Investing in our common future: Joint Action Plan for Women's and Children's Health

Draft for consultation

Author(s)/Editor(s): UN Secretary-General Ban Ki-moon
Publication date: 2010
Language: English

The health of women and children is at the forefront of the development agenda. bold, focused, and coordinated action is required to accelerate progress on the health MdGs. With only five years left until the 2015 deadline to achieve the Millennium development Goals, UN Secretary-General Ban Ki-moon has initiated a global effort on women’s and children’s health that will build upon and revitalize existing strategies and commitments, secure new commitmentsffrom a range of influential partners, and provide organization and accountabilityffor delivery, including at the highest levels.

This global effort builds on commitments made by Member states at the 2009 ECOSOC Ministerial review on Global health; the 2009 UNGA special session, Healthy Women, Healthy Children: Investing in our Common Future; the 54th session of the Commission on the Status of Women; and on regional commitments and efforts, such as the Maputo Plan of Action and the Campaign on Accelerated Reduction of Maternal Mortality in Africa (CARMMA).

2010 presents a critical opportunity for action – to assess and strengthen previous efforts, to embed women’s and children’s health in wider development issues (such as gender equality, education, hiV/Aids and water and sanitation), to increase investment in basic health systems, and to learn from successes to date from regions and countries. The Joint Action Plan for Women’s and Children’s health aims to broaden and intensify support for the health MdGs, reinforce existing commitments, secure new commitments, and establish an accountability framework for delivering results.

Seizing the moment for women and children

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. Considerable momentum already exists. Many countries have taken decisions to further prioritize women’s and children’s health within national and regional health agendas. Considerable progress has been made, even in some of the poorest countries. Innovations have succeeded in delivering care more effectively; existing and new financing mechanisms are ready for a scaled-up effort. If we can invest the necessary energy and resources, we will see major improvements. But we must act now to save lives, to achieve the MDGs, and to ensure our increasing investments are not lost.

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. Progress has been most tragically slow on addressing maternal mortality. Unnecessary deaths in childbirth result in economic and social catastrophe – depriving families of income and depriving surviving children of nurturing, nutrition, and education.

In many countries, even the most basic health care is unavailable to the majority of women and children. Investments must target the inequities that prevent the most vulnerable people in society from accessing the health care they require, for example, by removing financial barriers and providing social health protection. Unless that happens, the MDG targets will not be reached.

Women and children stand at the end of the health-care queue. Increasing investment in their health is not only right thing to do, it is also critical for stable, peaceful and productive societies:

  • Investing in good health is cost-effective. Providing basic 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.
  • Investing in women and children reduces poverty. Reducing out-of-pocket payments for women’s and children’s medical care will encourage access to health care while protecting poor families from financial hardship. This will allow them to provide for immediate needs and invest more in their future – for example, in housing, education, and incomegenerating 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.1 Poor sanitation leads to diarrhea 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 annually2 and hampers economic growth.3 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%.4 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.5

Women’s and children’s health and the MDGs

MDG 1. Eradicate extreme poverty and hunger

Improving the nutritional status of women and children is key to their health and well-being.

  • Nearly 3 million children a year die of under-nutrition.
  • Iron deficiency contributes to 115,000 maternal deaths each year.
  • Nutrition-related factors are responsible for about 35% of child deaths.
  • Routine deworming for intestinal parasites can contribute significantly to reducing hunger and improve utilization of food resources.

MDG 3. Promote gender equality and empower women

Empowering women brings a multiplier effect to the other MDGs, reduces poverty and improves the health of families

  • Women’s ability to decide the number and timing of their children is key to their empowerment and expanded opportunities for work, education and social participation.
  • Educated girls and women improve prospects for the whole family, thus helping to break the cycle of intergenerational poverty. In Africa, children of mothers who have received five years of education are 40% more likely to live beyond the age of 5.
  • Men play a pivotal role in achieving gender equality, including improving women’s and children’s health, reducing HIV transmission, and eliminating child marriage and genderbased violence.
  • Poverty is a huge contributor to too-early pregnancy and pregnancy-related mortality and morbidity in adolescents. It is also a huge driver of the HIV epidemic.

