usaid-actingonthecall-2014.pdf

Contributors

June 2014

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FOREWORD

By Dr. Rajiv Shah Administrator, USAID

This June, we mark the second anniversary of the Child Survival Call to Action, when the world came together to craft a global goal to end preventable child deaths by 2035. In the last two years, we pioneered a new approach that has empowered partner countries to achieve this aspiration by leading with robust business plans and evidence-based report cards. With a strong foundation in place, now is the time for the global community to mobilize around results-oriented country action plans to realize a world where every child everywhere lives to celebrate his or her 5th birthday.

Since the beginning of the Obama Administration, the U.S. has invested $13 billion in global child and maternal survival. Emblematic of the strong bipartisan legacy of American leadership in global health, this commitment represents a 56% increase in annual funding since 2008. Most importantly, we have aligned our resources in priority countries and toward life-saving interventions that have the greatest impact on mortality. We have focused on the 24 countries — primarily in sub- Saharan Africa and South Asia — that account for 70% of child and maternal deaths and half of the unmet need for family planning.

Over the last 18 months, we have undertaken an ambitious review of every dollar USAID spends preventing child and maternal mortality in these 24 countries to identify inefficiencies and accelerate reductions in child and maternal mortality. This report outlines the results of this review. It demonstrates how we are advancing President Obama’s commitment with a smart, strategic, and cost-effective approach that will bend the curve of progress, even in a time of global fiscal restraint.

Ending preventable child and maternal deaths will require more than resources.

It requires a new model of development that harnesses the power of science and business to push the boundaries of possibility. In South Asia, for example, we supported randomized control trials and feasibility studies demonstrating that chlorhexidine could cut newborn mortality by 23%. We partnered with a local Nepali pharmaceutical company and community health workers to deliver the life-saving antiseptic to expectant mothers. Today, efforts to introduce it are underway in 15 other countries.

Through Saving Lives at Birth: A Grand Challenge for Development, we are investing in 59 global health innovations just like chlorhexidine that are already having an impact on the ground — from stopping the transmission of HIV/ AIDS to infants to helping newborns take their first breath.

The results worldwide have been extraordinary. In two years alone, we have helped achieve an eight percent reduction in under-five mortality in the 24 focus countries, saving 500,000 lives. Maternal mortality has fallen by half in these same countries over two decades. Global donor funding for child and maternal survival has increased at an annualized rate of 14% over the past decade, while more than two-thirds of the 24 priority countries spent a greater proportion of general government expenditure on health in 2012 than they did 10 years prior.

We are proud of this progress, but more must be done to ensure every child survives and thrives and no mother dies from preventable causes as a consequence of pregnancy and childbirth. We need our partners to join with us and align their investments with country-owned plans that focus on delivering results for the most vulnerable families in the most vulnerable communities. By accelerating our rate of progress together, we can save the lives of 15 million children and nearly 600,000 women by 2020.

Reaching this goal is only possible if we increase access to voluntary family planning, enabling couples to act on the choice to have smaller families and invest more in the health and well-being of each child. When couples have smaller families, children grow up healthier and economies flourish.

Two years in a row, President Obama has called upon us in his State of the Union address to join the world in ending extreme poverty and its most devastating consequences — child hunger and child death — in the next two decades. It is an ambitious but achievable vision. With a clear path for action, we can deliver on this fundamental human aspiration and usher in one of the greatest contributions to progress in history.

ACTING ON THE CALL:

Ending Preventable Child and Maternal Deaths Report June 2014

CONTENTS

I. List of Acronyms

II. Introduction: Issuing the Call Child Survival: Call to Action and A Promise Renewed

III. Acting on the Call: 24 Country Action Plans Afghanistan Bangladesh Democratic Republic of Congo Ethiopia Ghana Haiti India Indonesia Kenya Liberia Madagascar Malawi Mali Mozambique Nepal Nigeria Pakistan Rwanda Senegal South Sudan Tanzania Uganda Yemen Zambia

IV. Acting on the Call: Sharpening the Focus on Bottlenecks by UNICEF

V. Acting on the Call: Technical Approaches to Proven Interventions by USAID Newborn Immunization Prevention and Treatment of Childhood Illness Nutrition Maternal Health Family Planning Ensuring Healthy Behaviors Water, Sanitation, and Hygiene

VI. Conclusion

Acknowledgements

VII. Annex A: Data Sources and Methodology

VIII. Annex B: Award Data:

Tables on Principal USAID Awards by Country

Christian Connections for International Health

ACRONYMS

APR A Promised Renewed

ARV Antiretroviral

CATS Community Approaches to Total Sanitation

CDC Centers for Disease Control and Prevention

CHWs Community health workers

CPR Contraceptive prevalence rate

DHS Demographic and Health Surveys

DTP3 Diphtheria, tetanus, pertussis

EPCMD Ending preventable child and maternal deaths

FTF Feed the Future iCCM Integrated community case management

IDA International Development Association

IDB United States Census Bureau’s International Database

IGME Interagency Group for Child Mortality Estimation

IHME Institute for Health Metrics and Evaluation

LiST Lives Saved Tool

MDGs Millennium Development Goals

MMR Maternal mortality ratio

MNCH Maternal, newborn, and child health

MOH Ministry of Health

NGOs Non-governmental organizations

ORS Oral rehydration solution

ORT Oral rehydration therapy

PEPFAR President’s Emergency Plan for AIDS Relief

PMI President’s Malaria Initiative

PMTCT Prevention of mother-to-child-transmission [of HIV]

RMNCH Reproductive, maternal, newborn, and child health

SUN Scaling up nutrition

TB Tuberculosis

UNAIDS The Joint United Nations Programme on HIV and AIDs

UNFPA United Nations Population Fund

UNICEF United Nations Children’s Fund

USAID United States Agency for International Development

WASH Water, Sanitation, and Hygiene

WHO World Health Organization

A Child Survival Revolution All women deserve to give birth safely, and all children — no matter where they are born — deserve the same chance to survive and thrive. Over the last 30 years, the global community has responded to the urgency of this mission, raising child and maternal survival to the top of the international development agenda. Just as the Green Revolution transformed agricultural production and prevented widespread famine, the child survival revolution is saving millions of lives and unleashing a virtuous cycle of progress and opportunity.

