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This is an archived USAID document retained on this web site as a matter of public record.
Testimony of Dr. Kent Hill
Assistant Administrator for Global Health
USAID's Child Survival and Maternal Health Program
Subcommittee on Africa and Global Health
Committee on Foreign Affairs
U.S. House of Representatives
March 13, 2008
Chairman Payne, Congressman Smith, and other distinguished members of the Committee, I would like to thank you for convening this important hearing. I especially thank you and the Congress for the sustained support provided through the years for our Child Survival and Maternal Health programs. That support has enabled USAID to play a leadership role in an international effort that has made significant improvements in maternal and child health. And, we greatly appreciate your recognition of USAID's contribution to this effort.
I first want to acknowledge the importance of the theme that you have set for this hearing, the "unmet need" for progress in child survival. I will tell you about some of the important successes of USAID's child survival and maternal health program because these successes are what give us confidence that we can meet this "unmet need." I then will briefly discuss why this is a good time to hold this hearing and the special opportunities that exist to accelerate progress in child survival. In closing, I will describe our strategic approach to achieving the greatest impact on maternal and child mortality with the resources we have. Our goal is for our programs to build sustainability.
Despite significant progress in reducing child deaths, almost 10 million pre-school children die each year, almost all of them in poor countries. What is particularly tragic is that most of these deaths are preventable. Almost four million deaths are newborn infants who do not survive beyond the first week or month of life. By the time many children reach school age, the effects of illness and malnutrition have reduced permanently their potential to learn, grow, and be productive citizens of their countries.
We appreciate your recognition of the urgent need to improve the survival and well-being of mothers. USAID's approach to child survival and maternal health is integrated because we know that the survival and health of young children, especially newborns, starts with the health of their mothers and the care those mothers receive during pregnancy and childbirth. Each year, half a million mothers still make the ultimate sacrifice, losing their lives in the process of giving birth. Millions more suffer complications that produce lifelong disability.
For a quarter of a decade, with the support of Congress, USAID has been working to improve the survival of mothers and children. When the U.S. Child Survival program began in the early 1980s, almost 15 million children died each year in the developing world. If the global community had done nothing, with the increasing number of children born each year, that number now would have reached 17 million. USAID and UNICEF, however, chose to launch the "Child Survival Revolution" that has become a global collaboration with other donors, multilateral organizations, U.S. private voluntary organizations and NGOs, researchers, the private sector, and, especially, country governments. As a result of all these efforts UNICEF announced in 2007 that the estimated number of child deaths in the world had fallen below 10 million annually. That number is still far too high, but the drop does mean that our efforts have made a real difference.
USAID works to address the "unmet need" in child survival and maternal health through discovery, diffusion and scale-up, and long term sustainability of effective health interventions.
- We support research to develop high impact, low cost interventions, for example, ways to treat low birth weight babies, prevent and treat life-threatening infections of newborns, and save mothers from bleeding to death after giving birth.
- We support countries to expand their use of new and existing high impact, cost-effective interventions, for example, vaccines, vitamin A, treatments for sick children and mothers in pregnancy and childbirth, newborn care, breastfeeding and improved nutrition for children and pregnant women, and improved household water quality.
- We help countries build the essential elements of health systems and human capacity they will need to sustain progress in maternal and child health.
I would like to provide some successful examples of USAID's programs.
- In Indonesia, USAID has a long history of supporting the Government of Indonesia's maternal health program, focusing primarily on strengthening the capacity of skilled birth attendants to provide basic essential obstetric care, including prevention of bleeding immediately after birth, the leading cause of maternal mortality. According to a global survey, Indonesia had the highest use of active management of the third stage of labor to prevent bleeding. From 1992 to 2000, maternal mortality dropped by 21 percent.
- In Bolivia, as the government implemented a national health insurance system that covered maternity services, USAID trained health care providers in obstetric care and promoted culturally appropriate birth practices and 24-hour-a-day quality care of women. From 1990 to 2004, maternal mortality dropped by 44 percent.
- In Bangladesh, home-based essential newborn care, coupled with successful identification and treatment or referral of newborn infections by trained community health workers, reduced newborn mortality by 33 percent in a pilot program supported by USAID. The Government of Bangladesh now has developed a newborn health strategy to scale up lessons learned from this pilot. USAID has replicated this low-cost, high impact approach of reducing newborn mortality in several other countries.