MDG 4. Reduce child mortality

At the current rate, the MDG 4 target of reducing the mortality rate for under-fives by two-thirds by 2015 will not be met, especially among newborns

  • Nearly 9 million children under 5 die each year from causes that can be prevented (by immunization, for example) or treated.
  • 3.6 million infants per year die at birth or during the first month of life, accounting for an estimated 40% of all under-5 mortality.
  • More than 1 billion children lack at least one of their essential needs – food, water, shelter, health care – for survival, growth and development.
  • Under-nutrition contributes to one-third of deaths of children aged between one month and 5 years.

MDG 5. Improve maternal health

In many countries, achieving the MDG 5 targets of improved maternal health and universal access to reproductive health remains a distant dream

  • The majority of women are dying from preventable causes for which highly effective interventions are known. The most common causes of maternal death are hemorrhage, infection, unsafe abortion, eclampsia (very high blood pressure leading to seizures) and obstructed labor.
  • At least 200 million women lack access to family-planning services. This results in 76 million unplanned pregnancies and 22 million unsafe abortions annually.
  • Pregnancy- and childbirth-related deaths, including those from unsafe abortion, are the top killers worldwide of girls aged 15-19, with nearly 70,000 girls dying each year.
  • About 16 million women aged 15-19 give birth every year – about 11% of births worldwide. 95% of these births occur in low- and middle-income countries.
  • About 15% of total maternal deaths worldwide, and 26% in Africa, occur among adolescents.

MDG 6. Combat HIV/AIDS, malaria and other diseases

Many women and children still die needlessly from HIV/AIDS, TB and malaria

  • Globally, the leading cause of death among women of reproductive age is HIV/ AIDS. In countries with high HIV prevalence, AIDS-related complications are among the leading causes of maternal mortality.
  • An estimated 5.4 million youths are living with HIV. About 59% of them are girls.
  • 15.7 million women are living with HIV, leading to 850,000 deaths annually. Only 45% of women receive anti-retroviral treatment to prevent mother-to-child transmission.
  • 280,000 children die from AIDS every year. Only 38% of children living with HIV receive anti-retroviral treatment.
  • Malaria kills 1 million people a year, most of them children under 5. Severe anemia and low birth weight both improve significantly with appropriate treatment and control of malaria.
  • Half of the 11.5 million TB cases and 1.4 million deaths each year occur in women.

MDG 7. Ensure environmental sustainability

Sustainable access to safe drinking water and adequate sanitation is critical for the basic health and safety of women and children.

  • Over 700 million people need access to improved drinking water.
  • Dirty water and inadequate sanitation lead to diseases, including diarrhea, typhoid, cholera and dysentery, that kill over 4,100 children every day.
  • Better water quality and sanitation services reduce expectant mothers’ susceptibility to diseases.
  • In developing countries, adolescent girls’ dropout rates skyrocket due to lack of appropriate sanitation facilities at their schools.
  • Women and young girls can face violence and attacks when walking to and from water sources through isolated areas.
Working together to accelerate progress

For this Joint Action Plan to have its intended impact, all stakeholders must come together as part of a coordinated effort. In line with the Paris Declaration and the Accra Agenda for Action, partners including governments, policymakers, civil society, community organizations, global and regional institutions, donors, philanthropic foundations, UN agencies, the private sector, health-care professionals, and the academic and research community, are asked to commit to working together in the following areas:

Making progress on women’s and children’s health will require focused and coordinated attention, especially at the times 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. 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
  • Country-led health plans. Partners must build on existing national health plans – in the areas of financing, delivery and monitoring of an integrated package of priority health interventions – to improve access to women and girl-centered services.
  • Health systems strengthening. Partners must 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, and manage scarce resources more effectively.
  • Integrated delivery of health care. Partners must improve integration of programs and approaches, focusing their efforts on joint goals that span all the health-related MDGs. Partners should integrate 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 service in one location and at one time. In particular, they must build stronger links with HIV/AIDS, malaria and TB programs and services, to jointly serve women and children affected by those diseases. In Africa, reductions in maternal and childhood mortality have been enhanced by effective treatment of HIV/AIDS and prevention of mother-to-child transmission of HIV.
  • Coordinated research and innovation. Partners must expand research for women’s and children’s health by developing new interventions (such as vaccines, medicines and diagnostic devices) and new ways of delivering care. They must develop and adopt a coordinated global research agenda for women’s and children’s health
Tapping the potential of innovation

We know that progress is possible. Some of the poorest countries are now making significant reductions in maternal and neonatal mortality. 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 mobile phones and other communication tools.

