What Happens After Women Come Through the Door? Undernutrition: Translating Rhetoric into Action 22 Moving Toward Gender Equitable Health Organizations 12 19
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In this issue:
06 Women and Girls: Big Advances, Big Needs Remain
10 Ending Child Marriage with this Generation
COVER STORY: changing the paradigm for women and girls
12 What Happens After Women Come Through the Door?
16 CHWs: Agents for Reducing Child Mortality
14 Women and Girls in a Changing World 19 Undernutrition: Translating Rhetoric into Action 22 M oving Toward Gender Equitable Health Organizations 25 Young People Need Evidence-Based Information Too
screenshots Photo by Chessa Latifi
04 Female Genital Mutilation 05 ? Men for Every 100 Women 05 Child Marriage Hotspots
letter from the editor
Rhonda Stewart Graphic Design
Shawn Braley Web
Changing the Paradigm for Women and Girls Did you know that 25,000 girls are married each day? That’s about 750,000 girls each month, about 9.1 million girls each year. These are not numbers that are often discussed, even in global health circles. The question is, why not? As the title of John Donnelly’s article suggests, there have been big advances in the health of women and girls, yet significant work has yet to be done. As a whole, maternal mortality rates have declined, girls are given more opportunities for education, and greater prospects for better health. But in many parts of the world, childbirth is still dangerous, women are subject to sexual violence, and girls are married off at 16. How do we change the paradigm for women and girls? This issue of GLOBAL HEALTH highlights a number of ways, including: access to knowledge, better nutrition, empowerment and the ability to make their own choices. The role of community health workers and other caregivers in providing accessible services of high quality cannot be overstated. We are indebted to the legions of (primarily) women who dedicate their time to providing access to care even in the most remote corners of the world. In closing, I invite you to view the more than 550 photographs from around the globe submitted via Flickr as part of the Women and Girls in a Changing World Photo Contest.
Tina Flores Executive Editor, GLOBAL HEALTH firstname.lastname@example.org ISSUE 10 spring 2011
email@example.com Global Health Council Board of Directors
Joel Lamstein, SM, chair William Foege, MD, MPH, chair-emeritus Valerie Nkamgang Bemo, MD, MPH Alvaro Bermejo, MD, MPH George F. Brown, MD, MPH Rev. Dr. Joan Brown Campbell Christopher Elias, MD, MPH Elizabeth Furst Frank, MBA Julio Frenk, MD, PhD Michele Galen, MS, JD Gretchen Howard, MBA Hon. Jim Kolbe, MBA Patricia McGrath Reeta Roy Jeffrey L. Sturchio, PhD, President and CEO Global Health is published by the Global Health Council, a 501(c)(3) nonprofit membership organization that is funded through membership dues and grants from foundations, corporations, government agencies and private individuals. The opinions expressed in Global Health do not necessarily reflect the views of the Global Health Council, its funders or members. Learn more about the Council at www.globalhealth.org
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go to www.globalhealthmagazine.com for further reading
Photo contest fan favorite
GLOBAL HEALTH Magazine’s photo contest, Women and Girls in a Changing World, drew more than 550 entries from around the globe. Most of the photos were quite beautiful and moving. All of them were reflections of women and girls at different points in their lives. We would like to thank Dominic Chavez and Daniel Grimm for serving as external jurors and all the photographers for sharing their work. The winning photo is featured on page 14. The fan favorite (left) is Women of Hilltribes; Sapa, Vietnam by Kent Truong.
C available exclusively online At the Intersection of Human Rights and Health: Disrespectful and Abusive Treatment of Women during Childbirth
C Dim Sum Desert Flower
The Civilized World
C Field Notes
Victory over Violence: Overcoming Sexual and Gender Based Violence in DR Congo
Global health statistics
Estimated prevalence of female genital mutilation in girls and women 15 – 49 years (%)
Central African Republic 25.7 Côte d’Ivoire 36.4 Djibouti 93.1 Egypt 91.1 Kenya 27.1 Liberia 58.2 Mali 85.2 Niger 2.2 Nigeria 29.6 Senegal 28.2 Sierra Leone
Somalia 97.9 Uganda 0.8
ISSUE 10 spring 2011
Source: World Health Organization
Page 5 â€”
? Men for every 100 Women
25,000 girls married each day
girls married in 10 years
hotspots % of girls married before 18 Niger 74.5 Chad 71.5
(Islamic Republic of)
Mali 70.6 bangladesh 66.2 guinea 63.1 central african republic
mozambique 55.9 burkina faso 51.9 nepal 51.4 ethiopia 49.2 malawi 48.9
madagascar 48.2 sierra leone 47.9 cameroon 47.2 eritrea 47
uganda 46.3 india 44.5 Nicaragua 43.3 zambia 41.6 tanzania 41.1
United Arab emirates
Source: United Nations
Source: International Center for Research on Women
By john donnelly
Women and Girls’ Health Big Advances, Big Needs Remain By john donnelly
Photo by Lindsay Miles-Pickup
ADDIS ABABA, Ethiopia – One hundred years after the first International Women’s Day, when the burning issue was securing women’s right to vote in the United States and Europe, the plight of women and girls, and their health conditions in the developing world easily shows many improvements. Compared to one or two decades ago, women and girls fare markedly better. Education rates have climbed. Fertility rates have dropped. The average age of marriage has gotten older. The numbers, though, tell two stories: The advances have been astounding and the unmet need remains great.
ISSUE 10 spring 2011
At this critical political moment, with rich-world governments slashing budgets that could impede progress for women and girls in the developing world, many wonder whether the movement for women and girls will continue to soar – or sputter. In interviews with dozens of women in sub-Saharan Africa as well as policy makers and analysts who work in developing countries around the world, those in the thick of gender issues say the changes in the last generation alone are far greater than commonly perceived, but also that tens of millions of girls and women remain trapped in poverty in large part because of their sex.
John Donnelly is a freelance writer specializing in global health issues. He reported from Addis Ababa, Ethiopia; Freetown, Sierra Leone and Washington, D.C., for this article.
