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Health and HIV Global Strategy

Copyright Š 2011 Catholic Relief Services For any commercial reproduction, please obtain permission from or write to Catholic Relief Services 228 West Lexington Street Baltimore, MD 21201–3413 USA Cover photo: Karen Kasmauski for CRS Download this and other CRS publications at

Health and HIV Global Strategy

TABLE OF CONTENTS Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Health Systems Strengthening Strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 IR1: Individuals Demonstrate Improved Health Practices . . . . . . . . . . . . . 4 Output 1.1: Individuals practice appropriate preventive behaviors for self and dependents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Output 1.2: Individuals seek high-quality health services in a timely manner . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Output 1.3: Individuals adhere to medical treatments . . . . . . . . . . . . . 6 IR2: Communities Address Their Health Needs More Effectively . . . . . . . 7 Output 2.1: Communities advocate for effective health services . . . . . 8 Output 2.2: Communities participate actively to improve preventive, curative and rehabilitative services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 IR3: Public and Private Providers Improve the Quality of Their Health Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Output 3.1: Local facilities implement appropriate management systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Output 3.2: Local facilities provide quality healthcare services . . . . . 13 Output 3.3: Local facilities use strategic information to improve healthcare services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Output 3.4: Local networks of healthcare facilities support and learn from each other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 IR4: CRS Health and HIV Programs Increase Sectoral and Organizational Linkages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Output 4.1: CRS Health and HIV programs facilitate collaboration with other CRS sectors and sectors outside CRS . . . . . . . . . . . . . . . . . . . . . 16 Annexes Annex 1: Health Trends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Annex 2: Organizational Capacity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Annex 3: Health and HIV Global Strategy . . . . . . . . . . . . . . . . . . . . . . . 26 Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27 ii

ABBREVIATIONS C-DOTS Short-course community directly observed treatment CRS

Catholic Relief Services


Human immunodeficiency virus


Integral human development


Intermediate result

MDR-TB Multidrug-resistant TB SO

Strategic objective


Tuberculosis bacilli


World Health Organization


INTRODUCTION In serving poor and marginalized people, the Catholic Relief Services (CRS) seeks to help them live life to their full potential. To do so, our programming is guided by Catholic Church teaching on integral human development (IHD), which forms the guiding principles behind our work. IHD promotes the good of every person and the whole person, and is a process that enables individuals and communities to live with dignity and improve the quality of their lives. IHD helps us to address the multiple needs of the poor, either directly through programs that we support with our partners or indirectly by linking to programs and services provided by other organizations (see Figure 1.) The IHD conceptual framework allows us to examine household and community assets as well as structures and systems that affect health positively or negatively. It also allows us to look at the trends and threats that influence health status and the degree to which people have access to health care services and can influence the management of those services. Figure 1. Integral Human Development Framework Shocks, Cycles & Trends

Outcomes Strategies



Spiritual & Human Physical



Access & Influence

Institutions & Organizations Public Private Collective

SYSTEMS Social Economic Religious Political Values & beliefs

Political Financial

Feedback = Opportunities or Constraints To that end, the CRS global health and HIV strategy will use the IHD framework as a lens to understand household and community dynamics. This will help us to develop effective strategies and approaches to address health challenges (see Annex 1). To address these challenges, CRS has established one strategic objective and four intermediate results that aim to influence behaviors and systems at three different levels (see Figure 2):


• Within families, by changing practices • Within communities, by reinforcing health structures • Within the sphere of public, private and faith-based providers, by improving access to high-quality preventive and curative health services Figure 2. Strategic objective and intermediate results

Overarching SO: Strengthened local health systems meet the health needs of the poorest and most vulnerable people.

IR1: Individuals demonstrate improved health practices.

IR2: Communities address their health needs more effectively.

IR3: Public and private providers improve the quality of their health services.

IR4: CRS health programs increase sectoral and organizational linkages.

