New York—A new fund dedicated to improving the health of mothers in developing countries will try out some innovative approaches, offer original arguments and set firm performance standards as it gears up over the next four years, according to those closest to the action.
The Thematic Fund for Maternal Health opened for business January 1 at UNFPA, the United Nations Population Fund, in response to developing-country demand for a special focus on this issue. Its goal is to raise US$465 million by 2011 and to leverage those funds to have a significant impact in the 75 countries where maternal mortality and disability rates are worst. Ireland was the first to donate, pledging 2 million Euros, and Spain was next at 6 million Euros. Fund coordinator Yves Bergevin of UNFPA's Technical Support Division said "promising discussions" with governments, foundations and some non-traditional donors made him confident that more is on the way.
"It is critical to invest in women if we are to achieve the Millennium Development Goals," especially MDGs 4 (improve child health) and 5 (improve maternal health), said UNFPA Executive Director Thoraya Obaid in announcing the Thematic Fund. "We urge countries to dedicate more resources to improving national health systems, training skilled birth attendants and promoting family planning."
The launch follows renewed global attention to stubbornly high rates of maternal and newborn death and disability in the developing world, in contrast to growing overall life spans and declining child deaths. A woman still dies from pregnancy-related causes every minute – more than 536,000 per year, 99 percent of them in the poorest countries. Another 10 million suffer injury or long-term disability, and four million newborns also die. The loss to families, communities and countries robbed of so much potential creativity and labor has been estimated at more than US$15 billion per year.
The landmark Women Deliverconference drew 2,000 advocates to London last October to discuss the situation and generate the political will and new investment needed. Participants agreed that the tragedy is needless: the deaths are virtually all avoidable with known techniques, and at reasonable cost. "Millions of deaths and disabilities could be prevented if every woman had access to reproductive health services," Obaid said: basic care including family planning; skilled care during labor and delivery; and emergency obstetric care when needed for complications. The World Health Organization estimates that by 2015, $6 billion a year will be needed to provide such services in the 75 countries where 95 percent of maternal deaths occur.
The investment would be a good one, said the cabinet ministers from 35 of those countries in a joint statement at Women Deliver: it "pays off in terms of social and economic benefits for the family, the community and society at large." They called for a special fund and pledged to become advocates at home for "increased commitment of financial and human resources to address the causes of high maternal and neonatal mortality."
The timing of this raised awareness is perfect, said Bergevin. The new fund will rely on partnerships among governments, UN organizations, non-governmental groups, foundations and other international actors to succeed. It will coordinate with existing initiatives, such as UNFPA's own programs to create secure supplies of contraceptives and end female genital cutting and obstetric fistula; the Global Campaign for the Health MDGs, including the International Health Partnership initiated by Prime Minister Gordon Brown of the United Kingdom and by Prime Minister Jens Stoltenberg of Norway and related initiatives; and the global Partnership for Maternal, Newborn and Child Health. All aim to accelerate the achievement of the health-related MDGs while strengthening countries' health systems and promoting the harmonization of donor aid to countries.
In the Thematic Fund's current startup phase, the maternal health aspects of the national health plans in 40 African countries are being evaluated by UNFPA. Initial interventions will occur in 25 countries with favorable prospects, most in sub-Saharan Africa and south Asia. Rosters of available technical expertise and regional institutions are being drawn up, while field workers assess national needs, collect data and promote the program among policy-makers and community leaders. Survivors of birth complications, in particular obstetric fistula are on board as advocates and to generate local and global support and pressure for change, especially among women themselves. Specific country goals will be set that are more detailed than previous assessments have allowed, Bergevin said. For example, a government might decide to achieve skilled care for 80 percent of all deliveries in a certain community by a certain date, which requires deciding how many midwives must be recruited, trained and deployed in what places to make that possible.
The fund is considering asking governments to use "performance-based funding" as part of their persuasive arsenal. This innovative approach might reward a clinic in cash for every baby it delivers safely, for example (defining safe delivery as one that occurs in a well-functioning facility, with skilled professionals present who have recognized midwifery competence and where basic emergency care and referral to advanced emergency care are both available if needed. Every achievement would generate more funding. The prospect of direct reward would thus be an incentive to "scale up" – to increase the clinic's overall capacities, the quality of its personnel and its general effectiveness, and to make women in the area aware that the services are available. These are all goals of the Thematic Fund at every level – clinic, hospital, health system management and national policy change.
The fund's $465 million over four years is only two percent of the need, Bergevin noted, so that it can only be a catalyst: mobilizing funds from other sources and providing key technical assistance, equipment and supplies to promote rapid scale-up. Specific objectives will depend on each country's capacity and situation.
Overall benchmarks for the fund's performance will be results-based in relation to the UN's indicators of global progress toward MDG 5: proportion of births attended by skilled personnel, rate of contraceptive prevalence, adolescent birth rate, antenatal care coverage and the unmet need for family planning.
Such accountability is increasingly important among donors and non-traditional funders, such as the smaller foundations and selected corporations that UNFPA is courting. "It's a change in philosophy more than a change in accounting. Everyone in the chain will have to be thinking about performance," Bergevin said.
The task is daunting but it has been done before. Malaysia, Sri Lanka and Bolivia took six to ten years to cut their maternal mortality rates from 400 to 200 per 100,000 live births, according to UN and World Bank figures; Sri Lanka cut it again from 200 to 100 in another six to seven years, and Chile, Egypt, Colombia and Thailand did the same. Then Thailand joined Honduras and Nicaragua in cutting their rates from 100 to 50 per 100,000 live births in another four to six years. The Thematic Fund hopes that success in its first 25 target countries will lead to additional contributions so that it can introduce its program in the 50 remaining needy countries between 2012 and 2015.
One important goal will be recruitment of new health care workers to help alleviate the world shortage. Every target country will be encouraged to provide incentives for recruitment, training and retention of such workers as well as to do more with existing personnel. "If people have decent working conditions, drugs and supplies, they will work even with sub-optimal salaries," Bergevin said. "There are many approaches to make the money go farther."
UNFPA will manage the new fund as part of its Strategic Plan 2008-2011, its Country Programmes and Global and Regional Programmes by expanding its workforce in the target countries and working closely with other UN organizations and international partners.
Nobody is more excited about the Thematic Fund for Maternal Health than people working in the countries where it will operate. "Ethiopia aspires to take part in this program at the earliest possible stages" said Ethiopia's Minister of Health Tedros Adhanom Ghebreyesus. "The Government is highly committed to attaining the MDG targets and maternal health has been reflected in the HSDP III [Health Sector Development Programme III] as a priority area of intervention. Currently, big effort is going on to ensure universal primary health care coverage through an Ethiopian flagship program called Health Extension Program and accelerated expansion of health facilities and human resources, which will address issues of maternal mortality and improve access to maternal health services. It is my sincere hope that more resources will be available by development partners for the same and I look forward to working closely with the Maternal Health Thematic Fund to make the future maternal survival much promising to our mothers and for all Ethiopians."
Download the overview paper: Thematic Fund for Maternal Health Accelerating Progress Towards Millennium Development Goal 5