Child Survival and Maternal Health: U.S. Agency for International Development Programs, FY2001-FY2008

Child Survival and Maternal Health:
U.S. Agency for International Development
Programs, FY2001-FY2008
July 18, 2008
Tiaji Salaam-Blyther
Specialist in Global Health
Foreign Affairs, Defense, and Trade Division



Child Survival and Maternal Health: U.S. Agency for
International Development Programs,
FY2001-FY2008
Summary
Appropriations for child survival and maternal health programs (CS/MH) have
grown by about 22% during the tenure of President George W. Bush. Most of that
growth occurred in FY2008, when Congress provided $521.9 million for CS/MH
programs, up from $361.1 million in FY2001. Although Congress provided support
during this time for other global health initiatives that affect CS/MH, such as some
$19.7 billion for international programs that prevent and treat human
immunodeficiency virus/ acquired immunodeficiency syndrome (HIV/AIDS),
tuberculosis (TB), and malaria, other global health interventions are discussed only
as they relate to USAID’s CS/MH programs.
According to latest estimates, 9.7 million children under the age of five died in
2006; some 26,000 each day. The majority of those deaths occurred in developing
countries, and almost half of them in Africa. On average, nearly 90% of all child
deaths are caused by neonatal infections and five other diseases: acute respiratory
infections (primarily pneumonia), diarrhea, malaria, measles, and HIV/AIDS.
Undernutrition contributes to more than half of these deaths.
More than 500,000 women die each year due to pregnancy-related causes, and
many more suffer debilitating long-term effects, such as obstetric fistula. Most of
these deaths occur in developing countries. About 20% of global maternal deaths are
linked to undernutrition, and about 75% result from obstetric complications, most
often hemorrhage, sepsis, eclampsia, and prolonged or obstructed labor.
While most health experts applaud the recent increase in U.S. commitment to
global health, many remain concerned that funding is largely aimed at specific
diseases, such as HIV/AIDS and malaria. Other health programs that offer life-
saving interventions for women and children are overlooked and underfunded, they
contend, particularly in sub-Saharan Africa. In addition to proposing an increase in
funding for CS/MH programs, some observers urge Congress to boost support for
health systems so that countries can better address a wide range of health issues that
affect child survival and maternal health. This report will be updated at the end of
the 110th Congress.



Contents
In troduction ......................................................1
Child Survival....................................................1
Maternal Health...................................................4
USAID’s Efforts to Improve Child Survival............................10
Child Survival and Undernutrition................................11
Micronutrient Supplementation and Fortification................11
Infant and Young Child Feeding.............................11
Child Survival and Acute Respiratory Infections (Pneumonia)..........12
Child Survival and Malaria.....................................13
Child Survival and HIV/AIDS...................................13
Child Survival and Diarrhea ...................................15
Child Survival and Measles.....................................16
USAID’s Efforts to Improve Maternal and Newborn Health...............17
Maternal Health and Hemorrhage................................17
Maternal Health and Sepsis.....................................18
Maternal Health and Hypertensive Disorders.......................18
Maternal Health and Prolonged or Obstructed Labor.................18
Maternal Health and Unsafe Abortions............................19
Changes in USAID Global Health Appropriations.......................20
FY2001-FY2003 .............................................20
FY2004-FY2008 .............................................21
Issues for Congress...............................................23
Consider Role of Family Planning in Improving Maternal and
Child Health.............................................24
Increase Support for Health System Strengthening and Improve
Donor Coordination.......................................24
Encourage Governments to Increase National Health Budgets..........25
Legislation Introduced in the 110th Congress Related to Maternal and
Child Health.................................................27
List of Figures
Figure 1. USAID Global Health Programs: FY2001-FY2003
(current U.S. $ millions).......................................21
Figure 2. USAID Global Health Programs: FY2004-FY2008
(current U.S. millions).........................................23



Table 1. Key Causes of Death Among Children Younger than Five
Years, 2000..................................................2
Table 2. Millennium Development Goals to Be Achieved by 2015...........3
Table 3. Global Progress in Reducing Child Mortality.....................3
Table 4. Regional and U.S. Maternal Care and Mortality Rates..............6
Table 5. Causes of Maternal Deaths: 1990-2006..........................7
Table 6. Health Worker Density in 68 Priority Countries and the United States.8
Table 7. USAID Global Health Programs: FY2001-FY2003...............20
Table 8. USAID Global Health Programs: FY2004-FY2008...............22



Child Survival and Maternal Health:
U.S. Agency for International Development
Programs, FY2001-FY2008
Introduction
Although a number of U.S. agencies and departments implement global health
programs that might improve child survival and maternal health (CS/MH), this report
focuses only on CS/MH programs conducted by the U.S. Agency for International
Development (USAID) from FY2001 to FY2008. This report also discusses the
interconnected nature of USAID’s global health programs, such as how
advancements made in addressing malaria might improve maternal and child
survival.
Child Survival
In the United Nations Children’s Fund (UNICEF) report The State of the
World’s Children 2008: Child Survival, UNICEF Executive Director Ann Veneman
celebrated the decline of total annual deaths among children under age five. In 2006,
an estimated 9.7 million children in that age range died, representing a 60% drop in
under-five mortality since 1960.1 Despite the decrease, Ms. Veneman asserted that
a critical number of daily deaths among children under five remains high; some
26,000 die each day. Most studies that measure child mortality focus on deaths that
occur before age five because 90% of childhood deaths occur during this time, while

37% occur during the neonatal period (the first 28 days), amounting to about 42


million annual newborn deaths.
The majority of child deaths occur in developing countries, and almost half of
them in Africa. On average, nearly 90% of all child deaths are caused by neonatal
infections and five infectious diseases: acute respiratory infections (mostly
pneumonia), diarrhea, malaria, measles and HIV/AIDS (Table 1). According to
UNICEF, undernutrition is the underlying cause of up to half of these deaths.3


1 UNICEF, The State of the World’s Children 2008: Child Survival, p. 2, at
[http://www.unicef.org/sowc08/report/report.php], visited on February 5, 2008.
2 World Health Organization’s (WHO) website on child health, at [http://www.who.int/
features/factfiles/child_health2/en/index.html], visited on February 5, 2008.
3 UNICEF, The State of the World’s Children 2008: Child Surival, p. 2.

Table 1. Key Causes of Death Among Children Younger than
Five Years, 2000
(% of total deaths)
Infectious DiseasesNon-Infectious Diseases
Total
Acute To t a l No n-
Region Respiratory Diarrheal HIV/ Infectious Neonatal Infectious
Infections M a laria Disea ses AIDS M e a sles Disea ses Causes Injuries Other Disea ses
Africa 21.1 17.5 16.6 6 .8 4.3 66.3 26.2 1 .9 5.6 33.7
Americas 11.6 0 .4 10.1 1 .4 0.1 23.6 43.7 4 .9 27.9 76.5
Southeast Asia18.11.120.10.63.543.444.42.39.956.6
Europe 13.1 0 .5 10.2 0 .2 0.1 24.1 44.3 6 .2 25.4 75.9
East 19.0 2 .9 14.6 0 .4 3.0 39.9 43.4 3 .2 13.5 60.1
Med iter r a nean
Western 13.8 0 .4 12.0 0 .3 0.8 27.3 47.0 7 .3 18.4 72.7
P acific
Global 19.0 8 .0 17.0 3 .0 3.0 50.0 37.0 3 .0 11.0 51.0
Source: World Health Organization (WHO), 2007 World Health Statistics, p. 31.
Note: Figures may not add up to 100% because of rounding.
Some health experts assert that maternal and child health are particularly
important to monitor, because their mortality rates serve as a barometer for overall
health conditions.4 Supporters of this idea often use the Millennium Development
Goals (MDGs) listed in Table 2 to demonstrate the interconnected nature of health
and development and to gauge improvements in child and maternal health (Table 3).5
MDGs 4 and 5 call for a two-thirds reduction in child and maternal mortality. The
ability to reach those goals, however, is affected by progress in other MDGs. For
example, countries with significant undernourished populations (MDG 1) that lack
sufficient access to clean water (MDG 7) tend to have higher maternal and child
mortality rates (MDGs 4 and 5); undernourished women and children are also more
likely to be impoverished (MDG 1) and are more susceptible to infectious diseases,
such as HIV/AIDS, TB, and malaria (MDG 6). UNICEF found that 62 countries
were making no progress towards the Millennium Development Goal on child
survival; nearly 75% of these were in Africa.


4 UNICEF, The State of the World’s Children 2008: Child Survival, p. 2.
5 In September 2000, the United Nations (U.N.) General Assembly adopted the Millennium
Declaration, which committed member states to providing resources to help needy countries
reach eight Millennium Development Goals by 2015. U.N. General Assembly, United
Nations Millennium Declaration, September 18, 2000, at [http://www.un.org/
millennium/declaration/ares552e.pdf], visited on February 5, 2008.

