(Photos by MSH/Brigid Boettler, CARE/Ben Weingrod, and MSH/Rachel Hassinger)
For seven days last month, Management Sciences for Health was proud to host six Congressional staffers as they participated in a study tour to Malaysia—to learn about how the country has made major global health investments and how those investments have saved the lives of women and families.
The staffers—Adriane Casalotti, Legislative Director (Rep. Lois Capps, D-CA), John Ariale, Chief of Staff (Rep. Ander Crenshaw, R-FL), Maggie Dougherty, Legislative Aide (Senator Marco Rubio, R-FL), Aaron Allen, Legislative Assistant (Rep. Juan Vargas, D-CA), Kelli Ripp, Legislative Aide (Rep. Aaron Schock, R-IL), and Melinda Cep, Policy Advisor (Rep. Rosa DeLauro, D-CT)—took part in 17 different educational briefings, networking receptions, dinner panels and meetings.
Staffers met with over 50 technical, political, advocacy, and global health experts and heard personal stories from mothers, patients, and global health advocates from around the world. A noted highlight of the tour included a meeting with US actor/singer/humanitarian Mandy Moore, who described firsthand the benefits of malaria bednet distribution projects in Central Africa.
An added benefit of this informational tour of Malaysia was the staffers’ opportunity to attend the 3rd Women Deliver Conference, this decade’s largest event on maternal health and women’s rights. Along with over 4,500 attendees from around the world, the US staffers were able to attend sessions of their interest.
Thanks to the Ministry of Health of Malaysia and the Negeri Sembilan Family Planning Association (the leading voluntary family planning, sexual and reproductive health organization in Malaysia), the study tour included visits to Putrajaya, the small town of Seremban, and the historic city of Melaka to visit government and NGO reproductive health clinics and youth centers. During a tour of the Negeri Sembilan Family Planning Association, the staffers joined a group of neighborhood youth to identify important “social ills” that children and adolescents face in Malaysia. All of these site visits served as vivid demonstrations of the benefits of Malaysia’s investment in maternal and child health.
As the study tour came to a close, the staffers found themselves informed, inspired, and better able to understand the cross-cutting investment that is maternal health and women’s rights.
“Just think of all the good that could come from advocating for ensuring that women and girls have the right to access maternal and reproductive healthcare … women’s rights and access to maternal and reproductive healthcare must be a highlight of our global development agenda,” John Ariale blogged during the tour. “The issue is too important to ignore, or be mired in obtuse political innuendo. With the right focus and attention we can ensure that sexual and reproductive health is readily available and sustainable for all women.”
Learn more about the Congressional Study Tour
Crystal Lander is the director of policy and advocacy, and Brigid Boettler the outreach and events specialist, at MSH.
Universal health coverage received a lot of play at the recent Women Deliver conference. Universal health coverage (UHC) is a mechanism for health that ensures affordable, accessible, quality care for all. Over 50 countries are on their way toward achieving UHC, and several have already attained it. Many have supported UHC as an overall framework for the health goals in the Post-2015 development agenda.
