For the first time in history, we have the available knowledge and technologies to reach the world’s most marginalized children with life-saving interventions. Now is a time for action, to deliver on our long-standing commitment to end preventable child deaths. By working together with renewed determination, we can accelerate declines in child and maternal mortality, enabling more countries to achieve Millennium Development Goals (MDGs) 4 and 5 by 2015 and sustaining the momentum well into the future. Learn about A Promise Renewed.
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In the slums of Latin America, 117 million people live in poverty. The region’s megacities, including Mexico City, Sao Paulo, Bogota, Rio de Janeiro, and Lima, generate over-crowded living conditions without access to clean water or electricity, poor nutritional status, and often lack of basic health services. These marginalized populations are made up of the poor, the homeless, and vulnerable indigenous groups that have migrated to the city in search of a better life; they are the urban poor of Latin America.
The combination of these social determinants generates a breeding ground for tuberculosis (TB).
Around the world, tuberculosis rates are often high in urban areas and in the Americas it is no exception. Twenty-five percent of Peru’s urban poor live in Lima-Callao, which reports 60% of the tuberculosis cases for the entire country and 85% of drug-resistant tuberculosis cases which is difficult and costly to treat.
As populations continue to explode throughout the region, health conditions will continue to worsen if they are not addressed, particularly in slums. In 2011, 30,000 people died of tuberculosis in the Americas and there were 268,000 new reported cases. Worldwide, 1.4 million lost their fight against the disease. Tuberculosis, once thought an old disease, is the new emerging problem for the most vulnerable.
Tuberculosis has been used as a prime example of a “social disease” because it finds its nest among the poor and marginalized. The control of tuberculosis in cities requires social, economic, and environmental interventions to improve living conditions and increase access to health services. USAID has funded the Pan American Health Organization (PAHO) to tackle this concentrated epidemic in key cities across the Americas.
PAHO currently works with municipalities in Sao Paulo, Brazil; Bogota, Colombia; and Lima, Peru to improve their tuberculosis programs that service the urban poor. The successes from these cities will be shared with Mexico City, Guayaquil, and other megacities in Latin America and around the world.
As urbanization rates continue to increase, so are the chances of tuberculosis among the urban poor. Tuberculosis is contagious but also curable; acting now while the epidemic is concentrated will help avoid astronomical costs for treatment and keep the region healthy.
World TB Day is Sunday, March 24.
Fighting tuberculosis (TB) is extremely tough on any patient. Treatment consists of multiple pills each day over the course of at least six months. The medicines often have significant side effects and adhering to treatment often infringes on a patient’s ability to work and interact with his/her family. As prolonged and harsh as it sounds, that is actually the best case scenario for a TB patient. Those who contract or develop TB that is resistant to “first-line” treatments (the most commonly prescribed TB medicines) will be prescribed a still harsher combination of thousands of pills and shots—a draining course of treatment with greater side effects that can last as long as two years. And even then, a clean bill of health is far from guaranteed.
As grueling and debilitating as TB treatment may be for an adult, a child who is infected with TB will face an even rougher road. Treatments for children with TB are the same for children as they are for adults, but the recommended dosages are different. However, pediatric-appropriate versions of TB treatment remain absent from the marketplace. In 2010, WHO issued new guidelines for pediatric TB treatments, however, in the years since, child-friendly TB treatments in the correct dosages have not been produced. Parents or caregivers are left to split or crush adult pills for children, estimating the proper amount of medicine. If they guess wrong, children can be undertreated, resulting in poor outcomes and the development of drug-resistant forms of TB.
Furthermore, because treatments are designed for adults, none of the medicines used to treat children come in formulations that are easy for children to take. This means every dose becomes an adventure for the little ones and their caregivers—a struggle lasting as long as two years in attempt to cure the disease.
As a parent, I find it hard to understand how children with TB can be so neglected. Even among TB patients, who are underserved as a whole, children are particularly vulnerable and face the toughest road to cure when sick. But we’re going to change that! USAID is teaming up with TB Alliance, which is dedicated to the research and development of better TB drugs, to change course, help our children, and brighten the future prospects for the youngest TB patients.
In this new partnership, efforts will promote new understanding of the problem that can help lead to the sustainable supply of new TB drug formulations for children. And a stronger emphasis on patient care will help the world’s youngest TB patients comfortably and confidently survive one of the most persistent diseases ever known.
