as little as $1 to $5, childhood immunization can give a child a year of life free from disability and suffering.8

7 Frost J, Finer L, Tapales A. The Impact of Publicly Funded Family Planning Clinic Services on Unintended Pregnancies and Government Cost Savings. Journal of Health Care for the Poor and Underserved 19 (2008): 778–796.8 Mills A. and Shillcutt S. Copenhagen Consensus Challenge paper on Communicable Diseases, 2004.

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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 annually10 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 progressWe 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 include family planning information and services, antenatal, newborn and 9 Horton S, Shekar M, McDonald C, Mahal A, Brooks JK (2010) Scaling up Nutrition: What will it Cost? World Bank: Washington DC.10 USAID, 2001. USAID Congressional Budget Justification FY2002: program, performance and prospects – the global health pillar. United States Agency for International Development: Washington, DC.11 Bloom D, Canning D. The Health and Wealth of Nations, Science, 2000, Vol. 287, pp 1207-1208.12 Horton S, Shekar M, McDonald C, Mahal A, Brooks J (2010), Scaling up Nutrition: What will it Cost? World Bank: Washington DC.13 Maternal, Newborn and Child Health Network for Asia and the Pacific (2009) Investing in maternal, newborn and child health - the case for Asia and the Pacific. Geneva: World Health Organization and the Partnership for Maternal, Newborn and Child Health.

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postnatal care, emergency obstetric newborn care, quality skilled care during childbirth at appropriate facilities, and safe abortion services (when not 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 to support 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 adequately serve 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 effective high-quality care, as well

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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 moneyWe 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, Malawi and Burkina Faso14 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

14 Benin: U5-MR from 184 in 1990 to 121 in 2008, government health expenditure per capita $13. Malawi: U5-MR from 225 in 1990 to 100 in 2008, $14 per capita. Burkina Faso: U5-MR from 201 in 1990 to 110 in 2008, $14. Sources: Countdown to 2015 Decade Report (2000-2010). See website for report and associated Lancet article: http://www.countdown2015mnch.org; Africa Public Health info.

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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 alone15. 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 Testing Centers16. 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 workers17.

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

15 Singh S, Darroch J, Ashford L, Vlassoff M. Adding It Up: The Costs and Benefits of Investing in Family Planning and Maternal and Newborn Health. Guttmacher Institute and UNFPA, 2010. 16 Extending Service Delivery Project: Best Practice Brief # 1. Extending Service Delivery Project, USAID.17 PAHO, March 2008, http://www.paho.org/english/dd/pin/ePersp001_news04.htm.

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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 channelsA number of international and regional taskforces18 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.

Today, funds for women's and children's health flow to countries through multiple channels, including traditional bilateral funding and multilateral channels. Donors and recipient countries are committed to significantly improve harmonization and alignment at the country level, to reduce fragmentation and to ensure that more funding is rapidly and effectively channelled to those who need it. One new consolidated channel, called the Health Systems Funding Platform, commits the World Bank, the GAVI Alliance, and the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund), with the support of WHO, to coordinate and align their funding for health systems with countries’ plans, timelines and processes. The Platform is being introduced in several countries and other funders are joining - through it, over US$1.45 billion19 of new money has been committed to countries.20

18 The Taskforce on Innovative International Financing for Health Systems conducted a detailed analysis of around 100 existing innovative financing mechanisms to assess their potential for use to strengthen health systems, and developed a priority list of 24 mechanisms. More Money for Health and More Health for the Money, Taskforce on Innovative International Financing for Health Systems, 2009. Constraints to Scaling Up and Costs: Working Group 1 Report, Taskforce on Innovative International Financing for Health Systems, 2009. 19 This represents funds committed through the expanded IFFIm (GAVI managed), and the Results Based Trust Fund managed by the World Bank. This funding has been supported by the governments of Norway, UK and Australia. 20 This channel will use both joint assessment and a harmonized financial management framework. The joint assessment is based on an agreed set of IHP+ attributes for sound health sector plans, which include the requirement that all relevant government and non-government stakeholders in country participate in the assessment. Under a harmonized financial management framework, funding from different agencies will not necessarily be pooled.

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Nepal is one example of a country moving ahead with the Platform as a way to align partners’ programs and grants with Nepal’s own national health plan.