Working together over the last three decades, we have expanded coverage of voluntary family planning, dramatically improved access to new vaccines, integrated nutrition and hygiene into global health, and launched innovative public-private partnerships to extend our reach. Since 2010, the Helping Babies Breathe partnership has trained and equipped 130,000 health workers in 60 countries to provide life-saving resuscitation for newborns with asphyxia, with results in Tanzania showing a 47% reduction in early newborn mortality. From 1990 to 2012, the world achieved a 72% reduction in the risk of a child dying from pneumonia or diarrhea, thanks in part to the introduction of vaccines against rotavirus and pneumococcus and improvements in treatment — both advances supported by diverse public and private organizations, including USAID. Together with its partners, the President’s Malaria Initiative contributed to the significant reduction in malaria mortality rates in children under five in Africa by an estimated 54% between 2000 and 2012.

INTRODUCTION: ISSUING THE CALL

1990 1995 2000 2005 2010 2015

D ea th s pe r

1, liv e bi rt hs

Under-five mortality rate

Infant mortality rate

Neonatal mortality rate

MDG Target: 47

TARGET: UNDER-FIVE MORTALITY RATE

24 Priority Countries

USE OF MODERN METHODS OF CONTRACEPTION

24 Priority Countries

1990–1995 1996–2000 2001–2005 2006–2010 2011–2013

Pe rc en ta ge

Any Modern Method

Permanent Methods

Long-Acting, Reversible Methods

Short-Acting Methods

Source: UNFPA

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All told, from 1990 to 2012, the total number of child deaths fell by 48% from 12.6 million to 6.6 million. In the last 20 years, nearly 100 million child lives have been spared, and the rate at which mortality is declining continues to accelerate. The total number of maternal deaths also decreased globally by 45% from 523,000 in 1990 to 289,000 in 2013.

By the time the Millennium Development Goals (MDGs) were adopted in 2000, the global community had recognized the fundamental connection between health and development, and the momentum surrounding the overall efforts to reduce child and maternal mortality only accelerated. In 2010, UN Secretary- General Ban Ki-moon launched Every Woman Every Child to present a roadmap for enhanced financing, strengthened policy, and improved service to address the major health challenges facing vulnerable women and children. As progress has advanced, so too has our definition of child survival, which has evolved over the last 30 years to include a more integrated picture of health, development, and well-being.

Despite this extraordinary progress, rates of child and maternal death remain unacceptably high. Hundreds of thousands of mothers continue to die during what should be a joyous moment in their lives, and millions of children die from causes we know how to prevent. Today, a woman’s risk of dying from childbirth in sub-Saharan Africa is more than 47 times greater than in the United States.

A New Approach at the Call to Action That is why, in June 2012, the Governments of Ethiopia, India, and the United States, in collaboration with UNICEF, hosted the “Child Survival:

Call to Action.” Designed to focus the disparate priorities of the global health community, the Call to Action set a single, comprehensive, and achievable goal: ending preventable child deaths by 2035. More than 175 countries and over 400 civil society and faith organizations signed a pledge in support.

This global commitment became known as A Promise Renewed (APR).

Reenergizing the child survival movement, A Promise Renewed set a global goal of fewer than 20 deaths per thousand live births in all countries by the year 2035.i It kicked off an effort to find agreement on a similar goal of fewer than 50 maternal deaths per 100,000 live births by 2035.ii Recently, the global community came together at the World Health Assembly to endorse a global newborn action plan and set a target to reduce preventable newborn deaths to a global average of 7 deaths per 1,000 live births by 2035, and a national target of fewer than 10 deaths per 1,000 live births by 2035. Progress is underway for a related measure and benchmark for family planning.

Perhaps most importantly, APR outlined a modern new approach to child survival through five strategic shifts (see text box) and encouraged countries themselves to take the lead. Complementary efforts in family planning (London Summit on Family

THE CALL TO ACTION’S FIVE STRATEGIC SHIFTS:

• Increase efforts in the countries that account for the largest share of under-five deaths

• Reach the most underserved populations

• Target priority causes of mortality with innovation efforts and interventions poised to go to scale

• Invest beyond health programs to include empowering women and supporting an enabling environment

• Create transparency and mutual accountability at all levels, with strengthened commitment to common metrics for tracking progress

Nigeria: October 2012: President Goodluck Jonathan launched Saving One Million Lives, a comprehensive initiative to scale up access to essential primary health services and commodities for Nigeria’s women and children.

WHO Eastern Mediterranean Region: January 2013: After extensive consultation, Eastern Mediterranean Region member states identified greatest needs, created action plans, and selected priority countries.

Ministers of Health meeting in Dubai committed to accelerate progress toward MDGs 4 and 5 in the region.

Ethiopia: January 2013: The Government of Ethiopia convened Ministers of Health, global health policy analysts, and technical experts from 20 African countries to review regional progress on child survival, take stock of lessons learned, call for greater accountability, and reaffirm commitment to reducing under-five mortality rates to fewer than 20 deaths per 1,000 live births.

India: February 2013: The Government of India held a high-level Child Survival forum with state policymakers, technical advisers, civil society organizations and private sector actors to launch the Reproductive Maternal Neonatal Child and Adolescent Health Strategy.

Zambia: April 2013: The Fir st Lady of Zambia hosted a national launch of A Promise Renewed and unveiled a four-year road map that aims to save an average of 27,000 maternal and child lives per year.

Sierra Leone: May 2013: The government launched a national effort to accelerate a decline in maternal and child deaths and developed a scorecard with stakeholders to symbolize a commitment to tracking reproductive, maternal, newborn, and child health (RMNCH) interventions at subnational levels.

Democratic Republic of Congo: May 2013: Under A Promise Renewed, the DRC Ministry of Health launched the national acceleration framework to reduce infant and maternal mortality.