Yesterday at an event hosted by AEI and the Center for American Progress, USAID Administrator Raj Shah spoke about President Obama’s vision to end extreme poverty through innovation and partnership. His remarks mentioned an important corollary goal – the end of preventable child deaths. The first audience question commended the visionary Child Survival Call to Action held in Washington last year and asked about progress at country-level. Administrator Shah responded that the movement to end preventable child deaths is nothing short of extraordinary.
Since the Call to Action, 172 countries have now signed A Promise Renewed pledge to accelerate declines in child deaths. More than 400 civil society and faith-based organizations as well as over 2,000 individuals have also pledged support. Each signature represents a renewed commitment to give every child the best possible start in life. Governments are leading the effort to convene policymakers, technical experts, and development partners in a concerted effort to scale-up high-impact strategies for maternal, newborn and child survival. Below are a few highlights of countries leading and how USAID is supporting this important work.
USAID and other donors are supporting the Ministry of Health to develop an action plan to end preventable child deaths in Bangladesh, particularly at district level. This plan will identify priority actions and benchmarks to reach the goal of no more than 20 deaths/1,000 live births by 2035, or earlier. A technical advisory group has been convened to discuss evidence-based interventions that can be deployed in Bangladesh to bend the curve. This includes programs to address Pneumoccocal and Rotavirus vaccines, corticosteroids, clean cord care, child drowning and Kangaroo Mother Care, among others. Given the fact that 60% of child deaths in Bangladesh occur within in the first 28 days of life, there is a huge need for post-natal monitoring to reduce stubborn neonatal mortality rates.
Building upon the Child Survival Call to Action, USAID recently launched a public private partnership: Survive and Thrive. This partnership will expand the coverage of quality and high impact maternal newborn services starting with essential newborn care, and link pediatricians, midwives, and obstetricians from American professional associations to peer associations in Burma to build capacity in service delivery. Survive and Thrive will partner with civil society and professional and educational institutions, work within the Ministry of Health’s health system, support the programs of the 3MDG Fund, and maximize synergy with community-based programs of existing partners.
At the African Leadership on Child Survival meeting hosted by the Government of Ethiopia earlier this year, the consensus reached by over twenty African countries present was both significant and historic. The participating countries declared, in a consensus statement, that they are committed to developing and implementing country-led roadmaps that integrate ongoing efforts to accelerate progress to end preventable deaths among children by 2035, and reduce the mortality rate to below 20 per 1,000 live births in all African nations. Recently, Ethiopia’s Ministry of Health (MOH) signed a Memorandum of Understanding with Namibia. Officials from Namibia are undertaking a study tour to review Ethiopia’s health extension program.
At India’s recent Call to Action, the Government of India launched the Reproductive Maternal Neonatal Child Health Adolescent health strategy (RMNCH+A), which serves as a roadmap for the States. India also released several guidance documents including implementation of newborn care as well as management of pneumonia and diarrhea. A National Child Survival Scorecard was showcased, and States were encouraged to develop their own scorecards and to monitor progress. USAID’s Maternal and Child Health Integrated Project (“MCHIP”) supported the Ministry of Health and Family Welfare in organizing the recent India National Call to Action for Child Survival and Development, and USAID will continue to provide support in establishing quick response teams for Indian states with the highest child mortality that have committed to accelerating their efforts for child survival.
USAID supported a national newborn conference in Jakarta from Feb 26-March 1. The conference included international experts from India and the U.S. as well as representatives from the Indonesia’s Ministry of Health, key professional associations, academia, and district and provincial health leaders. This was the first such event in Indonesia focusing on newborn survival. Responding to Indonesia’s commitment to A Promise Renewed and the MOH’s call to accelerate progress toward the MDGs, this conference addresses one of the key indicators slowing achievement of MDG goal 4. DHS data from 2012 is now available and demonstrates no progress in newborn mortality since 2007. The rate remains at 19/1000 live births. Partners are committed to reducing this rate by 25% by 2017, in partnership with USAID, UNICEF and WHO, and an exceptionally strong collaborative relationship with the Ministry of Health.