Table 2. Millennium Development Goals to Be Achieved by 2015
MDG 1Eradicate extreme poverty and hunger.
MDG 2Achieve universal primary education.
MDG 3Promote gender equality and empower women.
MDG 4Reduce child mortality by two-thirds.
MDG 5Reduce maternal mortality by two-thirds.
MDG 6Combat HIV/AIDS, malaria, and other diseases.
MDG 7Ensure environmental sustainability (includes halving the proportion of
those without access to clean water).
MDG 8Develop a global partnership for development.
Source: U.N. website on the U.N. Millennium Development Goals, at [http://www.un.org/
millennium/declaration/ares552e.pdf].
Table 3. Global Progress in Reducing Child Mortality
Infant Mortalityab
Ra te U5 M R AARR
Progress# of deaths per 1,000live births# of deaths per1,0000 live birthsObserved%Required %
To w a r dc
RegionMDG 419902006199020061990-20062007-2015
Sub -Sahar a n 95 44 187 160 1.0 10.2 Insufficient
Afr i c a Progress
East and83401651311.49.6Insufficient
So uth Progress
Afr i c a
West and107482081860.711.0No
Ce ntr a l Progress
Afr i c a
Middle East362679463.46.2Insufficient
and NorthProgress
Afr i c a
South Asia6244123832.57.8Insufficient
Progress
East Asia and232055294.05.1On Track
P acific
Latin221555274.24.7On Track
America and
Caribbean
Central and241853274.24.7On Track
East Europe
Industrialized541063.26.6On Track


Co unt r i e s

Infant Mortalityab
Ra te U5 M R AARR
Progress# of deaths per 1,000live births# of deaths per1,0000 live birthsObserved%Required %
To w a r dc
RegionMDG 419902006199020061990-20062007-2015
D e ve l o p i ng 54 33 103 79 1.7 9 .3 Insufficient
Co unt r i e s Progress
W o rld 4 9 3 0 9 3 7 2 1 .6 9.4 I nsufficient
Progress
Source: UNICEF, State of the World’s Children 2008: Child Survival.
a. U5MR — Under-Five Mortality Rate
b. AARR — Average Annual Rate of Reduction in the under-five mortality rate.
c. MDG 4 — Millennium Development Goal 4: to reduce child mortality by two-thirds by 2015.
Notes:
Observed % the rate at which U5MR has fallen from 1990 to 2006.
Required % — the rate at which U5MR must fall in order to cut under-five mortality by two-thirds
by 2015 (MDG 4).
On Track U5MR is less than 40, or U5MR is 40 or more and the observed AARR is 4.0% or more.
Insufficient progress U5MR is 40 or more and the observed AARR is between 1.0% and 3.9%.
No progress U5MR is 40 or more and the observed AARR is less than 1.0%.
Maternal Health
UNICEF asserts that child survival and maternal health are inextricably linked.
More than 500,000 women die each year due to pregnancy-related causes, and an
additional 15-20 million more suffer debilitating long-term effects,6 such as obstetric
fistula (discussed below). The vast majority of women who die during or shortly
after labor live in developing countries where maternal mortality rates are
significantly higher than in industrialized nations (Table 4). The United Nations
Food and Agriculture Organization (FAO) maintains that almost all of these deaths
could be prevented if women in developing countries had access to adequate diets,
safe water and sanitation facilities, basic literacy, and health services during7
pregnancy and childbirth. UNICEF estimates that 20% of all maternal deaths are
linked to undernutrition and that about 75% of maternal deaths are caused by


6 USAID website on maternal health, at [http://www.usaid.gov/our_work/global_health/
mch/mh/index.html], visited on June 23, 2008.
7 FAO, State of Food Insecurity in the World 2005, p. 20, at [http://www.fao.org/docrep/

008/a0200e/a0200e00.htm], visited on February 5, 2008.



obstetric complications including hemorrhage,8 sepsis, hypertensive disorders (mostly
eclampsia), prolonged or obstructed labor, and unsafe abortions.9
Maternal mortality and morbidity rates are generally higher for mothers younger
than 20 years who typically have more pregnancy and delivery complications, such
as toxemia, anemia, premature delivery, prolonged labor, and cervical trauma, and
are at higher risk of delivering low birth weight babies. Pregnancy-related
complications are the leading cause of death among 15- to-19-year-olds around the
world, and their babies have higher morbidity and mortality rates.10 The United
Nations estimates that adolescents give birth to 15 million infants each year. Girls
aged between 15 and 19 years are twice as likely to die from childbirth as women in
their twenties, and those younger than 15 years are five times as likely to die.11 A
survey conducted in Mali indicated that the maternal mortality rate for girls aged
between 15 and 19 years was 178 per 100,000 live births and 32 per 100,000 for
women aged between 20 and 34 years.12


8 Postpartum hemorrhage occurs when the woman bleeds excessively from her uterus after
a baby is delivered. Sepsis is a blood infection that people whose immune systems are
weakened due to illness, such as cancer or HIV/AIDS, are more prone to contract. Infants
may contract the disease from their mothers. Also referred to as toxemia, preeclampsia is
a condition that occurs when a pregnant women has high blood pressure accompanied by
a high level of protein in the urine. Eclampsia occurs when preeclampsia is untreated. In
addition to preeclampsia symptoms, women with eclampsia often have seizures. Eclampsia
can also cause coma or death of the mother and baby before, during, or after childbirth.
9 UNICEF, Countdown to 2015: Maternal, Newborn & Child Survival, 2008, p. 42, at
[ h t t p : / / www.who.i nt / p mn ch/ Count downt o2015FINALREPORT -a pr 7.pdf ]
10 CDC, Family Planning Methods and Practice: Africa, 2001, at [http://www.cdc.gov/
reproductivehealth/Products&Pubs/Africa/Africa_bk.pdf]
11 United Nations, We the Children: End-Decade Review of the Follow-Up to the World
Summit for Children, 2001, at [http://www.unicef.org/specialsession/documentation/
documents/a-s -27-3e.pdf].
12 Too Young to Wed: The Lives, Rights and Health of Young Married Girls. International
Center for Research on Women, 2003. [http://www.icrw.org/docs/tooyoungtowed_1003.pdf]

Table 4. Regional and U.S. Maternal Care and Mortality Rates
PrenatalSkilledMaternalLifetime Risk
CareAttendantInstitutionalMortality Ratioof Maternal
Coverageat DeliveryDelivery(per 100,000)Death, 1 in:
Region 2000-2006 2005
Sub -Sahar a n 69% 43% 36% 920 22
Afr i c a
East and71%40%32%76029
South Africa
West and67%46%39%1,10017
Central Africa
Middle East and72%79%68%210140
North Africa
South Asia65%41%36%50059
East Asia and89%87%69%150350
P acific
Latin America and94%n/a86%130280
Caribbean
Industrialized n/a 99% n/a 8 8,000
Co unt r i e s
D e ve l o p i ng 75% 59% 53% 450 76
Co unt r i e s
Least Developed61%38%27%87024
Co unt r i e s
United Statesn/a99%n/a114,800
World 75% 63% 53% 400 92
Source: Compiled by CRS from UNICEF, State of the World’s Children 2008: Child Survival.
Causes of maternal death vary significantly among regions. Data collected from
1990 through 2006 indicate that hemorrhage caused about 34% and 31% of maternal
deaths in Africa and Asia, respectively. In industrialized nations and Latin America
and the Caribbean, hemorrhage caused an estimated 13% and 21% of maternal
deaths, respectively (Table 5). The United Nations has found that regions with the
lowest proportions of skilled health attendants at birth also have the highest maternal
mortality rates.13 In sub-Saharan Africa, 43% of women gave birth with the
assistance of a skilled birth attendant, 65% in south Asia, and 99% in industrialized
nations. One in every 22 women in sub-Saharan Africa will likely die from
pregnancy-related causes, as will one in every 59 Asian women. In industrialized
nations, meanwhile, one in every 8,000 woman faces the probability of dying from
pregnancy-related causes.


13 United Nations, The Millennium Development Goals Report: 2007, at [http://www.un.org/
millenniumgoals/pdf/mdg2007.pdf].

Table 5. Causes of Maternal Deaths: 1990-2006
DevelopedLatin America and
Cause of DeathCountriesAfricaAsiathe Caribbean
Number of Maternal
Deaths 2,823 4,508 16,089 11,777
Hemo rrhage 13.4% 33.9% 30.8% 20.8%
Hyp e rtensive
Diso rders 16.1% 9.1% 9.1% 25.7%
Sepsis/Infectio ns 2.1% 9.7% 11.6% 7.7%
Abortio n 8 .2% 3 .9% 5 .7% 12.0%
Obstructed Labor0.0%4.1%9.4%13.4%
Anemia 0.0% 3.7% 12.8% 0.1%
HIV/AIDS 0.0% 6.2% 0.0% 0.0%
Ectopic Pregnancy4.9%0.5%0.1%0.5%
Other 55.3% 28.9% 20.5% 19.8%
Source: Khalid Khan et al., “WHO Analysis of Causes of Maternal Death: A Systematic Review,”
Lancet.
UNICEF has found that health systems in many countries do not have the
capacity to reduce mortality nationwide.14 Of the 68 priority countries that account
for 97% of all maternal and child deaths, 54 (80%) have health workforce densities
below the critical threshold (2.5 health workers per 1,000 people) for significantly
improving their health conditions and reaching the health-related MDGs (Table 6).
South Africa and Swaziland are the only two sub-Saharan African countries among
the 68 priority countries that have reached the minimum standard. Child and maternal
survival rates are higher in areas with ample numbers of health workers to administer
immunizations, easy access to clean water, controlled mosquito populations, and
sufficient access to nutritious food.15
While the greatest shortage of health care workers in absolute terms is in
southeast Asia (mostly in Bangladesh, India, and Indonesia), sub-Saharan Africa
suffers from the greatest proportional shortage of health care workers in the world.16
WHO estimates that there are 57 countries with critical shortages of health care
workers, of which 36 are in Africa and none in industrialized nations. Globally,
WHO estimates that an additional 4.3 million health workers are needed, and that on
average, countries across Africa would need to increase their number of health
workers by about 140% in order to meet the minimum threshold of 2.5 health care
professionals per 1,000 people.