More money for health Increased efficiency and effectiveness can only take us so far. We must also raise more money for women’s and children’s health by 2015. Significant additional annual investments are needed in high burden countries to scale-up efforts in support of the health MDGs – MDGs 1c, 4, 5 and 6 - over and beyond what is spent today. In the 49 lowest income countries21, this gap ranges from US$27 billion per year in 2011 to US$42 billion in 2015 22. Of this gap, women’s and children’s health accounts for almost half of the funding needed: from US$14 billion in 2011 (US$10 per capita) up to US$22 billion in 2015 (US$14 per capita)23 (see Figure 2).

Of the US$21 billion gap in 2015 for women’s and children’s health, US$15 billion are needed for health-systems strengthening to enable the delivery of other interventions and programs. Approximately US$7 billion is required for the interventions and programs for women and children. These include the package of essential interventions and services previously mentioned. More information about these estimates is available in a background paper on www.pmnch.org [FOR FINAL VERSION].

Figure 2. Estimated annual funding shortfall for women’s and children’s health in 49 developing countries, 2011- 2015

21 The 49 countries addressed in this document are: Afghanistan, Angola, Bangladesh, Benin, Bhutan, Burkina Faso, Burundi, Cambodia, Central African Republic, Chad, Comoros, Democratic Republic of Congo, Djibouti, Eritrea, Ethiopia, Equatorial Guinea, Gambia, Guinea Bissau, Haiti, Kiribati, Lao PDR, Lesotho, Liberia, Madagascar, Malawi, Maldives, Mali, Mauritania, Mozambique, Myanmar, Nepal, Niger, Rwanda, Samoa, Solomon Islands, Sao Tome and Principe, Senegal, Sierra Leone, Somalia, Sudan, Tanzania, Timor-Leste, Togo, Tuvalu, Uganda, Vanuatu, Yemen and Zambia.22 The estimates are based on the findings and methodology of the Taskforce on Innovative International Financing for Health Systems and adapted for Joint Plan of Action (JPA) as follows. The Taskforce estimated costs using two different approaches – Scale Up One, based on the Normative Approach developed by WHO in collaboration with UNAIDS and UNFPA, and Scale Up Two, based on the Marginal Budgeting for Bottlenecks (MBB) approach developed by the World Bank and UNICEF in collaboration with the UNFPA and the PMNCH. For the JPA, it was agreed to use median of the Normative approach and the MBB approach to communicate size of the funding gap. In addition, the estimates were revised from a 2009-2015 timeframe to a 2011-2015. More Money for Health and More Health for the Money, Taskforce on Innovative International Financing for Health Systems, 2009. Constraints to Scaling Up and Costs: Working Group 1 Report, Taskforce on Innovative International Financing for Health Systems, 2009. Constraints on Scaling Up the Health MDGs: Costing and Financial Gap Analysis, WHO, 2009, 2010. Health Systems for the MDGs: Country Needs and Funding Gaps, World Bank/UNICEF/UNFPA/PMNCH, 2009. WHO updates 2010. MBB updates 2010.23 The estimates are calculated in US Dollars (2005 US$).

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SIDEBAR: What does this money buy? Assuming the additional funding needs are filled each year from 2011 – 2015, the coverage of health infrastructure and proven interventions would improve dramatically for the most vulnerable women and children in these 49 countries.

This funding would significantly increase access to life-saving interventions. In 2015, for example, the following additional interventions will be provided: (Final data will be provided on Friday)

XX women of reproductive age to have access to family planning XX women to benefit from skilled birth attendance and antenatal care XX infants fully immunized Additional 120 million children would be protected from pneumonia XX under five children receive vitamin A 3.7 million women and children receive ART XX long lasting ITNs to be distributed from 2009 to 2015

This funding would also significantly improve the health infrastructure available to the world’s poorest women and children. In 2015, this would mean that:

85 thousand additional health facilities (including health centers, district and regional hospitals)

3 million additional health personnel (including community health workers, nurses /midwives, physicians, technicians and administrative staff)

Bridging the financial gap

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For the 49 lowest income countries, domestic resources need to be increased but will not be enough on their own. In the best case scenario, we estimate that an additional US$7 billion of domestic funding could be available between 2011 and 2015 if GDP growth continues and this growth is translated through government leadership into increased expenditures for women’s and children’s health. However, this is far below the US$85 billion needed for these countries over the same period.

Other low and middle income countries are better able to cover their own needs.24 Increases in GDP, if translated by strong leadership into funding for women’s and children’s health, could increase the money available between 2011 and 2015 by US$59 billion. This amount could be applied to covering these countries’ domestic funding gaps and then to providing support to the 49 lowest income countries.