The strategy sets out targets to reduce child mortality by 48% and maternal mortality by 31%, saving the lives of 430,000 children and 7,900 mothers over the next three years.

Senegal: July 2013: Senegal’s Minister of Health launched A Promise Renewed in Dakar. The Ministry of Health aims to work with partners to save 10,000 children by the end of 2015.

Bangladesh: July 2013: The Government of Bangladesh pledged to end preventable child deaths by scaling-up interventions proven to address preventable causes of child mortality, with a special emphasis on newborn survival.

Liberia: July 2013: President Ellen Johnson Sirleaf launched A Promise Renewed: Committing to Child Survival in Liberia at a gathering of community leaders, health workers, government officials and development partners.

African Union Conference: August 2013: The Campaign for Accelerated Reduction of Maternal Mortality in Africa targeted cross-sectoral leadership to mobilize actions and build greater accountability and transparency for both child and maternal survival.

Latin America Regional Launch:

September 2013: The Government of Panama hosted A Promise Renewed for the Americas. The regional forum convened 26 Ministers of Health from the Latin America and Caribbean region joining seven international partners in signing the Declaration of Panama, reaffirming their commitment to end all preventable child and maternal deaths by 2035.

Benin: November 2013: The go vernment launched a national effort in support of maternal and child survival.

Malawi: November 2013: In support of maternal, newborn, and child health, Vice President Khimbo Kachali launched Malawi’s scorecard and highlighted the nation’s sharpened plan, emphasizing newborn health.

Uganda: November 2013: Honorable Edward Kiwanuka Sekandi, Vice President of Uganda, unveiled a sharpened reproductive, maternal, newborn, and child health plan that aims to prevent an additional 40% of under-five deaths and 26% of maternal deaths by 2017.

Every African and Asian country listed here has also made a commitment to the FP2020 goal of enabling an additional 120 million women and girls to use contraceptives by 2020. Many other countries have held APR launches (Philippines, Peru, Côte d’Ivoire, Tanzania, and Yemen) or are considering launches later in 2014 (Afghanistan, Cameroon, Ghana, Indonesia, Kenya, Mali, Mozambique, Namibia, Nepal, and Pakistan).

LEADING BY EXAMPLE: PROGRESS SINCE A CALL TO ACTION

Planning and Family Planning 20201) and nutrition (Nutrition for Growth Compact) have signifi cantly expanded the level of collaboration around critical child and maternal heath programming.

Country Ownership At the Call to Action, partner countries stepped forward to lead with energy and focus. Representatives from fi ve countries that contribute to more than 50 percent of child deaths worldwide (India, Nigeria, Democratic Republic of the Congo, Pakistan, and

Ethiopia) made public commitments to change their practices to accelerate progress and bend the curve on reducing under-fi ve deaths. To date, 16 countries have launched national efforts to improve maternal, newborn, and child survival and accelerate declines in preventable maternal, newborn, and child deaths. More are planning launches in their countries.

These countries have also sharpened national strategies, set national targets, and developed scorecards to track progress. They have identifi ed target districts and communities where the highest rates of child and maternal deaths occur, and focused resources and energy on reducing those rates.

Country scorecards are based on national priorities and planning processes, with appropriate indicators, including indicators developed by the U.N. Commission on Information and Accountability for Women’s and Children’s Health, the Global Vaccine Action Plan, and the Countdown to 2015.

In Bangladesh, for instance, the government developed a fi ve-year strategy and a results framework with indicators that have been fully agreed to by eight donors — guiding their efforts through a highly functional Donor Coordination Committee.

Donors pool their resources through the World Bank and participate in annual program reviews and evaluations that are coordinated, transparent, and consistent with a shared vision based on the fi ve-year plan.

Other (includes tuberculosis, non-communicable diseases, and other health focus areas)

Health sector support

Malaria

HIV/AIDS

Family planning

Maternal, newborn, and child health

Note: Includes funds allocable by country and health focus area from bilateral agencies, the European Commission, World Bank, regional development banks, GAVI Global Fund, Gates Foundation, and Bloomberg Philanthropies.

‘91 ‘92 ‘93 ‘94 ‘95 ‘96 ‘97 ‘98 ‘99 ‘00 ‘01 ‘02 ‘03 ‘04 ‘05 ‘06 ‘07 ‘08 ‘09 ‘10 ‘11‘90

Source: IHME

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DEVELOPMENT ASSISTANCE FOR HEALTH, BY HEALTH FOCUS AREA

24 Priority Countries (Figure A)

1 At the London Summit on Family Planning, more than 20 governments made commitments to address the policy, fi nancing, delivery, and socio-cultural barriers to women accessing contraceptive information, services, and supplies.

Donors also pledged an additional US$2.6 billion in funding in support of the Summit goal of enabling an additional 120 million women and girls to use contraceptives by 2020.

This global commitment became known as FP2020.

Investing More in Health Child and maternal survival is increasingly being recognized as a fi scal priority both globally and within countries themselves.

Thanks to this momentum, government health expenditures have seen meaningful growth. Of the 24 countries examined in depth in the following sections of this report, 17 spent a greater proportion of general government expenditure on health in 2012 than they did ten years prior.iii

Meanwhile, donor health funding for maternal, newborn, and child heath grew at an annualized rate of 14% over the past decade. Combined family planning and maternal, newborn, and child health (MNCH) funding averaged approximately $1.8 billion annually during the period 2008–2011, which was 2.4 times greater than the annual average during the previous four years.

An overview of global health funding representing donor expenditures in health or development assistance for health for the 24 countries is presented in Figure A, by health area. The global health funding disbursed for MNCH includes spending on vaccinations, antenatal, postnatal, and maternal care, and other expenditures vital to maintaining the health of children and mothers. Sources of MNCH funding are shown in Figure B for the 24 countries2. MNCH spending totaled $2.0 billion in these countries in 2011 — up from $1.6 billion in 2010.

