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Health Policy Advancing Social and Economic Development by Investing Health Policy Advancing social and economic development by investing in women’s and children’s health: a new Global Investment Framework Karin Stenberg, Henrik Axelson, Peter Sheehan, Ian Anderson, A Metin Gülmezoglu, Marleen Temmerman, Elizabeth Mason, Howard S Friedman, Zulfi qar A Bhutta, Joy E Lawn, Kim Sweeny, Jim Tulloch, Peter Hansen, Mickey Chopra, Anuradha Gupta, Joshua P Vogel, Mikael Ostergren, Bruce Rasmussen, Carol Levin, Colin Boyle, Shyama Kuruvilla, Marjorie Koblinsky, Neff Walker, Andres de Francisco, Nebojsa Novcic, and Carole Presern, Dean Jamison, Flavia Bustreo, on behalf of the Study Group for the Global Investment Framework for Women’s and Children’s Health* A new Global Investment Framework for Women’s and Children’s Health demonstrates how investment in women’s Published Online and children’s health will secure high health, social, and economic returns. We costed health systems strengthening November 19, 2013 and six investment packages for: maternal and newborn health, child health, immunisation, family planning, HIV/ http://dx.doi.org/10.1016/ S0140-6736(13)62231-X AIDS, and malaria. Nutrition is a cross-cutting theme. We then used simulation modelling to estimate the health and *Study Group members listed at socioeconomic returns of these investments. Increasing health expenditure by just $5 per person per year up to 2035 the end of the paper in 74 high-burden countries could yield up to nine times that value in economic and social benefi ts. These returns Department of Health Systems include greater gross domestic product (GDP) growth through improved productivity, and prevention of the needless Financing (K Stenberg MSc), deaths of 147 million children, 32 million stillbirths, and 5 million women by 2035. These gains could be achieved by Family, Women’s and Children’s an additional investment of $30 billion per year, equivalent to a 2% increase above current spending. Health (F Bustreo MD), Department of Reproductive Health and Research Introduction (A M Gülmezoglu PhD, Substantial reductions in maternal and child deaths The leading causes of maternal mortality—obstetric M Temmerman PhD, have been achieved worldwide in the last two decades. haemorrhage, hypertensive disorders of pregnancy, sepsis, J P Vogel MBBS), Department of Maternal, Newborn, Child and 14 The global maternal mortality ratio reduced by 47% in and unsafe abortion —are, to a large extent, preventable in Adolescent Health 1990–2010 and the under-5 mortality reduced by 47% in most high-burden countries. Death from these causes can (Elizabeth Mason MSc, 1990–2012.1,2 However, this falls short of the rates of usually be prevented by well equipped health facilities, the Mikael Ostergren MD), World reduction needed by 2015 to achieve the Millennium Health Organization, Geneva, Switzerland; World Health Development Goals (MDGs) 4 and 5. Despite rapid Organization, Phnom Penh, economic growth in many Asian countries, south Asia Key messages Cambodia (H Axelson MSc); The Partnership for Maternal, still accounts for a third of child and maternal mortality • Additional investments of US$5 per person per year in (appendix). Communicable, maternal, neonatal, and Newborn & Child Health, 74 countries, with 95% of the global maternal and child hosted by the World Health nutritional causes account for 25% of deaths and remain mortality burden, would yield high rates of return, Organization dominant causes of premature mortality in sub-Saharan producing up to nine times the economic and social (A de Francisco MD, 3 S Kuruvilla PhD, N Novcic MPhil, Africa. Maternal causes are a signifi cant cause of death benefi t by 2035. for women aged 15–34 years, accounting for 11% of C Presern PhD); SickKids Center • Continuing historical trends of coverage increases is not for Global Child Health, 3 deaths in 2010. suffi cient. Accelerated investments are needed to bring Toronto, ON, Canada, and Sustained global and regional eff orts are being made health benefi ts to the majority of women and children. Center of Excellence in Women & Child Health, The Aga Khan to support countries to accelerate progress, including • Compared with current trends, our accelerated investment the UN Secretary-General’s Global Strategy for University, Karachi, Pakistan scenario estimates that a total of 5 million maternal (Prof Z A Bhutta PhD); The GAVI Women’s and Children’s Health, and the Campaign on deaths, 147 million child deaths, and 32 million stillbirths Alliance, Geneva, Switzerland Accelerated Reduction of Maternal, Newborn and Child can be prevented in 2013–35 in 74 high-burden countries. (P Hansen PhD); Bloomberg Mortality in Africa.4–7 As part of these initiatives, much School of Public Health, Johns • Expanding access to contraception will be a particularly Hopkins University, Baltimore, work has been done to calculate where additional cost-eff ective investment potentially accounting for half MD, USA (N Walker PhD); investment is needed to improve health systems and of all the deaths prevented in the accelerated