14 UNICEF, Countdown to 2015: Maternal, Newborn & Child Survival, 2008, p. vii.
15 Laurie Garrett, “The Challenge of Global Health,” Foreign Affairs, New York: Jan/Feb

2007, Vol. 86, Issue 1, at [http://www.foreignaffairs.org/20070101faessay86103/laurie-


garrett/the-challenge-of- global-health.html], visited on February 5, 2008.
16 WHO, 2006 World Health Report, p. 12, at [http://www.who.int/whr/2006/en/].

Table 6. Health Worker Density in 68 Priority Countries and the
United States
Phy sicia ns Nurses
Level ofProgress Number
MaternalToward Number perper
MortalityMDG 4Number1,000Number1,000
Country1997-20042005Since 1990
Afghanistan4,1040.194,7520.22Very HighNo progress
Angola8810.0813,1351.15Very HighNo progress
Azerbaij an 29,687 3.55 59,531 7.11 Lo w Insuf f i c i e n t
Bangladesh38,4850.2620,3340.14Very HighOn track
Benin3110.045,7890.84Very HighInsufficient
Bolivia10,3291.2227,0633.19ModerateOn track
Botswana7150.404,7532.65HighNo progress
Brazil198,1531.15659,1113.84ModerateOn Track
Burkina Faso7890.065,5180.41Very HighNo Progress
Burma 17,791 0.36 19,254 0.38 H i g h Insuf f i c i e n t
Burundi2000.031,3480.19Very HighNo progress
Cambodia 2 ,047 0.16 8,085 0.61 H i g h Insuf f i c i e n t
Cameroon3,1240.1926,0421.60HighNo progress
Central3310.081,1880.30Very HighNo progress
African
Republic
Chad3450.042,3870.27Very HighNo progress
China1,364,0001.061,358,0001.05LowOn track
Congo7560.203,6720.96Very HighNo progress
Dem.5,8270.1128,7890.53Very HighNo progress
Republic of
Co ngo
Cote d’Ivoire2,0810.1210,1800.60Very HighInsufficient
Djibouti1290.182570.36Very HighInsufficient
Egypt38,4850.54146,7612.00ModerateOn track
Equatorial1530.302280.45Very HighNo progress
Guinea
Eritrea2150.052,5050.58HighOn track
Ethiopia1,9360.0314,8930.21Very HighInsufficient
Gabon3950.296,9745.16HighNo progress
Gambia1560.111,7191.21Very HighInsufficient
Ghana3,2400.1519,7070.92Very HighNo progress
Guatemala9,9650.9044,9864.05ModerateOn track



Phy sicia ns Nurses
Level ofProgress Number
MaternalToward Number perper
MortalityMDG 4Number1,000Number1,000
Country1997-20042005Since 1990
Guinea9870.114,7570.55Very HighInsufficient
Guinea1880.121,0370.67Very HighInsufficient
B i ssa u
Haiti1,9490.258340.11Very HighOn track
India 645,825 0.60 865,135 0.80 H i g h Insuf f i c i e n t
Indonesia29,4990.13135,7050.62HighOn track
Iraq17,0220.6632,3041.25HighNo progress
Kenya4,5060.1437,1131.14Very HighNo progress
Korea75,0451.5783,3331.75HighNo progress
Laos2,8120.594,9311.03Very HighOn track
Lesotho890.051,1230.62Very HighNo progress
Liberia1030.036130.18Very HighNo progress
Madagascar 5,201 0.29 5,661 0.32 H i g h Insuf f i c i e n t
Malawi2660.027,2640.59Very HighInsufficient
Mali1,0530.086,5380.49Very HighNo progress
Mauritania3130.111,8930.64Very HighNo progress
Mexico195,8971.9888,6780.90LowOn track
Morocco15,9910.5124,3280.78ModerateOn track
Mozambique 514 0.03 3,954 0.21 H i g h Insuf f i c i e n t
Nepal5,3840.215,6640.22Very HighOn track
Niger3770.032,7160.22Very HighInsufficient
Nigeria34,9230.28210,3061.70Very HighInsufficient
Pakistan 116,298 0.74 71,764 0.46 H i g h Insuf f i c i e n t
Papua New2750.052,8410.53HighInsufficient
Guinea
Peru29,7991.1717,1080.67ModerateOn track
Philippines44,2870.58127,5951.69ModerateOn track
Rwanda4010.053,5930.42Very HighNo progress
Senegal5940.063,2870.32Very HighInsufficient
Sierra Leone1680.031,8410.36Very HighNo progress
Somalia3100.041,4860.19Very HighInsufficient
South Africa34,8290.77184,4594.08HighNo progress
Sudan 7 ,552 0.22 28,704 0.84 H i g h Insuf f i c i e n t
Swaziland 12,697 2.03 28,586 4.58 High Insufficient



Phy sicia ns Nurses
Level ofProgress Number
MaternalToward Number perper
MortalityMDG 4Number1,000Number1,000
Country1997-20042005Since 1990
Tajikistan 12,697 2.03 28,586 4.58 Moderate Insuf f i c i e n t
Tanzania8220.0213,2920.37Very HighInsufficient
T o go 225 0.04 2,141 0.43 H i g h Insuf f i c i e n t
Turkmenistan20,0324.1843,3599.04ModerateOn track
Uganda2,2090.0816,2210.61Very HighInsufficient
Yemen 6 ,739 0.33 13,506 0.65 H i g h Insuf f i c i e n t
Zambia1,2640.1219,0141.74Very HighNo progress
Zimbabwe2,0860.169,3570.72Very HighNo progress
United States730,8012.562,669,6039.37notnot
applicable applicable
Source: WHO, 2006 World Health Report: Working Together for Health, at
[ h t t p : / / www. wh o . i n t / wh r / 2006/en/].
Notes: Bolded text in the Physicians and Nurses columns indicates countries have the minimum
number (2.5) of health workers per 1,000 people. In some cases, the combined total of physicians and
nurses enable countries to reach the threshold, with nurses significantly outnumbering doctors.
Bolded text in the Level of Maternal Mortality and Progress Towards MDG4 columns reflects those
countries that havehigh orvery high maternal mortality rates and/or have madeno progress” or
insufficient” progress towards reducing the under-five mortality rate by two-thirds by 2015 (MDG
4). In most cases, those with at least 2.5 health workers per 1,000 people have moderate or low
maternal mortality rates and/or are on track to reach MDG 4.
USAID’s Efforts to Improve Child Survival
The U.S. Agency for International Development is the lead U.S. agency
responsible for improving child survival around the world. According to USAID,
research that it supported during the 1970s and 1980s has been used to develop17
interventions and technologies now used to save millions of children. Over the past

20 years, USAID has committed more than $6 billion in support of global child18


survival efforts. About half of those funds were committed from FY2001-FY2008,
when Congress appropriated $3.4 billion to child survival and maternal health efforts.
Recognizing that six health problems (acute respiratory infections, diarrhea,
malaria, HIV/AIDS, measles, neonatal complications) cause about 90% of all child
deaths in developing countries and that undernutrition contributes to half of these,


17 See USAID website on maternal and child health at [http://www.usaid.gov/our_work/
global_health/mch/ch/techareas/ddcontrol_brief.html], visited on February 7, 2008.
18 See USAID’s website on child health at [http://www.usaid.gov/our_work/global_health/
mch/ch/index.html], visited on February 7, 2008.

USAID allocates a significant proportion of its child survival funds to addressing
these health issues.19 This section summarizes information USAID has presented
about its efforts to improve child and maternal health.
Child Survival and Undernutrition
The United Nations Food and Agriculture Organization (FAO) argues that the
vast majority of the nearly 10 million children who die each year “would not die if
their bodies and immune systems had not been weakened by hunger and
malnutrition.”20 Ten WHO-supported community-based studies conducted from
1991 through 2001 of children under age five found that children who are mildly
underweight are about twice as likely to die of infectious diseases as children who
are better nourished; for those who are moderately to severely underweight, the risk
of death is five to eight times higher.21 The studies also indicated that 45% of
children who died after contracting measles were malnourished, as were more than

60% of children who died after the onset of severe diarrhea.