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But a 2010 survey done by a group called The Last 10 Kilometers – a Bill & Melinda Gates Foundation funded project implemented by JSI Research & Training Institute – found that contraceptive use in several provinces had jumped to 40 percent. The country attributes the change to its large-scale rollout of health extension workers. Roughly 45,000 have been trained in the last five years, but analysts say the change here and elsewhere is due to a complex stew of ingredients. Consider three stories, and the different factors pushing change in each. Roman Tesfay, director general of the Policy, Planning and Finance General Directorate at the Federal Ministry of Health, said she is reminded of the generational change every day. “When I was a girl, my mom always was pushing me to work at home and not to study,” she said in her office one day this spring. “But I don’t do that to my child.” Her daughter, Matot, 15, is so talkative and confident that Roman and her husband believe she will be a lawyer “or become the first female president in Ethiopia.” She laughs at the thought, but added that her mother, Argegash Lesanwork, whose education stopped in the sixth grade, notices her granddaughter’s promise: “She tells my daughter that she is lucky to have this opportunity.” Netsanaye Assaye, a journalist and communications specialist who has worked extensively on gender issues, said she sees far less sexual harassment of women in urban and rural areas. Five years ago, a prominent trial in the Tigre region led to a 22-year prison sentence for a man who raped a 9-year-old girl. “Before, and I hate to say it, but rape happened so much that it was almost a tradition, and men would say they raped the girl because they loved her. But that case changed the lives of girls all over Ethiopia.” She also said that a decade ago she was commonly harassed by men even as she crossed a street; now, she said that rarely occurs. And five years ago, Mekdesyilme Yilma was HIVpositive and no one knew outside her family. Now her country knows. She is one of the leaders of the
Photo by Julia Jay
In Ethiopia a rapidly evolving situation bears close watching as a harbinger of things to come, several women leaders said. The East African country of 85 million people has had low literacy rates for girls, high fertility rates, and low use of contraceptives for decades. But the situation is far from static. For instance, just 14 percent of Ethiopia’s women aged 15 to 49 were using one form of modern contraception in 2005, according to a Demographic and Health Survey.
Network of Positive Women Ethiopians, which has grown to 24 chapters across the country, each with an average of 300 women. More than 8,000 women have joined chapters in the past four years. The HIV-positive women, who have spoken at countless rallies, press conferences, briefings and community gatherings, have transformed a stigmatized, hidden population to one leading the way in Ethiopia for women’s rights, say observers. “Women were never encouraged to get out and address people in public,” said Yilma, 37, the mother of two children. “Women can’t even laugh loudly in this country. It’s the way we were raised. If I didn’t have HIV, I couldn’t have gone to the media. But being positive gave me the strength to do it.” Belkis Giorgis, a gender specialist at Management Sciences for Health (MSH) in Ethiopia, said the change has been dramatic. “They are the most articulate women you can imagine,” she said. “The founder of the organization wanted to start her own Oprah Winfrey show. That should tell you something.” And yet for every woman who makes advances in the developing world, there is another who is stalled or falling behind. In Freetown, Sierra Leone, living in a community under a bridge and next to a refusestrewn river, Lydia Nasim, 17, said all she wanted was enough funds to go to university for accounting “and be someone in this world.” “But there is no way I can make my dreams come true,” she said. “I have no opportunity. I am a school-going girl, I strike out to survive, but it’s hard to survive, to make ends meet. I want to follow my education, but I
tens of millions of girls Photo by Psoi@flicker.com
and women remain trapped in poverty in large part because of their sex.
have no way, I have no upper hand. In this Africa, we are begging for them (donors or governments) to help us so we can help ourselves to follow on with our education. But it seems they are not turning to us. We are lost. Lost.”
ramped up in the mid-1970s onward, has been cited as a major reason for the decline. In Latin America, even as the population grew by more than 100 million from 1990 to 2010, the fertility rate declined from 3.1 births per woman to 2.1.
Even with so many in Lydia’s predicament, the global numbers show a steady sea change of progress. Consider:
Several countries maintain sky-high fertility rates, including Afghanistan with an average of 6.53 children per woman, the Democratic Republic of Congo at 5.84, and Chad at 5.31.
Fertility In sub-Saharan Africa, the overall trends in countries that have completed DHS surveys show fertility decline in all countries except Uganda and Tanzania over the past decade. Several countries experienced major declines over the past 20 years, led by Ghana and Kenya with roughly 40 percent declines, and Benin, Cameroon, Nigeria and Rwanda, with roughly 20 percent declines. Sub-Saharan Africa wasn’t the only region to experience such reduction in births. In Asia, one of the most remarkable changes has been in Bangladesh, where the fertility rate dropped from nearly seven children per woman in the late 1960s to about 2.4 in 2007, according to DHS surveys. A nationwide family planning program,
ISSUE 10 spring 2011
Education The average grade level achieved by young women ages 20-24 rose from 3.8 in 1985 to six in 2005, according to an analysis by the National Research Council and the Institute of Medicine. (Young men’s average grade levels increased from six to 7.4 during the same period.) The percentage of young women who never attended school fell from 39 percent in 1985 to 18 percent in 2005. Age of marriage Child marriage – those under age 18 – is still widespread among young women (see pages 5 and 10). In 1985, according to the National Research Council study, 52 percent of women in the developing
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world married before 18, and that dropped to 38 percent in 2005. High rates of child marriage still occur in Western and Middle Africa and South Asia. The study found that young women who marry as minors are more likely to have few, if any, years of schooling and are largely from poor, rural areas. Several experts pointed to education as the key driver of change for girls and women in the years ahead. “I think if you really step back and look at the big picture, probably the biggest improvement has been in girls’ education,” said Ann Starrs, president and co-founder of Family Care International. “There is still significant inequity compared to boys’ education in most, but now not all, developing countries. In the Caribbean, girls are more likely to be educated than boys. But in the Middle East, North Africa and subSaharan Africa, girls lag significantly behind boys, even if there’s been a significant reduction in that inequity.” Starrs and others said with the current global focus on safer motherhood and reducing the numbers of deaths during and after childbirth – reflected in MDG5, considered to be lagging behind other MDG goals – many countries are taking a multi-prong approach. Part of this will be to put more funding into programs that discourage early marriage and encourage more family planning, which reduces the numbers of births and creates more spacing between births. Starrs noted the “fair amount of politics in the United States” around family planning over the last generation, but she said the most defining fact about global health funding has been the leap in funds to fight AIDS and, to a lesser extent, malaria and basic vaccines, while almost all else has seen no increase or small declines. She also said that political movements for the health of women and girls needed the added lift of good timing. For instance, the International Conference on Population and Development in Cairo in 1994 was seen by many as a turning point from policy makers dictating a population control approach to a “people-centered reproductive rights approach.” But, Starrs said, “Donors weren’t as interested in family planning as much then.”