investment London School of Hygiene and 8,9 service delivery in low-income countries. Our analysis scenario. Tropical Medicine, London, UK builds on this work, with particular focus on the (J E Lawn PhD); The Ministry of • More than a third of the additional costs required are health Health and Family Welfare, substantial social and economic benefi ts that can systems investments that are also required for services Government of India, India accrue when a country invests in the health of its beyond those for reproductive, maternal, newborn, and (A Gupta MBA); Health Section, women and children. child health. An ambitious scale-up would require an UNICEF, UN Plaza, New York, NY, USA (M Chopra MD); UN The investment gaps are well known: insuffi ciently additional 675 000 nurses, doctors, and midwives in 2035, 10 Population Fund, New York, resourced health systems with low coverage of cost- along with 544 000 community health workers. NY, USA (H S Friedman PhD); US 11 eff ective interventions, and poor health information and • The new global investment framework could serve as a Agency for International 12 management systems, making ineffi cient use of limited guide to countries to optimise investments in women’s Development, Washington DC, resources.13 This in turn leads to unacceptably high rates USA (M Koblinsky PhD); Victoria and children’s health within national health and University, Melbourne, VIC, of preventable maternal and child deaths with signifi cant development plans over the next two decades. Australia (B Rasmussen PhD, social and economic losses. www.thelancet.com Published online November 19, 2013 http://dx.doi.org/10.1016/S0140-6736(13)62231-X 1 Health Policy P Sheehan DPhil, K Sweeny PhD); presence of a skilled care provider (even at the lowest level We have undertaken a new analysis that extends the Independent Consultant, of the health system), a functioning referral system, and a earlier work by estimating the eff ects of investment on Canberra, ACT, Australia reliable supply of life-saving commodities. Some services RMNCH across the continuum of care, including family (I Anderson MSc); Indendent Consultant, Cali, Colombia are key interventions to prevent maternal deaths, such as planning, stillbirths, and newborn health (which have (J Tulloch MBBS); University of contraception, antenatal care, skilled birth attendance, not always been included in previous studies). It also Washington, Seattle, WA, USA integrated reproductive health care in the postnatal phase, extends the timeframe to 2035 (this end date was chosen (C Levin PhD, Prof D Jamison PhD); University postnatal care, and a range of services for adolescents and to align our analysis with the The Lancet Commission on of California, San Francisco, CA, women. However, access to them remains low, especially Investing in Health) and analyses the economic and USA (C Boyle MBA) among the poorest in high-burden countries.15 social returns on investment. The fi ndings of this Correspondence to: Health systems investments are also required to prevent analysis will contribute to broader policy dialogue on Karin Stenberg, Department of child mortality. WHO has estimated that 17% of deaths in eff ective health investments, including by being an input Health Systems Governance and children younger than 5 years are due to diseases that can to The Lancet Commission on Investing in Health, which Financing, World Health 16 Organization, Avenue Appia, be prevented by routine, cost-eff ective vaccination. is expected to publish its report in December, 2013. 1211 Geneva, Switzerland Although coverage rates of immunisation are high The analysis provides an updated estimate of the health, [email protected] compared with other maternal and child health inter- social, and economic benefi ts of investing in strengthening ventions, many children still die from easily preventable health systems to deliver RMNCH interventions in 74 low- See Online for appendix diseases, including pneumonia and diarrhoea.17 New income and middle-income countries that account for pneumococcal and rotavirus vaccines now exist to prevent more than 95% of maternal and child deaths. It provides a these disorders. Coverage can be scaled up by strengthening global cost estimate of the level of investment required for existing supply chains and by training health workers to the integrated delivery of a set of evidence-based RMNCH provide integrated care at facilities, and through outreach interventions. In modelling investment needs and health activities to rural communities. Robust health information outcomes, the analysis supports an implementation systems and good management are also needed to ensure approach that factors in equity and the social determinants effi cient and eff ective immunisation coverage. of health—ie, by considering the eff ect of conditional cash High rates of malnutrition underlie more than 45% of transfers on increasing the proportion of women giving all deaths in children younger than 5 years and are a birth in health facilities. While recognising the intrinsic signifi cant factor in maternal mortality.
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