Good nutrition can improve child survival, health, and cognitive development,
while undernutrition impairs the immune system.22 Children with impaired immune
systems disproportionately suffer from common childhood illnesses such as diarrhea,
pneumonia, and measles. Undernourished children have also been found to be more
susceptible to other infectious diseases such as malaria and tuberculosis. This section
discusses USAID’s nutrition programs, which focus on micronutrient
supplementation and fortification and infant and young child feeding (IYCF).
Micronutrient Supplementation and Fortification. “USAID-supported
micronutrient programs add vital immune-building micronutrients including zinc,23
vitamin A, iron, and iodine to processed foods such as rice and sugar.” USAID
funds are also used to expand research on biofortified crops, which could improve
the micronutrient content of basic foods, such as maize enhanced with vitamin A,
iron, and zinc; beans enhanced with iron and zinc; and sweet potatoes enhanced with
vitamin A. Micronutrient supplementation and other USAID nutrition programs are
integrated with other interventions, including safe water, hygiene and sanitation.
Infant and Young Child Feeding. USAID estimates that more than “two-
thirds of malnutrition-related infant and child deaths are associated with poor feeding


19 See USAID’s website on child survival at [http://www.usaid.gov/our_work/global_health/
mch/ch/index.html], visited on February 13, 2008.
20 FAO, State of Food Insecurity in the World 2005, p. 18, at [http://www.fao.org/docrep/

008/a0200e/a0200e00.htm], visited on February 5, 2008.


21 WHO, Comparative Quantification of Health Risks, 2004, p. 108, at [http://www.who.int/
publications/cra/chapters/volume1/0039-0162.pdf].
22 Information in this paragraph was summarized by CRS from USAID’s website on
nutrition, at [http://www.usaid.gov/our_work/global_health/nut/]
23 Information on USAID’s micronutrient efforts was compiled by CRS from USAID’s
website on nutrition, at [http://www.usaid.gov/our_work/global_health/nut/], visited on
February 13, 2008.

practices during the first two years of life.”24 According to USAID, “less than one
third of infants in most countries are exclusively breastfed during the first six months
of life.” Early cessation of breastfeeding and introducing foods either too early or too
late expose infants to disease. USAID contends that the foods that are introduced are
often nutritionally inadequate and unsafe. One USAID-supported study showed that
“exclusively breastfed infants have 2.5 times fewer episodes of childhood diseases,
are four times less likely to die of acute respiratory infection, and are up to 25 times
less likely to die of diarrheal diseases.” The study also indicated that continued
breastfeeding during acute episodes of diarrhea protects infants from loss of energy
and protein during illness. In communities affected by HIV/AIDS, USAID works
with its implementation partners to integrate safe infant feeding practices with
programs that prevent mother-to-child HIV transmission (PMTCT). USAID spends
about $30 million each year on nutrition programs, which include Vitamin A, iodine,
food fortification, anemia packages, and zinc.25
Child Survival and Acute Respiratory Infections (Pneumonia)
UNICEF asserts that pneumonia can be largely prevented if indoor pollution is
minimized and if children are adequately nourished, exclusively breastfed, and
receive Vitamin A and zinc supplements (as necessary).26 Children should also
receive the full series of immunizations against infections that directly cause
pneumonia, such as Haemophilus influenzae type b (Hib), and those that can lead to
pneumonia as a complication (e.g., pertussis). International health organizations also
seek to expand access to vaccines that protect against Streptococcus pneumoniae, the
most common cause of severe pneumonia among children in the developing world.
USAID reports that since 2002, it has supported the administration of
immunizations to almost 500 million children and the treatment of more than 375
million cases of child pneumonia.27 In the mid-1990s, UNICEF and WHO developed
the Integrated Management of Childhood Illness (IMCI) with USAID support. The
strategy integrates interventions for diarrhea, acute respiratory infections,
malnutrition, and malaria. In recent years, USAID has expanded the IMCI strategy.28


24 Information in this paragraph was summarized by CRS from USAID’s website on IYCF,
at [http://www.usaid.gov/our_work/global_health/nut/techareas/childfeeding.html], visited
on February 13, 2008.
25 Remarks by Kent Hill, Assistant Administrator, Bureau for Global Health at the launch
of the Lancet’s Series on Maternal and Child Under-Nutrition, January 16, 2008. See
[http://www.usaid.gov/press/speeches/2008/sp080116.html], visited on June 23, 2008.
26 See UNICEF, “UNICEF Welcomes Spotlight on a Major Cause of Childhood Deaths in
Latest WHO Bulletin,” May 1, 2008, at [http://www.unicef.org/media/media_43753.html],
visited on July 21, 2008.
27 USAID, “Investing in People,” May 31, 2007, Fact Sheet, at [http://www.usaid.gov/press/
factsheets/2007/fs070531_1.html], visited on February 7, 2008.
28 USAID website on Integrated Management of Childhood Illnesses (IMCI), at
[http://www.usaid.gov/our_work/global_health/mch/ch/techareas/imci.html], visited on
February 7, 2008.

Child Survival and Malaria
Approximately 40% of the world’s population, mostly those living in the
world’s poorest countries, are at risk of malaria. Every year, more than 500 million
people become severely ill with malaria. Most cases, and most deaths, are in sub-
Saharan Africa, though Asia, Latin America, the Middle East, and parts of Europe
are also affected. The disease is particularly deadly for children; at least 1 million
infants and children under age five in sub-Saharan Africa die each year from malaria
— approximately one every 30 seconds.
USAID has been engaged in malaria eradication efforts since the 1950s. In
2005, the President proposed the President’s Malaria Initiative (PMI), an interagency
effort that aims to increase support for U.S. international malaria programs by more
than $1.2 billion from FY2006 through FY2010 in 15 targeted countries and reduce
the number of malaria deaths by 50% in those countries by 2010.29 USAID
coordinates all PMI activities, which are implemented in partnership with the Centers
for Disease Control and Prevention (CDC) of the Department of Health and Human
Services (HHS). Advancements made under the initiative are not reported by agency,
thus it is not possible to distinguish USAID’s contributions to U.S. anti-malarial
programs.
In January 2008, USAID reported that in its first year, PMI reached more than
6 million people and within two years, reached more than 25 million.30 Activities
included
!indoor residual spraying in 10 PMI countries, benefitting more than

17 million people;


!procuring and distributing more than 4.7 million long lasting
insecticide-treated nets (LLITNs) and retreating more than 1.1
million insecticide-treated nets (ITNs);
!procuring 12.6 million malarial treatments, including the distribution
of 6.2 million;
!training more than 28,000 health workers in the correct use of
malarial treatment; and
!purchasing more than 4 million anti-malarial tablets to reduce the
impact of malaria in pregnancy.
Child Survival and HIV/AIDS
HIV/AIDS is preventable and treatable, but not curable. Most of the 420,000
children who acquired HIV in 2007 contracted the virus from their HIV-infected31
mothers during pregnancy, birth, or breastfeeding. With successful interventions


29 For more information on PMI see [http://www.fightingmalaria.gov/].
30 USAID, “The President’s Malaria Initiative,” January 2008, Fact Sheet, at
[http://www.fightingmalaria.gov/resources/pmi_fastfacts.pdf], visited on February 8, 2008.
31 WHO’s website on the prevention of mother-to-child HIV transmission (PMTCT) at
(continued...)

the risk of mother-to-child HIV transmission can be reduced to 2%. About 33% of
HIV-positive pregnant women in most resource-limited countries — where the
burden of HIV is highest — receive drugs that can prevent mother-to-child HIV
transmission (PMTCT).32 Nevirapine, a drug widely used to prevent mother-to-child
HIV transmission, costs between $0.29 and $0.40 per dose.33 A Nevirapine tablet is
taken by the mother at the onset of labor and Nevirapine syrup is given to the infant
within 72 hours of birth.34
WHO asserts that it is critical that children are diagnosed early and provided
with antiretroviral therapy (ART) as early as possible, as the course of HIV infection
is faster and more aggressive in children. The cost of ART is significantly higher for
children than for adults. UNAIDS estimates that an annual supply of generic ARTs
costs about $260 per child, while the same regimen for adults costs about $183.35
Fixed-dosed treatments, in which two or three different drugs are combined in a
single pill, have proved to be most effective, though they are more expensive for
children. In 2005, a one-year supply of a standard three-drug regimen for an adult
costs an average of $148 in low-income countries, but the regimen for children cost
$2,000 per child and $800 for a generic version. The Clinton Foundation, however,
was able to negotiate with pharmaceutical companies to charge lower prices for
pediatric ARTs in its programs — about $0.16 per day or $60 per year.36
Health experts point out that ART is not the only treatment that can be used to
reduce child mortality among HIV-positive children. Treatment of opportunistic
infections, such as pneumonia, can also improve child survival among HIV-positive
children. Cotrimoxazole — a drug used to treat pneumonia — has been found to
reduce mortality in children with HIV/AIDS by about 30% and costs about $0.03 per
day or $10 per year. It is estimated that only 10% of the 4 million children who need
the drug are receiving it.37


31 (...continued)
[http://www.who.int/hiv/mtct/en/index.html], visited on February 8, 2008.
32 WHO, UNAIDS, and UNICEF, Towards Universal Access: Scaling Up Priority
HIV/AIDS Interventions in the Health Sector, 2008, p. 7, at [http://www.who.int/hiv/pub/
towards_universal_access_report_2008.pdf].
33 USAID and Partners for Health Reformplus, Costing Nevirapine Delivery to Infants: A
Zambian Case Study, August 2004, p. 9, at [http://www.who.int/hiv/amds/countries/
zmb_CostingNevirapineDeliveryInfants.pdf], visited on June 10, 2008.
34 USAID and Path, The Nevirapine Infant-Dose Pouch for Use in Prevention of Mother-to-
Child Transmission of HIV/AIDS Programs, August 2006, p. 2, at [http://www.path.org/
files/T S_NV P_sourcing_guide.pdf].
35 Ibid.
36 Clinton Foundation, “President Clinton Announces Breakthroughs in HIV/AIDS
Treatment for Children,” November 30, 2006, press release, at
[ h t t p : / / www.cl i n t onf oundat i on.or g/ 113006-nr -c f -hs-a i -i nd-pr -wj c -a nnounces-
breakthroughs-in-hiv-aids-treatment-for-children.htm], visited on February 8, 2008.
37 Ibid.