One of the first questions arising with UHC is how to pay for it. At a session on Wednesday afternoon, May 29th, panelists gathered to discuss UHC and financing. The panel was organized by Population Services International (PSI). According to Ben Bellows of Population Council, who started off the discussion, “UHC systems are characterized by quality and low out-of-pocket costs to consumers.” Bellows spoke about Kenya’s scaling up of voucher programs for family planning and other services. The government of Kenya budgeted for procurement of voucher services and the program resulted in addressing 70 percent of unmet needs in two of the poorest quintiles. “Family planning vouchers are an entry point for UHC, targeting uncovered populations. They bring quality improvement, reduced out-of-pocket spending, and are a useful entry point for a more expanded package of services later. “
Ben Bellows of Population Council. (Photo credit: MSH/Ayotte)
Panelist Dr. Jonathan D. Quick, MSH President and CEO, highlighted two goals of UHC: improve health (including maternal health and family planning) and reduce medical impoverishment due to out-of-pocket payments. Quick suggested taking a look at the delivery side as a way to transform a health system toward UHC–especially a look toward medicines, where 50 percent of out-of-pocket spending is spent on medicines and 150 million are medically impoverished. “If we are to restructure funds and financing, we have to look at pharmaceuticals, including contraceptives. Informal drug shops are where most people get their medicines—typically poor quality at a high price. But in Tanzania, with funding from the Bill and Melinda Gates Foundation, MSH and the private sector transformed these drug shops into licensed drug sellers, selling items that included sanitary products, so girls can stay in school, and antimalarials. Ninety percent of these sellers are women. We need to ask, ‘Are informal drug shops included in UHC programs?’” said Quick. “In Tanzania, yes, the national insurance fund is reimbursing them. In Ghana, they are part of the program. “
Jono Quick of MSH. (Photo credit: MSH/Ayotte)
Rob Yates of the World Health Organization (WHO) asserted, “Public financing is key to UHC in order for all people to receive the quality health services they need without suffering financial hardship.” But who is covered, what services, what do people pay out of pocket?
Yates spoke about health financing in Sierra Leone. In Sierra Leone, the president launched free care for women and children. Health centers that had been empty before due to high cost were suddenly full. “Private, voluntary, financing mechanisms are not a good way to finance a health system,” he said. Yates noted that Jim Kim, President of the World Bank, recently stated that user fees are unjust. “Public compulsory insurance works—it forces the healthy and wealthy to subsidize the poor,” said Yates. “More groups in the formal and informal sector have emerged to join social and voluntary insurance schemes. Some countries use public monthly tax funding to cover the untargeted informal sector. Sri Lanka, Brazil, Thailand, Mexico, China, Malaysia, Fiji, Ghana, Rwanda, and Costa Rica have all achieved UHC. Three to watch in the next decade are South Africa, India, and Indonesia. Public financing can come from income tax, natural commodities tax, oil revenue.”
Yates continued, “UHC is easy to understand—an attainable goal—especially as countries make the transition to become middle income states. UHC brings politics into the health systems agenda. It is an opportunity to celebrate national successes. “
UHC and Sexual and Reproductive Health Rights
International Planned Parenthood Foundation (IPPF) and WHO sponsored another UHC session on Wednesday evening, moderated by Dr. Quick of MSH.
Jono Quick of MSH. (Photo credit: MSH/Ayotte)
Dr. Quick began the session with four propositions: 1. Global momentum for UHC is accelerating; 2.) UHC is the only approach for women and girls; 3) Understand potential risks of UHC; 4) Informed advocates will make all the difference in minimizing those risks.
Yates offered UHC as the health umbrella in the Post-2015 development framework. “UHC is not a great insurance plot or communism by the back door. It is a whole movement. UHC is about ALL people receiving the quality services that they need. It’s about curative services—and also about financial protection and about what should be in a benefits package. ..UHC is inherently political— which is a good thing.”
Rob Yates. (Photo credit: MSH/Ayotte)
Yates continued: “UHC is a good idea for the health community to rally around. Everyone can understand it. It is inspiring and motivational. People understand ‘We demand universal health care.’ People get it. They don’t get ‘we want healthy life expectancy.’ UHC captures the imagination of politicians and the UN. It’s political for all the right reasons and sensible to unite the health community around it—otherwise, divided we fall.”