2 Data exclude funds from WHO, UNAIDS, UNFPA, and NGOs because these data could not be broken out by recipient country.

The growth throughout the period from 2006 to 2011 was driven by increases in spending by development partners, such as the United States, the GAVI Alliance, the Bill & Melinda Gates Foundation, and most recently by increases in the International Development Association (IDA) funding through the World Bank.

As reported by the Institute for Health Metrics and Evaluation (IHME) in Financing Global Health 2013, government health expenditure as a source has grown over time in all regions of the world. Levels of government health expenditure for all health focus areas are presented in Figure C.

Governments in the Asia region spend the most on health, driven largely by spending by the Chinese government.

‘91 ‘92 ‘93 ‘94 ‘95 ‘96 ‘97 ‘98 ‘99 ‘00 ‘01 ‘02 ‘03 ‘04 ‘05 ‘06 ‘07 ‘08 ‘09 ‘10 ‘11‘90

Source: IHME

Bi lli on s of

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1.5

.5

RECENT GROWTH IN DAH FOR MNCH COMES FROM INCREASES IN MULTIPLE CHANNELS

24 Priority Countries (Figure B)

Regional development banks

World Bank – IDA

World Bank – IBRD

BMGF

GAVI

European Commission

Other bilaterals

Canada

United Kingdom

United States

Note: Bloomberg Philanthropies, which cannot be seen in the figure channeled $2.4M and $0.9M of MNCH DAH in 2010 and 2011 respectively.

Latin America follows, and government spending on health in sub-Saharan Africa trails signifi cantly.

The U.S. Government remains a world leader in global health, focusing on delivering meaningful results in three key areas: ending preventable child and maternal deaths, creating an AIDS-free generation, and protecting communities from infectious diseases. Since the beginning of the Obama Administration, the U.S. Department of State and the U.S. Agency for International Development have invested $13 billion in global child and maternal survival, family planning, nutrition, and malaria — all contributing to ending preventable child and maternal deaths. Emblematic of the strong bipartisan legacy of American leadership in global health, this commitment represents a 56% increase in annual funding since 2008.

In addition, the U.S. Government makes signifi cant investments in related health activities that contribute to reducing child and maternal mortality.

Some funding to end preventable child and maternal deaths also is part of other U.S. Government-wide initiatives, including (PEPFAR; www.

pepfar.gov), the President’s Malaria Initiative (PMI; www.pmi.gov), and Feed the Future (FTF; www.feedthefuture.

gov). Many other U.S. Government agencies contribute to global health goals, including the Department of State, the Centers for Disease Control and Prevention, the Department of Health and Human Services, the Peace Corps, and the Millennium Challenge Corporation. The United States remains steadfast in its commitment to funding quality interventions along with country partners, multilateral organizations, and other donors. Responding to global health challenges is a shared responsibility that cannot be met by one nation alone.

‘95 ‘96 ‘97 ‘98 ‘99 ‘00 ‘01 ‘02 ‘03 ‘04 ‘05 ‘06 ‘07 ‘08 ‘09 ‘10 ‘11

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VARIED GOVERNMENT SPENDING ON HEALTH ACROSS REGIONS

(Figure C)

North Africa/Middle East

Caribbean

Latin America, Andean

Latin America, Central

Latin America, Southern

Latin America, Tropical

Oceania

Asia, Central

Asia, East

Asia, South

Asia, Southeast

Sub-Saharan Africa, Central

Sub-Saharan Africa, East

Sub-Saharan Africa, Southern

Sub-Saharan Africa, West

Fiscal Year

Fiscal Year

Fiscal Year

Fiscal Year

Fiscal Year

Fiscal Year

TOTAL

DOS AND USAID ($ MILLIONS) 7,741 8,477 8,279 8,608 8,420 8,826 50,352

ENDING PREVENTABLE CHILD AND MATERNAL DEATHS 1,736 2,206 2,183 2,285 2,262 2,398 13,070

CREATING AN AIDS FREE GENERATION 5,609 5,713 5,684 5,893 5,773 6,000 34,672

PROTECTING COMMUNITIES FROM INFECTIOUS DISEASES 396 558 413 430 385 428 2,610

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ACTING ON THE CALL:

CHANGING THE WAY WE WORK AT USAID

As a result of sustained global commitment and growing country ownership, we stand within reach of achieving goals once unimaginable:

ending preventable child and maternal deaths by 2035, and bringing about a grand convergence in life expectancy between poor and rich nations. The global and national mobilizations of the last two years have made a meaningful difference. By analyzing the causes of child and maternal death and the current coverage of life-saving interventions, we have identified the investments that will have the greatest impact, and enable us to work together to save the lives of 15 million children and nearly 600,000 women by 2020 in 24 focus countries. If we continue to accelerate this rate of reduction through to 2035, we can realize a world where children survive and thrive and no mother dies from preventable causes as a consequence of childbirth.

These investments not only represent a great moral achievement, but also a down payment on a more peaceful and prosperous planet. In country after country, we have seen population growth slow and economic growth take off as families choose to have fewer children, those children survive and thrive, and social and economic policies support their education and employment. Today, we know that investments in global health deliver a payoff 9 to 20 times in economic and social dividends.

In order to succeed, however, progress must be driven by domestic resources and supported by targeted international contributions. We must all step forward and align our investments with country-owned plans that focus on delivering results for the most vulnerable families in the most vulnerable communities.

Whether we represent a small civil society organization or a large multinational company, all of us must work together to achieve this goal — ensuring we support local change agents across society, from the community health worker who travels to a remote mountain village to the Minister of Health who builds her nation’s health budget.

Changing the Way We Work at USAID The Call to Action galvanized response in the United States, as USAID has aligned its resources in priority countries and toward the life-saving interventions that have the greatest impact. Over the last 18 months, USAID has undertaken a rigorous review of maternal and child health funding to identify inefficiencies and accelerate progress.

To achieve these results, USAID has shifted its focus to 24 countries, primarily in sub-Saharan Africa and South Asia, that account for 70% of maternal and child deaths and half of the unmet need for family planning.