Because of this, we call on countries and partner organizations to help bridge the financial gap for the 49 lowest income countries. Two main principles inform our call for financial commitments. First, financial commitments should be additional, meaning that countries and organizations contribute money beyond what is already committed. Second, each country or organization should contribute its fair share according to its means – the women’s and children’s health benefits everyone and should be supported by all countries and stakeholders. Figure 3 illustrates the critical importance of national governments, in addition to the private sector and external stakeholders.

Figure 3: Fair share estimate for 49 low income countries by stakeholder groups [Draft - to be updated]

24 Country income classifications follow the World Bank categorizations of countries.

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Stakeholders have a role to play in both providing new funds and allocating funds to women’s and children’s health. Below we highlight potential sources for new funding by stakeholder groups.

Table 1: Sources of funds to bridge the financial gap

Funder Source of funds49 lowest income countries

Ensure increases in GDP translate into up to $7 billion for the health of their women and children.

ODA: Other governments

Other low and middle income countries should provide funds for 49 lowest income countries, after first funding their own internal programs. With a growing share of the world’s economy, many middle income countries have already started to assist low income countries. For example, China, India, Venezuela, the Republic of Korea, Turkey and Brazil have all increased their contributors in recent years. High income countries must make a greater contribution to women’s and children’s health. Already the G8, The Netherlands, New Zealand, Norway, Switzerland, and Korea have committed US$5.8 billion. We anticipate that more countries will join them in the coming years.

Voluntary / innovative contributions

Raise US$2.5 billion to US$7.5 billion cumulatively by 2015 through innovative financing mechanism. For example, UNITAID has negotiated a tax on all flights departing from partner countries which has raised close to US$1 billion since its inception. UNICEF’s Check Out For Children has raised $22 million by asking hotel guests to donate US$1 at check out.

Other: Private sector Make contributions to improving access to medicines in low income countries through donations, price differentiation, and product development etc. According to the Access to Medicines Index 201025, there is a wide variation between companies. Bringing each company up to best practice standards could make very significant contributions in women’s and children’s health for the 2 billion poor people with out access to this trillion dollar market.

Other: Foundations Must contribute their fare share, in addition to what they are already funding. Already several organizations have made additional commitments to women’s and children’s health, over and above their current commitments.

ALTERNATIVE TO TABLE 1

Sources of new funds for women’s and children’s health will need to come from governments themselves and traditional donors as well as new donors. The 49 lowest income countries should ensure that increases in GDP translate into up to $7 billion for health of their women and children. With a growing share of the world’s economy, other low and middle

25 See Access to Medicines website at www.accesstomedicineindex.org

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http://www.accesstomedicineindex.org/


income countries could donate funds after first funding their own internal programs. For example, China, India, Venezuela, the Republic of Korea, Turkey and Brazil have all increased their contributors in recent years. Traditional donors - like foundations and high income countries – need to increase further their support for women’s and children’s health and will likely still provide a majority of the necessary funding. In addition, other countries can do more. The private sector can provide donations, price differentiation, product development and other contributions to improve access to medicines for the people without access to this trillion dollar market. Finally, voluntary / innovative contributions could contribute up to US$2.5 billion to US$7.5 billion cumulatively by 2015 like UNITAID’s surcharge on flights (raised US$1 billion since 2006) and UNICEF’s Check Out For Children program (raised $22 million).

The allocation of new funds to women’s and children’s health is equally important to ensuring that funds reach those who need them. We call on all organizations to make decisions about how much of their own money to allocate to women’s and children’s health. This clearly includes the organizations mentioned above, in particular governments. In addition, Multilateral Development Banks (MDBs), with their increase annual lending capacity26 from US$37 billion to US$71 billion, could allocate more money to the provision of grants, credits and loans for women’s and children’s health. GAVI and the Global Fund both have a critical role to play in allocating funds for childhood immunization and ensuring that more funds flow to women, adolescents and children through countries’ HIV/AIDS, TB and malaria programs. Finally, many NGOs and civil society organizations receive substantial external and governmental contributions that could be funneled toward women’s and children’s health. All organizations needs to make concrete commitments to increase the proportion of funding allocated to women’s and children’s health over the next 5 years.