Anjali Sen. (Photo credit: MSH/Ayotte)
Panelist Anjali Sen of International Planned Parenthood Federation (IPPF) said that IPPF works to provide access to quality sexual and reproductive health right (SRHR) services regardless of ability to pay. “We know the health risks to women and children. Populations are younger.Young women give birth. Maternal mortality is high and the contraceptive prevalence rate is low. Women are denied basic health care. IPPF supports a concept of UHC that is enshrined in our philosophy of equity and links care to need: Give the poorest and most vulnerable access without pushing them further into poverty. “ Sen stated that IPPF hopes UHC is included in Post- 2015 framework and wants UHC to include sexual reproductive health rights in essential benefit packages: ”SRHR must be part of the package. For the right to health to be truly universal, it must look at the health of women. SRHR is a critical component yet often neglected in global schemes. Only 20 UHC schemes include SRHR/FP in their essential benefits package. We all know that SRHR was belatedly added to the MDGs—too little, too late. Progress toward meeting the unmet need for family planning has cost women dearly. “
Caroline Halmshaw. (Photo credit: MSH/Ayotte)
Panelist Caroline Halmshaw of Interact/Action for Global Health asserted that there is no guarantee that SRHR will be in the Post -2015 development framework. But we need to ensure SRHR is embedded in other goals. “We also need unity in the health sector on UHC,” said Halmshaw.” For UHC to succeed, we must address the stigma and discrimination toward women and overcome it. UHC has to make sure people who are excluded are covered now. How will we include the most marginalized? People in sex work, criminals; all those who have no access to government services? UHC is huge opportunity for the SRHR community. UHC is a health systems approach.”
Jackson Chekweko. (Photo credit: MSH/Ayotte)
Panelist Jackson Chekweko of Reproductive Health Uganda, spoke to an example in Uganda: “Uganda abolished user fees in 2011, resulting in an uptake in family planning and maternal health services. UHC will be a given—yet how do we get governments to secure funding for UHC? Civil society pushed government to improve on this.“
Yates concluded, “UHC is a developing country agenda. [Developing countries] are the ones pushing UN resolutions. The UHC movement is happening worldwide; we can’t ignore it. And it is a safe goal. Yet, each country will need to grapple with rationing. No country has universal coverage for everything immediately— not everything is free or even high quality. For example, cancer treatments are expensive. It is naive to think we will get everything. All of civil society has to decide what’s in or out, when we think UHC. “
UHC: A Women’s Issue
Dr. Quick conducted a TED-style talk during Thursday’s “To the Point” series on “Why UHC is a Women’s Issue.”
Barbara Ayotte is director of strategic communications at MSH.
On Tuesday, May 28, MSH brought together fragile states staff from Democratic Republic of the Congo (DRC), Haiti, and Afghanistan to share their field experiences with congressional staffers in Malaysia for the Women Deliver conference. The dinner panel, “Delivering Maternal, Newborn, and Child Health (MNCH) in Fragile and Post-Conflict States,” featured Philippe Tshiteta of MSH DRC, Sandra Guerrier of MSH Haiti, and Dr. Mushfiq of MSH Afghanistan, and also Sandra Krause, the director of sexual and reproductive health at Women’s Refugee Commission, and Paola Cirillo, the Syria and Middle East program officer at Italian NGO AIDOS.
The five panelists shared vivid stories of the major barriers to and strategies for delivering MNCH and reproductive health services in the difficult contexts in which they work.
Despite many challenges, the common emergent theme was that simple, low cost interventions—such as having skilled birth attendants, immunizations, and proper hand washing—can have powerful impacts on effectively saving lives and improving the health of women and children even in post-conflict and post-disaster settings. The event left attendees with a better sense of the on-the-ground realities that MNCH health workers face in fragile states and an improved understanding of the need for improvements to health systems infrastructures in these environments.
Every year, an estimated 14 million girls are forcibly married before they turn 18 . . . that’s something like 39,000 girls every day! That’s the first thing I heard as I walked into the late afternoon session on child marriage presented at the Women Deliver Conference in Kuala Lumpur this week. Beyond the moral question of this issue, there are huge health and welfare implications. Low- and middle-income countries are now focusing on girl brides and child marriage because they recognize that they can’t reach their development goals otherwise. Donor countries are also interested for similar reasons; child marriage has an enormous impact on economic development and global health.