Mobile phones are an example of how innovation creates unprecedented potential for scale-up. There are more than 4.5 billion mobile phones in the world. 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, such as referring people to their nearest health-care facility, and advancing health literacy by educating families and service providers.

Public-private partnerships tap the enormous potential of the private sector to increase innovation, risk-taking, improve the quality of services, and to accelerate access to advanced technologies. Innovation also applies to leadership. In several places, 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.

Because of the vast array of innovations being explored, there is an urgent need to evaluate different models so that we can learn what works and has most potential for being integrated into the health system.

Investing to reach our common goals6

To make the substantial progress required on the health MDGs by 2015, additional financing will be required.7 Currently, total spending on health programs in 49 developing countries alone is an estimated US$31 billion8 per year. In 2011, the funding shortfall is estimated to be at least US$15 billion and up to US$19 billion9 (see Figure 2). Of this amount, up to US$14 billion would be needed for healthsystems strengthening. Approximately US$2 billion is required for programs directly targeting reproductive, women’s and children’s health, including family planning, vaccination, and the management of childhood illnesses. The remaining US$3 billion is needed for other health issues, such as providing essential drugs or combating HIV/AIDS, TB, and malaria and addressing nutrition, water and sanitation. The global community can fill this funding gap, and must commit to do so this year. We need more money for health, and we must also find ways to get more health for the money.

Figure 2. Estimated annual funding shortfall for the health MDGs (including women’s and children’s health) in 49 developing countries, 2011- 2015
More money for health: how we can bridge the gap6

Funding for women’s and children’s health is not a cost, it is an investment. To reach the necessary funding levels, countries – rich and poor alike – will need to increase substantially their current financial commitments. So too will other stakeholders. The financial plan to raise funds is summarized in the table below. This plan identifies that at least US$15 billion in additional annual contributions, from a range of funding partners, is urgently required. Ongoing efforts will ensure that funding for subsequent years is increased.

Table 1. Proposed challenge scenario for all actors to increase funding commitments for women’s and children’s health in 2011
What the investment will achieve6

The world can unite to improve – significantly – the lives of women and children, especially in the poorest countries. Assuming the additional funding needs identified in Figure 2 are contributed each year from 2011 to 2015, the coverage of proven interventions would dramatically improve for the most vulnerable women and children in 49 developing countries.

  • Vaccinations for an additional 150 million children in GAVI-eligible countries.11
  • 164 million more children treated for pneumonia and a further 150 million children treated for diarrhea.
  • 150 million more couples using modern methods of family planning.
  • Hundreds of millions of women and newborns receiving high-quality care before, during and after birth.
  • The training of an additional 2.5 million health-care professionals and 1 million community health workers.
  • Millions of women and children receiving interventions to prevent or treat deadly diseases such as HIV/AIDS, TB and malaria.
  • Millions of women and children receiving interventions, such as supplements, to reduce chronic malnutrition in young children.

By 2015, this improved coverage would include:

More health for the money: increasing efficiency in our funding channels

This Joint Action Plan aims to ensure that countries and partners fulfill their existing financial commitments and develop new partnerships and commitments. It also seeks to secure financial commitments from new partners. But beyond that, it aims to enable a much more efficient use of resources.

The current health-financing architecture will need to be improved if it is to deliver the necessary outcomes. A number of international and regional taskforces related to the harmonization of donor and multilateral support have recommended that financing should be long-term and predictable, and committed to one comprehensive national strategy or plan, one set of indicators, and one monitoring and accountability mechanism. Yet for both 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, creating fragmentation. Countries without a unified national health strategy do not have clearly articulated health priorities that can guide the use of funds.