Are they interested now? “There’s a real awareness among some of the key donors that reproductive health and family planning needs to be placed back on the priority agenda, but so far it’s not enough to make up for the declines,” she said.
In the meantime, many countries are pushing for more focus on reproductive health issues on their own. One is Senegal. Dr. Bocar Daff, the director of Reproductive Health in the Ministry of Health, said when he started in his job in 2008 the issue was not given priority. He started pushing for more services and now “when we go into the regions to talk about health issues, we are always getting requests for a special day or entire week of focusing on importance of reproductive health. That’s very telling. People have started changing their vision of reproductive health.” Donors should shift more funding toward these programs, he said. He specifically mentioned the Global Fund to Fight AIDS, Tuberculosis and Malaria, which he said “has a very low budget for reproductive health.” Daff said he has a personal motivation to promote reproductive health – the future health of his two daughters, ages 20 and 10. “I want to be sure when they utilize reproductive health services, they will be able to have services available to them that are of good quality,” he said. “Today, if I see that women have good reproductive health services available to them, part of it speaks to my efforts. If I see they don’t have good services, part of it also is my efforts. Sometimes I can’t sleep at night because I think of so many things that aren’t moving as well as they should be.” In Senegal, Ethiopia, Nepal, Bangladesh and many other countries, the backbone of the strategy has been to expand women community health workers. Some are voluntary positions, but an increasing number, including the 45,000 workers in Ethiopia, are paid. Many experts see a global boom in health extension workers in the next generation. “These are success stories,” said Halida Akhter, an MSH global technical leader for family planning and reproductive health whose career started in Bangladesh in 1969 on a family planning project. “We’ve been able to bring down the fertility rate, the maternal mortality also has gone down, and my feeling still is the people involved in providing services, and in getting services, getting the message out, helping each other – they are all women.” Akhter likes this model of women helping women. “You give information to women and they make best use of it,” she said. “You give decision making power, and they will make the best use of it. Investing in women is the best investment.” GH —
By Tamara Kreinin
Photo by David Evans
Ending Child Marriage with this Generation: A Smart Decision
An adolescent girl living in poverty could be the most powerful person in the world. If she is reached early enough, she can accelerate economies, arrest major global health issues, and break cycles of poverty. When a girl gets a chance to stay in school, remain healthy and gain skills, she will marry later, have fewer and healthier children, and earn an income that she’ll
ISSUE 10 spring 2011
invest back into her family and community. When she can grow into a woman and become an educated mother, an economic actor, an ambitious entrepreneur, or a prepared employee, she breaks the cycle of poverty. She and everyone around her benefits. Child marriage is one of the barriers preventing the 600 million adolescent girls in developing countries from
Tamara Kreinin is executive director, women and population at the United Nations Foundation.
77 percent of adolescent girls aged 15-19 surveyed
India, Sierra Leone and Zimbabwe, which have all passed laws that either raise the age of child marriage or outlaw child marriage all together.
For example, in 2008, the Indian government introduced a program in seven states that will give payments to parents when a girl reaches the age of 18 and is not married. In Zimbabwe, a bill was passed in 2007 that made cultural practices, including pledging girls for marriage, illegal. Now we need to continue to create international Story and photos By David Rochkind pressure to spur change at a faster rate. We need to implement the solutions we know exist to combat the practice of child marriage. In particular, in countries or sub-national regions with a high prevalence of child marriage, the U.S. administration should enhance its strategy to effectively address the issue; integrate child marriage into existing U.S. foreign assistance programs unleashing their full potential. One in seven is forced that are currently undermined by this practice, including into marriage before the age of 15, and if these trends maternal health, violence, HIV prevention, education and continue, 100 million girls will marry over the next economic development; collect data on the prevalence decade – that is about 25,000 children married every of child marriage and best practices to monitor and day for the next 10 years. report on progress made; and continue to report on Child marriage triggers a cycle of poverty, disadvantage child marriage as part of the State Department’s Annual and despair. At a basic level, it puts girls at great risk. Human Rights Report. Fifty percent of girls in developing countries become mothers before age 18 – many before their bodies have The UN Foundation’s Girl Up campaign has added its matured – which puts them at higher risk for infant voice to the chorus of advocates deriding the harmful and maternal mortality. In fact, the leading cause of practice of child marriage. More than100,000 teen death among girls ages 15-19 worldwide is medical supporters are rallying together, and asking the Obama complications due to pregnancy. Girls between the Administration to strategically address the issue of child ages of 10 and 14 are five times more likely to die in marriage so that girls in places like Ethiopia, Malawi and pregnancy or childbirth than women aged 20 to 24; Guatemala won’t be forced into getting married and sadly, the vast majority of these deaths take place bearing children as children themselves. The girls are also within marriage. raising critical dollars that will go toward UN programs fighting to end child marriage in Ethiopia and Malawi. Child brides are also at higher risk of contracting HIV as their husbands are at times older men with more sexual These girls should be applauded for standing up for experience. They are also more vulnerable to sexual their sisters in developing countries and joining the and domestic violence at the hands of their husbands – coalition of organizations, including International and are more likely to think that it is OK when they are Women’s Health Coalition (IWHC), CARE and victims of abuse. The 2011 State of World’s Children International Center for Research on Women (ICRW), report found that 77 percent of adolescent girls aged who have been leading the charge to bring an end to the 15-19 surveyed in Ethiopia, believed a husband is destructive practice of child marriage. justified in striking his wife, in comparison to 53 percent of boys. Investing in adolescent girls and placing them at the center of international and national action is the right While the statistics are daunting, there are solutions thing to do. It is also the smart thing to do. The truth and a tremendous opportunity before us. Developing is, adolescent girls will either accelerate growth or nations around the world are making efforts to combat perpetuate poverty. It all depends on how we choose to child marriage by changing laws and enforcing existing invest resources to make current efforts more effective ones. In recent years, we have begun to see progress on by also addressing the health and rights needs of girls. GH laws related to child marriage in countries like Ethiopia,
in Ethiopia believed a husband is justified
in striking his wife, in
comparison to 53 percent of boys.