Among the panelists at this session, aptly titled “Let Girls be Girls, Not Brides,” were Nyaradzayi Gumbonzvanda (World YWCA), Suzanne Petroni (International Center for Research on Women), Lakshmi Sundaram (Global Coordinator for the Girls Not Brides campaign), and Sarita Prabhakar Wagh, a young woman from India who convinced her parents not to marry her off while she was still a girl. Each presented compelling research and information that was beyond belief. A study by Anita Raj, PhD, on the prevalence of child marriage and its impact on fertility in India suggests that just a 10 percent drop in child marriage could lead to a 70 percent drop in maternal mortality. In developing countries, the leading cause of death for girls 15 to 19 years old is complications from pregnancy and childbirth. This situation of “bonded labor,” as it’s sometimes described, also contributes to high morbidity rates, lower literacy rates, and harmful social norms where girls continue to be under-valued.
Young girls are fortunate when support comes from those at home. Ms. Wagh told the audience that her father said about her when she was young, “Until she is well educated, we will not even discuss marriage!” She credited her father for her own emancipation, and said he was extremely supportive.
As health professionals, many of us are aware that higher numbers of girl brides mean higher morbidity, higher maternal and child mortality, higher risk of HIV and AIDS, higher vulnerability to domestic violence, lower rates of literacy, So how can health leaders, managers, and policy-makers help, particularly if they work in one of the 10 countries with the highest rates of child marriage (that includes Niger, Chad, Central African Republic, Bangladesh, Guinea, Mozambique, Mali, Burkina Faso, South Sudan, and Malawi)? They can do three things:
First and foremost, they can help prevent it by letting parents know the health dangers associated with child marriage.
Just as importantly, they can provide sexual and reproductive health information and contraception to the young girls (and boys) who are already married.
They can also ensure that health workers get the knowledge and skills they need to understand the adverse effects of early marriage, and promote a supportive environment for child brides who enter the health system so that they are not stigmatized.
I had the pleasure of presenting stories and results from a successful DRC project on Tuesday, May 28, day one of Women Deliver 2013.
The USAID-funded Integrated Health Project (IHP) in the Democratic Republic of Congo (DRC), implemented by Management Sciences for Health, the International Rescue Committee and Overseas Strategic Consulting, Ltd, is creating better conditions for, and increasing the availability and use of high-impact health services, products, and practices in 80 health zones in four provinces (Kasaï Occidental, Kasaï Oriental, Katanga, and Sud Kivu.
IHP addresses three major bottlenecks hampering the performance of health services: (1) poor availability of medicines and essential inputs related to supply chain management; (2) limited availability of qualified human resources to implement high-impact interventions for the health of the mother and the child; and (3) low quality of care.
Audience members participate in a Q&A with the panelists. (Photo: R. Hassinger/MSH)
Although working in a fragile state where instability persists, IHP applies a development approach that demonstrates that, even against many odds, health programs can achieve results in challenging settings—they just need to be innovative and persistent to achieve their goals.
Using a range of high-impact practices and approaches in maternal, neonatal, and child health and family planning that were selected through careful analysis, including use of the Lives Saved Tool (LiST)—such as integrated services, Leadership Development Programs, fully-functional service delivery points, and a range of behavior change communication approaches (i.e. mHealth and Champion Communities)—IHP has achieved impressive results in fistula care, family planning, rates of assisted delivery, and active management of the third stage of labor, among other health indicators.
An important focus of the program is counseling women and families on healthy timing and spacing of pregnancies at health center and community level. Community-based distribution of family planning methods is improving contraceptive security and promoting a range of modern contraceptive methods and includes training and supporting community workers to deliver family planning and to refer and accompany couples to health centers to choose a contraceptive method.
Selected findings include:
Couple years of protection as of March 2013 was 122,523, which is 111% of the target of 110,000.
New acceptors of family planning as of March 2013 was 136,302, or 113% of the target of 120,728.
As of December 2013, the percent of women receiving Active Management of the Third Stage of Labor, at 84%, was 105% of the target of 80%.
IHP is getting the right commodities into the right, competent hands at the right time to produce impressive results, against all odds.