They are: Afghanistan, Bangladesh, the

Democratic Republic of the Congo, Ethiopia, Ghana, Haiti, India, Indonesia, Kenya, Liberia, Madagascar, Malawi, Mali, Mozambique, Nepal, Nigeria, Pakistan, Rwanda, Senegal, South Sudan, Tanzania, Uganda, Zambia, and Yemen. These countries are characterized by high magnitude (numbers) and/or severity (rates) of maternal and child deaths and also meet the following criteria:

• Governments have demonstrated a commitment to working with partners and civil society to achieve accelerated reductions in maternal and under-five mortality;

• Opportunities exist to integrate and leverage broader U.S. Government resources, such as the President’s Malaria Initiative; the President’s Emergency Plan for AIDS Relief; family planning; basic education; nutrition; and Feed the Future, President Obama’s global food security initiative; and

• Opportunities exist for effective leveraging of USAID resources against those of the host country as well as other international partners, such as the Global Fund to Fight AIDS, Tuberculosis and Malaria, and the GAVI Alliance.

Within these countries, USAID has committed to geographically align around priority districts and shift resources toward newborn health, immunization, and treatment of childhood illness, including expanding access to a broader range of contraceptive methods and essential commodities for reproductive health (e.g., implants), maternal health (e.g., oxytocin, magnesium sulfate), newborn health (e.g. chlorhexidine, antenatal corticosteroid, injectable antibiotics, and resuscitation equipment), and child health (e.g., amoxicillin, ORS/ zinc). In addition, USAID will continue to seek greater cost effi ciency through its procurement processes, including exploring co-location, cost-sharing, and collaboration with local fi rms and NGOs.

There have been dramatic reductions in deaths of children and mothers since 1990 in these 24 countries. Despite this, not every country is on track to reach Millennium Development Goals 4 (a two-thirds reduction in under-fi ve mortality), 5a (a three-quarters reduction in maternal mortality by 2015), and 5b (universal access to reproductive health). Even in those countries with dramatic progress, there remains signifi cant work to reach every woman and child and usher in sustainable new advances in newborn, child, and maternal health.

70 80

2/3 decline compared to 1990

50 60

Bangladesh

Malawi

Nepal

Liberia

Tanzania

Ethiopia

Rwanda

Madagascar

Indonesia

Mozambique

Uganda

South Sudan

Senegal

India

Zambia

Yemen

Mali

Haiti

Afghanistan

Ghana

Nigeria

Pakistan

Kenya

Congo DR

24 priority countries

Less than 2/3 decline compared to 1990

Aggregated decline

In percent (%)

100 20 30 40

PERCENTAGE DECLINE IN UNDER-FIVE MORTALITY RATE (1990 TO 2012)

Source: UNICEF analysis based on UN IGME 2013

The following sections represent strategic, results-oriented country action plans for the 24 priority countries. Each plan includes:

• USAID’s Ending Preventable Child and Maternal Deaths (EPCMD) investments, fi scal years 2009 through 2014;

• Identifi ed priorities toward which USAID is aligning its leadership and programs;

• Additional actions to drive EPCMD; and

• Cumulative modeling of all potential lives saved by 2020.

Modeling and Data Sources The information presented on the following pages comes from common, publicly available sources outlined further in Annex A. Sources were chosen to maximize ability to compare across countries in a single year and based on common methodologies for estimation. Therefore, the numbers presented may vary from recently released data and/or from the offi cial numbers used within countries.

The Lives Saved Tool (LiST) has been used in a number of countries to analyze the impact that priority interventions can have on accelerating reductions in child and maternal mortality. Using this tool, one can measure how many lives will be saved by scaling up interventions. In this

70 80

Decline of 3/4 or more compared to 1990

50 60

Rwanda

Nepal

Bangladesh

Ethiopia

Afghanistan

India

Mozambique

South Sudan

Pakistan

Indonesia

United Republic of Tanzania

Uganda

Malawi

Nigeria

Zambia

Mali

Ghana

Liberia

Haiti

Yemen

Madagascar

Senegal

Democratic Republic of Congo

Kenya

Decline of less than 3/4 compared to 1990

100 20 30 40

PERCENT DECLINE IN MATERNAL MORTALITY RATIO,

24 PRIORITY COUNTRIES (1990 TO 2013)

Maternal mortality ratio decline (%)

Aggregated decline

Source: UNICEF analysis based on MMEIG 2014

24 priority countries document, the modeled results presented assume scale up of high-impact interventions to achievable rates of coverage by 2020 (see annex A for methodology).

In order to project the child and maternal lives that could be saved, projected coverage rates of effective interventions between 2012 and 2020 are reviewed against current rates of coverage. The “best performer” scenario changes coverage for each intervention based on the rate of progress achieved by the best performing country within categories.

The “best performer” values were developed based on analyses of the full set of 75 countdown countries, but stratified according to similar interventions type and level of baseline coverage to arrive at a “best performer” rate of change for each intervention within each country. This projection of coverage change is used to estimate under-five mortality reduction between 2012 and 2020, based on the changes in both coverage in both coverage and contraceptive prevalence rate.

Bangladesh, Nepal, and Indonesia were used as the reference countries for the demographic impact best performer model. For this reason, there will be no additional lives saved due to demographic impact in these countries.

24 PRIORITY COUNTRIES: DISTRIBUTION OF DEATHS

AMONG CHILDREN UNDER AGE 5, BY CAUSE

Neonatal 44%

Diarrhoea 10%

Malaria 8%

Injuries 5%

All other causes of death 21%

Pneumonia 15%

Pre-term birth complications, 16%

Pneumonia (neonatal), 2%

Intrapartum-related events, 11%

Diarrhoea (post-neonatal), 10%

Other neonatal, 3%

Congenital abnormalities, 3%

Tetanus, 1%

Sepsis, meningitis and encephalitis, 7%

Diarrhoea (neonatal), 0%

Pneumonia (post-neonatal), 13%

Measles, 2%

Other, 15%

Meningitis and encephalitis, 3%

AIDS, 2%

Malaria, 8%

Injuries, 5%

Source: UNICEF

AFGHANISTAN ≥100

50–74

<50

75–100

UNDER-5

MORTALITY

RATE:

2009 2010 2011 2012 2013 2014 TOTAL

ENDING PREVENTABLE CHILD AND MATERNAL DEATHS Fiscal Year Fiscal Year Fiscal Year Fiscal Year Fiscal Year Fiscal Year

USAID $ IN MILLIONS 87 141 136 113 125 116 718

USAID HAS COMMITTED TO:

Support the joint U.S. Government and Government of the Islamic Republic of Afghanistan goals:

• Contribute to donor pooled resources through the Afghanistan Reconstruction Trust Fund to support delivery of the Basic Package of Health Services to increase access to, quality of, and use of primary health care services with a focus on high-impact interventions, such as antenatal services, skilled attendance at delivery, postpartum and newborn care, routine immunization, malnutrition, diarrhea, and pneumonia.