C Child Marriage Facts and Figures. ICRW (See page 5). C Adolescents, 2011 State of the World’s Children Report.
By steve hodgins
Photos courtesy of Jhpiego
What Happens After Women Come Through the Door?
The UN Secretary General has led an initiative to which $40 billion has been committed for maternalchild health. This has resulted in the formation of the Commission on Information and Accountability for Women’s and Children’s Health. The Commission, in turn, has formed a Working Group on Accountability for Results, chaired by Lancet editor Richard Horton, which has been tasked with recommending how results should be tracked and proposing a short list of indicators.
For maternal health, the working group has recommended tracking maternal mortality ratio and “attendance by a skilled provider.” Although not reflected in the proposed indicators, their recommendations included a strong call for attention also to be given to quality of care. This is to be commended. It is important to make the content and quality of care a priority, rather than only tracking contact with the health care system, which is really all we are measuring using the standard
ISSUE 10 spring 2011
Steve Hodgins is the leadership global team leader of USAID’s flagship Maternal and Newborn Child Health Program MCHIP/John Snow Inc.
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It is important to make the content and quality of care a priority, rather than only tracking contact with the health care system. indicators of skilled birth attendance and antenatal care visits. With significant new funding commitments for improving women’s and children’s health over this past year, we have a valuable opportunity to effectively focus the attention of policy makers, donors, program managers and technical assistance partners in a way to bring about substantial gains in health status. Identifying suitable indicators is challenging; there are several important criteria to be met. First, they need to be effective for policy advocacy. That means, in the words of Stephen Harper, which Richard Horton quoted in his comment in the Lancet on Feb. 5, that we need “to strip out the complexity, boil the problem down, decide on a few priorities, choose a ‘few simple things.’” Furthermore, indicators chosen need to be measurable with some reasonable degree of validity. And finally, and this is the point I want to emphasize here, they need to communicate appropriate signals to program managers. This is important because as program managers we focus our efforts on what we are required to measure. As global benchmark indicators, we have been relatively well served by those used for child and newborn health. Most measure use of specific technical interventions or household practices with a direct and well established causal link with mortality risk (e.g. percentage of children sleeping under an insecticide-treated mosquito net, percentage of children with diarrhea treated with oral rehydration salts, percentage of children aged 12-23 months who are fully immunized). Using indicators with such characteristics, we communicate a clear signal to policy makers, donors and program managers that they need to marshal their efforts to increase coverage of these effective interventions and practices. For maternal health, however, we have relied heavily on skilled attendance at birth and antenatal care, both of which have been measured only as contacts with the
health care system. Noticeably absent as benchmark indicators for maternal health have been the content and quality of care. This has meant sending a signal to program managers that what is important is getting women through the front doors of their health facilities. The Working Group on Accountability for Results has recommended skilled attendance at birth as one of its very short list of recommended indicators. While this may be necessary and appropriate, I would like to make a plea to the Commission for clear language also to be included in its final recommendations on accountability that clearly draws attention to the importance of content and quality of care. In this connection, it is relevant to note that in an increasing number of countries, use of oxytocin (or other suitable uterotonic) during the third stage of labor is now being included in national health information systems (e.g. in Senegal, Chad and several countries in Latin Ameria). Like the benchmark indicators used in child health, this indicator meaningfully measures rate of use of an intervention effective in driving down deaths due to one of the most important causes. Although most countries are not yet in a position to report on this indicator, this is almost ‘ready for prime-time.’ As we look to how best ensure accountability for results under the new maternal-child health initiative, and as we look to the challenges of achieving MDGs and how best to measure progress, an indicator like uterotonic use in the third stage of labor (which addresses the principal cause of maternal deaths in sub-Saharan African and South Asia) is a good example of the kind of measurement of content and quality of care that is needed. Use of such indicators at the highest policy level sends a clearer message to program managers that they need to give serious attention to what happens after women come through the front door. GH —
A Dance for Girls’ Rights
A young girl performs a dance about standing up to violence in her community as part of International Medical Corps’ recognition of International Women’s Day. Since the earthquake over a year prior, she has lived in a displacement camp in Portau-Prince, Haiti.
Women and Girls in a Changing World Photography Contest
ISSUE 10 spring 2011
The winner of GLOBAL HEALTH Magazine’s photo contest, Women and Girls in a Changing World, is ‘A Dance for Girls’ Rights’ by Chessa Latifi a program officer for International Medical Corps in Haiti. Latifi began taking photographs while visiting Kosova after the 1999 war, where much of her extended family lives. She has worked for International Medical Corps in Iraq and now in Haiti, where she oversees an emergency response program that includes four primary health clinics, several dozen water and sanitation projects, and a disaster risk reduction program as well as an emergency medicine development program at the largest hospital in the country. These pages feature a selection of Latifi’s other work from Haiti.
Q&A with Chessa Latifi
When did you start taking photographs?