- In Ethiopia, we are supporting the government in extending access to basic maternal and child health care through training and deployment of thousands of new community health workers. At the same time, we are helping to strengthen Ethiopia's health system through a new national drug logistic system, an improved health information system, and a strengthened ability to estimate costs and budget for basic health services. Ethiopia has seen under-five deaths decline by almost 30 percent since 1998, supported by these changes.
- In Nepal, we have been developing and scaling up a program that links female community health volunteers with the health system to bring vitamin A, immunization, and treatment of child illness to villages that in the past had no health care. This program now reaches more than half the population of Nepal. Nepal has recorded a decline in under-five child mortality of 41 percent since 1998.
- After the fall of the Taliban in 2001, Afghanistan registered some of the worst health statistics in the world: 1 in 4 children died before his/her first birthday and 1 in 6 women died in childbirth in her lifetime. USAID and its partners started immediately with measles immunizations and then launched a program that provided a basic package of health services to mothers and children in rural Afghanistan. The program also paid attention to rebuilding key elements of the health system, including management, drug supply, and training. Since then, under harsh and insecure conditions, skilled attendance at birth has tripled and under-five mortality has been reduced by 26 percent, saving the lives of 80,000 children per year.
These countries demonstrate that it is possible to make real progress despite continuing poverty, instability, and sometimes conflict. As shown in the displayed chart, this progress also is occurring more broadly in USAID-assisted countries throughout the world. The 15 countries show an average 33 percent reduction in under-five child deaths.
15 USAID- Assisted Countries Achieving 20-50% Reductions in U5 MR in the Last Ten Years:
|
Country | Under-5 Mortality (deaths/1,000 births) | Year | To | Under-5 Mortality (deaths/1,000 births) | Year | Percent Reduction |
|---|
| Bangladesh | 106 | 1998 | → | 69 | 2006 | 35 % |
| Bolivia | 85 | 1998 | → | 61 | 2006 | 28 % |
| Cambodia | 163 | 1998 | → | 82 | 2006 | 50 % |
| Ethiopia | 173 | 1998 | → | 123 | 2006 | 29 % |
| Guatemala | 52 | 1998 | → | 41 | 2006 | 21 % |
| Haiti | 130 | 1998 | → | 80 | 2006 | 39 % |
| India | 105 | 1998 | → | 76 | 2006 | 28 % |
| Indonesia | 56 | 1998 | → | 34 | 2006 | 39 % |
| Madagascar | 157 | 1998 | → | 115 | 2006 | 27 % |
| Malawi | 213 | 1998 | → | 120 | 2006 | 44 % |
| Mozambique | 206 | 1998 | → | 138 | 2006 | 33 % |
| Nepal | 100 | 1998 | → | 59 | 2006 | 41 % |
| Pakistan | 136 | 1998 | → | 97 | 2006 | 29 % |
| Philippines | 44 | 1998 | → | 32 | 2006 | 27 % |
| Sudan | 115 | 1998 | → | 89 | 2006 | 23 % |
Source: State of the World's Children reports, 2000 & 2008
Similarly, this graph shows that within relatively short periods of time maternal mortality has declined on average 32 percent in 10 USAID-assisted countries.
10 USAID- Assisted Countries Achieving 20-50% Reductions in Maternal Mortality
Data point plotted is midpoint of date range
Sources: DHS series except Bangladesh: National Institute of Population Research and Training 2002. Results reported here for Bangladesh are pregnancy-related mortality ratios. Egypt: National Maternal Mortality survey 2000 - Ministry of Health and Population
This progress is the result of USAID working hand-in-hand with many partners, including the private sector and civil society, other international bilateral partners, and the country governments. Nevertheless, much remains to be done. In countries where infant and child mortality has declined, newborn mortality still remains high. Globally, newborn mortality now accounts for almost 40 percent of under-five mortality.
Some countries, particularly in Africa, have made slow or no progress toward the child mortality and maternal health Millennium Development Goals (MDGs). Countries in Asia and the Americas show progress at the national level on meeting these MDGs, yet this progress often masks growing health disparities within countries.