USAID reports that since 1986, it has spent $6 billion on HIV/AIDS
interventions in more than 100 countries.38 Since the inception of the President’s
Emergency Plan for AIDS Relief (PEPFAR), USAID stopped reporting its projects’
outcomes. Instead all participating agency and department outcomes are reported as
PEPFAR advancements. Through September 2007, PEPFAR implementing agencies
and departments have provided more than $289.2 million to initiatives that have
offered care and support to some 2.7 million orphans and vulnerable children
(OVC).39 PEPFAR’s food and nutrition programs reached some 332,000 OVC,
50,000 pregnant or lactating women, and an additional 20,000 severely malnourished
individuals who were on ART. PEPFAR’s child-focus programs support training for
those who care for OVC, promote the use of time- and labor-saving technologies,
support income-generating activities, and connect children and families to essential
health care and other basic social services.
The Administration asserts that support for people living with HIV/AIDS who
receive treatment, care, and support services should also be considered when
analyzing support for children, as HIV-infected adults receiving support are better
able to provide a nurturing, protective environment for their children. Through
September 2007, PEPFAR has committed some $1.5 billion for programs that offer
care and support to people living with HIV/AIDS.
In FY2006 and FY2007, PEPFAR partnerships dedicated nearly $191.5 million
to pediatric treatment for some 85,900 children and from FY2004 through FY2007,
PEPFAR-implementing agencies supported PMTCT services for women during more
than 10 million pregnancies. PMTCT services included the provision of ART to
HIV-positive women in over 827,000 pregnancies, preventing an estimated 157,000
infant HIV infections.
Child Survival and Diarrhea
Through research, UNICEF, WHO, and USAID found that diarrhea could be
prevented and treated with Oral Rehydration Salts (ORS) and fluids, breastfeeding,
continued feeding, and selective use of antibiotics and zinc supplementation for 10-
14 days.40 USAID reports that since 2002, it has provided more than $1.5 billion in
support of the treatment of almost 5 billion episodes of child diarrhea with lifesaving


38 USAID’s website on HIV/AIDS, at [http://www.usaid.gov/our_work/global_health/aids/],
visited on March 6, 2008. From FY2004-F72008, PEPFAR participating agencies and
departments spent $19.7 billion on global HIV/AIDS, tuberculosis, and malaria programs.
For more information on PEPFAR, see CRS Report RL33771, Trends in U.S. Global AIDS
Spending: FY2000-FY2008, and CRS Report RL34192, PEPFAR: From Emergency to
Sustainability, both by Tiaji Salaam-Blyther.
39 PEPFAR-related outcomes were compiled by CRS from the Office of Global AIDS
Coordinator, The Power of Partnerships: The U.S. President’s Emergency Plan for AIDS
Relief Fourth Annual Report to Congress, p. 8, 2008, at [http://www.pepfar.gov/
documents/organization/100029.pdf], visited on February 12, 2008.
40 WHO/UNICEF, “Clinical Management of Acute Diarrhea,” Joint Statement, at
[ ht t p: / / www.af r o . w ho.i nt / cah/ document s / i nt e r vent i on/ acut e _di ar r hoea_j oi nt _st at ement .pdf ]

ORS.41 USAID also controls diarrheal disease by training health workers, promoting
breastfeeding, applying social marketing and modern communication techniques, and
expanding community capacity to administer ORS.
USAID’s anti-diarrhea programs also focus on hygiene, which plays a
significant role in the transmission of diarrhea. USAID estimates that handwashing
with soap can decrease diarrhea prevalence among children by 42% to 46%.42 While
soap is found in most households, USAID contends that handwashing with soap is
not common in poorer communities and that soap is usually reserved for bathing or
washing clothes and dishes. In one USAID-supported study, 1% of mothers in
Burkina Faso used soap to wash their hands after using the toilet and 18% after
cleaning a child’s bottom.43 In slums in Lucknow, India, 13% of mothers were
observed using soap after cleaning up a child and 20% after going outside to
defecate. USAID supports public-private partnerships that promote handwashing
with soap and other hygienic practices, such as safe storage and treatment of water,
which can reduce diarrhea prevalence by 30% to 40%.
Child Survival and Measles
WHO asserts that measles immunization is one of the most cost-effective public
health interventions available for preventing childhood deaths and that it carries the
highest health return for the money spent, saving more lives per unit cost than any
other health intervention.44 The vaccine, injection equipment and operational costs
amount to less than $1 per dose. The vaccine, which has been available for more
than 40 years, costs about $0.33 per bundled dose (vaccine plus safe injection
equipment) if bought through UNICEF. In many countries where the public health
burden of rubella and/or mumps is considered to be important, the measles vaccine
is often incorporated with rubella and/or mumps vaccines as a combined, live-
attenuated (weakened) measles-rubella (MR) or measles-mumps-rubella (MMR)
vaccine. If bought through UNICEF, a MR vaccine costs about $0.65 per bundled
dose, and MMR costs about $1.04 to $1.50 per bundled dose.
Immunization coverage rates for measles vaccination vary significantly by
region. WHO and UNICEF estimate that in 2006 about 80% of all children were
vaccinated, up from 72% in 2000. From 2000 to 2006, an estimated 478 million
children from nine months to 14 years of age received measles vaccinations through
supplementary immunization activities in 46 out of the 47 priority countries with the


41 USAID, “Investing in People.” May 31, 2007, Fact Sheet, at [http://www.usaid.gov/press/
factsheets/2007/fs070531_1.html], visited on February 7, 2008.
42 USAID website on hygiene improvement interventions, at [http://www.usaid.gov/
our_work/global_health/eh/techareas/improvement_interventions.html], visited on February

12, 2008.


43 USAID website on optimal handwashing, at [http://www.usaid.gov/our_work/global_
health/eh/techareas/handwashing.html], visited on February 12, 2008.
44 Information in this section was compiled by CRS from WHO, “Measles,” November
2007, Fact Sheet, at [http://www.who.int/mediacentre/factsheets/fs286/en/], visited on
February 8, 2008.

highest burden of measles. These accelerated activities have resulted in a significant
reduction in global measles deaths. Overall, global measles mortality decreased by
68% between 2000 and 2006. The largest gains occurred in Africa, where measles
cases and deaths fell by 91%.
USAID does not indicate how it specifically addresses measles, though it asserts
that immunization programs are one of its greatest public health success stories.45
USAID-supported immunization programs “train health workers; strengthen planning
capacity; and improve the quality of service delivery and vaccine administration” in
more than 100 countries. USAID also partners with others, such as Global Alliance
for Vaccines and Immunization (GAVI), the Vaccine Fund, and the Bill and Melinda
Gates Foundation to bolster countries’ capacity to administer vaccines.
USAID’s Efforts to Improve Maternal and
Newborn Health46
USAID’s maternal health programs seek to ensure healthy pregnancy outcomes
in low-resource environments through a wide range of interventions, including
nutritional supplementation for mothers, treatment for parasitic worms that disrupt
nutrient absorption, tetanus toxoid immunizations, prevention of mother-to-child
HIV transmission, intermittent treatment for malaria, and detection and treatment of
syphilis.
USAID advocates that families plan for all births to be attended by a skilled
birth attendant and that communities develop contingency plans for accessing
emergency obstetric care for mothers who deliver at home — the preferred method
in many cultures. USAID trains birth attendants to avert infant deaths by facilitating
infant breathing, resuscitating, and caring for the infant in the event of birth asphyxia;
ensuring hygienic cord and eye care; and encouraging immediate breastfeeding.
Community-based maternal health interventions include teaching families and
communities to recognize birth complications and where to bring a mother for
emergency care, identifying transportation to a hospital ahead of time, identifying a
blood donor for the mother, and creating a savings plan for health care costs. This
section discusses how USAID reports it addresses key causes of maternal mortality.
Maternal Health and Hemorrhage
USAID estimates that 32% of all maternal deaths are caused by postpartum47
hemorrhage. Low-cost interventions can prevent and treat the condition. In order