My earliest pictures are from visiting Kosova after the war in 1999. At 15 years old, I was intent on documenting the destruction with a 35mm Nikon. I don’t have the negatives anymore, but I have the old prints of rubble, graffiti, bullet holes, and one portrait of my grandmother that I still cherish. What has finding photography meant to you?
It means I can convince people that these far corners of the world - Haiti or Kurdistan, for example - are not what they believe. These places are oftentimes much more wondrous than expected. What do you think is special and unique about the winning image?
Much of her dance was listless, just moving through the steps. And then, at the captured moment, she burst out and really expressed herself. It was beautiful. Any advice for people looking to get into photography?
First, put your camera down and look around. You want to see your surroundings with your eyes first, not your camera lens. Then, pay attention to your composition. What has been the most moving experience for you in the field?
It was actually the moment captured in the winning photograph. This girl really expressed herself, and it was amazing to be there to witness it, and feel like I had a small part in giving her that platform at International Medical Corps’ clinic. What does photography give to global health?
Photographs provide a connection to and awareness of a subject to an audience. In a world of growing distractions, a photograph is evidence of the true reality of others. GH —
Community Health Workers:
Key Agents for Reducing Child Mortality
By Robert Black and Henry Perry
ISSUE 10 spring 2011
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Millions of poor and marginalized mothers and children in the developing world do not get basic health care because it is simply unavailable, too far away, or too expensive. This remains the primary reason why nearly 350,000 women die during pregnancy or childbirth and 8 million children younger than 5 years-old die every year from preventable or treatable causes. Nearly 4 million of these deaths occur among newborns less than one month old, which is roughly equivalent to the total number of babies born annually in the U.S. In places like Afghanistan, which is ranked the toughest place to be a mother, according to Save the Children’s 2011 State of the World’s Mothers report, two of every five children are malnourished and one in five will die before their fifth birthday. Compare that to Norway – which is ranked as the best place to be a mother – where only one in 333 children die before the age of 5.
A growing body of evidence shows that community health workers (CHWs) can effectively reach the poorest, sickest children, with the potential to save millions of lives by providing care when and where it’s needed most. With initial training of six weeks or less, these workers may serve as volunteers or for modest incentives or salaries. They can be trained to distribute vitamin A capsules and other critical micronutrients; promote sanitation (hand washing, water treatment, safe water storage, latrine construction); distribute mosquito nets to prevent bites at night that spread malaria; diagnose and treat pneumonia, diarrhea, malaria, newborn sepsis and severe malnutrition; and promote healthy behaviors such breastfeeding, appropriate care of newborns, and immunizations of mothers and children. There are two areas where CHWs have especially great potential to save lives and reduce overall rates of child mortality around the world: the diagnosis and treatment of childhood pneumonia and the provision of homebased newborn care.
Robert Black, MD, MPH is the Edgar Berman Professor in International Health and chair of the Department of International Health at the Bloomberg School of Public Health, Johns Hopkins University. Henry Perry, PhD MD, MPH is a senior associate, health systems, at the Department of International Health at the Bloomberg School of Public Health, Johns Hopkins University.
Photos courtesy of Save the Children
For a variety of reasons, in many parts of the world, pregnant women and young children will not receive lifesaving health care unless there is a female community health worker nearby to provide it. If we want to solve the interconnected problems of maternal and newborn and child mortality, we must do a better job of reaching these mothers and children with skilled care.
Globally, pneumonia is the leading cause of under-5 mortality, responsible for 18 percent of deaths. An analysis of the combined results of six published studies now indicates that the diagnosis and treatment of childhood pneumonia by CHWs can reduce the risk of death by 36 percent in children with this condition, and it can reduce the overall risk of death for all children living in geographic areas where the program exists by 24 percent. Only one-quarter of children in the 68 highest
2011 Mothers’ Index Rankings
Top 10 places to be a mother 1. Norway 2. Australia 3. Iceland 4. Sweden 5. Denmark 6. New Zealand 7. Finland 8. Belgium 9. Netherlands 10. France mortality countries (where 97 percent of child deaths occur) currently receive antibiotics when they have symptoms suggestive of pneumonia. CHWs could play a critical role in filling this treatment gap. Newborn deaths (those that occur during the first 28 days of life) account for 41 percent of all deaths among children younger than 5. The major causes of newborn mortality include pre-term birth complications, birth asphyxia and sepsis. In settings where most births take place in the home – because health facilities are not accessible or are not acceptable to the population – community health workers can provide critical services that save lives. CHWs can identify pregnant women and provide them with basic education during prenatal home visits; promote clean delivery; provide essential newborn care; manage birth asphyxia (if they attend the delivery); assist with hygienic care of the umbilical cord; diagnose and refer (or treat if referral is not possible) cases of newborn sepsis; and assist with healthy practices after birth, such as preventing hypothermia, preventing infection and promoting immediate breastfeeding. An analysis of combined results of 18 studies of home-based newborn care provided by CHWs indicates that newborn mortality can be reduced by 24 percent using this approach. Many countries could benefit from a coordinated global effort to train, equip and supply more community health workers. Recognizing this, UN Secretary-General Ban Ki-moon has called for an additional 1 million CHWs to help close a global shortfall of 3.5 million health workers. Of course, community health workers cannot do this job alone. They must be supported and supervised by wellmanaged and adequately resourced health systems. This requires political commitment; professional
bottom 10 places to be a mother 155. central african republic 156. sudan 157. mali 158. eritrea 159. DR Congo 160. chad 161. Yemen 162. Guinea-bissau 163. Niger 164. afghanistan Source: Save the Children
leadership; practical training and refresher training; and reliable logistical support for basic medicines and supplies. Donor governments and developing country governments need to plan and budget for the increased number of health workers and their support if we hope to achieve the health Millennium Development Goals. The world community has a moral obligation to prevent the needless deaths of children and newborns. James Grant, the renowned executive director of UNICEF from 1980 to 1995 and champion of what is often referred to as the First Child Survival Revolution, repeatedly reminded us that “morality must march with capacity.” We now know that community health workers have the capacity to be the difference between life and death for millions of children. What is needed now is the leadership and political will to build the health systems and grow the CHW talent pool so children born in remote impoverished communities will have someone to give them a fighting chance to survive and thrive. GH —