• Support maternal nutrition during pregnancy and use of complementary foods for children being weaned and develop a regional strategy for food fortifi cation under the Almaty consensus.

• Support expansion and address retention of Afghanistan’s cadre of 22,000 community health workers, including supporting community midwifery and community nursing programs to address shortage of female workers.

• Increase access to, quality of, and use of family planning services through direct support to community and faith-based organizations.

• Strengthen sanitation and hygiene approaches in the basic package of health services

• Identify and pilot strategies, including private sector partnerships, social protection of families, and risk-pooling to strengthen long-term fi nancial sustainability of the health system.

• Strengthen governance and management capabilities within the health sector to support quality health service delivery.

• Strengthen disease-surveillance systems, such as the Disease Early Warning System, as well as improved use of data to inform policies and decision-making.

WORKING TOGETHER, WE CAN DO MORE:

• Strengthen the government’s resilience to ensure that health sector gains are sustained as donor resources decline.

• Maintain donor coordination and combination of resources to enhance the provision of the Basic Package of Health Services.

• Improve the quality of and confi dence of the hospital sector through the Essential Package of Hospital Services.

• Increase multi-sectoral integration, especially the inclusion of health education into the existing education and agricultural systems to reach the household level.

• Strengthen capacity of national authorities in emergency preparedness and response, especially for recurrent natural disasters.

• Address inequality in access to healthcare and expand service provision through restored and upgraded health care facilities, including expanded provision of services to rural areas still unreachable.

• Strengthen capacity of the Ministry of Public Health to ensure availability of high quality essential medicines and commodities.

BENDING THE CURVE:

REDUCING CHILD MORTALITY

PROJECTED INTERVENTION IMPACTS

OVER FIRST 5 YEARS OF LIFE: 2012–2020

COUNTRY DATA: POPULATION AND

CHILD & MATERNAL MORTALITY

13.5M 2.6M 96K 176 739K 1,300

30.4M 4.8M 103K 98 1.2M 400*

‘08 ‘20‘19‘18‘17‘16‘15‘14‘13‘12‘11‘10‘09

U nd er -5

M or ta lit y R at e pe r

1, Year: 2008–2020

Antenatal corticosteroids for preterm lab

Balanced energy supplementation

All other pregnancy and pre-pregnancy

Labor and delivery management

Neonatal resuscitation

Clean birth practices

All other birth

Full supportive care for sepsis/pneumoni

Clean postnatal practices

Thermal care

Immediate assessment and stimulation

KMC — Kangaroo mother care

All other postnatal

Pneumococcal

Measles

H. influenzae b

DPT

Rotavirus

All other infancy

Antibiotics for childhood diseases

ORS — oral rehydration solution

Handwashing with soap

Improved sanitation

Water connection in the home

Appropriate complementary feeding

Therapeutic feeding — for severe wasting

Zinc — for treatment of diarrhea

Improved water source

All other childhood

Birth

Pregnancy & Pre- Pregnancy

Postnatal

Infancy

Childhood

15K 30K 45K 60K

Total Population Population Under 5 Years Under-5 Deaths /Year BirthsUnder-5 Mortality Rate Per 1,000 Live Births

Maternal Mortality Ratio Per 100,000 Live Births

*2013

WASH

19%

HIV

0%

Child Health 23%

Malaria 0%

Immunization 30%

Child Nutrition 6%

Neonatal Health 8%

Maternal Health 13%

Maternal Nutrition 1%

% CUMULATIVE

LIVES SAVED

Child Lives Saved from Demographic Impact

15K 30K 45K 60K 168K

UNDER-5 LIVES SAVED

WORKING TOGETHER, WE CAN REACH THESE GOALS

BY 2020

Under-5 Mortality Rate per 1,000 Maternal Mortality Ratio per 100,000

*2013

470,000 CHILD LIVES SAVED

OF WHICH 170,000 ARE DEATHS AVERTED DUE TO

FAMILY PLANNING INTERVENTIONS

19,000 WOMEN’S LIVES SAVED

OF WHICH 13,000 ARE DEATHS AVERTED DUE TO

FAMILY PLANNING INTERVENTIONS

400*

Demographic impact is the projected impact of family planning interventions on reducing the number of deaths due to fewer unintended pregnancies.

COUNTRY DATA: POPULATION AND

CHILD & MATERNAL MORTALITY

90 13.5M 2.6M 96K 176 739K 1,300

Total Population Population Under 5 Years Under-5 Deaths /Year Under-5 Mortality Rate Births Maternal Mortality Ratio Per 1,000 Live Births Per 100,000 Live Births