The Ministry of Health in Liberia is sharpening its child survival plan using evidence and aligning donors to support the plan. There is great donor support and commitment to implementing the national plan through the alignment of programs. A launch for A Promise Renewed is being planned by the Government of Liberia. A steering committee led by the Government of Liberia and comprised of representatives from NGOs, house of representatives, representatives from different Ministries has been established and meets regularly to plan the launch event. An expected key outcome of the launch is greater mobilization of support and resources at the counties, civil society organizations and community leaders around A Promise Renewed.
For more information about A Promise Renewed, please visit: apromiserenewed.org.
Actress and Avon Foundation for Women Ambassador, Salma Hayek Pinault, recently presented the USAID-funded CHAMPION project in Tanzania with one of five Avon Communications Awards: Speaking Out about Violence against Women for its outstanding work to bring attention to the need to end violence against women. The CHAMPION Project, implemented by EngenderHealth with communications support from FHI360, received the award for their work on the Kuwa Mfano wa Kuigwa (Be a Role Model) mass media campaign. The award recognizes outstanding communications campaigns that are helping change communities, policies, institutions, and behaviors to end violence against women.
The CHAMPION Project’s Kuwa Mfano wa Kuigwa campaign is part of a five-year effort to engage men in Tanzania by increasing their involvement in addressing the underlying gender issues and power imbalances in relationships. The campaign, which was launched in Tanzania in collaboration with the Ministry of Community Development, Gender and Children in December 2011, aims to turn men from bystanders to champions with its key message, “Violence is everyone’s problem. Be a role model. Earn respect by standing up to violence.”
Watch a TV spot from the award-winning campaign below and learn more.
This blog is part of the Global Health Research & Development Blog Series.
Asking the right questions is the first step to generating the ‘downstream’ evidence needed for the implementation of health policies and practices, as my colleague E. Callie Raulfs-Wang described in her March 12 blog. And fostering the right partnerships is crucial to determining the right questions. Partnerships facilitate operations research, or the testing of scalable solutions that overcome barriers to access, demand, and quality in real world settings. Investing in operations research to accelerate results is also a key strategy in the Global Roadmap of the Child Survival Call to Action. This pledge, signed by more than 160 governments, renewed their commitment to child survival and to eliminating all preventable child mortality in two decades, as USAID Administrator Rajiv Shah explained.
USAID’s Child Survival and Health Grants Program (CSHGP) supports new operations research partnerships among non-governmental organizations (NGOs), academia, and ministries of health to generate evidence about how to solve critical challenges in the implementation and scale-up of high impact maternal, newborn, and child health interventions. By working in partnership with ministries of health, studies are designed to meet the ministries’ expressed needs for evidence that would strengthen their systems. Solutions are tailored to local contexts, with relevance to global implementation challenges, such as how best to: integrate services within and across sectors; improve the continuum of care to maximize access and lower costs; ensure equity in access to health information and appropriate use of services; and strengthen systems’ capacity for accountability to communities.
As USAID’s Jim Shelton commented in Nature magazine this year, promoting health literacy for preventive health behaviors such as handwashing and breastfeeding, and deploying community-based interventions for services and health education, are among the priority public health approaches needed now for universal access to health.
Some questions that must be addressed in order to operationalize these approaches include:
- How can community health workers (CHWs) more effectively reach households with timely information, case management, and referral?
- What are effective models for partnerships between health care providers and community agents/traditional caregivers to improve the continuum of care and increase demand for services through culturally appropriate and respectful care?
- How can data collected by communities be used as a communication and planning tool to improve the quality of care and accountability?
The answers to these questions would facilitate the research goals of integrated maternal and newborn health, child health, and nutrition, as outlined in USAID’s Report to Congress: Health-Related Research and Development Strategy. As stated in the research goals for health systems strengthening (HSS), “Ensuring equitable access to high-quality essential health services requires an increase in the evidence base on how to best implement HSS interventions and promote uptake of best practices.” These partnerships have the potential to achieve more than the sum of their parts by bringing together perspectives and skills that yield rigorous, relevant, and practical evidence.
At this year’s Global Maternal Health Conference in Arusha, Tanzania, presenters from CSHGP’s NGO partners in Peru, Liberia, Pakistan and Ecuador shared experiences on bridging the gap between communities and health systems to meet the maternal and newborn health needs of their most vulnerable populations . These research projects are helping ministries of health learn how best to operationalize and improve current policies on providing culturally competent, respectful care, and are testing new systems for overcoming geographic and financial barriers to safe childbirth. These partnerships are meeting the evidence needs of ministries of health that are striving to implement policies that make access to care more equitable.
