The latest edition of The Lancet – arguably one of the most influential and respected medical journals in the world – has just published a new global investment framework for investing in women’s and children’s health. The (pay-walled) article is available here.
The article is important because it provides a global estimate of the additional costs, and benefits, of investing in affordable, evidence–based interventions in the 74 high burden countries that together account for more than 95% of maternal and child deaths worldwide. Only 23 of these 74 countries are currently on track for achieving Millennium Development Goal (MDG) 4 of reducing child mortality by two thirds between 1990 and 2015. Only 9 of the 74 countries are on track to achieving the MDG goal 5a of reducing by three quarters the maternal mortality ratio by three quarters between 1990 and 2015.
The estimated benefits are significant
Scaling up essential interventions from current levels is estimated to prevent more than 147 million child deaths, 32 million stillbirths and more than five million maternal lives between 2013 and 2035.
Expanded coverage of family planning, in particular, would yield significant benefits. Increasing the use of modern contraceptives to 50% coverage on average across the 74 countries would reduce unintended pregnancies and thereby avert an estimated 54% of the maternal deaths and 47% of child deaths. High rates of socio-economic returns would be realised in low- and middle-income countries.
The estimated additional costs are ultimately affordable
The additional investment required for high coverage of essential interventions reaches US$ 30 billion per year in year 2035, with a cumulative total of US$ 678 billion in 2013-2035 (constant 2011 US dollars). US$174 billion (18%) of the total investment would be required in low-income countries where significant health gains can be made. Excluding China and India reduces the total cost estimate for 2013-2035 by one-third (China and India together account for 21.6% of the global number of maternal deaths and 27.6% of the global number of under-five deaths). On average an extra US$ 4.48 per capita will be needed in 2035, with a range across the 74 countries from US$ 1.2-US$ 112.7. The required additional investment for optimum coverage of health services by 2035 in 35 countries classified as low-income would be equivalent to an additional 6% increase in health expenditure compared to present-day health expenditure per capita.
What needs to be done
The analysis identifies several critical interventions on the demand side and the supply side of health care where international evidence suggests the greatest gains could be made, particularly amongst the poor and vulnerable. High impact investments include expanded immunisation; promotion of breastfeeding and improved nutrition; training and supervising health workers; ensuring that drugs get to rural populations by strengthening the supply chain; better collection of data through improving health information systems; allocating resources to supporting good governance through informed and transparent decision making; and investing in health financing mechanisms that reduce barriers to essential care and protect people from financial distress.
Implications for Australia
There is a major and unfinished development agenda in Australia’s near neighbourhood. In the Asia Pacific region, unacceptably high rates of maternal death prevail. To illustrate, Australia’s Maternal Mortality Ratio is 7 per 100,000 live births. Compare this to Cambodia (250 per 100,000 live births), Indonesia (220), Myanmar (200), Papua New Guinea (230) and Timor Leste (300). Despite progress, these countries also have relatively high levels of otherwise preventable infant and child deaths. Cambodia, Indonesia, Lao PDR, Myanmar, Papua New Guinea, Philippines, Solomon Islands, Timor Leste and Vanuatu are off track on one, or both, of the Millennium Development Goals (MDGs) to reduce maternal and child deaths (MDGs 4 and 5 respectively).
Australia’s aid program can play a critical role in actively helping to make life better for mothers, newborns and children in this region. That is partly because expenditure on health is so low in many of these countries that a small amount of aid funding can make a big difference. Total public expenditure on health is just $US 10 per person in Cambodia, compared to $US 3545 in Australia. It is just $ US 14 in Lao PDR, $US 30 in Indonesia, $US 33 in Timor Leste, and $US43 in PNG. Total public expenditure on health is an appalling $ US 2 per person per year in Myanmar. Money will make a difference in these situations. But so will technical expertise that Australia has in several world class institutions, such as the Burnett Institute, Menzies School of Health Research, and the Centre for International Child Health, University of Melbourne.
As the numbers of maternal and child deaths decline, it becomes increasingly important to be able to identify and track the most marginalized and impoverished populations where mortality is highest. This cannot be accomplished without improving country systems to reliably track and measure births, deaths and causes of death. Improved measurement through civil registration and vital statistics will greatly enhance each country’s – and Australia’s – ability to monitor aid, track mortality change and lives saved, protect human rights, and protect vulnerable populations. (See The Lancet Vol 381 April 13, 2013, Civil Registration and vital statistics – everybody’s business but nobody’s business, Alan Lopez and Jane Thomason, and The Lancet Vol 381 April 27 2013, Offline).
While, as always, sustainable development requires the bulk of the effort to be made by the developing countries themselves, Australian financial, technical, and policy support can be a catalyst for change. The new Global Investment Framework provides evidence based policies that could, and should, be scaled up. Australian assistance to support such change will help set in train favourable social, health, and demographic trends in the countries of our region and avert needless deaths and disability. Reducing death and disability will free up scarce financial and economic resources in countries of our region. All of this is in Australia’s national interest.
Dr. Flavia Bustreo is Assistant Director General, Family and Women’s Health, World Health Organization; Dr Jane Thomason, is an Adviser to WHO, Family and Women’s Health and CEO AbtJTA; Ian Anderson is Director Ian Anderson Economics Pty Ltd and a Research Associate at the Development Policy Centre. Dr Bustreo and Ian Anderson were contributing authors to the Lancet article.
 WHO (2013) World Health Statistics