Kristin Cooney is a director, country portfolio, at MSH.
For many women and newborns in developing countries, pregnancy and childbirth can be life-threatening. Ensuring access to essential high quality medicines and supplies across the continuum of care is often a hidden part of the solution.
Safe and effective maternal health medicines and supplies exist but are not often available when and where women, newborn and children need them the most.
These topics and more were discussed at a Maternal Health Commodities pre-conference event on Monday, May 27, sponsored by Family Care International, PATH, and Population Action International.
As maternal, newborn and child health medicines and supplies needs are being elevated on global agendas through global initiatives such as the UN Commission for life saving commodities for women and children, it takes multifaceted skills and efforts at country level to translate these global initiatives into appropriate local interventions that improve access to high quality medicines and supplies for women across the continuum of care.
MSH promotes a systems-strengthening approach to identify challenges with delivering essential pharmaceuticals and services to women, newborns and children by working with managers at all levels of health systems, policy makers, providers, and communities to build capacity and strengthen health systems to address these challenges and improve access of women and children to life saving medicines and supplies.
On Monday, May 27, MSH joined a group of international organizations to launch the Call for Universal Access to Cervical Cancer Prevention at the Global Forum on Cervical Cancer Prevention, one of the pre-conference events for the Women Deliver 3rd global conference in Kuala Lumpur, Malaysia.
It Is Possible
It’s estimated that there 530,000 new cervical cancer cases each year, of which about 85 percent are in low and middle Income Countries (LMIC). But the good news is that we know that cervical cancer is vaccine preventable. The cost of vaccines that prevent cervical cancers has been reduced significantly.
We also know that cervical cancer is treatable if diagnosed and treated early.
We have the tools, methods and diverse approaches for different settings. We know what works. We know what it costs. We have innovative game-changing solutions that can be taken to scale. And, we have a call to action that, if adopted and supported, would prevent suffering, avert millions of premature deaths among young girls and women, and would help promote a better quality of life for millions of girls and women in the world.
Through sharing and exchanging information at this conference, we were reminded that by addressing missed opportunities, and leveraging other global work and interventions like family planning and reproductive health; maternal, newborn, and child health programs; and all the progress made on infectious diseases, such as HIV/AIDS, we can significantly decrease the sufferings and death as result of cervical cancer.
For instance, we can translate the successes of immunization programs and decades of unprecedented global support for prevention and treatment of major killers like AIDS, tuberculosis and malaria prevention to potentially protect and reduce sufferings and death as a result of cervical cancer.
We know this is possible. Mildred is HIV positive and lives in rural Uganda. She was recently screened for cervical cancer. Because of community outreach, supported by the MSH-managed STAR-E project, funded by USAID, she went to a nearby clinic as part of the ongoing and expanded “Prevention for Positive” activities (Watch Mildred’s Story).
She was fortunate that her health care workers had the training to screen, diagnose and treat her pre-cancerous lesions correctly using the low cost innovative approach termed the Visual Inspection with Acetic Acid (VIA) method, and that health care providers and a community volunteer helped her to adhere to treatment.
Other women have not fared as well.
Opportunity and responsibility: Act Now
This is an exciting time: we can reduce the inequality of cervical cancer prevention, care and treatment; bridge the divide between and within countries and regions by:
leveraging existing platforms;
addressing missed opportunities;
advocating and increasing awareness to everyone, including legislators, parliamentarians, communities and health workers; and
acknowledging that integrated health programs serve families better
We need to debunk the myths; reduce barriers and stigma; promote community and country driven responses and make products, technology and medicine accessible to all at an affordable cost.
But we need toact now because no girl or woman deserves to die from preventable illness like cervical cancer, especially when we have a vaccine. All beneficiaries, like Mildred, must benefit from a “whole system ownership” response with contributions from all sectors (public, civil society, and private). All beneficiaries must be involved in the design and implementation of health system innovations.
We must must make cervical cancer a priority and act now.