Holding ourselves accountableAccountability is a critical component to the realization of the objectives set out in this document. It ensures that all partners deliver on the commitments and promises made as well as provides the evidence base to demonstrate that our actions and investments translate into tangible results and long-term outcomes nationally and globally. In addition, accountability guides future actions by informing us of what works, what needs to be improved, and which areas require more attention.

We do not propose to create a new accountability mechanism around this Joint Plan of Action. Instead, we will work to enhance and harmonize existing efforts and mechanisms in use at the country and global levels with the objective of creating a more robust and comprehensive approach to track and report on inputs, results and outcomes for women’s and children’s health. See Figure 4.

26 Estimated based on the G-20 Toronto Summit Declaration, June 26 – 27, 2010.

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Figure 4: Approach to tracking progress

National leadership and ownership are the foundations for accountability. As the majority of monitoring, evaluation, and reporting activities occur or originate at the country level, partners should work together to align with and strengthen countries’ accountability capacities in the context of national health strategies. In addition, this should be supported by strong community-based efforts to hold governments and other implementing organizations accountable for delivering on their commitments. India's National Rural Health Mission, for example, includes a community-based performance monitoring mechanism to ensure that the services reach those for whom they are intended, and that communities participate in the delivery of those services.

Strengthening national capacities also requires harmonized investments in country monitoring and evaluation systems to improve the availability and quality of data in countries. These investments should support countries’ efforts to strengthen their health information systems in line with the Call for Action on Health Information first proposed by the H827 and later adopted by 80 countries in Bangkok in February 201028. Priority investments, which may vary between countries, could include filling essential data gaps (e.g., intervention coverage, births, maternal and child deaths, health status), improving the tracking of resource flows and expenditures, and enhancing data quality assessment and analysis.

27 Includes WHO, UNICEF, UNFPA, UNAIDS, GFATM, GAVI, Bill and Melinda Gates Foundation, and the World Bank.28 The Bangkok Call for Action on Health Information involved 80 countries to discuss how to strengthen countries’ health information capacity. Five principles were adopted: transparency; good governance; capacity building and targeted investments; harmonization and integration; and future planning These principles are based on the H8’s 2010 essay titled, Meeting the Demand for Results and Accountability: A Call for Action on Health Data from Eight Global Health Agencies.

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Existing global mechanisms must also be leveraged to support accountability efforts at the national and global levels. Several mechanisms are being explored to track donors’ financial commitments and disbursements (e.g., OECD-DAC, Countdown to 2015), report on civil society organizations’ activities, and contribute to country-level initiatives (e.g., promotion of National Health Accounts to track health expenditures, UN initiative to develop a “unified costing tool”).

Reducing the reporting burden on countries will also positively contribute to more timely, effective, and efficient monitoring, evaluation, and reporting. A key step is to harmonize the large number of indicators in the health sector. Efforts are underway among partners to develop an agreed set of core indicators that will reduce the number of indicators countries report on while ensuring key information is still collected to track partners’ commitments and assess progress achieved in women’s and children’s health (i.e., outputs, outcomes, and impacts). This work is also expected to contribute to fewer or reduced reports that countries are asked to submit to UN agencies, multilateral institutions, donors, etc.

To ensure that progress is achieved and sustained in maternal, newborn, and child health and that all partners are meeting their commitments, a reporting and validation process is needed. Through 2015, we recommend that the UN General Assembly (UNGA) reviews progress on women’s and children’s health and highlights successes and opportunities for growth among partners. A follow-on review should take place in the World Health Assembly (WHA) to share the results with Ministers of Health so that they can take action. A high-level progress report in women’s and children’s health will be submitted annually or biennially to the UNGA and the WHA. This report will include assessment of progress against the commitments in this Joint Plan of Action. The report will be based on data, evaluation, and reporting provided by countries, the WHO, UNICEF, and other UN agencies as well as analytical work conducted by the independent academic institutions associated with the Countdown for 2015 with the support of the Partnership of Maternal, Newborn and Child Health (PMNCH).

A call to action – we all have a role to playEveryone can make a difference for women and children. Below we summarize the main roles and responsibilities for each key class of stakeholder. We challenge each country and organization to do its part and to hold others accountable for doing theirs.

Women, on behalf of themselves and their children, need to be active participants in their own health who 1) demand their health rights and the highest possible quality of care, and 2) actively learn and adopt best practices to prevent and treat illness. Men also have a critical role to play in supporting women to access health care, engage in family planning activities and overall encouraging greater gender equity and empowerment of women and girls.