To learn more about some of these 30 research partnerships in 23 countries check out this brief (PDF).
Read other posts in the Global Health Research & Development Blog Series:
- Microbicides, Vaccines, and TB Diagnostics Oh My! What’s New in HIV/AIDS Research?
- Where the Rubber Hits the Road: Evidence Informing Impact for Global Health
This originally appeared on Smart Global Health.
“In Zambia, when women have delivered, we say ‘Oh, you have survived.’” This chilling reminder of the impact of maternal mortality in sub-Saharan Africa came from Professor Elwyn Chomba, a Zambian government public health official interviewed by CSIS for a new video about the challenges of maternal mortality and a new initiative to address it.
Pregnancy-related deaths remain an acute problem in many places, despite overall global declines in rates of maternal mortality. Every day, nearly 800 women die from complications in pregnancy or childbirth, and 99 percent of these deaths occur in developing countries. These deaths are largely preventable with interventions and training to prevent or treat complications such as hemorrhage, infection, and obstructed labor, and with increased access to reproductive health services and emergency care.
We traveled to Zambia because it has a disproportionately high rate of maternal mortality – an estimated 440 women dying for every 100,000 live births, which is 20 times higher than the U.S. But Zambia, as well as Uganda, is also the site of a new program, called Saving Mothers, Giving Life (SMGL), designed to reduce maternal mortality by up to 50 percent in selected districts in a year.
SMGL builds on the fact that most maternal deaths result from one or more of three delays: in seeking care, in arriving at a health facility, and in receiving appropriate care. SMGL is working to address those delays by supporting linkages between communities and health facilities through Safe Motherhood Action Groups (SMAGs); by improving communications and transportation in the districts to speed the care and referrals of pregnant women; and by training and hiring health care providers, while improving equipment and standards of care at health facilities.
Although the U.S. government has been a driving force behind SMGL, it is a public-private partnership. The U.S. Agency for International Development leads SMGL for the U.S. Government, in partnership with the President’s Emergency Plan for AIDS Relief (PEPFAR), the Centers for Disease Control and Prevention, the Peace Corps, and the Department of Defense. The other SMGL partners include the governments of Norway, Zambia, and Uganda, the Merck for Mothers program, the American College of Obstetricians and Gynecologists, and Every Mother Counts.
SMGL has generated excitement, but its implementers know that there is no quick fix for reducing maternal mortality. Accordingly, the initiative faces significant challenges to national scale up and to sustainability, and many experts believe that the changes required will take years – not months — to achieve.
Effectively addressing maternal mortality — in Zambia and elsewhere — will demand ongoing commitment, from national governments and international partners– and investments in community awareness, in improving health facilities and transportation, and in expanding women’s access to health services, including family planning programs. As Professor Chomba said, we want to get to a point where “every woman can look forward to labor, and not say, I may die.”
This blog is part of the Global Health Research & Development Blog Series.
Like strands of human DNA, the genetic underpinnings of life, research and evidence are so closely intertwined they cannot be separated. Whether testing the efficacy of an HIV vaccine or the marketing strategy of a new contraceptive technology, quality research, careful methodology and rigorous analysis are fundamental for acquiring evidence useful in decision-making. As outlined in USAID’s Report to Congress: Health-Related Research and Development Strategy, the Agency supports a range of research activities, including both ‘upstream’ product research and ‘downstream’ implementation research. Along this continuum, USAID places a strong emphasis on evidence for informing development policies, practice and strategy.
As global health products are developed, we need evidence to demonstrate their effectiveness in developing country settings. For example, despite the fact that effective treatments exist for pneumonia, over 1.2 million children die each year from the disease. In the last few years, USAID has supported studies in Pakistan investigating the effectiveness of community-based treatment of severe pneumonia. Results from these studies have shown that oral antibiotics administered at home are as effective as injectable antibiotics administered in a hospital setting. This evidence prompted a 2012 revision of the WHO guidelines on outpatient management of severe pneumonia.