45 Information in this paragraph was summarized by CRS from USAID’s website on
immunizations, at [http://www.usaid.gov/our_work/global_health/mch/ch/techareas/
immunization.html], visited on June 23, 2008.
46 Unless otherwise indicated, this section was written in conjunction with USAID officials.
47 Khalid S. Khan et al., “WHO Analysis of Causes of Maternal Death: A Systematic
Review,” The Lancet, April 1, 2006, volume 367, at [http://www.thelancet.com/journals/

to avert postpartum hemorrhage deaths, USAID urges communities to ensure that all
mothers give birth in the presence of a trained health care practitioner who can
administer drugs that slow or stop the bleeding and apply other life-saving techniques
to prevent and treat postpartum hemorrhage. USAID-supported programs train birth
attendants to actively manage the third stage of labor, which includes controlled
traction of the umbilical cord, uterine massage, and the use of oxytocin — a drug that
slows the flow of blood. USAID reports that this intervention can prevent 60% of
hemorrhages.
Maternal Health and Sepsis
On average, sepsis or other infections cause nearly 10% of all maternal deaths
in Africa, Asia, Latin America, and the Caribbean.48 A number of factors contribute
to this problem. A USAID-supported study identified unhygienic delivery practices
as a key cause of the affliction. Common practices such as introducing unclean
hands, local herbs, or cloths inside the vagina during or after delivery and delivering
in unclean conditions all contribute to sepsis. In addition, untrained delivery
attendants might also use unclean instruments to cut the umbilical cord. USAID
supports efforts to distribute delivery kits and ensure the presence of a trained
delivery attendant at each birth to prevent mothers and babies from contracting
sepsis.49 In addition, USAID trains birth attendants to identify signs of infection and
to use antibiotics and other measures, where necessary.
Maternal Health and Hypertensive Disorders
Hypertensive disorders cause about 9% of maternal deaths in Africa and Asia
and nearly 26% of maternal deaths in Latin America and the Caribbean. USAID
trains health care providers to recognize the signs and symptoms of pre-eclampsia
(high blood pressure and proteinuria) and of eclampsia (convulsions) and to treat
mothers with anti-convulsant drugs and supportive care.
Maternal Health and Prolonged or Obstructed Labor
A mother might experience prolonged or obstructed labor if she is unable to
deliver her baby for any number of reasons, including the position of the baby, the
direction in which the baby faces, or if the baby’s head can not fit through the
mother’s pelvis. If the delivery complication is not resolved, the baby may die or the
mother and/or baby can suffer life-long debilities. Obstetric fistula is one of the most
common consequences of prolonged or obstructed labor for pregnant women in low-
resource settings.50


47 (...continued)
lancet/article/PIIS0140673606683979/fulltext].
48 Ibid.
49 WHO, Improving Neonatal Health in South-East Asia Region, April 2002, at
[http://pdf.usaid.gov/ pdf_docs/PNACR332.pdf].
50 Obstetric fistula occurs mostly when the mother can not deliver the baby after laboring
(continued...)

Young girls and women who were stunted due to undernourishment, and who
live in areas without obstetric care, are more likely to develop obstetric fistula
because of their underdeveloped pelvic regions. In Kenya, one study found that 45%
of all fistula cases were among adolescents.51 Obstetric fistula can be prevented by
delaying pregnancy until the girl’s pelvic region is fully developed, ensuring that
women have ready access to emergency obstetric care in the case of prolonged labor,
and removing the fetus through a caesarean surgery when needed.
USAID reports that it has supported fistula prevention programs since 1989 and
repair programs since 2005. Obstetric fistula prevention programs are commonly
integrated with other programs that address the major causes of maternal death and
disability. Key activities include increasing access for women to emergency
obstetrical care, encouraging the postponement of child marriage and sexual debut,
training families and community health practitioners to identify the signs of
prolonged or obstructed labor, increasing access for women to emergency obstetrical
care, and reducing stigma about obstetric fistula.52
Maternal Health and Unsafe Abortions
WHO estimates that complications due to unsafe abortion procedures account
for 13% of maternal deaths worldwide, amounting to 67,000 deaths each year.53
There are significant regional variations, however. In Latin America and the
Caribbean, the practice accounts for 12% of maternal deaths on average, while in
Africa, about 4% of women die after attempting an unsafe abortion.54 USAID reports
that its international family planning programs help to avoid these deaths and that it
has helped to avert an estimated 4 million maternal deaths over the last 20 years.


50 (...continued)
for two or more days. Pressure from the baby’s head can interrupt blood flow to tissues in
the pelvic area and, without intervention, the baby dies. The mother then passes the smaller,
decomposed body. After pushing for a number of days a hole develops in the tissue between
the vagina and bladder (and at times the rectum), causing incontinence. Fistula survivors
may also suffer nerve damage, which can make walking difficult. Fistula survivors are often
stigmatized and usually shunned due to their strong odor. For more information on obstetric
fistula, see CRS Report RS21773, Reproductive Health Problems in the World: Obstetric
Fistula: Background Information and Responses, by Tiaji Salaam-Blyther.
51 CDC, Family Planning Methods and Practice: Africa, 1999, at [http://www.cdc.gov/
reproductivehealth/Products&Pubs/Africa/preface.pdf], visited on June 9, 2008.
52 Information in this paragraph was compiled by CRS from USAID, USAID Bureau for
Global Health Fistula Strategy: FY2003-FY2008, at [http://www.usaid.gov/our_work/
global_health/mch/mh/fistula_strategy.doc], visited on June 24, 2008.
53 WHO, Facts on Induced Abortion Worldwide, October 2007, at [http://www.who.int/
reproductive-health/unsafe_abortion/induced_abortion_worldwide.pdf], visited on June 9,

2008.


54 Khalid S. Khan et al, “WHO Analysis of Causes of Maternal Death: A Systematic
Review,” The Lancet, April 1, 2006, volume 367.

Changes in USAID Global Health Appropriations
FY2001-FY2003
From FY2001 to FY2003, appropriations to USAID’s CS/MH programs, in
current terms, grew by about 8%, and overall support for USAID’s global health
programs grew by about 28% (Table 7). The bulk of that growth came from
increases in appropriations to HIV/AIDS and other infectious diseases (OID), which55
each grew by 65% and 24%, respectively. Higher appropriations for HIV/AIDS
programs during this time period reflect support for the President’s International56
Mother and Child HIV Prevention Initiative. The majority of OID funds were
directed to tuberculosis and malaria programs. Throughout these years, Congress
also demonstrated its strong support for the Global Fund to Fight HIV/AIDS,
Tuberculosis, and Malaria (Global Fund) with increased appropriations for U.S.
contributions to the Fund (Table 7 and Figure 1).
Table 7. USAID Global Health Programs: FY2001-FY2003
(current U.S. $ millions)
% Change:
FY2001 FY2002 FY2003 FY2001-
Program Ena c t e d Ena c t e d Ena c t e d FY2003
Child Survival/Maternal Health
(CS/MH) $361.1 $391.7 $389.7 0 .079
Vulnerable Children (VC)$36.7$32.3$34.3-0.065
HIV/AIDS $318.0 $424.0 $523.8 0 .647
Other Infectious Diseases (OID)$140.2$182.0$173.10.237
Family Planning/Reproductive
Health (FP/RH)$425.0$425.0$443.60.044
United Nations Childrens Fund
(UNICEF) Grant$109.8$120$119.28.6%
Global Fund $119.7$200.0$250.0108.9%
To tal 1510.5 1775 1933.7 28.0%
Source: USAID Budget Office, May 16, 2008.


55 The majority of OID funds were spent on TB and malaria programs. Other diseases were
supported by these funds, however, such as polio.
56 For more on U.S. global HIV/AIDS policies, see CRS Report RL33771, Trends in U.S.
Global AIDS Spending: FY2000-FY2008, by Tiaji Salaam-Blyther. Also see The White
House, “President Bush’s International Mother and Child HIV Prevention Initiative,” June

19, 2002, at [http://www.whitehouse.gov/news/releases/2002/06/20020619-1.html].