According to the World Health Organization (WHO), “a health system consists of all organizations, people and actions whose primary intent is to promote, restore or maintain health.” This includes efforts to influence determinants of health1 and engage in direct health-improving activities. A health system is, therefore, more than the pyramid of publicly-owned facilities that deliver personal health services. It includes, for example, a mother caring for a sick child at home, private providers, traditional practitioners, community health structures, health insurance organizations, and occupational health and safety legislators. It also includes inter-sectoral action by health staff, such as encouraging the Ministry of Education to promote girls’ education, a wellknown determinant of better health. Health systems strengthening reinforce households, community leadership around health, and public, private and faith-based providers of health services. Outcomes of strengthened systems include: 1. Improved health outcomes 2. Healthy, economically vibrant communities 3. Equitable access to healthcare 4. High-quality healthcare


H E A LT H SY S T E M S S T R E N G T H E N I N G S T R AT E GY CRS aims towards the goal of households enjoying optimal health. Strengthening health systems enables CRS to contribute to integral human development, specifically the health and well-being of households and individuals, by improving structures and systems that promote improved health outcomes. Improving health and well-being allows households and communities to become more resilient and better able to withstand epidemics and other shocks. Functional improvements in structures and systems ensure greater access and quality of care for poor and marginalized people. Improvements also facilitate greater community influence over the health system. The following conditions indicate that a health system is working. 1. Individuals demand their rights and responsibilities be respected (IR1). 2. Communities are engaged and practicing the guiding principles of solidarity, subsidiarity and the common good (IR2). 3. Health facilities are functioning based on efficiency, ownership, stewardship and accountability (IR3). 4. Planning and decisions are made based on quality health management information systems (IR3). 5. Human resources acquire key competencies required to deliver quality health services (IR3). 6. Public and private health systems collaborate with faith-based networks to address health challenges (IR4). 7. CRS builds capacity of its partners and staff to ensure public, private and faith-based health systems can properly forecast, quantify, implement and report on their activities in a timely manner (IR4).



Sara A. Fajardo/CRS


Households are often considered the primary producers of health.2 Good health enhances human assets, one of the components of integral human development. Households need the support and partnership of the wider community and public, private and faith-based health service providers. Individuals composing the households need to respond to community health mobilization activities and to be actively engaged. This means that individuals must work collaboratively with each other and within community structures to reduce barriers to optimal health for all. Family members within households and caregivers should assist their dependents in meeting their health needs. CRS health and HIV programming will support partners to work at the household level to help bring about the following behaviors:

Output 1.1: Individuals practice appropriate preventive behaviors for self and dependents Preventive practices will change according to location, prevalent health conditions, practice rates from knowledge to adoption, and other factors. Some preventive behaviors include: • Sleeping under a long-lasting impregnated net to prevent malaria • Adhering to ante- and post-natal recommendations • Practicing essential nutrition actions and following infant and young child feeding recommendations • Practicing proper hand-washing to prevent diarrhea • Seeking HIV, TB and other health testing and counseling services • Practicing abstinence and faithfulness within marriage to prevent the spread of HIV and other sexually-transmitted infections • Participating in health training and education activities to stay current about health needs • Modeling good health behavior to others. Support others to prevent illness and promote health.

Output 1.2 Individuals seek high-quality health services in a timely manner Assuming that health services are available, individuals must still be willing to access them. There are multiple factors that influence an individual’s decisions and actions related to accessing healthcare. CRS will help partners to influence religious, government, and influential leaders in communities to assume responsibility for mobilizing individuals to seek available health services. CRS supports interventions that increase individuals’ collaboration


with each other to reduce and remove barriers to health care access. Some positive indicators include: • Danger signs of illness are recognized and responded to • Pregnant women attend at least four antenatal visits and two postpartum visits • Caregivers complete infants’ basic immunization schedules by one year of age • The most vulnerable people have access to quality health services through transportation, savings, and other means necessary to facilitate access • Chronically ill patients attend all medical appointments • Community members serve as peer supporters to encourage appropriate health-seeking behavior

Output 1.3: Individuals adhere to medical treatments Adherence is defined as the degree to which a patient follows a medical regimen. Although adherence will vary according to multiple factors such as illness, the following are examples of desired adherence behaviors: • Chronically ill persons adhere to and comply with treatment • Persons and caregivers ensure full course intake of drugs to treat diseases • People recovering from illnesses eat appropriately • Vulnerable groups (e.g. senior citizens, disabled, orphans, widows and widowers) receive community support to meet their health needs



Mayling Simpson-Hebert/CRS


Before communities can effectively address their health needs, social and political assets often must improve. Strengthening communities’ relationships, social norms and networks will enable residents to acquire more tools and resources to effectively claim their rights and influence decisions. These are all components of integral human development. More specifically, CRS health and HIV programming will support partners to strengthen community structures to support the following:

Output 2.1: Communities advocate for effective health services CRS health and HIV programming will support partners to strengthen community structures to become formal mechanisms for civil society participation. CRS will work with local partner organizations and the Ministry of Health, where feasible, to ensure substantial and active community participation in health programs and move communities from passive participation to active engagement and participation in decision making. CRS will develop tools, materials and expertise so that it can work more effectively with partner agencies and local organizations to ensure communities are informed about health policies and services in their area. CRS will support training and skills building so that communities move from simply being informed about or invited to participate in meetings to developing coalitions and advocacy positions in order to lobby for changes in health care delivery and improved quality. This will contribute to universal access to health services. CRS will help partners to develop or strengthen community The people have the right structures such as citizens’ groups or and duty to participate health committees; such assistance individually and collectively could include working with community in the planning and structures to develop a mission, terms implementation of their health care. of reference, elected members and internal management procedures. —Alma Ata, 1978

Finally, CRS will assist community groups with organizational development issues such as volunteer recruitment and management, financial management, communication, planning, and community mobilization. Building capacity of community groups will enable them to have a voice in how decisions are made about resource allocation, the organization and regulation of care, and influence over what those decisions are. CRS will facilitate processes in which community structures represent all groups in the community, including the most vulnerable ones, and are able to select activities, strategies and processes that are feasible, cost-effective, culturally sensitive and sustainable. CRS will work towards a partnership between community organizations and government or national programs that affect the community’s health. CRS health and HIV programming will support partners to facilitate processes for individuals and community members to:


1. influence decision-makers at different levels, 2. increase their influence to ensure the quality of health care (preventive and curative), and 3. facilitate lasting behavioral and social change. CRS health and HIV programming will also facilitate processes for strengthening public, private and faith-based providers’ partnerships with community health structures to ensure timely preventive and curative services. This will mean a paradigm shift from prescribing how communities should be organized to becoming facilitators of processes in Demand from the communities that bear the which communities openly discuss burden of existing inequities how to become more influential. and other concerned groups Some positive indicators of in civil society are among the community empowerment are: most powerful motors driving universal coverage reforms

1. Community structures are able and efforts to reach the unreached and the excluded. to organize themselves and ensure equal representation: —PHC Now more than Ever, CRS health and HIV WHO, 2009 programming will help partners to facilitate processes that ensure communities organize themselves in a way that ensures all members, including the poor and marginalized, are represented and that women and men are equally represented. CRS will train community members and partners in methodologies that will help them empower themselves. CRS will also strengthen governance processes for community members to have equal voice and vote regarding the organization, management and development of activities to address health needs. 2. Community health structures represent their members effectively: Community health structures (or committees) will represent community members’ rights and responsibilities before health authorities when developing national and local health agendas and will ensure quality assurance mechanisms on local service delivery. 3. Community structures contribute to national plans and participate in local health planning: Community structures will contribute to the adaptation of successful health models to address the needs of community members and to ensure community participation in the implementation and supervision of health activities.

Output 2.2: Communities participate actively to improve preventive, curative and rehabilitative services CRS will help partners to implement activities that increase information about and alleviate barriers to disease prevention and treatment, expand prevention and treatment services at the community level where 9

appropriate, and refer patients to facility settings for complex cases. CRS will support community-based promotion of health services so that individuals and families have greater access to information, which will help them to make informed decisions about behaviors that may affect their health. This may include the development of a cadre of community health workers within a health network to extend information to the community level.

Primary health care “requires and promotes maximum community and individual self-reliance and participation in the planning, organization, operation and control of primary health care, making fullest use of local, national and other available resources; and to this end develops through appropriate education the ability of communities to participate. —Alma Ata, 1978

CRS will help its partners, including governments, plan for and train outreach and auxiliary workers as needed. Strengthening these community systems is critical to supporting community health promotion and prevention and to expanding access to information, preventive and curative services with the goal of universal coverage. Some examples of community participation are: 1. Community structures increase knowledge/facilitate behavior and social change on disease prevention and treatment. CRS will help its partners to assist community health workers or other outreach workers or volunteers to conduct information sessions at the household and village level to increase awareness about disease, including noticing signs and symptoms and seeking treatment. For example, one way volunteers can contribute to disease prevention is by providing information on HIV testing and transmission. 2. Community structures provide home treatment and prevention services. CRS will help its partners to support community structures in areas such as long-lasting impregnated mosquito net distribution, HIV awareness, home-based and palliative care, short-course community directly observed treatment (C-DOTS) and communitywide environmental cleaning for proper sanitation. 3. Community structures offer referral and support services. CRS health and HIV programming will support partners to encourage community structures to offer referral services for various illnesses and conditions, including complicated cases of TB, HIV, malaria, malnutrition, and diarrhea. In addition, community structures will provide support systems to patients and their families through group counseling and meetings, family-centered social services and home visits.



Karen Kasmauski for CRS


CRS health and HIV programming will strengthen private and public providers’ managerial and technical skill in line with the WHO’s six building blocks of health systems: • Good health services are those that deliver effective, safe, high-quality personal and non-personal health interventions to those who need them, when and where needed, with minimum waste of resources. • A well-performing health workforce is one that works in ways that are responsive, fair and efficient to achieve the best health outcomes possible, given available resources and circumstances. • A well-functioning health information system is one that ensures the production, analysis, dissemination and use of reliable and timely information on health determinants, health systems performance and health status. • A well-functioning health system ensures equitable access to essential medical products, vaccines and technologies of assured quality, safety, efficacy and cost-effectiveness, as well as their scientifically sound and cost-effective use. • A good health financing system raises adequate funds for health in ways that ensure people can use needed services and are protected from financial catastrophe or impoverishment associated with having to pay for them. • Leadership and governance involves ensuring that strategic policy frameworks exist and are combined with effective oversight, coalition building, appropriate regulations and incentives, attention to system design, and accountability. Ultimately, in order for facilities to provide the services that communities need, they must be adequately staffed with trained professional personnel and employ functioning policies to retain skilled health staff. In addition, the staff must know not only their clinical areas of expertise but also the communities in which they work. The managerial staff must be able to translate cost-effectiveness data into action, reviewing results and outcomes to ensure that those in the community are provided with the most effective and least costly options available. In addition, these facilities need to be linked to a larger network, becoming part of a healthcare community rather than a facility apart. Such health care networks can work together to affect change at larger policy and financial levels. These building blocks provide the foundation for favorable health outcomes by supporting the efficiency and responsiveness of facilities in the communities where they operate. They also ensure that the facilities and the communities are protected from risk as much as possible.


Output 3.1: Local facilities implement appropriate management systems CRS will work with local health facilities to ensure that they have appropriate systems in place to manage facility operations. Management systems should include components on human resources, operations, and financial management, as well as implementation of relevant policies and procedures, including standard operating procedures. An internal management system and appropriate leadership is required to ensure that the facility is well-managed. This system should also be monitored by internal checks and balances within the facility. CRS will work to ensure that such systems are implemented via a variety of activities including management training, seconding external staff and consultants to the facilities for short periods, reviewing management plans, assisting with the technical development of such systems, and various other activities according to the needs of the facility and CRS’ level of expertise.

Output 3.2: Local facilities provide quality healthcare services CRS will work with local authorities to help partners ensure that healthcare services provided at health facilities are in line with A health system needs staff, international and national medical funds, information, supplies, guidelines and are also culturally transport, communications and overall guidance and sensitive. To achieve this, CRS direction. And it needs to and local partners may engage provide services that are in a variety of activities, including responsive and financially training healthcare providers on fair, while treating people clinical issues, developing peer decently. and mentoring networks among healthcare providers, establishing —World Health Organization continuing education systems for healthcare workers, developing infrastructure, making essential health equipment and commodities more available and developing effective feedback systems.

Output 3.3: Local facilities use strategic information to improve healthcare services CRS will strengthen local facilities’ ability to use strategic information collected at the facility and community (service delivery and financial data) to improve health services. Local facilities may require support throughout the data continuum, from data collection to management to analysis and finally data use. CRS will encourage local facilities to include financial and cost data in their strategic information structures so that local partners can use such information to provide quality healthcare services at the lowest possible cost.


Output 3.4: Local networks of healthcare facilities support and learn from each other Supporting existing networks of healthcare providers and healthcare facilities, as well as creating networks when necessary, will ensure that local partners are linked into larger networks. These networks are often better placed to access government resources, donor funds, and external support. In advocacy efforts, a single combined voice is often more powerful than many individual voices. In addition, the networks link healthcare facilities to provide a common forum for discussion and learning. These networks can ensure that facilities do not operate in a vacuum, but instead are influenced by one another.



Debbie DeVoe/CRS


CRS’ commitment to social justice and structural change provides an opportunity to address program implementation from a perspective of integration. IHD tells us that meeting basic needs through programs based on a single technical intervention is no longer enough. Effective health and HIV programs must link with other sectoral interventions for maximum impact.

Output 4.1: CRS Health and HIV programs facilitate collaboration with other CRS sectors and sectors outside CRS CRS health and HIV programming will seek to achieve optimal integration of sectors as they affect health and HIV. CRS considers individuals in a holistic manner, in accordance with the integral human development principles and framework. Therefore, this IR will ensure that, where possible, natural, physical and financial assets are accessible, as they also contribute to improving and maintaining positive health outcome. Gaps within other sectors that adversely affect health will be met by coordinating with CRS sector teams or by developing partnerships or strategic alliances with other actors. CRS’ health and HIV programming teams will continue to partner with other entities such as government, PVOs, donors and community groups who provide services and programs across different sectors. This integration of complementary services will enable CRS and its partners to respond to the multiple needs of the people we serve. CRS health and HIV programming will collaborate both internally and externally in assessing needs and planning for new programs and will coordinate implementation. Assessments and planning will include strategic program plans, where appropriate, as well as projects. In designing health interventions, CRS health staff will also collaborate, where appropriate, with other sectors to ensure a program design that leverages the benefits of other sectors for positive health outcomes. CRS health and HIV sector staff will become more aware of the programs and plans of other sectors within CRS and services provided by external organizations. Opportunities for collaboration will be pursued to ensure that the multiple and complex needs of the people we serve are addressed. Some opportunities to foster effective collaboration include improving the following: 1. Access to safe water and sanitation. Poor sanitation and limited access to clean water are two of the most significant factors that contribute to increased morbidity and mortality. Evidence-based interventions, including waste management and hand washing with soap and water, have demonstrated effectiveness in reducing the incidence of diarrhea. CRS health and HIV programs will contribute to healthy households and communities by seeking opportunities to incorporate water and sanitation interventions and actions.


2. Access to appropriate livelihood strategies. Although some diseases affect people’s abilities to earn a living, many people can be fully productive and active in the workplace if supported by activities such as keyhole gardening or advocacy to reduce HIV stigma in the workplace. Interventions such as “baby-friendly farms” encourage mothers to practice exclusive breast-feeding while continuing to be productive. CRS will work to ensure that a health and HIV lens is integrated into other sectoral programs, resulting in adequate livelihoods for all people. 3. Access to appropriate locally-produced nutritious foods. Proper food can ward off hunger and contribute significantly to good nutrition and health. CRS health and HIV programs will seek to collaborate within CRS or with external partnerships to improve health status by working with communities to improve agricultural production. Increased production will support household consumption and generate income from sales in the market. This component of the health and HIV strategy is linked to the agriculture and health pillar in the CRS agriculture strategy. 4. Access to savings and microfinance. Financial services can facilitate savings or provide loans to purchase food and medicines, meet other essential needs, and provide platforms for discussing health issues. CRS health and HIV programs will incorporate savings-led and other livelihood strategies that enable households and communities to generate and protect income needed to meet basic needs. 5. Access to education. It has been well documented that a mother’s education has a significant effect on her child’s health and nutrition and that a girl’s education level affects the health of her future child.3 Schools can help promote healthy behaviors, from hand-washing to keeping water safe, to practicing life skills to promoting HIV prevention. CRS health programs will incorporate girls’ rights to education and ensure that schools have the means to promote healthy behaviors. 6. Access to equitable and fair services. CRS will work with communities, governments and faith-based health providers to ensure that access to high-quality health services is available to all.

CRS gender approach Gender-responsive programs will help CRS health and HIV programming and partners to better consider power issues and determine how roles and responsibilities of both men and women are critical factors affecting the household and community levels. Taking into account gender differences will facilitate the design of more appropriate responses; highlight opportunities and resources within affected households, communities and services; and link health and HIV programming with long-term development. Gender-responsive programs will also help to ensure that health and HIV programming is planned and implemented in a way that benefits all sectors of a population, in line with an analysis of people’s specific rights, needs, and capacities.


Overcoming gender imbalance in the implementation of a project’s activities has been a challenge in CRS health and HIV programming, and lessons learned from these experiences will be applied to correct this imbalance. CRS will set gender objectives for staff composition and participation in trainings. Men will be strongly encouraged to participate in health activities, and specific messages will be directed at them (e.g. to encourage men to seek preventive and curative services for themselves, to support women in child care, to support women and children’s access to health services, and to share in fieldwork responsibilities.) Women’s roles in the division of labor at the household and community levels will be taken into account in program planning. Women’s representation in key community positions related to health will be strongly encouraged. CRS health and HIV programming and partners will use a gender lens to ensure more equitable access to quality health services for girls, boys, women and men by: Integrating gender analysis into proposal design, implementation and evaluation. A gender analysis will help guide long-term planning and ensure desired results are achieved. It will serve as a framework for illuminating opportunities and constraints in developing CRS health and HIV program activities at all levels. Strengthening CRS health and HIV programming and partners’ capacity to systemically integrate and apply gender assessment, planning and monitoring tools into their health and HIV activities at national and local levels. Implementing gender-responsive health activities at national and local levels with a view toward demonstrating practical applications and results.

CRS sustainability approach CRS’ strategy to ensure sustained outcomes is achieved by working at different levels: Individual—through behavior change, to ensure healthy practices are adopted and practiced beyond the life of the project. Community—by facilitating processes of community empowerment to help people obtain the skills and competencies they will need to become more actively involved in advocating and mobilizing others to demand their rights to health care. Financial—by facilitating processes for civil society to identify new and sustainable ways to access local financial resources, and at the same time engaging in advocacy to influence key stakeholders (local governments and national ministries) to prioritize and allocate funds to continue implementing health-related activities (preventive and curative). 18



Community Empowerment Social and Behavioral Change


Community Empowerment

Social and Behavioral Change




IR2: Communities address their health needs more effectively (program)

Knowledge Management

Behavior Change Partnerships




IR4: CRS health programs increase sectoral organizational linkages (internal & program)

Access to Services

Organizational Development


IR3: Public and private providers improve the quality of their health services (program)

Strengthened local health systems meet the health needs of the poorest and most vulnerable people

IR1: Individuals demonstrate improved health practices (program)


Figure 3. Results framework

ANNEX 1: HEALTH TRENDS Each year, malaria afflicts approximately a half-billion people (roughly the population of the United States, Canada, and Mexico combined). Malaria kills more than a million people per year. Every 30 seconds in Africa a child dies of malaria. Malaria incapacitates people, keeping countries poor. In addition to the health burden, malaria illness and death cost Africa about $12 billion per year. Half the world’s population (3.3 billion people) lives in areas at risk of malaria transmission in 109 countries and territories. Thirty-five countries (30 in sub-Saharan Africa and five in Asia) account for 98% of global malaria deaths. WHO estimates that in 2008 malaria caused 190–311 million clinical episodes, and 708,000–1,003,000 deaths. 89% of the malaria deaths worldwide occur in Africa. Malaria is the fifth leading cause of death from infectious diseases worldwide (after respiratory infections, HIV, diarrheal diseases, and tuberculosis). Malaria is the second leading cause of death from infectious diseases in Africa, after HIV-related illnesses.4 More than two billion people—one third of the world’s total population—are infected with tuberculosis (TB) bacilli, the microbes that cause TB. One in every ten of those people will become sick with active TB in his or her lifetime. A total of 1.77 million people died from TB in 2007 (including 456,000 people with HIV), equal to about 4,800 deaths a day. TB is a disease of poverty, affecting mostly young adults in their most productive years. The vast majority of TB deaths are in the developing world, with more than half occurring in Asia. Twenty-two burden countries account for 80% of the new TB cases in the world. CRS works in at least 15 of these countries. Multidrug-resistant TB (MDR-TB) is a form of TB that does not respond to the standard treatments using first-line drugs. MDR-TB is present in virtually all countries surveyed by WHO and its partners. There were an estimated 511,000 new MDR-TB cases in 2007 with three countries accounting for 56% of all cases globally: China, India and the Russian Federation. Extensively drug-resistant TB (XDR-TB) occurs when resistance to second-line drugs develops. It is extremely difficult to treat and cases have been confirmed in more than 50 countries. People living with HIV are at a much greater risk of contracting both.5 Since the beginning of the epidemic, almost 60 million people have been infected with HIV and 25 million people have died of HIV-related causes. In 2009, some 33.3 million people were living with HIV and there were 2.6 million new infections and 1.8 million HIV-related deaths. In 2009, around 370,000 children were born with HIV, bringing to 2.5 million the total number of children under 15 living with HIV. Young people account for around 40% of all new adult (15+) HIV infections


worldwide. Sub-Saharan Africa is the region most affected and is home to 67% of all people living with HIV worldwide and 91% of all new infections among children. The epidemic has orphaned more than 16 million children, 90% of whom live in sub-Saharan Africa. The percentage of HIV-positive pregnant women who received treatment to prevent transmission of the virus to their child increased from 33% in 2007 to 45% in 2008. Latest data indicate that fewer than 40% of young people have basic information about HIV and less than 40% of people living with HIV know their status. The number of new HIV infections continues to outstrip the numbers on treatment—for every two people starting treatment, a further five become infected with the virus. HIV treatment: More than 5.2 million people in low- and middle-income countries now have access to HIV treatment at the end of 2009. This represents an increase of 30% in one year and a 13-fold increase since 2004. Despite considerable progress, global coverage remains low: in 2008, only 42% of those in need of treatment had access (compared with 35% in 2007). In 2008, only 38% of children in need of treatment in lowand middle income countries received it. Tuberculosis and HIV: One third of people living with HIV are co-infected with TB. Tuberculosis is a leading cause of death among people living with HIV and yet is mostly curable and preventable.6 Neonatal and maternal mortality: In most countries, child mortality has been decreasing in recent decades; however, both neonatal and maternal mortality have largely remained the same. Neonatal mortality accounts for almost 40% of the estimated annually 9.7 million children under-five deaths and for nearly 60% of infant (under-one) deaths. This means that a child is about 500 times more likely to die in the first day of life than at one month of age. The largest absolute number of newborn deaths occurs in South Asia—India contributes a quarter of the world total—but the highest national rates of neonatal mortality occur in sub-Saharan Africa. A common factor in these newborn deaths is the health of the mother. Each year more than 500,000 women die in childbirth or from complications during pregnancy. Babies whose mothers have died during childbirth have a much greater chance of dying in their first year than those whose mothers remain alive. Ninety-nine percent of maternal and newborn mortality occurs in the developing world, where more than 50% of women still deliver without the assistance of skilled health personnel. This is a powerful statement about inequity and access to quality care. Eighty percent of maternal deaths are caused by direct obstetric causes such as hemorrhage, infection, hypertensive disorders of pregnancy and 21

complications of unsafe abortion. And for every woman who dies from complications related to childbirth, approximately 20 more suffer injuries, infections and disabilities that are usually untreated and ignored and that can result in life-long pain and social and economic exclusion.7 Proper nutrition is a powerful good: people who are well-nourished are more likely to be healthy, productive and able to learn. Good nutrition benefits families, communities and the world as a whole. Malnutrition is, by the same logic, devastating. It plays a part in more than a third of all child deaths in developing countries. It blunts the intellect, saps the productivity of everyone it touches and perpetuates poverty. Although fewer children are undernourished than in the 1990s, one in four, or 143 million children in the developing world under the age of five are still underweight and only 38% of children under six months are exclusively breastfed. While significant progress has been made in relation to vitamin A supplementation and salt iodization, micronutrient deficiencies remain a significant public health problem.8 Gender inequity: The determinants of health include biological, behavioral, social, political, cultural, and economic factors which are all influenced by unbalanced power relations and gender norms within a given society. While men, women, boys and girls all face health challenges, the risks and vulnerabilities throughout their lifetimes are not the same. Health risks and vulnerabilities vary depending on the sex, age, and gender norms within a society. Gender disparities at all levels contribute to ill health for both sexes, but ill health among girls and women impacts not only current but also future generations.9 Differences between males and females emerge at a young age in ways that have long-term implications for mental and physical health. For example, girls are exposed to more abuse than boys, may be subjected to female genital mutilation/cutting or early marriage, and are less likely to attend school. Limited education reduces a girl’s access to health information and employment opportunities, as well as her ability to care for her future children. As a result of their lower socio-economic status, women may be unable to access health care due to lack of control over the decision making process, lack of availability, distance to services, or the cost of care. Poor quality of care, including lack of confidentiality, lack of privacy, and lack of appropriate services, may also limit health seeking behaviors.10 On the other hand, gender norms often result in a perception by men that seeking health care is weak or unmanly, and therefore they may delay seeking care resulting in poorer outcomes than if they had sought treatment earlier. Due to societal norms, boys and men are often encouraged to be more physical and to take risks. As a result they may be attracted to more dangerous professions such as the police or military. More men than women die or are injured as a result of crime, fights, 22

and warfare. Men experience more disability as a result of consuming unhealthy foods, alcohol, and smoking.11 Social norms often condone multiple concurrent sexual partners for men, increasing the risk for sexually transmitted infections (STIs) and HIV. A gender analysis will help guide long-term planning and ensure desired results are achieved. It serves as a framework for illuminating the opportunities and constraints in developing health program activities at all levels.


ANNEX 2: ORGANIZATIONAL CAPACITY Below is a list of key competencies CRS will need at the HQ, region and country levels in order to achieve the organization’s goals. Technical skills in specific areas:

1. Malaria 2. Tuberculosis/HIV 3. Other Communicable diseases 4. Non-Communicable Diseases 5. Maternal and Newborn Care 6. Strategic Information Management 7. Health Systems Strengthening a. Identity and governance b. Strategy and planning c. General management d. External relations and partnerships e. Sustainability f. Financial and physical resource management g. Programming, services and results 8. Nutrition 9. Water, Hygiene and Sanitation

Learning and sharing: 1. Facilitation 2. M&E 3. Documentation and publication 4. Marketing 5. Public relations 6. Knowledge management 7. Gender analysis 8. Organizational learning


Management: 1. Human resources management and development: a. Staffing/more staff (CRS and Church partners) b. Leadership/direction/support for health staff c. Clear roles and definition of responsibilities at different levels 2. Finance management 3. Budgeting 4. Procurement and supply management

Partnerships: 1. Donor mapping 2. Business development 3. Government agency cooperation 4. Advocacy skills 5. Contribute to Caritas capacity in health and HIV programming 6. Coaching



Health and HIV Global Strategy


Global Hunger


Global Health

Malaria prevention &

HIV care & treatment TB care & treatment


Partners Catholic facilities Catholic associations U.S. Catholic networks

Integral Human Development

Community Faith-based treatment mobilization networks Maternal & child Health workers CSOs care MOH Health financing OVC care INGOs Medical supplies Nutrition Local governments Pharmaceuticals Water & Referrals Academic institutions Sanitation

Building blocks Stewardship Management information

IR1: Individuals demonstrate improved health practices. IR2: Communities address their health needs effectively. IR3: Public & private providers improve quality of health services. IR4: CRS health programs increase intersector & organizational linkages.

SO: Strengthened local health systems meet the health needs of the poor and vulnerable.

Mission: CRS carries out the commitment of the Bishops of the United States to assist the poor and vulnerable overseas.



NOTES 1. “Health Impact Assessment (HIA),” World Health Organization, http://www​ 2. Debra Schumann and W. Henry Mosley, “The Household Production of Health,” Social Science and Medicine 38(2): 201–4. 3. “Accelerating the Efforts to Advance the Rights of Adolescents Girls,” last modified March 3, 2010, World Health Organization, /mediacentre/news/statements/2010/joint_statement_20100303/en/. 4. World Health Organization, World Malaria Report, 2008 (Geneva: WHO Press, 2008), /9789241563697/en/index.html. 5. “Tuberculosis and HIV,” World Health Organization, /topics/tb/en/index.html. 6. “2009 AIDS Epidemic Update,” Joint United Nations Program on HIV/AIDS, /2009AIDSEpidemicUpdate/. 7.

United Nations Children’s Fund, The State of the World’s Children, 2009: Maternal and Newborn Health (New York: United Nations Children’s Fund, 2008),

8. “Health and Nutrition,” United Nations Children’s Fund, http://www.unicef .org/nutrition/. 9. “Gender, Women and Health,” World Health Organization, http://www.who .int/gender/women_health_report/en/index.html. 10. Ibid.


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Health and HIV Global Strategy  

This document outlines CRS' global strategy to strengthen local health systems and better meet the needs of the poorest and most vulnerable...

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