We at USAID believe it is possible to reach more newborns, children, and mothers and accelerate progress toward the respective MDGs. In the past few years, new resources and commitments have appeared, which we believe can lead to a "second wave" of global efforts to increase child survival:
- New resources are available from private sector partners like the Bill and Melinda Gates Foundation, bilateral donors such as the U.K. and Norway, and multilateral partners, including UNICEF.
- The MDGs are stimulating increased international and country-level attention to the need for accelerated progress to reach the child and maternal survival goals.
- This attention is producing new international cooperation such as the inter-agency "Countdown 2015," which will monitor and report on progress toward these goals in 60 priority countries.
- The African Union recently approved a new "Framework for Accelerated Progress in Child Survival." Work on a similar regional collaboration for maternal and child health is beginning in Asia.
- In response to these MDGs and countries' commitment to accelerate social development, some countries are substantially increasing their own investments in maternal and child health. India is an impressive example where a Prime Ministerial "National Rural Health Mission" represents the commitment of more than two billion dollars a year to improve health status among the underserved poor.
These new developments and resources provide an important opportunity for USAID to leverage non-USAID resources to provide more assistance. We have a recognized leadership role in the global child survival and maternal health effort. USAID is unique among international partners in child survival and maternal health:
- We have the technical expertise to support ground-breaking research and to guide development of solid, evidence-based programming;
- We have Missions on the ground that can adapt this evidence to each country's situation and coordinate our support with other donors and with government strategies, and
- We have the strong partnerships with NGOs, faith-based and other civil society organizations, and the private sector at both international and country levels.
We see USAID's approach as supportive of the recently endorsed Paris Declaration principles that promote:
- leadership in development activities by countries themselves;
- alignment of foreign assistance with countries' own priorities, systems, and approaches;
- harmonization among external partners to reduce the complex burden of assessments, plans, monitoring approaches, and reporting; and
- results-oriented investments by both countries and their donor partners.
Now with the support of Congress, we have additional resources to apply these strengths. USAID focuses its strategic approach in child survival and maternal health to achieve the greatest possible health and development impact with our maternal and child health resources.
We plan to use the major share of those resources in approximately 30 USAID-assisted countries that represent at least 50 percent of maternal and child deaths worldwide. These countries are characterized by:
- the highest numbers and rates of child deaths;
- commitment of the host country government to work with partners and civil society for accelerated reduction of maternal and under-five mortality;
- capacity of the USAID mission and the country to manage and program increased resources, and
- opportunities to interact with other resources, including other USG investments such as PL 480 Title II, the President's Malaria Initiative, the President's Emergency Plan for AIDS Relief (PEPFAR), and our own emergency programs as well as the investments of other donors, multilateral agencies, the Global Fund, and others.
Given the political, cultural, and epidemiological context as well as the available resources and infrastructure, a deliberate process to determine the best mix of key interventions must occur for each priority country. Through our Missions and Regional Bureaus, we will work with these priority countries to achieve and sustain the greatest possible reduction of maternal and child mortality and malnutrition with programs that:
- identify and scale up the high impact interventions most relevant to the country;
- strengthen health systems and the human capacity to support and sustain improved child and maternal health outcomes;
- link water and sanitation investments to improved children's health;
- complement other USG, donor, and host country resources, and
- in post-conflict settings such as Liberia, Democratic Republic of Congo, and southern Sudan, extend basic services as quickly as possible while rebuilding the foundations of health systems.
By 2013, we aim to achieve an average 25 percent reduction of maternal and under-five mortality in these 30 priority countries as well as an average 15 percent reduction of child malnutrition in at least ten of these countries.
At the same time, we recognize the critical human resource constraints on progress in many countries. Therefore, as part of our plan, we are making a commitment to increase by at least 100,000 the number of trained, equipped, and supervised community health workers and volunteers serving at the primary care and community levels in these priority countries. This measurable health system change will provide and extend critical health services in the countries and communities which need them most. The success of these community health workers and volunteers will depend upon a health system that can deliver the necessary interventions and commodities and also ensure quality of care and retention of these workers.
In this work we will continue the successful collaborations we have with other USG agencies. This includes our work with CDC on family planning, water and sanitation, immunizations, and polio eradication, and our work with NIH and others on new vaccine development as well as our collaboration with PEPFAR and the President's Malaria Initiative.
Thank you again for this opportunity. We at USAID share the commitment you have demonstrated to the continuing needs of children and families in poor countries.
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