Figure 1. USAID Global Health Programs: FY2001-FY2003
(current U.S. $ millions)


Source: USAID Budget Office, May 16, 2008.
Note: In FY2001, $62 million was provided to global TB interventions and $55 million to malaria
programs; in FY2002, $72 million to TB and $71 million to malaria; and in FY2003, $76.6 million
to TB and $65.4 million to malaria.
FY2004-FY2008
From FY2004 through FY2008, U.S. support for global HIV/AIDS, TB, and
malaria programs began to dominate discussions about USAID’s health programs.
While some Members applauded the Administration’s focus on HIV/AIDS,
particularly through the President’s Emergency Plan for AIDS Relief (PEPFAR),57
they questioned why the Administration requested less for other global health
interventions, particularly those related to child survival, maternal health, family58
planning, and reproductive health. Other Members challenged the Administration
to consider the ability of recipient countries to absorb burgeoning HIV/AIDS funds
57 For more information on PEPFAR, see CRS Report RL33771, Trends in Global AIDS
Spending: FY2000-FY2008, and CRS Report RL34192, PEPFAR: From Emergency to
Sustainability, both by Tiaji Salaam-Blyther.
58 At a FY2007 House Foreign Operations Appropriations Subcommittee hearing on
USAID’s FY2007 budget request, for example, Representative Nita Lowey questioned the
effectiveness of increasing spending on the Millennium Challenge Corporation (MCC) and
PEPFAR, while proposing a reduction or no change in spending for other development
assistance and non-AIDS programs.

because of overtaxed health infrastructures. Congress urged the Administration to
better integrate HIV/AIDS and other health programs, particularly those related to TB
and nutrition.
Still, appropriations to HIV/AIDS, TB, and malaria far outpaced support for
USAID’s other health programs. From FY2004 through FY2008, Congress provided
$19.7 billion for global HIV/AIDS, TB, and malaria programs.59 During that same
time period, Congress appropriated $4.6 billion to USAID’s child survival and
maternal health, vulnerable children, and family planning and reproductive health
initiatives (Table 8 and Figure 2).
Table 8. USAID Global Health Programs: FY2004-FY2008
(current U.S. $ millions)
%% of Global Health
Change: B udg et
FY2004 FY2005 FY2006 FY2007 FY2008 FY2004-
Program Ena c t e d Ena c t e d Ena c t e d Ena c t e d Est i ma t e FY2008 FY2004 FY2008
CS/MH 442.9 451.7 447.8 427.9 521.9 17.8% 26.6% 25.1%
VC 36.0 35.3 29.7 19.6 20.5 -44.3% 2.2% 1.0%
HIV/AIDS 555.5 384.7 373.8 345.9 371.1 -33.2% 33.4% 17.9%
OID 200.5 215.8 445.1 586.4 707.9 253.1% 12.0% 34.0%
T B [85.1] [92.0] [91.5] [94.9] [162.2] [90.6%] [5.1%] [7.8%]
Malaria [79.9] [90.8] [102.0] [94.9] [349.6] [337.5%] [4.8%] [16.8%]
H5 N1 n/a [16.3] [161.5] [248.0] [115.0] [605.5%]a n/a [5.5%]
(Avian Flu)
Other [35.5] [16.7] [90.1] [161.5] [81.1] [128.5%] [2.1%] [3.9%]
FP /RH 429.5 437.0 435.0 435.6 457.2 6 .5% 25.8% 22.0%b
Global Fund397.6248.0247.5247.50.0n/an/a
(GF)
Total with GF2,062.01,772.51,978.92,062.92,078.60.8%n/an/a
Total without1,664.41,524.51,731.41,815.42,078.624.9%cn/an/a
GF
Source: USAID Budget Office, May 16, 2008.
Notes: Contributions to UNICEF are not included in this table, because Congress has appropriated
those funds to GHAI since FY2004.
Abbreviations: CS/MH — Child Survival/Maternal Health; VC — Vulnerable Children; OID —
Other Infectious Diseases; and FP/RH — Family Planning/Reproductive Health.
a. Because Congress began funding global avian flu interventions in FY2005, this percentage reflects
changes in appropriations from FY2005 through FY2008.
b. In FY2008, Congress provided the full U.S. contribution to the Global Fund from Foreign
Operations Appropriations to GHAI. CRS did not calculate changes in appropriations to the
Global Fund, because the Global Fund is not a bilateral program that the United States controls
or through which the United States provides direct assistance. The final row reflects the
increase in appropriations to USAID’s global health programs without considering U.S.
contributions to the Global Fund.
c. Excludes U.S. contributions to the Global Fund.


59 For more information see CRS Report RL33771, Trends in Global AIDS Spending:
FY2000-FY2008, by Tiaji Salaam-Blyther.

Figure 2. USAID Global Health Programs: FY2004-FY2008
(current U.S. millions)


Source: USAID Budget Office, May 16, 2008.
Issues for Congress
Congress has consistently boosted appropriations to USAID’s global health
programs throughout the Administration of President George W. Bush, though
mostly for specific diseases. From FY2001 through FY2008, Congress has supported
the President’s calls for higher spending on targeted, disease-specific U.S. programs
through three key initiatives: the President’s International Mother and Child HIV
Prevention Initiative (FY2002-FY2004), PEPFAR (FY2004-FY2008), and the
President’s Malaria Initiative (FY2006-FY2010). At the same time, appropriations
to other health issues, such as child survival and maternal health have changed little
(with the exception of FY2008, when appropriations to CS/MH activities increased).
While most health experts applaud the recent increase in U.S. commitment to
countering the global spread of diseases like HIV/AIDS, many remained concerned
that other health programs that offer life-saving interventions for women and children
are overlooked and underfunded, particularly in sub-Saharan Africa. The World
Health Organization asserts that some two-thirds of child deaths are preventable
through practical, low-cost interventions. Those expressing concern about the
apportionment of U.S. global health funds argue that HIV/AIDS, TB, and malaria are
not the only diseases killing people. In addition to proposing an increase in funding

for CS/MH programs, some observers urge Congress to boost support for other
health issues that affect child survival and maternal health.60
Consider Role of Family Planning in Improving Maternal and
Child Health
Some urge Congress to consider how voluntary family planning could improve
maternal and child health. According to USAID, family planning activities protect
the health of women by reducing high-risk pregnancies and the health of children by
allowing sufficient time between pregnancies; prevent HIV/AIDS with information,
counseling, and access to male and female condoms; reduce abortions; and protect61
the environment by stabilizing population growth. Others oppose funding family
planning for a number of reasons, including concern that in some countries abortions
and coercive practices may occur in family planning programs.
Family planning can help improve the morbidity and mortality rates of
adolescent girls. In many rural areas of developing countries, girls are married and
begin to have children in their teen years. Some research indicates that mothers
younger than 20 years of age are at higher risk of delivering low-birthweight babies
and suffer more pregnancy and delivery complications, such as toxemia, anemia,
premature delivery, prolonged labor, and cervical trauma. Girls between 15 and 19
years of age are twice as likely to die from childbirth as women in their twenties, and
those younger than 15 years of age are five times as likely to die.62 Young girls are
also more likely to develop obstetric fistula. In Kenya, one study found that 45% of
all fistula cases were among adolescents.63 Obstetric fistula can be prevented by
delaying pregnancy until the girl’s pelvic region is fully developed and performing
caesarean surgery when needed. The condition can be repaired for about $300, a cost64
that is prohibitive to most young girls and women in the most affected countries.
Increase Support for Health System Strengthening and
Improve Donor Coordination
Some observers advocate that Congress increase spending on health systems,
because to significantly reduce maternal and child mortality, governments must be
able to effectively undertake a range of health strategies, including ensuring income


60 Also see WHO’s website on The Partnership for Maternal, Newborn, and Child Health,
at [http://www.who.int/pmnch/about/en/], visited on June 23, 2008.
61 See USAID’s website on family planning, at [http://www.usaid.gov/our_
work/global_health/pop/], visited on June 9, 2008.
62 The Elimination of All Forms of Discrimination and Violence Against the Girl Child,
United Nations Economic and Social Council, E/CN.6/2007/2, December 12, 2006, at
[http://daccessdds.un.org/ doc /UNDOC/GEN/N06/ 657/13/PDF/N0665713.pdf?OpenElem
ent], visited on June 9, 2008.
63 CDC, Family Planning Methods and Practice: Africa, 1999, at [http://www.cdc.gov/
reproductivehealth/Products&Pubs/Africa/preface.pdf], visited on June 9, 2008.
64 See UNFPA website on obstetric fistula, visited on June 13, 2007.

and food levels; the nutritional and health status of mothers; access to
immunizations, oral rehydration therapy, and maternal and child health services
(including prenatal care); safe drinking water; and basic sanitation.65 Improvements
in these areas are significantly affected by the strength of health systems and
availability of health workers. UNICEF has found that without donor support, health
systems in many countries cannot deliver essential interventions (such as
vaccinations) sufficiently enough to reduce mortality nationwide.66
Supporters of strengthening health systems urge Congress to direct USAID to
better coordinate its health assistance with other donors and with respective health
ministries to improve efficiency and overall health outcomes. Proponents of this idea
point to WHO’s International Health Partnership and related Initiatives (IHP+) — a
coalition of international health agencies, governments, and donors committed to
improving health and development outcomes in developing countries and reaching
the health-related MDGs.67 The IHP+ encourages donors to create a compact with
countries to commit development partners and governments to support one results-
oriented national health plan in a harmonized way that will ensure predictable, long-
term financing from both national and international sources. A compact is a contract
through which the international community and the recipient country reach consensus
on results based on mutual accountability. Country compacts bind all donors and
respective government agencies to one single country health plan, one monitoring
and evaluation plan, one budget (with external funding harmonized with recipient
countries’ budget cycles), one reporting and validation process, and benchmarks for
government performance.
Encourage Governments to Increase National Health Budgets
Global health experts increasingly underscore the role recipient governments
should play in improving health systems. Some critics contend that donors must
consider the role that political will plays in minimal health spending by many
developing countries. According to the International Monetary Fund (IMF), when
asked about the most important reason health funds go unspent, some 29% of health
practitioners who were surveyed cited a lack of political will, and only 1% blamed
IMF or World Bank restrictions.68


65 UNICEF, The State of the World’s Children 2008: Child Survival, pp. 3 and 5.
66 UNICEF, Countdown to 2015: Maternal, Newborn & Child Survival, 2008, p. vii.
67 Information on IHP+ was summarized by CRS from WHO’s website on IHP at
[http://www.who.int/healthsystems/ihp/en/index.html] and WHO, International Health
Partnership and related Initiatives (IHP+) Harmonization of Health in Africa (HHA):
Interregional Country Health Sector Teams Meeting, February 28 — March 1, 2008, at
[http://www.who.int/healthsystems/FINAL_IHP_LusakaWayForward.pdf], visited on June

16, 2008.