The International Health Partnership and other initiatives (IHP+) has adopted a set of principles that countries and donors should follow 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 should harmonize their health and development budgets and provide clear and separate health budget lines, with all spending and donor financing on-budget.

Today, funds for women’s and children’s health flow through multiple channels, including traditional bilateral funding and multilateral channels. In order to address fragmentation, WHO, along with the World Bank, the GAVI Alliance, and the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund), has created a harmonized and consolidated channel for support for health systems to achieve MDGs 4, 5, and 6 outcomes. This channel, the Health Systems Funding Platform, commits funders to coordinate their support for strengthening health systems and to align it with countries’ timelines and processes. It is already being implemented in several countries (see Figure 3).12

Figure 3. Health Systems Funding Platform
Ensuring accountability

Accountability is essential to ensure that our collective approach to improving women’s and children’s health can be realized. An accountability framework that is harmonized with other such frameworks and indicators is required to track progress each year and identify areas where it is lagging. Through the efforts of all stakeholders, this will generate feedback about what works, and ensure that all partners share a common understanding of the challenges. Progress should be monitored and assessed annually as part of the accountability process.

The accountability framework will track the policy, program and financial commitments of all stakeholders involved in implementing the Joint Action Plan, and show how these commitments contribute to improvements in women’s and children’s health at the local, national and global levels. A set of core principles will guide efforts to develop the framework:

  • Comprehensiveness. The framework should cover the full spectrum of indicators. This begins with funding commitments and the efficiency of funding flows, to the results and eventual outcomes of all activities.
  • Quality. All the framework’s accountability indicators must be “SMART”: specific, measureable, accurate, realistic, and time-bound.
  • Efficiency. The framework should use existing monitoring frameworks and indicators from various sources (e.g., WHO and OECD/DAC) to minimize the reporting burden while providing timely, independent, public reporting on progress.
  • Commitment. The framework should link the commitments of diverse constituencies, including donors, government and civil society, to specific indicators.
  • Improvement and innovation. The framework should explore ways of strengthening accountability efforts in countries and among global partners. To launch a truly unified effort, all stakeholders are urged to adopt the accountability framework. Building upon the core principles, it will contain the following elements:
  • Reports on what we pledge. Annual reporting approaches, such as scorecards and annual reports; mid-term assessments of health outcomes; and adherence to financial, policy, and program commitments.
  • Assessment of impact. A process to track progress on women’s and children’s health at the community, national and global levels, supported by a performance measurement framework and monitoring strategy.
  • Clear roles and responsibilities. An accountability matrix clearly outlining the actions, expectations and contributions of all stakeholders.
  • The capacity to monitor and report. The framework will include a commitment to building capacity to establish and strengthen integrated health information systems. This will accelerate efforts to monitor, report and evaluate progress on health MDGs at the country-level and globally.
A call to action

Signing up to this Joint Action Plan is the first step towards better health for women and children the world over. The Plan’s principles, commitments, tracking mechanisms and accountability framework will result in more effective use of money, greater collaboration and more promises kept. Most importantly, those most in need will gain a safe and better future.

All of us have a role to play… examples of actions that could be taken by stakeholders

Governments and policymakers

  • Expand on existing national health plans, and update them where appropriate to ensure that women’s and children’s health budgets and services are prioritized.
  • Increase governments’ portion of budget allocated to health and build on existing regional commitments to increase access to sexual and reproductive health services (Maputo).
  • Fully integrate the following into all primary health-care facilities: family planning, HIV/ AIDS services, abortion-related care (where legal), and maternal, newborn and child care.
  • Ensure that services exist in more marginalized geographic and poverty-stricken areas. • Strengthen health systems, prioritizing the health of women, girls and children by means of targeted policies, programs, and budgeting.
  • Engage the private sector in promoting innovative financing initiatives focused on improving health outcomes for women, girls and children.
  • Establish systems to measure progress, accessibility and service quality, and to ensure accountability and data quality.
  • Promote health education and awareness programs; adopt community participatory approaches, innovative communications, and behavioral change approaches to increasing demand for and removing barriers to accessing health services.
  • Address gender inequality through new initiatives or investments.