12 30.4M 4.8M 103K 98 1.2M 400*

PROJECTED INTERVENTION IMPACTS

OVER FIRST 5 YEARS OF LIFE: 2012–2020

15K 30K 45K 60K 168K Child Lives Saved from Demographic Impact

Antenatal corticosteroids for preterm lab

Balanced energy supplementation

All other pregnancy and pre-pregnancy

Labor and delivery management

Neonatal resuscitation

Clean birth practices

All other birth

Full supportive care for sepsis/pneumoni

Clean postnatal practices

Thermal care

Immediate assessment and stimulation

KMC — Kangaroo mother care

All other postnatal

Pneumococcal

Measles

H. influenzae b

DPT

Rotavirus

All other infancy

Antibiotics for childhood diseases

ORS — oral rehydration solution

Handwashing with soap

Improved sanitation

Water connection in the home

Appropriate complementary feeding

Therapeutic feeding — for severe wasting

Zinc — for treatment of diarrhea

Improved water source

All other childhood

Birth

Pregnancy & Pre- Pregnancy

Postnatal

Infancy

Childhood

15K 30K 45K 60K

00 1000010000 2000020000 300003000030000 4000040000 5000050000 6000060000

15K 30K 45K 60K

UNDER-5 LIVES SAVED

BENDING THE CURVE:

REDUCING CHILD MORTALITY

‘08 ‘20‘19‘18‘17‘16‘15‘14‘13‘12‘11‘10‘09

U nd er

-5 M or ta lit y

R at e pe r 1, Year: 2008–2020

‘20

*2013

% CUMULATIVE

LIVES SAVED

WASH

19%

HIV

0%

Child Health 23%

Malaria 0%

Immunization 30%

Child Nutrition 6%

Neonatal Health 8%

Maternal Health 13%

Maternal Nutrition 1%

WORKING TOGETHER, WE CAN REACH THESE GOALS

Under-5 Mortality Rate per 1,000 Maternal Mortality Ratio per 100,000

2012 98 400*

2020 54 293 2035 20 50

*2013

BY 2020

470,000 CHILD LIVES SAVED

OF WHICH 170,000 ARE DEATHS AVERTED DUE TO

FAMILY PLANNING INTERVENTIONS

19,000 WOMEN’S LIVES SAVED

OF WHICH 13,000 ARE DEATHS AVERTED DUE TO

FAMILY PLANNING INTERVENTIONS

Demographic impact is the projected impact of family planning interventions on reducing the number of deaths due to fewer unintended pregnancies.

BANGLADESH ≥100

50–74

<50

75–100

UNDER-5

MORTALITY

RATE:

2009 2010 2011 2012 2013 2014 TOTAL

ENDING PREVENTABLE CHILD AND MATERNAL DEATHS Fiscal Year Fiscal Year Fiscal Year Fiscal Year Fiscal Year Fiscal Year

USAID $ IN MILLIONS 34 41 49 57 60 66 306

USAID HAS COMMITTED TO:

Scale up proven solutions in maternal functions, including commodity newborn and child health: procurement and distribution channels and routine health • Expand the reach of prioritized information systems.newborn interventions through the

National Newborn Health Strategy, Improve nutrition:

focusing on the introduction of • Collaborate with the Feed the antenatal corticosteroids for preterm Future initiative to reduce stunting babies, chlorhexidine for umbilical and wasting among children through cord care, newborn resuscitation, and improved infant and young child antibiotics for treatment of newborn feeding practices, and improved infection. household dietary diversity through

• Support the introduction of homestead food production.

rotavirus and pneumococcal • Assist the government’s efforts vaccines through the Expanded under the National Nutrition Program on Immunization. Strategy to scale up prioritized

• Build on successful public and nutrition interventions nationally, private child health platforms to including exclusive breastfeeding, manage diarrhea and pneumonia appropriate complementary feeding, through the national integrated and iron-folate supplementation plan for the Management of during pregnancy.

Childhood Illnesses. • Support the development of

• Increase equitable access to and a national strategy to manage utilization of safe delivery services, moderate and acute malnutrition, including comprehensive emergency and assist the government to obstetric care. Work through implement the strategy nationwide.

NGOs, the private sector, and the Sustain focus on reducing unmet need for public sector to roll out life-saving family planning:

treatments, including magnesium sulfate for preeclampsia/eclampsia • Increase access to long-acting, and active management of the third reversible contraceptives and stage of labor, in addition to safe permanent methods of family delivery kits for women who deliver planning nationwide.

at home. • Expand investment adolescent

• Provide technical assistance to health services to reduce early the Government of Bangladesh childbearing and closely spaced to strengthen key health systems pregnancies.

WORKING TOGETHER, WE CAN DO MORE:

• Share lessons learned from the Government of Bangladesh’s highly innovative approach to donor coordination that pools the resources of eight health donors through the World Bank.

• Address inequities through a focus on reaching marginalized populations with essential services, especially among the urban poor and those living in geographically isolated areas, including urban centers and wards that have no government presence under the NGO Health Service Delivery Project.

• Ensure uninterrupted supply of essential commodities — especially commodities that require cold chain — through investments in the supply chain and supply chain management

BENDING THE CURVE:

REDUCING CHILD MORTALITY

PROJECTED INTERVENTION IMPACTS

OVER FIRST 5 YEARS OF LIFE: 2012–2020

COUNTRY DATA: POPULATION AND

CHILD & MATERNAL MORTALITY

112M 17.8M 531K 143 4M 800

161M 17.5M 126K 41 3.6M 170*

‘08 ‘20‘19‘18‘17‘16‘15‘14‘13‘12‘11‘10‘09

U nd er -5

M or ta lit y R at e pe r

1, Year: 2008–2020

Antenatal corticosteroids for preterm labor

Balanced energy supplementation

Micronutrient supplementation

All other pregnancy and pre-pregnancy

Labor and delivery management

Neonatal resuscitation

Clean birth practices

Antibiotics for PPROM — pre-term/premature rupture of membranes

All other birth

Clean postnatal practices

Thermal care

Immediate assessment and stimulation

Full supportive care for sepsis/pneumonia

KMC — Kangaroo mother care

Chlorhexidine

All other postnatal

Pneumococcal

Promotion of breastfeeding

Rotavirus

Measles

All other infancy

Antibiotics for childhood diseases

ORS — oral rehydration solution

Handwashing with soap

Water connection in the home

Improved sanitation

Therapeutic feeding — for severe wasting

Treatment for moderate acute malnutrition

All other childhood

Birth

Pregnancy & Pre- Pregnancy

Postnatal

Infancy

Childhood

20K 40K 60K 80K

Total Population Population Under 5 Years Under-5 Deaths /Year BirthsUnder-5 Mortality Rate Per 1,000 Live Births