68 Berg, Andrew, “Budgeting to Reduce Poverty in Africa,” IMF African Department, April
11, 2007, at [http://www.imf.org/external/pubs/ft/survey/so/2007/POL0628A.htm], visited
on June 16, 2008.

According to WHO, on average each year, the 57 countries with severe
shortages of health workers spend about $33 per person on health;69 comparatively,
each year the U.S. government spends approximately, $2,548 per capita on health.70
The entire continent of Africa spends less than 1% of the world’s expenditure on
health.71 African leaders have pledged to increase spending on health.
In April 2001, Members of the African Union (AU) and the Organization of
African Unity (OAU) signed the Abuja Declaration on HIV/AIDS, Tuberculosis, and
Other Infectious Diseases, in which signatories pledged to spend at least 15% of their
national budgets on health care.72 According to the Progress Report on the
Implementation of the Plans of Action of the Abuja Declarations on Malaria (2000),
and HIV/AIDS and Tuberculosis (2000/1 to 2005), 33% of AU States had allocated
10% or more of their national budgets to the health sector by 2004, 38% spent
between 5% and 10% on health care, and 29% indicated reserving less than 5% of
their national budgets for health systems. Only Botswana reported spending at least

15% on health.73


Although most health experts agree that African governments need to boost
their health budgets, some counter that poor political will is not the primary cause of
low health spending. Instead, opponents argue that structural adjustment programs
and conditional lending practices have limited African governments’ abilities to
increase investments in public health and health worker education.74 Shrunken health
budgets have led to a decline in the quality of education and training opportunities
for medical students, a perpetual shortage of health supplies and equipment (e.g.,
sanitation gloves and hypodermic needles), insufficient medicine and vaccine stocks,
and a brain drain of African health workers. The International Development
Research Center maintains, however, that discussions about the impact of structural
adjustment, conditional lending, and health reform on public health infrastructures


69 WHO, Working Together for Health: The World Health Report 2006, Slide 8, at
[http://www.who.int/whr/2006/media_centre/WHR06_slides_en.pdf], visited on June 17,

2008.


70 Ibid, p. 189, at [http://www.who.int/whr/2006/whr06_en.pdf], visited on June 17, 2008.
71 Ibid, p. xix.
72 Abuja Declaration, [http://www.un.org/ga/aids/pdf/abuja_declaration.pdf].
73 Progress Report on Abuja Declarations, [http://www.africa-union.org/root/au/
conferences/past/2006/may/summit/doc/en/SP_ExCL_ATM6I_Progress_Report.pdf], visited
on June 9, 2008. The progress report showed that most of the countries that had allocated
less than 5% were in West and Central Africa. Those countries reporting spending 10% or
more included, South Africa (10%), Mozambique (11%), Libya (11.3%), Uganda and
Namibia (12%), Tanzania, Gambia, and Ghana (13%), Sao Tome (14%), and Zimbabwe
(14.5). Ethiopia reported spending the least on health care, with 2% of the national budget
reserved for those purposes.
74 “World Bank: Hazardous to Africa’s Health,” Africa Action, April 21, 2006 at
[ h t t p : / / www.af r i caact i on.or g/ r e sour ces/page.php?op=r ead&document i d =207&t ype=7&
issues=11&campaigns=2], and “Nurse Exodus Leaves Kenya in Crisis,” Guardian
Unlimited, May 21, 2006, at [http://www.guardian.co.uk/kenya/story/0,,1779821,00.html],
visited on June 9, 2008.

are often laden with biased terminology that observers use to make “sweeping
triumphalist or catastrophist arguments.”75 The organization found that results of
structural adjustment, conditional lending, and health reform were mixed and that the
organization could “support neither the opinion of those who believe the erosion of
public expenditure on health is a characteristic feature of adjustment, nor of those
who hold the opposite view.”76
Legislation Introduced in the 110th Congress
Related to Maternal and Child Health
Below is a list of bills introduced to date in the 110th Congress to directly and
indirectly improve maternal and child health.
H.Amdt. 360 to H.R. 2764, Consolidated Appropriations Act of 2008,
increased support for maternal and child health by $5 million for FY2008. The
amendment was incorporated into the bill, which was enacted and became P.L.110-

161.


H.R. 5501 and S. 2731, Tom Lantos and Henry J. Hyde United States Global
Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of

2008, authorize $50 billion and $48 billion, respectively, for international HIV/AIDS,


TB, and malaria interventions and require that women receiving drugs to prevent
mother-to-child HIV transmission are also provided with or referred to appropriate
maternal and child services. The House version, which passed by recorded vote, 308-

116, calls for linkages to and referral systems for NGOs that implement multi-


sectoral approaches for access to HIV/AIDS education and testing in family planning
and maternal health programs supported by the United States. The Senate version
does not include language on family planning. The Senate passed H.R. 5501 by
voice vote, 80-16, with a substitute amendment that inserted the language of S. 2731
after amendments were made on the Senate floor.
H.R. 1302 and S. 2433, Global Poverty Act of 2007, require the President to
develop and implement a comprehensive strategy to advance U.S. efforts to promote
the reduction of global poverty, the elimination of extreme global poverty, and the
achievement of the Millennium Development Goal of reducing by one-half the
proportion of people worldwide, between 1990 and 2015, who live on less than $1
per day. Language in the bills indicates that improving maternal and child health is
part of this comprehensive strategy. The House passed the bill by voice vote on


75 International Development Research Center, Safeguarding the Health Sector in Times of
Macroeconomic Instability, 2008, Foreword, p. 4, at [http://www.idrc.ca/openebooks/

370-6/], visited on June 16, 2008.


76 Ibid, Chapter 11, p. 209. Also see Center for Global Development, Does the IMF
Constrain Health Spending in Poor Countries? Evidence and an Agenda For Action, July

2007, at [http://www.cgdev.org/content/publications/detail/14103/], visited on June 16,


2008.



September 25, 2007, and referred it to the Senate Foreign Relations Committee. The
Senate version was placed on the Senate calendar on April 24, 2007.
H.R. 2266 and S. 1418, U.S. Commitment to Global Child Survival Act of
2007, provide assistance to improve the health of newborns, children, and mothers
in developing countries, and for other purposes. The House version was referred to
the House Foreign Affairs Committee. The Senate version was reported out of the
Senate Foreign Relations Committee and placed on the Senate legislative calendar.
H.R. 1225, Focus on Family Health Worldwide Act of 2007, amends the
Foreign Assistance Act of 1961 to improve voluntary family planning programs in
developing countries, and for other purposes. The bill was referred to the House
Foreign Affairs Committee.
H.R. 2114, Repairing Young Women’s Lives Around the World Act, provides
a U.S. voluntary contribution to the United Nations Population Fund for the
prevention, treatment, and repair of obstetric fistula. The bill was referred to the
House Foreign Affairs Committee.
H.R. 2604, United Nations Population Fund Women’s Health and Dignity Act,
provides financial and other support to the United Nations Population Fund to carry
out activities to save women’s lives, limit the incidence of abortion and maternal
mortality associated with unsafe abortion, promote universal access to safe and
reliable family planning, and assist women, children, and men in developing
countries to live better lives. The bill was referred to the House Foreign Affairs
Committee.
S. 1998, International Child Marriage Prevention Act of 2007, authorizes funds
to reduce child marriage, and for other purposes. The bill was referred to the Senate
Foreign Relations Committee.
S. 2682, United Nations Population Fund Restoration Act of 2008, directs U.S.
funding to the United Nations Population Fund for certain purposes including
maternal and child health. The bill was referred to the Senate Foreign Relations
Committee.
H.Res. 1045, Global Security Priorities Resolution, while acknowledging a
need to address the threat of international terrorism and protect the global security of
the United States, calls for reducing the number and accessibility of nuclear weapons
and preventing their proliferation. The resolution estimates that “the savings
generated in the long term by significant reduction of nuclear armaments will be
appreciable, with estimates as high as $13 million annually.” The resolution directs
a portion of these savings towards child survival, hunger, and universal education,
and calling on the President to take action to achieve these goals. The resolution was
referred to the House Foreign Affairs Committee.
H.Res. 1022, affirms the House’s commitment to promoting maternal health
and child survival at home and abroad through greater international investment and
participation and recognizes maternal health and child survival as fundamental to the
well-being of families and societies, and to global development and prosperity. The



House agreed to suspend the rules and agree to the resolution, as amended, but the
motion to reconsider was agreed to without objection.