Beyond effectiveness studies, like the one conducted in Pakistan, we need studies that focus on the implementation and adoption of public health interventions, also known as implementation science. USAID’s 2012 Global Health Strategic Framework: Better Health for Development iterates a commitment to implementation research and the “scale-up of evidence-based, equitable, inclusive, and locally adapted health solutions.” USAID is meeting this challenge in multiple ways; some examples include:
- To increase understanding of the ‘what’ and ‘how’ of implementation research, USAID in partnership with Johns Hopkins University and George Washington University, has launched an open-access peer-reviewed journal called Global Health: Science & Practice;
- To accelerate product development and the introduction of new technologies, USAID has initiated the Center for Accelerating Innovation and Impact (CII), which engages key experts to identify state-of-the-art ‘best practices’ around product marketing, introduction, and scale;
- To expand knowledge of interventions that have “high impact,” the Bureau for Global Health has developed several High-Impact Practices (HIPs) in family planning; maternal, newborn, and child health; nutrition; and health systems strengthening. For example High-Impact Practices in family planning are best practices that, when scaled up and institutionalized, will maximize investments in a comprehensive family planning strategy.
Since 2011, USAID and partners have hosted three evidence summits addressing critical challenges in global health. Not an ordinary conference, an evidence summit is an organized process that convenes leading scholars and health practitioners to review the latest research and provide evidence- based guidance for improved health performance, an understanding of knowledge gaps, and research agenda recommendations. These summits have addressed: Protecting Children Outside of Family Care, Enhancing Provision and Use of Maternal Health Services through Financial Incentives, and Enhancing Community Health Worker Performance. A fourth evidence summit on Behavior Change Communication for Child Survival will be held later this year.
The local adaptation of health solutions is where the rubber meets the road. Each developing country is characterized by its own unique population, culture, health challenges and infrastructure. To enable the development of local solutions to local problems, USAID is supporting the Partnerships for Enhanced Engagement in Research (PEER) Health program. PEER Health is a capacity-building program which provides research grants to developing country investigators in partnership with National Institutes of Health researchers focused on addressing local health challenges.
Asking the right question, at the right time, in the right way, is not easy. As global health moves into the 21st century, more complex health challenges, including non-communicable diseases, the integration of health services, and the strengthening of health systems, present themselves. Solid evidence based on rigorous research is an indispensable ingredient for the successful introduction and scale of health products and services. As the 2012 health research report to Congress attests, USAID remains committed to pursuing an evidence-based agenda in global health.
E. Callie Raulfs-Wang is a Research Advisor for USAID Center for Accelerating Innovation and Impact.
Read other posts in the Global Health Research & Development Blog Series:
This year’s International Women’s Day theme is “A promise is a promise: Time for action to end violence against women”. In observance, this week USAID is profiling brave individuals and dynamic programs focused on addressing gender-based violence around the world.
The statistics are staggering: one out of three women will be beaten, coerced into sex, or otherwise abused in her lifetime. Not only are the economic, legal, and social effects devastating and lasting, but gender-based violence has serious health implications.
Physical and sexual violence affects women’s health and well-being and detracts from her reproductive health. Women who have experienced violence are more likely to use contraceptive methods in secret, be stopped by their abusive partner from using family planning, and have a partner who refuses to use a condom. Consequently, they are more likely to have unintended pregnancies and unsafe abortions, and to become pregnant as adolescents. Children of abused women have a higher risk of death before reaching age five and violence during pregnancy is associated with low birth weight of babies. Forced and unprotected sex and related trauma increase the risk that women will be infected by STIs and HIV.
The health sector can play a vital role in preventing gender-based violence by helping to identify abuse early, providing victims with the necessary treatment, and referring women to appropriate and informed care. USAID supports stand-alone activities as well as programs that integrate anti-gender violence activities and messages into broader health efforts. Emphasis is placed on prevention interventions such as community mobilization and behavior change communication activities to address and transform the underlying norms that perpetuate violence. By addressing gender violence, health programs can enhance their effectiveness, enable women who have experienced violence to benefit from existing programs, and prevent the escalation of such violence.
Freeing women from violence results in healthier lives for them and for their families. In turn women and their families are able to contribute more to their communities and nations.
This blog is part of the Global Health Research & Development Blog Series.