Maternal Mortality Ratio Per 100,000 Live Births

*2013

WASH

9%

HIV

0%

Child Health 16%

Malaria 0%

Immunization 20%

Child Nutrition 9%

Neonatal Health 16%

Maternal Health 28%

Maternal Nutrition 2%

% CUMULATIVE

LIVES SAVEDUNDER-5 LIVES SAVED

WORKING TOGETHER, WE CAN REACH THESE GOALS

BY 2020

Under-5 Mortality Rate per 1,000 Maternal Mortality Ratio per 100,000

*2013

366,000 CHILD LIVES SAVED

15,600 WOMEN’S LIVES SAVED

<20

170*

<50

CHILD & MATERNAL MORTALITY

90 112M 17.8M 531K 143 4M 800

Total Population Population Under 5 Years Under-5 Deaths /Year Under-5 Mortality Rate Births Maternal Mortality Ratio Per 1,000 Live Births Per 100,000 Live Births

12 161M 17.5M 126K 41 3.6M 170*

*2013

PROJECTED INTERVENTION IMPACTS

OVER FIRST 5 YEARS OF LIFE: 2012–2020

UNDER-5 LIVES SAVED

20K20K 40K40K 60K60K 80K80K

Antenatal corticosteroids for preterm labor

Balanced energy supplementation

Micronutrient supplementation

All other pregnancy and pre-pregnancy

Labor and delivery management

Neonatal resuscitation

Clean birth practices

Antibiotics for PPROM — pre-term/premature rupture of membranes

All other birth

Clean postnatal practices

Thermal care

Immediate assessment and stimulation

Full supportive care for sepsis/pneumonia

KMC — Kangaroo mother care

Chlorhexidine

All other postnatal

Pneumococcal

Promotion of breastfeeding

Rotavirus

Measles

All other infancy

Antibiotics for childhood diseases

ORS — oral rehydration solution

Handwashing with soap

Water connection in the home

Improved sanitation

Therapeutic feeding — for severe wasting

Treatment for moderate acute malnutrition

All other childhood

Birth

Pregnancy & Pre- Pregnancy

Postnatal

Infancy

Childhood

0 1000020000200003000040000400005000060000600007000080000

BENDING THE CURVE:

REDUCING CHILD MORTALITY

‘08 ‘20‘19‘18‘17‘16‘15‘14‘13‘12‘11‘10‘09

U nd er

-5 M or ta lit y

R at e pe r 1, Year: 2008–2020

% CUMULATIVE

LIVES SAVED

WASH

9%

HIV

0%

Child Health 16%

Malaria 0%

Immunization 20%

Child Nutrition 9%

Neonatal Health 16%

Maternal Health 28%

Maternal Nutrition 2%

0 1000020000300004000050000600007000080000

WORKING TOGETHER, WE CAN REACH THESE GOALS

Under-5 Mortality Rate per 1,000 Maternal Mortality Ratio per 100,000

2012 41 170*

2020 24 108 2035 <20 <50

*2013

BY 2020

366,000 CHILD LIVES SAVED

15,600 WOMEN’S LIVES SAVED

DEMOCRATIC

REPUBLIC OF CONGO

≥100

50–74

<50

75–100

UNDER-5

MORTALITY

RATE:

2009 2010 2011 2012 2013 2014 TOTAL

ENDING PREVENTABLE CHILD AND MATERNAL DEATHS Fiscal Year Fiscal Year Fiscal Year Fiscal Year Fiscal Year Fiscal Year

USAID $ IN MILLIONS 38 47 67 76 92 104 423

USAID HAS COMMITTED TO:

Deliver high-impact maternal and child survival interventions:

• Expand coverage — from 100 iCCM sites to 185 — of an integrated maternal and child health service package that includes: essential newborn care; promotion of early and exclusive breastfeeding; and integrated treatment of childhood illnesses for malaria, pneumonia, and diarrhea in 25 priority health zones in East Kasai, West Kasai, South Kivu, and Katanga Provinces.

• Expand integrated treatment of malaria and diarrhea at the community level building on the President’s Malaria Initiative platform.

Currently, PMI reaches approximately one-third of the country’s population.

• Support for immunization coverage improvements, including scaling up the newly introduced pneumococcal vaccine and planning for introduction of the rotavirus vaccine.

• Strengthen collaboration with democracy and governance and education sectors to address signifi cant system bottlenecks to service delivery.

Reduce malnutrition in high-risk children:

• Integrate best practice nutrition interventions into integrated service delivery packages.

• Expand promotion of exclusive breastfeeding and appropriate complementary feeding.

• Collaborate with Food for Peace programs to improve capacity for community-based management of malnutrition in targeted health zones.

Expand access to voluntary family planning:

• Expand access to a wide range of culturally acceptable methods of family planning, including implants, fertility awareness methods, and community-based distribution of Depo-Provera.

• Increase focus on postpartum family planning.

• Leverage the PEPFAR platform and support the expansion of integrated family planning and prevention of mother-to-child transmission of HIV sites to include 256 sites in Kinshasa, Orientale, and Katanga Provinces.

Ensure commodities reach all levels of the health system, from the central level down to the community:

• Build the capacity of the central procurement entity, FEDECAME, to effectively manage the national supply chain system.

• Expand accessibility of high-priority commodities, such as long-acting, reversible contraceptives, antibiotics, malaria rapid diagnostic tests and treatment, chlorhexidine, misoprostol, Vitamin A, and newborn resuscitation devices.

• Strengthen information systems and human resource capacity to ensure commodities reach all service delivery points with minimal stock-outs.

WORKING TOGETHER, WE CAN DO MORE:

• Support the government’s supply chain system and procurement partners, FEDECAME, and harmonize supply chain strengthening efforts.

• Expand use of voluntary family planning, giv en continued high fertility.

• Align efforts to ensure effective prevention and treatment of childhood pneumonia and diarrhea, ensuring correct use of available, low-cost treatments,…