Civil society

  • Track progress and hold governments and donors to account on their commitments.
  • Coordinate approaches to women’s, girls’ and children’s health with those of countries, other NGOs, international agencies and donors.
  • Build advocacy alliances within and beyond the reproductive, maternal, newborn and child health community.
  • Engage parliamentarians, regional networks, and youth, human rights, professional and civil-society organizations to increase political and financial support.
  • Raise awareness through media campaigns

Regional bodies

  • Ensure that the Joint Action Plan reinforces regional efforts to achieve the MDG 4 and 5 targets.
  • Identify and share best practices and lessons learned, and act as technical advisors, advocates, funders, and monitors.
  • Draw the world’s attention to the serious shortfalls on MDGs 4 and 5 and assist in tracking progress at the regional level.

Donors

(OECD countries, non-OECD members and global philanthropic institutions.)

  • Provide predictable, long-term and substantial financial and other resources to contribute to the achievement of MDGs 4 and 5.
  • Keep the health of women and children high on the list of global priorities.
  • Align donor aid with national health plans where they exist, work with countries to develop national health plans where they do not.

Private sector

  • Develop novel drugs, vaccines, and other interventions that will improve health services and outcomes for women and children.
  • Provide donations and reduce the price of goods and supplies.
  • Support innovations, such as mobile phones to strengthen health systems.
  • Support public health messaging through mainstream media and other communications channels.

UN and multilateral agencies

  • Adopt clear guidelines on technical and managerial support.
  • Provide technical assistance for countries’ capacity development.
  • Set norms and standards to accelerate progress towards MDGs 1c, 4, 5 and 6.
  • Work with countries to facilitate the effective and sustainable integration of health services.
  • Provide technical assistance on communications and behavioral change strategies to maximize the impact of health services and reduce barriers to using them.
  • Increase budget allocations for women’s and children’s health in order to meet the above commitments effectively.
  • Support implementation of systems to track progress, identify gaps, and strengthen strategies to achieve MDGs 1c, 4, 5, and 6.

Health-care professionals

  • Advocate for the health of women and children

Academic and research institutions

  • For programs related to women’s and children’s health, allocate a fixed percentage (e.g. 10%) of research budgets to implementation or basic research.
  • Adopt a coordinated research agenda to underpin this unique global effort.

References

1Horton S, Shekar M, McDonald C, Mahal A, Brooks JK (2010) Scaling up Nutrition: What will it Cost? World Bank: Washington DC.
2 USAID, 2001. USAID Congressional Budget Justification FY2002: program, performance and prospects – the global health pillar. United States Agency for International Development: Washington, DC.
3 Bloom DE, Canning D. The Health and Wealth of Nations, Science, 2000, Vol. 287, pp 1207-1208.
4 Horton S, Shekar M, McDonald C, Mahal A, Brooks JK (2010), Scaling up Nutrition: What will it Cost? World Bank: Washington DC.
5 Bloom DE, Williamson JG. 1998. Demographic Transitions and Economic Miracles in Emerging Asia. World Bank Economic Review, 12: 419-455. These findings may reflect the adoption of growthenhancing policy reforms.
6 The information in this section is subject to refinement based upon ongoing work of the Joint Action Plan Financing Working Group, led by the World Bank.
7 Adequately funding the desired health interventions and the supporting health system between 2009 and 2015 will require a large annual increase in capital and recurrent funding. The projections used here were made by the High-Level Task Force on Innovative Financing for Health Systems, using the WHO normative approach. It considers the amount of resources required to scale up a country’s health systems to a level considered “best practice” by experts and practitioners (Constraints on Scaling Up the Health MDGs: Costing and Financial Gap Analysis, WHO, 2009, 2010). The total estimated cost of children’s and women’s health includes 100% of the cost of health systems strengthening, because successful direct maternal and child health programs require a fully functioning, fully funded health system.
8 Constant 2005 US dollars.
9 There are several estimates of the cost of achieving the health MDGs. The figure of US$19 billion is based on the WHO normative approach.
10 Non-governmental organizations that carry out independent fundraising.
11 There are currently 72 GAVI-eligible countries, including 45 of the 49 developing countries included in the above cost estimate.
12 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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