ISSUE 10 spring 2011
C Click on the source at www.globalhealthmagazine.com
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By Tom arnold and David beckmann
Maternal and Child Undernutrition
Translating Evidence and Rhetoric into Action Will 2011 be remembered as a turning point in the global effort to combat maternal and child undernutrition? Although it’s an effort that has been the subject of much research and rhetoric in recent years, concrete action has lagged behind the indisputable data and the strong words. But in the last several months, we are starting to see real evidence of forward momentum; and in the coming months there will be new opportunities to increase this momentum. National governments, the United Nations, civil society organizations, development agencies, academia, foundations and the private sector are committing themselves with growing urgency and focus. Adequate nutrition is critically important during the first 1,000 days (from pregnancy to 2 years of age) of a child’s life. There is conclusive evidence of the impact of undernutrition on infant and child mortality and its largely irreversible long term effects on health and on cognitive and physical development. Globally, malnutrition is an underlying cause of onethird of all maternal and childhood deaths, in large part because young children who are malnourished are more susceptible to illness and life-threatening health conditions. Child malnutrition is further responsible for 11 percent of the global disease burden, thereby hindering progress toward the Millennium Development Goals. This evidence has underpinned a number of recent political and policy initiatives aimed at improving early childhood nutrition. A New Consensus Undernutrition causes an estimated 3.5 million maternal and child deaths annually. As U.S. Secretary of State Hillary Rodham Clinton said, “These deaths are Tom Arnold is CEO of Concern Worldwide. David Beckmann is president of Bread for the World.
intolerable because they are preventable.” Today, 195 million children are stunted. This is a third of all children in the world who are younger than 5 years-old. Of these, 90 percent live in just 36 countries, 21 of which are in sub-Saharan Africa. In some African countries the proportion of children stunted is as high as 50 percent. In January 2008 the Lancet issued a five-part series on nutrition which provided evidence on the impact of early childhood undernutrition. The most common form of malnutrition across the world is micronutrient deficiency, which affects 2 billion people. The four most widespread deficiencies are in vitamin A, zinc, iodine and iron, which are associated with 10 percent of all deaths in children under 5. Malnourished children are more at risk of contracting illnesses such as diarrhea, malaria and pneumonia. They are more likely to grow up to be shorter adults. Malnourished girls are more likely to give birth to low birth-weight offspring, contributing to a multigenerational cycle of malnutrition. Impaired cognitive function leading to lower educational performance and economic productivity means child undernutrition hinders economic development. In Zimbabwe, children who were stunted at preschool age started school seven months later, lost an average of 0.7 grades of schooling and earned 12 percent less over their lifetime, a trend mirrored in many studies. Where childhood malnutrition is pervasive, the loss to GDP can be as high as 2 to 3 percent, not including the indirect costs of malnutrition such as health care and lost wages due to illness. The barriers children, young women and mothers face in meeting their nutrition needs include poverty, a lack of education on healthy diets and infant care, a lack
The steps that need to be taken include: • Direct nutrition-specific interventions focusing on pregnant women and children younger than 2. • Nutrition-sensitive multi-sectoral approaches such as supporting agricultural development, improving social protection and ensuring access to health care. In 2009 the World Bank identified a package of 13 interventions for the first 1,000 days (C see table online). The World Bank estimated the total cost of the 13 interventions in the 36 highest burden countries at $11.8 billion annually, of which $1.5 billion would be absorbed by households. That package of interventions would save the lives of 1 million children annually.
Photo courtesy of Concern Worldwide
A Plan of Action In April 2010, A Framework for Action to Scale Up Nutrition (SUN) was launched to advocate a better focus on child undernutrition. It was endorsed by more than a hundred entities, including national governments, the United Nations, civil society organizations, development agencies, academia, foundations and the private sector. The Framework was followed by the development of A Road Map for Scaling Up Nutrition, which was launched at the UN General Assembly Summit for the Millennium Development Goals in September 2010. A transition team, chaired by the UN Secretary-General’s Special Representative for Food Security and Nutrition, Dr. David Nabarro, is now in place to oversee the SUN Road Map. of access to a diverse variety of nutritious foods, a lack of access to adequate health care and sanitation, restrictive cultural practices and low social status. In countries where gender inequality is great, high rates of hunger also occur as female members of a household will ‘eat least and last.’ Low rates of exclusive breastfeeding also inhibits a child’s growth and development and ‘suboptimal’ breastfeeding results in the death of 1.4 million young children each year. Complementary foods, ideally introduced at 6 months, may also be unavailable, of poor nutritional quality or introduced too early or too late. What can be done? The Lancet series indentified proven, high impact and cost effective interventions focused on the “window of opportunity” from minus 9 to 24 months (i.e. the first 1,000 days) to reduce death and disease and prevent irreversible harm.
ISSUE 10 spring 2011
The SUN Road Map envisages three stages of country participation: (a) national authorities taking stock of the national nutrition situation and of existing strategies, institutions, actors and programs; (b) national authorities developing their own plans for scaling up nutrition; (c) rapid scaling up of programs with domestic and external financing. The aim is that countries ready to scale up nutrition will start to receive intensive support from the international community by the end of 2011. To date, ‘early riser’ countries include: Bangladesh, Ethiopia, Guatemala, Malawi, Mozambique, Nepal, Niger, Peru, Senegal, Tanzania, Uganda, Mali, Rwanda, Sierra Leone, Ghana, Haiti and Zambia. The governments of countries facing the greatest undernutrition problems must be the main investors in efforts to scale up nutrition. But they need support from the other stakeholders committed to improve nutrition. National health systems which integrate
C Table: Evidence-based direct interventions to prevent and treat undernutrition
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improved nutrition practices need sustained investment and trained personnel. Additional financial resources will be required, some from a re-prioritization of national resources and international aid, others from additional net resources for early childhood nutrition. The social and cultural barriers to achieving improved child nutrition, including the low status of women in many societies, must be honestly acknowledged and addressed.