Nearly all great scientific advances can be traced back to methodical research and development (R&D). R&D is a critical step in meeting goals and achieving health results that are cost-effective, sustainable, and grounded in evidence. In December 2012, USAID released its new strategy for global health research and development. The report outlines how the Agency plans to address some of the world’s most challenging health and development issues through new technologies, research and evaluation, and the scale-up of interventions backed by scientific evidence. HIV/AIDS is a large component of this effort and the Agency, through the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), is supporting very promising HIV research in several areas, including microbicides, vaccines, and diagnostic tools to detect tuberculosis (TB) in HIV-positive patients.
Microbicides: Microbicides are substances that can be applied vaginally or rectally to reduce the risk of HIV transmission during sex. Vaginal microbicides are a particularly desirable innovation because women can use these products on their own to protect themselves from HIV infection. Given that women make up almost 60% of people living with HIV in sub-Saharan Africa and struggle to negotiate other HIV prevention methods – such as condoms – with their partners, USAID supports microbicide research and development as a key intervention in reaching an AIDS-free generation.
In 2010, the CAPRISA 004 clinical trial showed that a vaginal microbicide made up of 1% tenofovir gel (a topical form of the antiretroviral drug) protected women against HIV. Following this success, a new public-private joint venture, known as Propreven, is preparing to obtain regulatory approvals, create manufacturing capacity, and support product distribution of tenofovir gel in various African countries. Two additional studies are also underway – the FACTS 001 clinical trial, which is a follow-on to CAPRISA 004 and is currently in year two, and the CAPRISA 008, a study that is examining and addressing implementation issues for future microbicide programs. Both of these studies are supported by a U.S. and South African partnership made up of USAID, the Bill & Melinda Gates Foundation, and the Government of South Africa.
Vaccines: While microbicides are an important method in preventing HIV when tailored to specific populations, no single approach is likely to have as dramatic an impact on the HIV pandemic as an effective vaccine. That is why USAID has supported HIV vaccine research and development through the International AIDS Vaccine Initiative (IAVI) since 2001. IAVI is a public-private product development partnership that acts as a virtual pharmaceutical company to accelerate the development and clinical testing of HIV vaccine candidates. On the vaccine design front, IAVI and its partners in the Neutralizing Antibody Consortium (NAC) have designed four new immunogens – the active ingredients of vaccines that stimulate the immune system – and are testing these structures as part of potential HIV vaccines.
Two clinical trials involving IAVI’s work are examining new HIV vaccine regimens. One trial nearing completion in east Africa is evaluating a vaccine regimen that uses a new technique called electroporation and some exciting results are expected in the coming year. Electroporation applies a small charge to effectively distribute the contents of the vaccine in the muscle and enhance uptake of the DNA. Another trial poised to begin within the next few weeks will evaluate new viral vectors carrying HIV antigens.
TB Diagnostics: Microbicides and vaccines are critical priorities for USAID’s HIV prevention efforts; however, we must also provide care and support to people already living with HIV. Since tuberculosis is the leading cause of death among HIV-positive people, USAID supports the coordination of TB and HIV services to better care for people living with each disease. In recent years the prevention, diagnosis, and treatment of TB has become more complicated because of two factors: HIV-associated TB and multidrug-resistant (MDR) TB. HIV-associated TB often goes undetected because the most common TB diagnostic, called sputum smear microscopy, is not very effective in persons infected with HIV.
Fortunately, there is a promising new diagnostic for TB, including HIV-associated TB, on the horizon! This rapid and sensitive test, called the Cepheid Xpert MTB/RIF® assay, has the potential to revolutionize the diagnosis of TB. While Xpert still faces some operational and programmatic barriers, such as high costs and the need for a sustained power supply, USAID has already begun supporting the roll-out of this new tool by helping countries obtain Xpert machines, designing associated policy guidance and strategies, and developing technical approaches to guide implementation.
Research and development in these three key areas is what keeps USAID at the forefront in the fight against HIV/AIDS. As David Stanton, the Director of the Office of HIV/AIDS at USAID said, “These clinical trials and new technologies have the potential to dramatically change the HIV/AIDS landscape and reverse the trajectory of the global HIV pandemic.” To learn more about USAID’s strategy for global health research and development in the coming years, be sure to check out our latest Report to Congress: Health-Related Research and Development Strategy 2011-2015 (PDF).
Read other posts in the Global Health Research & Development Blog Series: