J. Stephen Morrison
Director, Global Health Policy Center
One intriguing proposition for doing business differently over the next five years, vis-à-vis achieving the Millennium Development Goals (MDGs) by 2015, has come from UNICEF and its new executive director Anthony Lake.
Based on a four month study, ‘Narrowing the Gaps to Meet the Goals,’ released in early September, UNICEF proposes that major gains in child (MDG-4) and maternal (MDG-5) health can be achieved through an “equity focus” – concentrating in a new and disciplined way on the lowest quintile (20%) of women and children living principally in low income, high mortality countries. This is a refreshing new idea.
The report argues that since 1990 disparities in poverty and child development persist or have worsened, despite a significant reduction in under-five mortality in low income countries. These improved averages conceal persistent, nagging gaps that should now be the priority focus of UNICEF and others’ efforts.
UNICEF acknowledges that reaching these populations can be costly and difficult: owing to remoteness, poor transport access, and weak infrastructure. Nonetheless, it argues that an equity focus can accelerate progress in MDG 4 and 5, reduce disparities, be cost effective, and reduce the out-of-pocket expenditure for the poor if a strategy concentrates on three steps: (i) upgrade select facilities for maternal and newborn care, including “waiting homes” for pregnant women; (ii) expand outreach services, eliminate user charges, extend cash transfers to the poorest to cover transport and other costs that impede use of services; and (iii) task shift – place greater reliance upon community-based health workers. UNICEF's report adds that preventive, promotive and curative principles need to underpin these steps:
“Preventive measures seek to prevent disease and undernutrition and to support pregnant women. Examples include immunization, micronutrient supplementation, antenatal care and prevent of mother-to-child transmission of HIV. Promotion measures foster feeding, hygiene and sanitation practices… early and exclusive breastfeeding, hand washing with soap, correct and comprehensive knowledge of HIV, and the use of insecticide-treated nets to prevent malaria are four such interventions… Curative measures aim to treat disease and conditions, and to support mothers and newborns during delivery and in the postpartum period. They include… antibiotic treatment for pneumonia, skilled attendance at delivery and emergency obstetric care, treatment of severe acute malnutrition, and prophylaxis and pediatric treatment for HIV and AIDS.”
UNICEF’s bold proposition attempts to speak to the moment we are in - of the need to renew the value proposition that equity lies at the core of global health; of making strategic use of responding to the considerable recent accumulated experience of what interventions work best; and of responding to increasing budgetary pressures and the need to demonstrate efficiency and prove concrete impacts through select, core steps, better data and better measurement.
For now, the UNICEF proposition rests on a modeling exercise; full proof that it can be successful lies ahead. It will be important for this approach to be put into practice in countries, with clear strategies, time lines, and budgets: how much will it cost to bring this vision to scale. And how quickly will we know whether the strategy is succeeding? It will also be important to clarify better what these changes will mean in terms of UNICEF and others stopping certain other activities. Finally, it will be important to explain how an equity focus can be reconciled with a U.S. approach which, according to President Obama's speech to the MDG Summit at the United Nations in September, will make development and health investments in countries that are governed well: that show economic growth, progress in anti-corruption, greater accountability and commitments and investing in their own budgets personnel and services. The UNICEF singular focus on equity is thus far quiet on how important governance will be in making future investments.
**Anthony Lake was at CSIS on Wednesday October 20 and presented this proposition to a gathering of experts. Please watch the event below**