Photo courtesy of Liam Burke, Concern Worldwide
The SUN transition team draws on the work of six task forces rallying for sustained support for SUN actions within participating countries. They deal with (a) national capacities and systems strengthening, (b) advocacy and communications, (c) social mobilization, (d) engagement of development agencies/donors, (e) involvement of the private sector in nutrition sensitive sustainable development and (f) monitoring and evaluation. Call to Action SUN is supported by the 1,000 Days advocacy initiative that focuses attention on the 1,000-day window of opportunity between pregnancy and a child’s second birthday, when adequate nutrition has the greatest impact on saving lives and on cognitive and physical development. The initiative aims to rally support for nations to improve their people’s nutritional status within 1,000 days – i.e. between the 2010 MDG Summit and June 2013. Bread for the World and Concern Worldwide participated in the 1,000 Days launch, calling for a broad set of voices and actors to speak up about the urgency and importance of scaling up nutrition interventions, especially in the first 1,000 days. A June 2011 summit meeting sponsored by the two organizations is one of a number of initiatives designed to organize a voice for civil society in order to maintain and build on the political momentum. We must do all we can to sustain political commitment to address the issue of maternal and child malnutrition, bolster and reinvigorate champions of this issue and help recruit new champions. We must help develop a shared advocacy agenda and strategy for the planned follow-up event at the next UN General Assembly and the upcoming G20 Summit, including a focus on financing to mobilize the additional resources needed to scale up nutrition.
The international nutrition community has accumulated extensive evidence concerning the burden, consequences and effective interventions related to undernutrition. Countries and their partners have extensive knowledge and experience concerning the management of multi-stakeholder platforms and the capacities needed for scaling up nutrition. A global momentum is building for a renewed effort to translate these assets into large-scale improvements in the nutrition of high burden countries. The coming years will be crucial for sustaining the commitment, the capacities and the coordination for these efforts to succeed. There are important roles in this process for members of the global health community and we look forward to building momentum to scale up nutrition interventions, especially in the first 1,000 days of a child’s life. GH —
By sarah johnson, ummuro adano and Willow gerber
Moving Toward Gender Equitable Health Organizations Environment
Mission, Vision & Strategy
Leadership & Governance Partnerships, external Relations & Networking
Figure 1: Organizational Capacity Building Framework
There have been significant investments in gender mainstreaming and training staff in health organizations to be “gender-sensitive” or to undertake “gender analysis.” However, these efforts to date have generally focused on changing attitudes and behavior of individual staff members, rather than changing the way the broader organization works. Change in the way health organizations address or remedy gender-based inequality has been minimal. What’s needed is an organized approach that requires people to work together to create new ways of acting within organizational functions that will lead to gender equity.
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With workforces ranging from five to 10 people to thousands of staff, local public sector institutions and NGOs delivering health services are not immune to the social differences between females and males learned throughout the life cycle and rooted in culture. Although change is occurring, hierarchical and patriarchal structures still exist; organizational culture is often more sensitive to men’s needs than women’s, work may be valued differently for women and men – either overtly or subliminally – and, at worst, flagrant gender discrimination as well as sexual harassment and abuse may exist. The net result is under appreciation and
Sarah Johnson is the director of the AIDSTAR-Two Project, Management Sciences for Health (MSH). Ummuro Adano is the deputy director and senior capacity building advisor for AIDSTAR-Two. Willow Gerber is the knowledge management officer at AIDSTAR-Two.
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Gender Quality Principles *Employment and Compensation: Policies and practices to eliminate gender discrimination in recruitment, hiring, pay and promotion *Work-Life Balance and Career Development: Policies and practices in favor of work-life balance, educational and career development *Health, Safety and Freedom from Violence: Policies to secure health, safety and well being of women workers *Management and Governance: Policies to ensure equitable participation in management and governance *Business, Supply Chain and Marketing Practices: Implementing non discriminatory business, supply chain, contracting and marketing practices *Civil and Community Engagement: Policies to promote equitable participation in civic life *Transparency and Accountability: Gender equality policies that are publicly disclosed (e.g., benchmarks for progress, commitment to these principles and policies by the executive director of the organization, etc.) © 2010 The San Francisco Department on the Status of Women and Calvert Group, Ltd.
under utilization of women at different levels of the organization, which affects not only working women but also productivity and the delivery of health services. Gender equity is not just an issue of human rights and justice; it is also a winning business formula. If women are to reach their full potential as health managers, leaders and workers, then health organizations and institutions must do more. Using existing organizational development frameworks and tools can help. Entry Points for Capacity Building Organizational capacity building is defined as the strengthening of internal organizational structures, systems and processes, management, leadership, governance and overall staff capacity to enhance organizational, team and individual performance. Effective organizational capacity building consists of evidenced-based approaches to meet a hierarchy of needs over time and it must occur with the full support of the organization’s leadership. At a time when attention is being placed on country ownership and health systems strengthening, organizational capacity building has a key role to play in strengthening institutions. It can also help to create gender supportive organizations. There are existing tools and approaches that can be used to promote greater equality within health institutions. The seven Gender Quality Principles offer standards to organizations and institutions by which progress can be assessed and measured. The AIDSTAR-Two project’s organizational capacity building framework (Fig. 1) is developed around a set of core organizational functions that must be present and functioning effectively in a sustainable institution. This framework speaks to many of the gender quality principles and also illustrate different entry points for
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assessing and addressing gender within organizational capacity building. Organizational assessments Even well managed successful organizations must constantly assess and adapt their management practices as demand and environments change. Typical organizational assessments evaluate the current capacity of management components including organizational mission and values, strategies, structure and internal management systems. These instruments can be easily adapted to also assess current organizational capacity and performance in gender equality, for example, examining the organization’s human resource policies. Much can be borrowed from the existing literature and toolkits on gender best practices and gender integration to adapt these tools; alternatively, organizational development assessment tools can be used along-side existing gender tools. Mission, value and strategy It is worthwhile to review the organization’s mission as well as the presence or absence of stated organizational values on gender equity. Organizational strategies – the broad approaches used to achieve the organizational mission – are often set during a strategic planning processes. Strategic planning offers an opportunity to assess external threats and opportunities and internal strengths and weaknesses and develop overall strategic objectives and strategies to reach a defined shared organizational vision set 2-3 years in the future. Such planning processes are an appropriate time to look at strategies to address gender equity. Structure Structure – which encompasses the formal lines of authority of an organization, distribution of responsibilities, the way that decisions are made, and internal communication mechanisms – answers
the question, are we organized in a way that facilitates what we want to do and where we want to go. Adjusting the organizational structure, assigning new roles and responsibilities to managers and staff, and improving internal communication effectiveness may help to facilitate an overall effort on gender strengthening and put women in new roles.