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Governments and policymakers at local, national and regional levels need to play a critical role in 1) increasing, approving and allocating funding to programs that benefit women and children through the development of prioritized national health plans 2) ensuring resources are used effectively, 3) encouraging the strengthening of the health system, including the health workforce, monitoring and evaluation systems and local community care, to better serve women and children, 4) introduce or amend legislation and policies that remove barriers and promote women’s and children’s health, including policies that link women's and children's health to other areas (other diseases, education, water and sanitation, poverty, nutrition, gender equity and empowerment) and 5) encouraging participation by wide-range of stakeholders (academics, private sector, civil society, health work force, donors) and harmonization of efforts.

UN and multilateral agencies are responsible for 1) defining and advocating for the adoption of norms, regulations and guidelines that underpin efforts in women’s and children’s health, 2) supporting countries directly in developing and aligning national health plans, 3) providing technical assistance and programmatic support to countries to scale up use of interventions and strengthen their health systems, including the health workforce and community-level care, 4) encouraging multi-sectoral linkages and integration of women’s and children’s health with other international efforts (such as education and gender equality), including harmonized reporting and 5) supporting implementation of systems to track progress and identify gaps.

Donor countries and global philanthropic institutions need to 1) provide predictable long term support (financial and programmatic) aligned with national plans and harmonized with other partners, 2) advocate to influence global health priorities to increase focus on women’s and children’s health, 3) support countries in developing and implementing national health plans and 4) support research to improve the health of women and children.

Civil society has an important role to play in 1) developing and testing innovative approaches to deliver essential services and outreach, especially to the most vulnerable and marginalized populations, 2) educating, engaging and mobilizing affected communities, 3) tracking progress and holding stakeholders accountable for their commitments at all levels, 4) strengthening community and local capabilities, and 5) advocating for increased attention and investment in women’s and children’s health.

Private sector need to engage powerfully in women’s and children’s health by 1) sharing best practices and partner with public sector to improve the health service delivery and provision of infrastructure, 2) developing new drugs, technologies and interventions to improve health services and outcome for women and children, and 3) investing resources and providing financial support or reduce prices for those goods.

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Health workforce29 need to be engaged in 1) providing the care of the highest quality, grounded in evidence-based medicine, good practice sharing through teams, the best tools possible and auditing of clinical practice, 2) working in collaboration to provide universal access to the essential package of interventions for women and children, 3) identifying areas for quality improvement of health services and potential innovations, 4) ensuring that women and children are treated with respect and with cultural and gender sensitivity when health services are provided, 4) advocating for better training, deployment and retention of workers, 5) providing information to track progress and hold authorities and donors accountable, and 6) working as advocates for continued strengthening of the health workforce.

Academic and research institutions are responsible for 1) deliver a prioritized and coordinated research agenda for women’s and children’s health, 2) encourage increased budget allocation (for research or implementation), 3) build research and innovation capacity at research institutions, especially in low and middle income countries, 4) strengthen the global network of academics, researchers and trainers from around the world, 5) report on trends and emerging issues to inform policies and 6) disseminate new research findings and best practices.

Looking forwardThis Joint Plan of Action is the first step towards better health for women and children the world over. But to have an impact, we must translate these ideas into concrete action guided by the ideas of this Joint Plan. We therefore look to each country and organization to make tangible commitments to improving financing, policy and service delivery, according to what each is best positioned to do. Examples of such commitments are provided in Annex 2.

In addition, we must work together. We must ensure that all women and children have access to a package of essential interventions and services supported by fully functional health systems with a skilled health workforce. We must integrate our efforts across diseases, services and other programs and rally around each country’s health plan. We must pursue innovative new tools and new approaches to delivery by investing in research and learning from on the ground experiences. By working together while each doing our fair share, we can have a major impact. Between now and 2015, we can save the lives of more than 16 million women and children, equivalent to the entire population of Cambodia, Chile, Malawi or the Netherlands. And we can bring hope and health to the many millions more who would otherwise have suffered needlessly.

29 Includes physicians, nurses, mid-wives, community health workers and others supporting the health infrastructure in countries. This section also includes the important role of their respective health care professional associations.

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The development of this draft was facilitated by The Partnership for Maternal, Newborn & Child Health. Please send comments to pmnch @who.int

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Annex 1: Linking women’s and children’s health with social determinants Interdependence and indivisibility is embedded in the MDGs. The two MDGs most closely focused on women’s and children’s health – MDG 4, on reducing child mortality and MDG 5, on improving maternal health - complement and interact with the other MDGs. Below we have highlighted these relationships and specific ways in which the community working towards improved health for women and children can connect with other efforts.

Poverty and hunger - nutrition (MDG 1). Poverty is a large contributor to unintended pregnancy and to pregnancy-related mortality and morbidity in adolescent girls and women. Reducing the costs to users of health care services can help to reduce poverty by ensuring women and children seek care when it is needed. Under-nutrition or nutrition-related factors contribute to 35% of under-5 deaths each year and also affect women’s health. Efforts must be made to link programs and interventions related to nutrition (e.g., exclusive breastfeeding for 6 months, use of supplements, deworming) into routine care for women and children at the community level.

Education (MDG 2). Gender parity in education has not yet been achieved. Educated girls and women improve prospects for the whole family, thus helping to break the cycle of intergenerational poverty. In Africa, for example, children of mothers who have received five years of education are 40% more likely to live beyond the age of 5. In addition, schools can serve as a point of contact with women and children, where health-related information can be shared and services offered.

Gender equality and empowerment of women (MDG 3). Empowerment and gender equality increase girls’ and women’s reproductive choices, reduce child marriages, and reduce discrimination and gender-based violence, all of which improve the health of women and children. Those working in women’s and children’s health should look for opportunities to coordinate advocacy and educational efforts for both men and women with organizations that focus on gender equality. In particular, shared programs could include family planning services, health education, and identifying women at risk for domestic violence at the point of care.

HIV/AIDS, malaria, and other diseases (MDG 6). Many women and children still die needlessly from diseases that we have the tools to prevent and treat, making reductions to mortality from these diseases essential to achieving MDGs 4 & 5. In Africa, for example, reductions in maternal and childhood mortality have been enhanced by effective treatment of HIV/AIDS and prevention of mother-to-child transmission (PMTCT) of HIV. Joint efforts to coordinate distribution of these interventions should be encouraged, for example integrating PMTCT into maternal and child health services or ensuring that mothers’ bringing their children for immunizations are offered services as well.

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Environmental sustainability – safe drinking water and sanitation (MDG 7). Sustainable access to safe drinking water and adequate sanitation is critical for the basic health and safety of women and children. Dirty water and inadequate sanitation lead to diseases in children and women (especially expectant mothers), including diarrhoea, typhoid, cholera and dysentery. Efforts to educate women and children about sanitation and to increase access to safe drinking water should be part of community-based health efforts.

Global partnerships (MDG 8). Global partnerships and the efficient provision of aid and financing are essential. These partnerships must work closely with private sector to develop new tools and innovative delivery approaches.

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Annex 2: Examples of Financial, Policy, and Service Delivery Commitments by Stakeholders

Financial Policy Service DeliveryPartner Countries

Increase or, at a minimum, maintain the portion of national budget dedicated to healthE.g. Country X to increase budget to health by y by 20XX

Allocate a significant share of the health budget for maternal, newborn and child health

Introduce or amend legislation and policies to promote women’s and children’s health E.g. Country X to pass and enforce law to prevent early marriage by 20XX

Remove health system bottlenecks to improve delivery of MNCH services (e.g., significantly expand or upgrade health worker cadres, such as midwives, nurses, community health workers) E.g. Country X to increase number of midwives by y

Expand services to address critical needs, such as community-based services for antenatal and emergency obstetric care, permanent family planning methods, etc.

E.g. Country X to increase access to family planning by Y

Donors, UN Agencies, Global Health Initiatives, NGOs, Private Foundations, and Private Sectors

Increase or, at a minimum, maintain funding levels for health and MNCH

Provide predictable, funding in a timely manner, as committed

Untie health aid within X years

Provide funding through existing or new harmonized approaches

Align funding and activities with countries’ health and MNCH plans

Coordinate and harmonize MNCH efforts, including application and reporting processes and technical assistance, with other stakeholders

Specific support to country health plans to deliver essential services.E.g. Donor / NGO X to support country Y to increase access to family planning services to y% by 20XX.

Reduce the reporting burden on partner countries by integrating and harmonizing reporting practices, indicators, etc.

Research Institutions

Increase portion of research budgets targeted to MNCH

Report on trends and emerging issues to inform MNCH policies

Regularly report and disseminate new research findings and best practices

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