significant role in fomenting and institutionalizing good practice in gender inside their organizations and worksites. Support and actions from senior leadership, including board of directors and advisory boards, are of fundamental importance, and might include public statements on gender equity, assessment of and changes in institutional norms, and modeling behavior.
Management systems Senior leaders, advisory or governance bodies with the support of HR officers, must examine the composition of their workforces and the roles and positions of women.
Leadership development programs serve to strengthen leadership competencies and skills to address challenges such as internal organizational gender policies and practices and career pathways for women or lack thereof. Change management practices and processes, a part of sound organizational development, must be used across all these and other activities to build gender equity and to assure that best laid plans are actually executed and produce measurable results.
Assessment and improvement in internal management systems, such as the human resource management system, can help assure that policies on recruitment, salaries, promotion, support and supervision are aligned with gender equity objectives. Promoting mentoring programs for women so that they have role models, and staff trainings in gender knowledge and skills and team building can also be useful. Multiple curricula on gender skills building exist. Improvements to other management systems can also contribute to overall institutional gender strengthening. For example, gender-sensitive indicators within the organization’s information and M&E systems are important for measuring progress, raising awareness of issues, improving the evidence-base for decision making, and helping to identify the exact issues that need priority attention. Partnerships, external relations and networking Organizations can partner on joint programming initiatives on topics such as violence against women and girls, anti-discrimination, and equal pay for equal work. Multi-stakeholder partnerships can include task forces that identify and tackle any of these and many more topical issues that enhance gender parity. Governance and leadership Organizational leaders – men and women alike – play the single most
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Conclusion Health and equity improve when an organization commits to gender mainstreaming, institutionalizes gender equitable internal policies and procedures, improves technical competency in gender integration, and pays attention to gender differences in the design of programs and measures impact. Speaking at a conference on gender at Radcliffe, Brigham Young University Professor Valerie Hudson reaffirmed what has been said many times and is supported by evidence, “There is no policy more effective in promoting development than the health and education of women.” Indeed, organizational health will also be greatly improved by planning and implementing effective organizational capacity development initiatives aimed at gender equity inside health institutions. Organizational capacity building, oriented by gender equity principles and frameworks for assessment, action and measurement can play a significant role in promoting gender equitable organizations. GH —
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By Ishita Chaudhry
Ishita Chaudhry founder and managing trustee of The YP Foundation.
Young People Need Evidenced-Based Information Too
I grew up in India with very little information about my sexuality, my body, or my right to health. My first memory of being taught about the human body was in primary school, when my teacher listed our body parts, “Head, face, neck, shoulders, stomach, hands, knees and toes.” I remember my friend asking the teacher, where the vagina was. We’d read the word in a book and didn’t know what it meant. We both got yelled at, with my friend being sent to the principal for “inappropriate conduct” and my class being given a lesson in how children from good families didn’t read “dirty things.” I was 10 years old at the time. Sixteen years later, at a workshop on sexuality education with young people in Delhi, a 20 year-old female college student from a well-known university asked one of my colleagues if the clitoris is in the foot and is an organ that keeps the heart healthy. Her question is not unusual. My colleague took it in stride and provided her with accurate information. It’s disappointing that throughout the course of our youth and adolescence, so many young people do not get even basic information about their anatomy, and even more disappointing considering that there are 1.2 billion people between the ages of 10 and 19 in the world today – the largest generation of adolescents ever. Young people, especially girls and young women, face great challenges to their well-being and their human rights. To face these challenges young people need evidence-based, accurate information about their sexual and reproductive rights and health, as well as support and skills to feel comfortable and confident about their bodies and their sexuality. Today The YP Foundation, an organization we founded when I was 17 in 2002, has grown from three high
Ishita Chaudhry is founder of the YP Foundation in India
school students working from my parents’ bedroom to a journey that has brought together 300,000 young people across India. In the last 9 years, we have created more than 250 projects in India that promote, protect and advance young people’s human rights by creating programs and influencing policies that build leadership and strengthen youth-led initiatives and movements. Together, we created India’s first youth-led and run campaign for legalizing and supporting the implementation of sexuality education across India. Our program, “Know Your Body, Know Your Rights,” has trained more than 300 young activists from different communities across 10 states in India, using social networking, poster campaigns, national and state level meetings to bring over 4,800 young people’s voices to the fore. For the first time, young people’s voices will reach policy makers. We are speaking up to our governments on our needs, aspirations and rights to accurate, life saving information on comprehensive sexuality education that is free from stigma, fear and judgment. We are at a historic moment: strong movements of young people are gaining momentum for their agendas centered on human rights and social justice. Young people’s lives are increasingly shaped by trends toward democracy and the rise of civil society. We must seize this opportunity and ensure that young people have the information and skills they need to navigate adulthood safely. This is the way that it should be, and until every woman and every young person in every part of the world can lead just and healthy lives, our work is not done and we cannot go back to the comfort of our silences. GH —
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